[Federal Register: October 5, 1998 (Volume 63, Number 192)]
[Notices]
[Page 53446-53456]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr05oc98-87]

[[Page 53446]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration
[HCFA-1039-N]
RIN 0938-AI87

Medicare Program; Hospice Wage Index

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Notice.

-----------------------------------------------------------------------

SUMMARY: This notice announces the annual update to the hospice wage
index as required by 42 CFR 418.306(c). This update is effective
October 1, 1998. The wage index is used to reflect local differences in
wage levels. The hospice wage index methodology and values are based on
recommendations of a negotiated rulemaking advisory committee and were
originally published in the Federal Register on August 8, 1997. This
update is the second year of a 3-year transition period. The second
transition year begins October 1, 1998 and ends September 30, 1999.

EFFECTIVE DATE: This notice is effective on October 1, 1998.

FOR FURTHER INFORMATION CONTACT: Carol Blackford, (410) 786-5909.

SUPPLEMENTARY INFORMATION:

I. Background

A. Statute and Regulations

    Hospice Care is an approach to treatment that recognizes that the
impending death of an individual warrants a change in the focus from
curative care to palliative care (relief of pain and other
uncomfortable symptoms). The goal of hospice care is to help terminally
ill individuals continue life with minimal disruption to normal
activities while remaining primarily in the home environment. A hospice
uses an interdisciplinary approach to deliver medical, social,
psychological, emotional, and spiritual services through use of a broad
spectrum of professional and other caregivers, with the goal of making
the individual as physically and emotionally comfortable as possible.
Counseling and respite services are available to the family of the
hospice patient. Hospice programs consider both the patient and the
family as a unit of care.
    Section 1861(dd) of the Social Security Act (the Act) provides for
coverage of hospice care for terminally ill Medicare beneficiaries who
elect to receive care from a participating hospice. The statutory
authority for payment to hospices participating in the Medicare program
is contained in section 1814(i) of the Act.
    Our existing regulations under 42 CFR Part 418 (issued on December
16, 1983, effective for hospice services furnished on or after November
1, 1983) establish eligibility requirements and payment standards and
procedures, define covered services, and delineate the conditions a
hospice must meet to be approved for participation in the Medicare
program. Subpart G of Part 418 provides for payment to hospices based
on one of four prospectively determined rates for each day in which a
qualified Medicare beneficiary is under the care of a hospice. The four
rate categories are routine home care, continuous home care, inpatient
respite care, and general inpatient care. Payment rates are established
for each category.
    The regulations at Sec. 418.306(c), which require the rates to be
adjusted by a wage index, were revised on August 8, 1997, through
publication of a final rule in the Federal Register (62 FR 42860). This
rule implemented a new methodology for calculating the hospice wage
index that was based on the recommendations of a negotiated rulemaking
committee. The committee reached consensus on a methodology and the
resulting committee statement, describing that consensus, was included
as an attachment to the August 8, 1997 final hospice wage index rule.
The provisions of the final hospice wage index rule are as follows:
    <bullet> The revised hospice wage index will be phased in over a 3-
year transition period. For the first year of the transition period, a
blended index was calculated by adding two-thirds of the 1983 index
value for an area to one-third of the revised wage index value for that
area. During the second year of the transition period, the calculation
is similar, except that the blend is one-third of the 1983 index value
and two-thirds of the revised wage index value for that area. During
the third transition year the revised wage index will be fully
implemented. The first transition year occurred October 1, 1997 through
September 30, 1998.
    <bullet> All hospice wage index values of 0.8 or greater are
subject to a budget neutrality adjustment to ensure that Medicare does
not pay any more in the aggregate than it would with the previous wage
index. The budget neutrality adjustment is calculated by multiplying
the hospice wage index for a given area by the budget neutrality
adjustment factor. The budget neutrality adjustment is to be applied
annually, both during and after the transition period.
    <bullet> All hospice wage index values below 0.8 receive the
greater of the following adjustments: the wage index floor, a 15
percent increase, subject to a maximum wage index value of 0.8; or, the
budget neutrality adjustment.
    <bullet> The wage index is to be updated annually, in the Federal
Register, based on the most current available hospital wage data.
    <bullet> Because the Virgin Islands is not an area designated under
the Prospective Payment System for hospitals, and does not have a
hospital wage index, the hospice wage index for the Virgin Islands will
be calculated by gathering information from the hospital cost report
and comparing hourly wages of the hospital located in the Virgin
Islands to the national average, as described in step 9 of item III(A)
(computation of the hospice wage index) in the proposed hospice wage
index rule published in the Federal Register on September 4, 1996 (61
FR 46583).
    Section 4442 of the Balanced Budget Act of 1997 requires payment
for routine and continuous home care to be made based on the geographic
location at which the service is furnished. The site of service
provision, as it is commonly referred to, was effective October 1, 1997
and was implemented through a Program Memorandum issued in September of
1997. This notice does not address implementation of the site of
service provision but merely takes this change into account when
analyzing the impact of the annual hospice wage index update.

B. Update to the Hospice Wage Index

    The second year of the 3-year transition period begins October 1,
1998 and ends September 30, 1999. In accordance with the agreement
signed by HCFA and all other members of the Hospice Wage Index
Negotiated Rulemaking Committee, we are using the most current HCFA
hospital data available, including any changes to the definitions of
MSAs, that allow us to publish this notice at least 4 months in advance
of the October 1, 1998 effective date. We will be using the 1997
hospital area wage index. Updated wage index values have been
calculated by adding one-third of the 1983 index value for each area to
two-thirds of the new wage index value. All wage index values are
adjusted by a budget neutrality factor of 1.04662 and are subject to
the wage index floor adjustment, if applicable. All of the calculations
described above have been completed by HCFA and are built into the wage
index values

[[Page 53447]]

reflected in both Tables A and B below. At this time, there are no
Medicare certified hospices located in the Virgin Islands. Therefore, a
wage index value for the Virgin Islands has not been calculated.

C. Tables

              Table A.--Hospice Wage Index for Urban Areas
------------------------------------------------------------------------
                              Urban area (constituent counties    Wage
       MSA code number             or county equivalents)         index
-------------------------------------------------------------------\1\--
0040........................  Abilene, TX.....................    0.9066
                              Taylor, TX
0060........................  Aguadilla, PR...................    0.5905
                              Aguada, PR
                              Aguadilla, PR
                              Moca, PR
0080........................  Akron, OH.......................    1.0563
                              Portage, OH
                              Summit, OH
0120........................  Albany, GA......................    0.8629
                              Dougherty, GA
                              Lee, GA
0160........................  Albany-Schenectady-Troy, NY.....    0.9030
                              Albany, NY
                              Montgomery, NY
                              Rensselaer, NY
                              Saratoga, NY
                              Schenectady, NY
                              Schoharie, NY
01606.......................  Albany-Schenectady-Troy, NY.....    0.8958
                              Schoharie, NY
0200........................  Albuquerque, NM.................    0.9737
                              Sandoval, NM
                              Valencia, NM
02006.......................  Albuquerque, NM.................    1.0186
                              Bernalillo, NM
0220........................  Alexandria, LA..................    0.9091
                              Rapides, LA
0240........................  Allentown-Bethlehem-Easton, PA..    1.0707
                              Carbon, PA
                              Lehigh, PA
                              Northampton, PA
0280........................  Altoona, PA.....................    0.9951
                              Blair, PA
0320........................  Amarillo, TX....................    0.9959
                              Potter, TX
                              Randall, TX
0380........................  Anchorage, AK...................    1.4074
                              Anchorage, AK
0440........................  Ann Arbor, MI...................    1.1528
                              Lenawee, MI
04406.......................  Ann Arbor, MI...................    1.2441
                              Washtenaw, MI
04407.......................  Ann Arbor, MI...................    1.2406
                              Livingston, MI
0450........................  Anniston, AL....................    0.8776
                              Calhoun, AL
0460........................  Appleton-Oshkosh-Neenah, WI.....    0.9662
                              Calumet, WI
                              Outagamie, WI
                              Winnebago, WI
0470........................  Arecibo, PR.....................    0.5905
                              Arecibo, PR
                              Camuy, PR
                              Hatillo, PR
0480........................  Asheville, NC...................    0.9296
                              Madison, NC
04806.......................  Asheville, NC...................    0.9647
                              Buncombe, NC
0500........................  Athens, GA......................    0.9416
                              Clarke, GA
                              Madison, GA
                              Oconee, GA
0520........................  Atlanta, GA.....................    1.0139
                              Barrow, GA
                              Cherokee, GA
                              Clayton, GA
                              Cobb, GA
                              Coweta, GA
                              DeKalb, GA
                              Douglas, GA
                              Fayette, GA
                              Forsyth, GA
                              Fulton, GA
                              Gwinnett, GA
                              Henry, GA
                              Newton, GA
                              Paulding, GA
                              Rockdale, GA
                              Spalding, GA
                              Walton, GA
05206.......................  Atlanta, GA.....................    0.9820
                              Bartow, GA
                              Carroll, GA
                              Pickens, GA
0560........................  Atlantic-Cape May, NJ...........    1.1498
                              Atlantic City, NJ
                              Cape May, NJ
0600........................  Augusta-Aiken, GA-SC............    0.9866
                              Columbia, GA
                              McDuffie, GA
                              Richmond, GA
                              Aiken, SC
06006.......................  Augusta-Aiken, GA-SC............    0.9333
                              Edgefield, SC
0640........................  Austin-San Marcos, TX...........    0.9206
                              Bastrop, TX
                              Caldwell, TX
06406.......................  Austin-San Marcos, TX...........    1.0067
                              Hays, TX
                              Travis, TX
                              Williamson, TX
0680........................  Bakersfield, CA.................    1.1268
                              Kern, CA
0720........................  Baltimore, MD...................    1.0549
                              Anne Arundel, MD
                              Baltimore, MD
                              Baltimore City, MD
                              Carroll, MD
                              Harford, MD
                              Howard, MD
                              Queen Anne's, MD
0733........................  Bangor, ME......................    0.9847
                              Penobscot, ME
0743........................  Barnstable-Yarmouth, MA.........    1.3359
                              Barnstable, MA
0760........................  Baton Rouge, LA.................    0.9398
                              Ascension, LA
                              East Baton Rouge, LA
                              Livingston, LA
                              West Baton Rouge, LA
0840........................  Beaumont-Port Arthur, TX........    0.9440
                              Hardin, TX
                              Jefferson, TX
                              Orange, TX
0860........................  Bellingham, WA..................    1.1508
                              Whatcom, WA
0870........................  Benton Harbor, MI...............    0.9273
                              Berrien, NJ
0875........................  Bergen-Passaic, NJ..............    1.2072
                              Bergen, NJ
                              Passaic, NJ
0880........................  Billings, MT....................    1.0192
                              Yellowstone, MT
0920........................  Biloxi-Gulfport-Pascagoula, MS..    0.8910
                              Hancock, MS
                              Harrison, MS
09206.......................  Biloxi-Gulfport-Pascagoula, MS..    0.9409
                              Jackson, MS
0960........................  Binghamton, NY..................    0.9543
                              Broome, NY
                              Tioga, NY
1000........................  Birmingham, AL..................    0.9788
                              Blount, AL
                              Jefferson, AL
                              St. Clair, AL
                              Shelby, AL
1010........................  Bismarck, ND....................    0.8893
                              Burleigh, ND
                              Morton, ND
1020........................  Bloomington, IN.................    0.9559
                              Monroe, IN
1040........................  Bloomington-Normal, IL..........    0.9630
                              McLean, IL
1080........................  Boise City, ID..................    0.9320
                              Canyon, ID
10806.......................  Boise City, ID..................    0.9931
                              Ada, ID
1123........................  Boston-Worcester-Lawrence-Lowell-   1.1805
                               Brockton, MA-NH.
                              Essex, MA
                              Middlesex, MA
                              Norfolk, MA
                              Plymouth, MA
                              Suffolk, MA
11236.......................  Boston-Worcester-Lawrence-Lowell-   1.1246
                               Brockton, MA-NH.
                              Hillsborough, NH
                              Merrimack, NH
11237.......................  Boston-Worcester-Lawrence-Lowell-   1.1356
                               Brockton, MA-NH.
                              Bristol, MA
11238.......................  Boston-Worcester-Lawrence-Lowell-   1.0935
                               Brockton, MA-NH.
                              Rockingham, NH
                              Strafford, NH
11239.......................  Boston-Worcester-Lawrence-Lowell-   1.1394
                               Brockton, MA-NH.
                              Worcester, MA
1125........................  Boulder-Longmont, CO............    1.0470
                              Boulder, CO
1145........................  Brazoria, TX....................    0.9451
                              Brazoria, TX
1150........................  Bremerton, WA...................    1.0810
                              Kitsap, WA

[[Page 53448]]

1240........................  Brownsville-Harlingen-San           0.9314
                               Benito, TX.
                              Cameron, TX
1260........................  Bryan-College Station, TX.......    0.9147
                              Brazos, TX
1280........................  Buffalo-Niagara Falls, NY.......    0.9884
                              Erie, NY
12806.......................  Buffalo-Niagara Falls, NY.......    0.9519
                              Niagara, NY
1303........................  Burlington, VT..................    1.1037
                              Franklin, VT
13036.......................  Burlington, VT..................    1.0444
                              Chittenden, VT
                              Grand Isle, VT
1310........................  Caguas, PR......................    0.6085
                              Caguas, PR
                              Cayey, PR
                              Cidra, PR
                              Gurabo, PR
                              San Lorenzo, PR
1320........................  Canton-Massillon, OH............    0.9670
                              Carroll, OH
                              Stark, OH
1350........................  Casper, WY......................    0.9866
                              Natrona, WY
1360........................  Cedar Rapids, IA................    0.9223
                              Linn, IA
1400........................  Champaign-Urbana, IL............    0.9731
                              Champaign, IL
1440........................  Charleston-North Charleston, SC.    0.9725
                              Berkeley, SC
                              Charleston, SC
                              Dorchester, SC
1480........................  Charleston, WV..................    1.0228
                              Kanawha, WV
                              Putnam, WV
1520........................  Charlotte-Gastonia-Rock Hill, NC-   1.0186
                               SC.
                              Cabarrus, NC
                              Gaston, NC
                              Lincoln, NC
                              Mecklenburg, NC
                              Rowan, NC
                              Stanly, NC
                              Union, NC
                              York, SC
1540........................  Charlottesville, VA.............    1.0824
                              Albemarle, VA
                              Charlottesville City, VA
                              Fluvanna, VA
                              Greene, VA
1560........................  Chattanooga, TN-GA..............    0.9415
                              Catoosa, GA
                              Dade, GA
                              Walker, GA
                              Hamilton, TN
                              Marion, TN
1580........................  Cheyenne, WY....................    0.9091
                              Laramie, WY
1600........................  Chicago, IL.....................    1.0607
                              DeKalb, IL
16006.......................  Chicago, IL.....................    1.1051
                              Kane, IL
                              Kendall, IL
16007.......................  Chicago, IL.....................    1.1832
                              Cook, IL
                              Du Page, IL
                              McHenry, IL
16008.......................  Chicago, IL.....................    1.1378
                              Grundy, IL
                              Will, IL
16009.......................  Chicago, IL.....................    1.1445
                              Lake, IL
1620........................  Chico-Paradise, CA..............    1.0960
                              Butte, CA
1640........................  Cincinnati, OH-KY-IN............    0.9617
                              Ohio, IN
16406.......................  Cincinnati, OH-KY-IN............    0.9455
                              Gallatin, KY
                              Grant, KY
                              Pendleton, KY
16407.......................  Cincinnati, OH-KY-IN............    0.9801
                              Brown, OH
16408.......................  Cincinnati, OH-KY-IN............    1.0294
                              Dearborn, IN
                              Boone, KY
                              Campbell, KY
                              Kenton, KY
                              Clermont, OH
                              Hamilton, OH
                              Warren, OH
1660........................  Clarksville-Hopkinsville, TN-KY.    0.8389
                              Christian, KY
                              Montgomery, TN
1680........................  Cleveland-Lorain-Elyria, OH.....    1.0031
                              Ashtabula, OH
16806.......................  Cleveland-Lorain-Elyria, OH.....    1.1037
                              Cuyahoga, OH
                              Geauga, OH
                              Lake, OH
                              Medina, OH
16807.......................  Cleveland-Lorain-Elyria, OH.....    1.0521
                              Lorain, OH
1720........................  Colorado Springs, CO............    1.0362
                              El Paso, CO
1740........................  Columbia, MO....................    1.0242
                              Boone, MO
1760........................  Columbia, SC....................    0.9764
                              Lexington, SC
                              Richland, SC
1800........................  Harris, GA......................    0.8749
18006.......................  Columbus, GA-AL.................    0.8992
                              Russell, AL
                              Chattahoochee, GA
                              Muscogee, GA
1840........................  Columbus, OH....................    1.0469
                              Delaware, OH
                              Fairfield, OH
                              Franklin, OH
                              Licking, OH
                              Madison, OH
                              Pickaway, OH
1880........................  Corpus Christi, TX..............    0.9607
                              Nueces, TX
                              San Patricio, TX
1900........................  Cumberland, MD-WV...............    0.9456
                              Allegany, MD
                              Mineral, WV
1920........................  Dallas, TX......................    1.0529
                              Collin, TX
                              Dallas, TX
                              Denton, TX
                              Ellis, TX
                              Kaufman, TX
                              Rockwall, TX
19206.......................  Dallas, TX......................    0.9604
                              Henderson, TX
                              Hunt, TX
1950........................  Danville, VA....................    0.8719
                              Danville City, VA
                              Pittsylvania, VA
1960........................  Davenport-Moline-Rock Island, IA-   0.9291
                               IL.
                              Scott, IA
                              Henry, IL
                              Rock Island, IL
2000........................  Dayton-Springfield, OH..........    1.0565
                              Clark, OH
                              Greene, OH
                              Miami, OH
                              Montgomery, OH
2020........................  Daytona Beach, FL...............    0.9209
                              Flagler, FL
20206.......................  Daytona Beach, FL...............    0.9548
                              Volusia, FL
2030........................  Decatur, AL.....................    0.8572
                              Lawrence, AL
                              Morgan, AL
2040........................  Decatur, IL.....................    0.8952
                              Macon, IL
2080........................  Denver, CO......................    1.1482
                              Adams, CO
                              Arapahoe, CO
                              Denver, CO
                              Douglas, CO
                              Jefferson, CO
2120........................  Des Moines, IA..................    0.9902
                              Dallas, IA
                              Polk, IA
                              Warren, IA
2160........................  Detroit, MI.....................    1.1737
                              Lapeer, MI
                              Macomb, MI
                              Monroe, MI
                              Oakland, MI
                              St. Clair, MI
                              Wayne, MI
2180........................  Dothan, AL......................    0.8717
                              Dale, AL
                              Houston, AL
2190........................  Dover, DE.......................    0.9636
                              Kent, DE
2200........................  Dubuque, IA.....................    0.9230
                              Dubuque, IA
2240........................  Duluth-Superior, MN-WI..........    1.0017
                              St. Louis, MN
                              Douglas, WI
2281........................  Dutchess County, NY.............    1.1228
                              Dutchess, NY
2290........................  Eau Claire, WI..................    0.9500
                              Chippewa, WI
                              Eau Claire, WI
2320........................  El Paso, TX.....................    1.0200
                              El Paso, TX
2330........................  Elkhart-Goshen, IN..............    0.9443
                              Elkhart, IN
2335........................  Elmira, NY......................    0.9440
                              Chemung, NY
2340........................  Enid, OK........................    0.8701

[[Page 53449]]

                              Garfield, OK
2360........................  Erie, PA........................    0.9647
                              Erie, PA
2400........................  Eugene-Springfield, OR..........    1.1426
                              Lane, OR
2440........................  Evansville-Henderson, IN-KY.....    0.9550
                              Posey, IN
                              Vanderburgh, IN
                              Warrick, IN
                              Henderson, KY
2520........................  Fargo-Moorhead, ND-MN...........    0.9672
                              Clay, MN
                              Cass, ND
2560........................  Fayetteville, NC................    0.9347
                              Cumberland, NC
2580........................  Fayetteville-Springdale-Rogers,     0.8000
                               AR.
                              Benton, AR
2580........................  Fayetteville-Springdale-Rogers,     0.8102
                               AR.
                              Washington, AR
2620........................  Flagstaff, AZ-UT................    0.9482
                              Coconino, AZ
26206.......................  Flagstaff, AZ-UT................    0.9242
                              Kane, UT
2640........................  Flint, MI.......................    1.1814
                              Genesee, MI
2650........................  Florence, AL....................    0.8029
                              Colbert, AL
                              Lauderdale, AL
2655........................  Florence, SC....................    0.8894
                              Florence, SC
2670........................  Fort Collins-Loveland, CO.......    1.0387
                              Larimer, CO
2680........................  Ft. Lauderdale, FL..............    1.1164
                              Broward, FL
2700........................  Fort Myers-Cape Coral, FL.......    0.9391
                              Lee, FL
2710........................  Fort Pierce-Port St. Lucie, FL..    1.0625
                              Martin, FL
                              St. Lucie, FL
2720........................  Fort Smith, AR-OK...............    0.8806
                              Crawford, AR
                              Sebastian, AR
                              Sequoyah, OK
2750........................  Fort Walton Beach, FL...........    0.8958
                              Okaloosa, FL
2760........................  Fort Wayne, IN..................    0.9217
                              Adams, IN
                              Huntington, IN
                              Wells, IN
2760........................  Fort Wayne, IN..................    0.9506
                              Allen, IN
                              De Kalb, IN
                              Whitley, IN
2800........................  Forth Worth-Arlington, TX.......    0.9797
                              Hood, TX
28006.......................  Forth Worth-Arlington, TX.......    1.0201
                              Johnson, TX
                              Parker, TX
                              Tarrant, TX
2840........................  Fresno, CA......................    1.0927
                              Madera, CA
28406.......................  Fresno, CA......................    1.1570
                              Fresno, CA
2880........................  Gadsden, AL.....................    0.9372
                              Etowah, AL
2900........................  Gainesville, FL.................    1.0097
                              Alachua, FL
2920........................  Galveston-Texas City, TX........    1.1495
                              Galveston, TX
2960........................  Gary, IN........................    1.0636
                              Lake, IN
                              Porter, IN
2975........................  Glens Falls, NY.................    0.8936
                              Warren, NY
                              Washington, NY
2980........................  Goldsboro, NC...................    0.8857
                              Wayne, NC
2985........................  Grand Forks, ND-MN..............    0.9098
                              Polk, MN
29856.......................  Grand Forks, ND-MN..............    0.9507
                              Grand Forks, ND
2995........................  Grand Junction, CO..............    0.9246
                              Mesa, CO
3000........................  Grand Rapids-Muskegon-Holland,      1.0385
                               MI.
                              Allegan, MI
30006.......................  Grand Rapids-Muskegon-Holland,      1.0568
                               MI.
                              Kent, MI
                              Ottawa, MI
30007.......................  Grand Rapids-Muskegon-Holland,      1.0333
                               MI.
                              Muskegon, MI
3040........................  Great Falls, MT.................    0.9738
                              Cascade, MT
3060........................  Greeley, CO.....................    1.0823
                              Weld, CO
3080........................  Green Bay, WI...................    0.9827
                              Brown, WI
3120........................  Greensboro-Winston-Salem-High       0.9866
                               Point, NC.
                              Davidson, NC
                              Davie, NC
                              Forsyth, NC
                              Guilford, NC
                              Randolph, NC
                              Stokes, NC
                              Yadkin, NC
31206.......................  Greensboro-Winston-Salem-High       0.9483
                               Point, NC.
                              Alamance, NC
3150........................  Greenville, NC..................    0.9291
                              Pitt, NC
3160........................  Greenville-Spartanburg-Anderson,    0.9142
                               SC.
                              Cherokee, SC
31606.......................  Greenville-Spartanburg-Anderson,    0.9372
                               SC.
                              Anderson, SC
31607.......................  Greenville-Spartanburg-Anderson,    0.9626
                               SC.
                              Greenville, SC
                              Pickens, SC
                              Spartanburg, SC
3180........................  Hagerstown, MD..................    1.0275
                              Washington, MD
3200........................  Hamilton-Middletown, OH.........    0.9757
                              Butler, OH
3240........................  Harrisburg-Lebanon-Carlisle, PA.    1.0721
                              Cumberland, PA
                              Dauphin, PA
                              Lebanon, PA
                              Perry, PA
3283........................  Hartford, CT....................    1.2533
                              Hartford, CT
                              Litchfield, CT
                              Middlesex, CT
                              Tolland, CT
3285........................  Hattiesburg, MS.................    0.8007
                              Forrest, MS
                              Lamar, MS
3290........................  Hickory-Morganton-Lenoir, NC....    0.9027
                              Caldwell, NC
32906.......................  Hickory-Morganton-Lenoir, NC....    0.9376
                              Alexander, NC
                              Burke, NC
                              Catawba, NC
3320........................  Honolulu, HI....................    1.2246
                              Honolulu, HI
3350........................  Houma, LA.......................    0.8894
                              Lafourche, LA
                              Terrebonne, LA
3360........................  Houston, TX.....................    1.0755
                              Fort Bend, TX
                              Harris, TX
                              Liberty, TX
                              Montgomery, TX
                              Waller, TX
33606.......................  Houston, TX.....................    0.9710
                              Chambers, TX
3400........................  Huntington-Ashland, WV-KY-OH....    0.9813
                              Boyd, KY
                              Carter, KY
                              Greenup, KY
                              Lawrence, OH
                              Cabell, WV
                              Wayne, WV
3440........................  Huntsville, AL..................    0.8711
                              Limestone, AL
34406.......................  Huntsville, AL..................    0.9057
                              Madison, AL
3480........................  Indianapolis, IN................    1.0554
                              Boone, IN
                              Hamilton, IN
                              Hancock, IN
                              Hendricks, IN
                              Johnson, IN
                              Marion, IN
                              Morgan, IN
                              Shelby, IN
34806.......................  Indianapolis, IN................    1.0252
                              Madison, IN
3500........................  Iowa City, IA...................    1.0545
                              Johnson, IA
3520........................  Jackson, MI.....................    0.9903
                              Jackson, MI
3560........................  Jackson, MS.....................    0.8593
                              Hinds, MS
                              Madison, MS
                              Rankin, MS
3580........................  Jackson, TN.....................    0.8737
                              Madison, TN

[[Page 53450]]

                              Chester, TN
3600........................  Jacksonville, FL................    0.9717
                              Clay, FL
                              Duval, FL
                              Nassau, FL
                              St. Johns, FL
3605........................  Jacksonville, NC................    0.8625
                              Onslow, NC
3610........................  Jamestown, NY...................    0.8902
                              Chautauqua, NY
3620........................  Janesville-Beloit, WI...........    0.9264
                              Rock, WI
3640........................  Jersey City, NJ.................    1.1770
                              Hudson, NJ
3660........................  Johnson City-Kingsport-Bristol,     0.9583
                               TN-VA.
                              Carter, TN
                              Hawkins, TN
                              Sullivan, TN
                              Unicoi, TN
                              Washington, TN
                              Bristol City, VA
                              Scott, VA
                              Washington, VA
3680........................  Johnstown, PA...................    0.9463
                              Cambria, PA
                              Somerset, PA
3700........................  Jonesboro, AR...................    0.8000
                              Craighead, AR
3710........................  Joplin, MO......................    0.8526
                              Jasper, MO
                              Newton, MO
3720........................  Kalamazoo-Battlecreek, MI.......    1.0749
                              Van Buren, MI
37206.......................  Kalamazoo-Battlecreek, MI.......    1.1141
                              Calhoun, MI
37207.......................  Kalamazoo-Battlecreek, MI.......    1.1724
                              Kalamazoo, MI
3740........................  Kankakee, IL....................    0.9227
                              Kankakee, IL
3760........................  Kansas City, KS-MO..............    0.9568
                              Clinton, MO
37606.......................  Kansas City, KS-MO..............    1.0086
                              Johnson, KS
                              Leavenworth, KS
                              Miami, KS
                              Wyandotte, KS
37607.......................  Kansas City, KS-MO..............    1.0130
                              Cass, MO
                              Clay, MO
                              Jackson, MO
                              Lafayette, MO
                              Platte, MO
                              Ray, MO
3800........................  Kenosha, WI.....................    1.0224
                              Kenosha, WI
3810........................  Killeen-Temple, TX..............    1.0433
                              Bell, TX
                              Coryell, TX
3840........................  Knoxville, TN...................    0.9366
                              Anderson, TN
                              Blount, TN
                              Knox, TN
                              Sevier, TN
                              Union, TN
38406.......................  Knoxville, TN...................    0.8953
                              Loudon, TN
3850........................  Kokomo, IN......................    0.9225
                              Howard, IN
                              Tipton, IN
3870........................  La Crosse, WI-MN................    0.9101
                              Houston, MN
                              La Crosse, WI
38706.......................  La Crosse, WI-MN................    0.9385
                              La Crosse, WI
3880........................  Lafayette, LA...................    0.8641
                              Acadia, LA
                              St. Landry, LA
38806.......................  Lafayette, LA...................    0.9271
                              Lafayette, LA
                              St. Martin, LA
3920........................  Lafayette, IN...................    0.9407
                              Clinton, IN
39206.......................  Lafayette, IN...................    0.9580
                              Tippecanoe, IN
3960........................  Lake Charles, LA................    0.8894
                              Calcasieu, LA
3980........................  Lakeland-Winter Haven, FL.......    0.9403
                              Polk, FL
4000........................  Lancaster, PA...................    1.0234
                              Lancaster, PA
4040........................  Lansing-East Lansing, MI........    1.0707
                              Clinton, MI
                              Eaton, MI
                              Ingham, MI
4080........................  Laredo, TX......................    0.8187
                              Webb, TX
4100........................  Las Cruces, NM..................    0.8982
                              Dona Ana, NM
4120........................  Las Vegas, NV-AZ................    1.0512
                              Mohave, AZ
41206.......................  Las Vegas, NV-AZ................    1.0941
                              Nye, NV
41207.......................  Las Vegas, NV-AZ................    1.1643
                              Clark, NV
4150........................  Lawrence, KS....................    0.9424
                              Douglas, KS
4200........................  Lawton, OK......................    0.9547
                              Comanche, OK
4243........................  Lewiston-Auburn, ME.............    0.9855
                              Androscoggin, ME
4280........................  Lexington, KY...................    0.9194
                              Bourbon, KY
                              Clark, KY
                              Fayette, KY
                              Jessamine, KY
                              Scott, KY
                              Woodford, KY
42806.......................  Lexington, KY...................    0.8699
                              Madison, KY
4320........................  Lima, OH........................    0.9893
                              Allen, OH
                              Auglaize, OH
4360........................  Lincoln, NE.....................    0.9465
                              Lancaster, NE
4400........................  Little Rock-North Little Rock,      0.9476
                               AR.
                              Faulkner, AR
                              Lonoke, AR
                              Pulaski, AR
                              Saline, AR
4420........................  Longview-Marshall, TX...........    0.8843
                              Upshur, TX
44206.......................  Longview-Marshall, TX...........    0.8996
                              Gregg, TX
                              Harrison, TX
4480........................  Los Angeles-Long Beach, CA......    1.3083
                              Los Angeles, CA
4520........................  Louisville, KY-IN...............    1.0420
                              Clark, IN
                              Floyd, IN
                              Harrison, IN
                              Bullitt, KY
                              Jefferson, KY
                              Oldham, KY
45206.......................  Louisville, KY-IN...............    0.9640
                              Scott, IN
4600........................  Lubbock, TX.....................    0.9380
                              Lubbock, TX
4640........................  Lynchburg, VA...................    0.8713
                              Bedford, VA
                              Bedford City, VA
46406.......................  Lynchburg, VA...................    0.8964
                              Amherst, VA
                              Campbell, VA
                              Lynchburg City, VA
4680........................  Macon, GA.......................    0.9874
                              Bibb, GA
                              Houston, GA
                              Jones, GA
                              Peach, GA
46806.......................  Macon, GA.......................    0.9404
                              Twiggs, GA
4720........................  Madison, WI.....................    1.0595
                              Dane, WI
4800........................  Mansfield, OH...................    0.9218
                              Crawford, OH
48006.......................  Mansfield, OH...................    0.9229
                              Richland, OH
4840........................  Mayaguez, PR....................    0.6098
                              Anasco, PR
                              Cabo Rojo, PR
                              Hormigueros, PR
                              Mayaguez, PR
                              Sabana Grande, PR
                              San German, PR
4880........................  McAllen-Edinburg-Mission, TX....    0.8764
                              Hidalgo, TX
4890........................  Medford-Ashland, OR.............    1.0662
                              Jackson, OR
4900........................  Melbourne-Titusville-Palm Bay,      0.9423
                               FL.
                              Brevard, Fl
4920........................  Memphis, TN-AR-MS...............    0.9748
                              Crittenden, AR
                              DeSoto, MS
                              Shelby, TN
                              Tipton, TN
49206.......................  Memphis, TN-AR-MS...............    0.8784
                              Fayette, TN
4940........................  Merced, CA......................    1.1164
                              Merced, CA
5000........................  Miami, FL.......................    1.0888
                              Dade, FL
5015........................  Middlesex-Somerset-Hunterdon, NJ    1.1426
                              Hunterdon, NJ
                              Middlesex, NJ
                              Somerset, NJ

[[Page 53451]]

5080........................  Milwaukee-Waukesha, WI..........    1.0522
                              Milwaukee, WI
                              Ozaukee, WI
                              Washington, WI
                              Waukesha, WI
5120........................  Minneapolis-St. Paul, MN-WI.....    1.0385
                              Pierce, WI
51206.......................  Minneapolis-St. Paul, MN-WI.....    1.1072
                              Anoka, MN
                              Carver, MN
                              Chisago, MN
                              Dakota, MN
                              Hennepin, MN
                              Isanti, MN
                              Ramsey, MN
                              Scott, MN
                              Washington, MN
                              Wright, MN
                              St. Croix, WI
51207.......................  Minneapolis-St. Paul, MN-WI.....    1.0561
                              Sherburne, MN
5160........................  Mobile, AL......................    0.9154
                              Baldwin, AL
                              Mobile, AL
5170........................  Modesto, CA.....................    1.1297
                              Stanislaus, CA
5190........................  Monmouth-Ocean, NJ..............    1.1070
                              Monmouth, NJ
                              Ocean, NJ
5200........................  Monroe, LA......................    0.9202
                              Ouachita, LA
5240........................  Montgomery, AL..................    0.8745
                              Autauga, AL
                              Elmore, AL
                              Montgomery, AL
5280........................  Muncie, IN......................    0.9813
                              Delaware, IN
5330........................  Myrtle Beach, SC................    0.8453
                              Horry, SC
5345........................  Naples, FL......................    1.0096
                              Collier, FL
5360........................  Nashville, TN...................    1.0693
                              Cheatham, TN
                              Davidson, TN
                              Dickson, TN
                              Robertson, TN
                              Rutherford, TN
                              Sumner, TN
                              Williamson, TN
                              Wilson, TN
5380........................  Nassau-Suffolk, NY..............    1.3852
                              Nassau, NY
                              Suffolk, NY
5483........................  New Haven-Bridgeport-Stamford-      1.2841
                               Waterbury-Danbury, CT.
                              Fairfield, CT
54836.......................  New Haven-Bridgeport-Stamford-      1.2525
                               Waterbury-Danbury, CT.
                              New Haven, CT
5523........................  New London-Norwich, CT..........    1.2525
                              New London, CT
5560........................  New Orleans, LA.................    1.0220
                              Jefferson, LA
                              Orleans, LA
                              St. Bernard, LA
                              St. Charles, LA
                              St. John The Baptist, LA
                              St. Tammany, LA
55606.......................  New Orleans, LA.................    0.9590
                              Plaquemines, LA
                              St. James, LA
5600........................  New York, NY....................    1.4545
                              Bronx, NY
                              Kings, NY
                              New York, NY
                              Putnam, NY
                              Queens, NY
                              Richmond, NY
                              Rockland, NY
                              Westchester, NY
5640........................  Newark, NJ......................    1.2297
                              Essex, NJ
                              Morris, NJ
                              Sussex, NJ
                              Union, NJ
5640........................  Newark, NJ......................    1.2028
                              Warren, NJ
5660........................  Newburgh, NY-PA.................    1.1476
                              Pike, PA
56606.......................  Newburgh, NY-PA.................    1.1382
                              Orange, NY
5720........................  Norfolk-Virginia Beach-Newport      0.9215
                               News, VA-NC.
                              Chesapeake City, VA
                              Gloucester, VA
                              Hampton City, VA
                              James 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
                              York, VA
57206.......................  Norfolk-Virginia Beach-Newport      0.8774
                               News, VA-NC.
                              Isle of Wight, VA
                              Mathews, VA
57207.......................  Norfolk-Virginia Beach-Newport      0.8769
                               News, VA-NC.
                              Currituck, NC
5775........................  Oakland, CA.....................    1.4914
                              Alameda, CA
                              Contra Costa, CA
5790........................  Ocala, FL.......................    0.9825
                              Marion, FL
5800........................  Odessa-Midland, TX..............    0.9804
                              Midland, TX
58006.......................  Odessa-Midland, TX..............    0.9453
                              Ector, TX
5880........................  Oklahoma City, OK...............    0.9606
                              Canadian, OK
                              Cleveland, OK
                              Logan, OK
                              McClain, OK
                              Oklahoma, OK
                              Pottawatomie, OK
5910........................  Olympia, WA.....................    1.1295
                              Thurston, WA
5920........................  Omaha, NE-IA....................    0.9694
                              Pottawattamie, IA
                              Douglas, NE
                              Sarpy, NE
                              Washington, NE
59206.......................  Omaha, NE-IA....................    0.9364
                              Cass, NE
5945........................  Orange County, CA...............    1.2439
                              Orange, CA
5960........................  Orlando, FL.....................    1.0096
                              Orange, FL
                              Osceola, FL
                              Seminole, FL
59606.......................  Orlando, FL.....................    0.9599
                              Lake, FL
5990........................  Owensboro, KY...................    0.8510
                              Daviess, KY
6015........................  Panama City, FL.................    0.9333
                              Bay, FL
6020........................  Parkersburg-Marietta, WV-OH.....    0.9357
                              Washington, OH
                              Wood, WV
6080........................  Pensacola, FL...................    0.9345
                              Escambia, FL
                              Santa Rosa, FL
6120........................  Peoria-Pekin, IL................    0.9883
                              Peoria, IL
                              Tazewell, IL
                              Woodford, IL
6160........................  Philadelphia, PA-NJ.............    1.2042
                              Burlington, NJ
                              Camden, NJ
                              Gloucester, NJ
                              Bucks, PA
                              Chester, PA
                              Delaware, PA
                              Montgomery, PA
                              Philadelphia, PA
61606.......................  Philadelphia, PA-NJ.............    1.1740
                              Salem, NJ
6200........................  Phoenix-Mesa, AZ................    0.9824
                              Pinal, AZ
62006.......................  Phoenix-Mesa, AZ................    1.0583
                              Maricopa, AZ
6240........................  Pine Bluff, AR..................    0.8521
                              Jefferson, AR
6280........................  Pittsburgh, PA..................    1.0758
                              Allegheny, PA
                              Fayette, PA
                              Washington, PA
                              Westmoreland, PA
62806.......................  Pittsburgh, PA..................    1.0575
                              Beaver, PA
62807.......................  Pittsburgh, PA..................    1.0389
                              Butler, PA
6323........................  Pittsfield, MA..................    1.1071
                              Berkshire, MA
6340........................  Pocatello, ID...................    0.9829
                              Bannock, ID
6360........................  Ponce, PR.......................    0.6185
                              Guayanilla, PR
                              Juana Diaz, PR
                              Penuelas, PR
                              Ponce, PR
                              Villalba, PR
                              Yauco, PR

[[Page 53452]]

6403........................  Portland, ME....................    1.0085
                              Cumberland, ME
                              Sagadahoc, ME
                              York, ME
6440........................  Portland-Vancouver, OR-WA.......    1.1251
                              Columbia, OR
64406.......................  Portland-Vancouver, OR-WA.......    1.1820
                              Clackamas, OR
                              Multnomah, OR
                              Washington, OR
                              Yamhill, OR
64407.......................  Portland-Vancouver, OR-WA.......    1.1693
                              Clark, WA
6483........................  Providence-Warwick-Pawtucket, RI    1.1119
                              Bristol, RI
                              Kent, RI
                              Newport, RI
                              Providence, RI
                              Washington, RI
6520........................  Provo-Orem, UT..................    1.0332
                              Utah, UT
6560........................  Pueblo, CO......................    0.9943
                              Pueblo, CO
6580........................  Punta Gorda, FL.................    0.9209
                              Charlotte, FL
6600........................  Racine, WI......................    0.9727
                              Racine, WI
6640........................  Raleigh-Durham-Chapel Hill, NC..    0.9817
                              Chatham, NC
                              Johnston, NC
66406.......................  Raleigh-Durham-Chapel Hill, NC..    1.0388
                              Durham, NC
                              Franklin, NC
                              Orange, NC
                              Wake, NC
6660........................  Rapid City, SD..................    0.8614
                              Pennington, SD
6680........................  Reading, PA.....................    1.0228
                              Berks, PA
6690........................  Redding, CA.....................    1.1905
                              Shasta, CA
6720........................  Reno, NV........................    1.2044
                              Washoe, NV
6740........................  Richland-Kennewick-Pasco, WA....    1.0462
                              Benton, WA
                              Franklin, WA
6760........................  Richmond-Petersburg, VA.........    0.9479
                              Charles City County, VA
                              Chesterfield, VA
                              Colonial Heights City, VA
                              Dinwiddie, VA
                              Goochland, VA
                              Hanover, VA
                              Henrico, VA
                              Hopewell City, VA
                              New Kent, VA
                              Petersburg City, VA
                              Powhatan, VA
                              Prince George, VA
                              Richmond City, VA
6780........................  Riverside-San Bernardino, CA....    1.1990
                              Riverside, CA
                              San Bernardino, CA
6800........................  Roanoke, VA.....................    0.9358
                              Botetourt, VA
                              Roanoke, VA
                              Roanoke City, VA
                              Salem City, VA
6820........................  Rochester, MN...................    1.0905
                              Olmsted, MN
6840........................  Rochester, NY...................    1.0266
                              Livingston, NY
                              Monroe, NY
                              Ontario, NY
                              Orleans, NY
                              Wayne, NY
68406.......................  Rochester, NY...................    0.9686
                              Genesee, NY
6880........................  Rockford, IL....................    0.9365
                              Ogle, IL
68806.......................  Rockford, IL....................    0.9976
                              Boone, IL
                              Winnebago, IL
6895........................  Rocky Mount, NC.................    0.9266
                              Edgecombe, NC
                              Nash, NC
6920........................  Sacramento, CA..................    1.2499
                              El Dorado, CA
                              Placer, CA
                              Sacramento, CA
6960........................  Saginaw-Bay City-Midland, MI....    1.0493
                              Bay, MI
                              Midland, MI
                              Saginaw, MI
6980........................  St. Cloud, MN...................    0.9731
                              Benton, MN
                              Stearns, MN
7000........................  St. Joseph, MO..................    0.8732
                              Andrew, MO
70006.......................  St. Joseph, MO..................    0.9283
                              Buchanan, MO
7040........................  St. Louis, MO-IL................    0.9265
                              Lincoln, MO
                              Warren, MO
70406.......................  St. Louis, MO-IL................    0.9715
                              Jersey, IL
                              Madison, IL
70407.......................  St. Louis, MO-IL................    0.9760
                              Clinton, IL
                              St. Clair, IL
70408.......................  St. Louis, MO-IL................    1.0109
                              Franklin, MO
                              Jefferson, MO
                              Monore, IL
                              St. Charles, MO
                              St. Louis City, MO
7080........................  Salem, OR.......................    1.0651
                              Marion, OR
                              Polk, OR
7120........................  Salinas, CA.....................    1.4579
                              Monterey, CA
7160........................  Salt Lake City-Ogden, UT........    1.0251
                              Davis, UT
                              Salt Lake, UT
                              Weber, UT
7200........................  San Angelo, TX..................    0.8669
                              Tom Green, TX
7240........................  San Antonio, TX.................    0.8764
                              Wilson, TX
72406.......................  San Antonio, TX.................    0.9599
                              Bexar, TX
                              Comal, TX
                              Guadalupe, TX
7320........................  San Diego, CA...................    1.2658
                              San Diego, CA
7360........................  San Francisco, CA...............    1.4769
                              Marin, CA
                              San Francisco, CA
                              San Mateo, CA
7400........................  San Jose, CA....................    1.4519
                              Santa Clara, CA
7440........................  San Juan-Bayamon, PR............    0.6207
                              Aguas Buenas, PR
                              Barceloneta, PR
                              Bayamon, PR
                              Canovanas, PR
                              Carolina, PR
                              Catano, PR
                              Ceiba, PR
                              Comerio, PR
                              Corozal, PR
                              Dorado, PR
                              Fajardo, PR
                              Florida, PR
                              Guaynabo, PR
                              Humacao, PR
                              Juncos, PR
                              Los Piedras, PR
                              Loiza, PR
                              Luguillo, PR
                              Manati, PR
                              Morovis, PR
                              Naguabo, PR
                              Naranjito, PR
                              Rio Grande, PR
                              San Juan, PR
                              Toa Alta, PR
                              Toa Baja, PR
                              Trujillo Alto, PR
                              Vega Alta, PR
                              Vega Baja, PR
                              Yabucoa, PR
7460........................  San Luis Obispo-Atascadero-Paso     1.1462
                               Robles, CA.
                              San Luis Obispo, CA
7480........................  Santa Barbara-Santa Maria-          1.1336
                               Lompoc, CA.
                              Santa Barbara, CA
7485........................  Santa Cruz-Watsonville, CA......    1.3871
                              Santa Cruz, CA
7490........................  Santa Fe, NM....................    1.0451
                              Los Alamos, NM
                              Santa Fe, NM
7500........................  Santa Rosa, CA..................    1.3069
                              Sonoma, CA
7510........................  Sarasota-Bradenton, FL..........    1.0255
                              Sarasota, FL
75106.......................  Sarasota-Bradenton, FL..........    1.0017
                              Manatee, FL
7520........................  Savannah, GA....................    0.8993
                              Bryan, GA
75206.......................  Savannah, GA....................    0.9349
                              Chatham, GA

[[Page 53453]]

                              Effingham, GA
7560........................  Scranton--Wilkes-Barre--            0.9364
                               Hazleton, PA.
                              Columbia, PA
                              Lackawanna, PA
                              Luzerne, PA
                              Wyoming, PA
7600........................  Seattle-Bellevue-Everett, WA....    1.1225
                              Island, WA
76006.......................  Seattle-Bellevue-Everett, WA....    1.1708
                              King, WA
                              Snohomish, WA
7610........................  Sharon, PA......................    0.9498
                              Mercer, PA
7620........................  Sheboygan, WI...................    0.9000
                              Sheboygan, WI
7640........................  Sherman-Denison, TX.............    0.9075
                              Grayson, TX
7680........................  Shreveport-Bossier City, LA.....    0.9461
                              Webster, LA
76806.......................  Shreveport-Bossier City, LA.....    1.0263
                              Bossier, LA
                              Caddo, LA
7720........................  Sioux City, IA-NE...............    0.9205
                              Woodbury, IA
                              Dakota, NE
7760........................  Sioux Falls, SD.................    0.8870
                              Lincoln, SD
77606.......................  Sioux Falls, SD.................    0.9375
                              Minnehaha, SD
7800........................  South Bend, IN..................    1.0021
                              St. Joseph, IN
7840........................  Spokane, WA.....................    1.1221
                              Spokane, WA
7880........................  Springfield, IL.................    1.0062
                              Menard, IL
                              Sangamon, IL
7920........................  Springfield, MO.................    0.8469
                              Webster, MO
79206.......................  Springfield, MO.................    0.8901
                              Christian, MO
                              Greene, MO
8003........................  Springfield, MA.................    1.0923
                              Hampden, MA
                              Hampshire, MA
8050........................  State College, PA...............    1.0411
                              Centre, PA
8080........................  Steubenville-Weirton, OH-WV.....    0.9438
                              Jefferson, OH
                              Brooke, WV
                              Hancock, WV
8120........................  Stockton-Lodi, CA...............    1.2084
                              San Joaquin, CA
8140........................  Sumter, SC......................    0.8348
                              Sumter, SC
8160........................  Syracuse, NY....................    0.9644
                              Cayuga, NY
81606.......................  Syracuse, NY....................    1.1682
                              Madison, NY
                              Onondaga, NY
                              Oswego, NY
8200........................  Tacoma, WA......................    1.1330
                              Pierce, WA
8240........................  Tallahassee, FL.................    0.9401
                              Gadsden, FL
                              Leon, FL
8280........................  Tampa-St. Petersburg-Clearwater,    0.9834
                               FL.
                              Hernando, FL
                              Hillsborough, FL
                              Pasco, FL
                              Pinellas, FL
8320........................  Terre Haute, IN.................    0.9016
                              Vermillion, IN
83206.......................  Terre Haute, IN.................    0.9106
                              Clay, IN
                              Vigo, IN
8360........................  Texarkana, AR-Texarkana, TX.....    0.9919
                              Miller, AR
                              Bowie, TX
8400........................  Toledo, OH......................    1.1202
                              Fulton, OH
                              Lucas, OH
                              Wood, OH
8440........................  Topeka, KS......................    1.0468
                              Shawnee, KS
8480........................  Trenton, NJ.....................    1.0866
                              Mercer, NJ
8520........................  Tucson, AZ......................    0.9950
                              Pima, AZ
8560........................  Tulsa, OK.......................    0.9259
                              Creek, OK
                              Osage, OK
                              Rogers, OK
                              Tulsa, OK
                              Wagoner, OK
8600........................  Tuscaloosa, AL..................    0.9266
                              Tuscaloosa, AL
8640........................  Tyler, TX.......................    1.0174
                              Smith, TX
8680........................  Utica-Rome, NY..................    0.9124
                              Herkimer, NY
                              Oneida, NY
8720........................  Vallejo-Fairfield-Napa, CA......    1.4234
                              Napa, CA
                              Solano, CA
8735........................  Ventura, CA.....................    1.1819
                              Ventura, CA
8750........................  Victoria, TX....................    0.8925
                              Victoria, TX
8760........................  Vineland-Millville-Bridgeton, NJ    1.0368
                              Cumberland, NJ
8780........................  Visalia-Tulare-Porterville, CA..    1.0922
                              Tulare, CA
8800........................  Waco, TX........................    0.8276
                              McLennan, TX
8840........................  Washington, DC-MD-VA-WV.........    1.1581
                              District of Columbia, DC
                              Calvert, MD
                              Charles, MD
                              Frederick, MD
                              Montgomery, MD
                              Prince Georges, MD
                              Alexandria City, VA
                              Arlington, VA
                              Fairfax, VA
                              Fairfax City, VA
                              Falls Church City, VA
                              Loudoun, VA
                              Manassas City, VA
                              Manassas Park City, VA
                              Prince William, VA
                              Stafford, VA
88406.......................  Washington, DC-MD-VA-WV.........    1.0725
                              Berkeley, WV
                              Jefferson, WV
88407.......................  Washington, DC-MD-VA-WV.........    1.0494
                              Clarke, VA
                              Culpeper, VA
                              Fauquier, VA
                              Fredericksburg City, VA
                              King George, VA
                              Spotsylvania, VA
                              Warren, VA
8920........................  Waterloo-Cedar Falls, IA........    0.9203
                              Black Hawk, IA
8940........................  Wausau, WI......................    1.0607
                              Marathon, WI
8960........................  West Palm Beach-Boca Raton, FL..    1.0658
                              Palm Beach, FL
9000........................  Wheeling, WV-OH.................    0.9314
                              Belmont, OH
                              Marshall, WV
                              Ohio, WV
9040........................  Wichita, KS.....................    0.9399
                              Harvey, KS
90406.......................  Wichita, KS.....................    1.0473
                              Butler, KS
                              Sedgwick, KS
9080........................  Wichita Falls, TX...............    0.8169
                              Archer, TX
90806.......................  Wichita Falls, TX...............    0.8376
                              Wichita, TX
9140........................  Williamsport, PA................    0.9544
                              Lycoming, PA
9160........................  Wilmington-Newark, DE-MD........    1.1851
                              New Castle, DE
                              Cecil, MD
9200........................  Wilmington, NC..................    0.9471
                              Brunswick, NC
92006.......................  Wilmington, NC..................    0.9649
                              New Hanover, NC
9260........................  Yakima, WA......................    1.0634
                              Yakima, WA
9270........................  Yolo, CA........................    1.1961
                              Yolo, CA
9280........................  York, PA........................    1.0165
                              York, PA
9320........................  Youngstown-Warren, OH...........    1.0124
                              Columbiana, OH
93206.......................  Youngstown-Warren, OH...........    1.0785
                              Mahoning, OH
                              Trumbull, OH
9340........................  Yuba City, CA...................    1.0981
                              Sutter, CA
                              Yuba, CA
9360........................  Yuma, AZ........................    0.9912

[[Page 53454]]

                              Yuma, AZ
------------------------------------------------------------------------
\1\ Wage index values are based on FY 1997 hospital cost report data
  prior to reclassification. This wage index is further adjusted. Wage
  index values greater than 0.8 are subject to a budget neutrality
  adjustment of 1.04662. Wage index values below 0.8 are adjusted to be
  the greater of a 15 percent increase, subject to a maximum wage index
  value of 0.8, or an adjustment by multiplying the hospital wage index
  value for a given area by the budget neutrality adjustment. All of
  these adjustments have been completed by HCFA and are built into the
  wage index values reflected in this table.

                  Table B.--Wage Index for Rural Areas
------------------------------------------------------------------------
                                                                  Wage
       MSA code number                  Nonurban area             index
-------------------------------------------------------------------\2\--
9901........................  Alabama.........................    0.8000
                              Alabama
99016.......................    Walker, AL....................    0.8682
9902........................  Alaska..........................    1.3387
9903........................  Arizona.........................    0.8696
9904........................  Arkansas........................    0.8000
9905........................  California......................    1.0488
9906........................  Colorado........................    0.8575
9907........................  Connecticut
                                Windham, CT...................    1.2283
                              Delaware
9908........................    Sussex, DE....................    0.9372
9910........................  Florida.........................    0.9209
                              Florida
99106.......................    Bradford, FL..................    0.9554
9911........................  Georgia.........................    0.8381
                              Georgia
99116.......................    Butts, GA.....................    0.8700
                              Georgia
99117.......................    Jackson, GA...................    0.8491
9912........................  Hawaii..........................    1.1244
9913........................  Idaho...........................    0.8877
9914........................  Illinois........................    0.8363
9915........................  Indiana.........................    0.8700
9916........................  Iowa............................    0.8058
                              Iowa
99166.......................    Bremer, IA....................    0.8367
9917........................  Kansas..........................    0.8045
9918........................  Kentucky........................    0.8267
                              Kentucky
99186.......................    Shelby, KY....................    0.9209
9919........................  Louisiana.......................    0.8119
9920........................  Maine...........................    0.8934
9921........................  Maryland........................    0.9262
9922........................  Massachusetts...................    1.0866
9923........................  Michigan........................    0.9531
9924........................  Minnesota.......................    0.8703
9925........................  Mississippi.....................    0.7972
9926........................  Missouri........................    0.8099
9927........................  Montana.........................    0.8828
9928........................  Nebraska........................    0.8000
9929........................  Nevada..........................    0.9770
9930........................  New Hampshire...................    1.0380
9931........................  New Jersey \1\..................  ........
9932........................  New Mexico......................    0.8873
9933........................  New York........................    0.8902
                              New York
99336.......................    Greene, NY....................    0.8975
9934........................  North Carolina..................    0.8504
9935........................  North Dakota....................    0.8109
9936........................  Ohio............................    0.9075
                              Ohio
99366.......................  Union, OH.......................    0.9521
9937........................  Oklahoma........................    0.8197
9938........................  Oregon..........................    1.0296
9939........................  Pennsylvania....................    0.9479
                              Pennsylvania
99396.......................    Monroe, PA....................    0.9281
                              Pennsylvania
99397.......................    Adams, PA.....................    0.9471
9940........................  Puerto Rico.....................    0.5905
9941........................  Rhode Island \1\................  ........
9942........................  South Carolina..................    0.8348
9943........................  South Dakota....................    0.8000
9944........................  Tennessee                           0.8000
99446.......................  Tennessee.......................
                                Sequatchie, TN................    0.8557
99447.......................  Tennessee.......................    0.8395
                                Grainger, TN
                                Jefferson, TN
9945........................  Texas...........................    0.8041
9946........................  Utah............................    0.9110
9947........................  Vermont.........................    0.9560
9949........................  Virginia........................    0.8402
9950........................  Washington......................    1.0445
9951........................  West Virginia...................    0.8742
9952........................  Wisconsin.......................    0.8807
9953........................  Wyoming.........................    0.9091
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.
\2\ Wage index values are based on FY 1997 hospital cost report data
  prior to reclassification. This wage index is further adjusted. Wage
  index values greater than 0.8 are subject to a budget neutrality
  adjustment of 1.04662. Wage index values below 0.8 are adjusted to be
  the greater of a 15 percent increase, subject to a maximum wage index
  value of 0.8, or an adjustment by multiplying the hospital wage index
  value for a given area by the budget neutrality adjustment. All of
  these adjustments have been completed by HCFA and are built into the
  wage index values reflected in this table.

II. Regulatory Impact Statement

A. Background

    We have examined the impacts of this notice as required by
Executive Order 12866, the Unfunded Mandate Reform Act, and the
Regulatory Flexibility Act (RFA) (Public Law 96-354). In this notice,
we identified an impact on hospices as a result of changes in the way
we compute the hospice wage index. The change in the methodology for
computing the wage index was determined through a negotiated rulemaking
committee and implemented in the August 8, 1997 final rule (62 FR
42860). This notice only described the effects of those changes in
conjunction with the annual update to the hospice wage index. Also, we
believe these changes to be insignificant.
1. Executive Order 12866 and RFA
    Executive Order 12866 directs agencies to assess all costs and
benefits of available regulatory alternatives and, when regulation is
necessary, to select regulatory approaches that maximize net benefits
(including potential economic, environmental, public health and safety
effects; distributive impacts; and equity). We have determined that
this notice is not an economically significant rule under this
Executive Order. The RFA requires agencies to analyze options for
regulatory relief for small businesses. For purposes of the RFA, States
and individuals are not considered small entities. However, most
providers, physicians, and health care suppliers are small entities,
either by nonprofit status or by having revenues of $5 million or less
annually. Approximately 74 percent of Medicare certified hospices are
identified as being voluntary, government, or other agency, and
therefore are considered small entities. Because the National Hospice
Organization estimates that approximately 65 percent of hospice
patients are Medicare beneficiaries, we have not considered other
sources of revenue in this analysis.
    As discussed below, payments to urban hospices in Puerto Rico will
experience the most significant decrease (11.6 percent) in payments
under this wage index. Looking at the effects of this rule on Puerto
Rico, we see that 21 of the 29 hospices in urban Puerto Rico can be
considered small entities that will experience an 11.6 percent decrease
in Medicare payments. Therefore, we anticipate this rule will have a
significant impact on a substantial number of small entities. However,
the methodology for the hospice wage index was previously determined by
consensus through a negotiated rulemaking committee that included
representatives of national hospice associations; rural, urban, large
and small hospices; multi-site hospices; and consumer groups. Based on
all of the options considered, the committee determined that the
methodology described in the committee statement, and adopted into
regulation on August 8, 1997 (62 FR 42860), were favorable for the
hospice community as a whole, as well as for the beneficiaries that
they serve. Therefore, we believe that mitigating the effects of small
entities has been taken into consideration.

[[Page 53455]]

2. Congressional Review
    Section 804(2) of Title 5, United States Code (as added by section
251 of Public Law 104-121), specifies that a ``major rule'' is any rule
that the Office of Management and Budget finds is likely to result in--
    <bullet> An annual effect on the economy of $100 million or more;
    <bullet> A major increase in costs or prices for consumers,
individual industries, Federal, State, or local government agencies, or
geographic regions; or
    <bullet> Significant adverse effects on competition, employment,
investment, productivity, innovation, or on the ability of United
States-based enterprises to compete with foreign-based enterprises in
domestic and export markets.
    We estimate that the impact of this notice will not be $100 million
or more; therefore, this rule is not a major rule as defined in Title
5, United States Code, section 804(2) and is not being forwarded to
Congress for a 60-day review period.
3. Unfunded Mandate
    The Unfunded Mandate Reform Act of 1995 also requires (in section
202) that agencies prepare an assessment of anticipated costs and
benefits for any rule that may result in an annual expenditure by
State, local, and tribal governments, in the aggregate, or by the
private sector, of $100 million or more. The notice has no
consequential effect on State, local, or tribal governments. We believe
the private sector costs of this rule fall below the threshold, as
well.
4. Rural Hospital Impact
    Section 1102(b) of the Act requires us to prepare a regulatory
impact analysis for any notice that may have a significant impact on
the operations of a substantial number of small rural hospitals. Such
an analysis must conform to the provisions of section 604 of the RFA.
For purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside a Metropolitan
Statistical Area and has fewer than 50 beds.
    Because this notice has no direct impact on small hospitals, in
accordance with 5 U.S.C. 604, the Secretary certifies that this notice
will not have a significant impact on the operations of a substantial
number of small rural hospitals.

B. Anticipated Effects

    In accordance with the Balanced Budget Act of 1997 (BBA of 1997),
hospices are now paid for home care services based on where the service
is rendered. This change was effective with FY 1998 and was implemented
on October 1, 1997. This impact analysis compares hospice payments
under the FY 1998 wage index (Column 4 of the table) to the second
transition year blend (Column 5). The wage index blend for the second
transition year of the 3-year transition is one-third of the 1983 wage
index added to two-thirds of the new wage index. The data used in
developing the quantitative analysis for this notice were obtained from
the December 1997 update of the national claims history file of all
bills submitted during fiscal year 1997. We deleted bills from hospices
that have since closed.
    Table C demonstrates the results of our analysis. In Column 2 of
the table we indicate the number of routine home care days that were
included in our analysis, although the analysis was performed on all
types of hospice care. Column 3 of Table C (below) indicates payments
that were made using the FY 1998 wage index. Column 5 of Table C is
based on FY 1998 claims and estimates payments to be made to hospices
using the FY 1999 wage index. For the purposes of this analysis, the
payments reflected in Column 3 were adjusted to account for the site of
service provision. This adjustment is shown in Column 4 of Table C.
    The final column, which compares Columns 4 and 5, shows the percent
change in estimated hospice payments made based on the category of the
hospice. The overall percentage change in hospice payments is 0.2
percent. However, the wage index itself is budget neutral to what would
have been paid using the 1983 wage index. The 0.2 percent is
attributable to the site of service provision, i.e., the effect on
payments resulting from the distribution of beneficiaries residing in
MSAs with different wage index values than the hospice.
    Table C categorizes hospices by various geographic and provider
characteristics. The top row of the table demonstrates the neutral
overall payment impact on 2,133 hospices included in the analysis. The
next two rows of the table categorize hospices according to their
geographic location (urban and rural). There are 1,385 hospices located
in urban areas included in our analysis and 748 hospices located in
rural areas. The next two groupings in the table indicate the number of
hospices by census region, also broken down by urban and rural
hospices. The next grouping shows the impact on hospices based on the
size of the hospice's program. We determined that the majority of
hospice payments are made at the routine home care rate. Therefore, we
based the size of each individual hospice's program on the number of
routine home care days provided in 1997. The next grouping shows the
impact on hospices by type of ownership. The final grouping shows the
impact on hospices defined by whether they are provider-based or
freestanding.
    The results of our analysis show that the greatest increases are
for urban and rural hospices in the New England region, 4.5 percent and
2.8 percent respectively, and for rural hospices in the Pacific
regions, with 3.8 percent. The greatest decreases, besides Puerto Rico,
are the rural West North Central and rural West South Central regions
with 3.1 percent and 4.0 percent respectively. The most dramatic shift
occurs in Puerto Rico, where urban payments decrease by 11.6 percent
and rural payments decrease by 12.3 percent. Since the wage index
values for the Puerto Rico region are more than 15 percent below the
1983 wage index value of 0.8, this region is most affected by the
revision to the wage index floor.
    Small hospice programs show small decreases while larger programs
show slight increases. Proprietary hospices show slight decreases in
payment due to the wage index change while voluntary programs gain
slightly. Finally, freestanding hospices show no percent change in
their wage index values while provider-based hospice programs show
small increases.

[[Page 53456]]

                                  Table C.--Impact of Hospice Wage Index Change
                                            (1)          (2)          (3)          (4)          (5)          (6)
----------------------------------------------------------------------------------------------------------------
All...............................        2,133       19,944    2,211,336    2,195,009    2,200,107          0.2
Urban Hospices....................        1,385       16,148   11,868,369    1,849,873    1,855,939          0.3
Rural Hospices....................          748        3,795      342,967      345,136      344,168         -0.3
Region (Urban):
    New England...................          102          568       72,785       72,694       75,979          4.5
    Middle Atlantic...............          176        1,849      226,264      225,095      228,443          1.5
    South Atlantic................          182        3,825      445,473      443,033      445,646          0.6
    East North Central............          224        2,599      300,801      297,570      296,812         -0.3
    East South Central............           89          770       83,503       81,985       81,082         -1.1
    West North Central............           99          937       96,630       94,617       94,224         -0.4
    West South Central............          197        2,373      249,586      243,893      240,371         -1.4
    Mountain......................           88          887      114,857      113,848      113,010         -0.7
    Pacific.......................          199        2,145      263,250      261,968      266,963          1.9
    Puerto Rico...................           29          194       15,221       15,169       13,410        -11.6
Region (Rural):
    New England...................           21           63        6,341        6,358        6,536          2.8
    Middle Atlantic...............           34          261       25,759       25,838       25,384         -1.8
    South Atlantic................          115          549       49,985       50,658       50,932          0.5
    East North Central............          121          442       40,906       41,264       41,511          0.6
    East South Central............           76        1,452      124,526      124,784      125,167          0.3
    West North Central............          164          399       36,089       36,241       35,127         -3.1
    West South Central............           82          255       22,474       22,926       21,999         -4.0
    Mountain......................           80          175       16,739       16,806       16,831          0.1
    Pacific.......................           52          185       19,122       19,229       19,773          2.8
    Puerto Rico...................            3           13        1,028        1,034          907        -12.3
Size (Routine Home Care Days):
    0-1,752 Days..................          533          417       48,237       48,051       47,757         -0.6
    1,753-4,225 Days..............          533        1,524      152,653      151,925      151,578         -0.2
    4,226-9,422 Days..............          533        3,420      352,974      351,698      352,436          0.2
    9,422+ Days...................          534       14,583    1,657,472    1,643,334    1,648,336          0.3
Type of Ownership:
    Voluntary.....................        1,373       13,516    1,492,335    1,483,835    1,492,700          0.6
    Proprietary...................          560        5,876      664,169      656,650      653,129         -0.5
    Government....................          172          474       47,067       46,818       46,550         -0.6
    Other.........................           28           78        7,766        7,705        7,727          0.3
Hospice Base:
    Freestanding..................          793       11,495    1,272,781    1,263,013    1,263,114          0.0
    Home Health Agency............          788        5,235      581,863      577,857      581,728          0.7
    Hospital......................          533        3,123      344,200      341,727      342,789          0.3
    Skilled Nursing Facility......           19           91       12,492       12,411       12,476          0.5
----------------------------------------------------------------------------------------------------------------
*The FY 1997 data used to construct the FY 1998 wage index was adjusted to account for the site of service
  provision that was included in the Balanced Budget Act of 1997.
**Percent change in hospice payments made from 1997, taking into account the site of service change.

    Authority: Section 1814(I) of the Social Security Act (42 U.S.C.
1395f(I)(1))

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

    Dated: July 7, 1998.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.
    Dated: August 4, 1998.
Donna E. Shalala,
Secretary.
[FR Doc. 98-26501 Filed 9-30-98; 9:53 am]
BILLING CODE 4120-01-P