[Federal Register Volume 69, Number 204 (Friday, October 22, 2004)]
[Rules and Regulations]
[Pages 62124-62162]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-23440]



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Part II





Department of Health and Human Services





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42 CFR Part 484



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Medicare Program; Home Health Prospective Payment System Rate Update 
for Calendar Year 2005; Final Rule

Federal Register / Vol. 69 , No. 204 / Friday, October 22, 2004 / 
Rules and Regulations

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 484

[CMS-1265-F]
RIN 0938-AM93


Medicare Program; Home Health Prospective Payment System Rate 
Update for Calendar Year 2005

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

ACTION: Final rule.

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SUMMARY: This final rule sets forth an update to the 60-day national 
episode rates and the national per-visit amounts under the Medicare 
prospective payment system for home health agencies. As part of this 
final rule, we are also rebasing and revising the home health market 
basket to ensure it continues to adequately reflect the price changes 
of efficiently providing home health services. In addition, we are 
revising the fixed dollar loss ratio, which is used in the calculation 
of outlier payments. This final rule will be the first update of the 
home health prospective payment system (HH PPS) rates on a calendar 
year update cycle. HH PPS was moved to a calendar year update cycle as 
a result of the provisions of the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003.

EFFECTIVE DATE: These regulations are effective on January 1, 2005.

FOR FURTHER INFORMATION CONTACT: Randy Throndset, (410) 786-0131. Debra 
Gillespie, (410) 786-4631. Mary Lee Seifert (Market Basket), (410) 786-
0030. Mollie Knight (Market Basket), (410) 786-7948.

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I. Background

A. Statutory Background

    The Balanced Budget Act of 1997 (BBA), (Pub. L. 105-33), enacted on 
August 5, 1997, significantly changed the way Medicare pays for 
Medicare home health services. Until the implementation of a home 
health prospective payment system (HH PPS) on October 1, 2000, home 
health agencies (HHAs) received payment under a cost-based 
reimbursement system. Section 4603 of the BBA governed the development 
of the HH PPS.
    Section 4603(a) of the BBA provides the authority for the 
development of a PPS for all Medicare-covered home health services 
provided under a plan of care that were paid on a reasonable cost basis 
by adding section 1895, entitled ``Prospective Payment For Home Health 
Services,'' to the Social Security Act (the Act).
    Section 1895(b)(1) of the Act requires the Secretary to establish a 
PPS for all costs of home health services paid under Medicare.
    Section 1895(b)(3)(A) of the Act requires that (1) the computation 
of a standard prospective payment amount include all costs of home 
health services covered and paid for on a reasonable cost basis and be 
initially based on the most recent audited cost report data available 
to the Secretary, and (2) the prospective payment amounts be 
standardized to eliminate the effects of case-mix and wage levels among 
HHAs.
    Section 1895(b)(3)(B) of the Act addresses the annual update to the 
standard prospective payment amounts by the home health applicable 
increase percentage as specified in the statute.
    Section 1895(b)(4) of the Act governs the payment computation. 
Sections 1895(b)(4)(A)(i) and (b)(4)(A)(ii) of the Act require the 
standard prospective payment amount to be adjusted for case-mix and 
geographic differences in wage levels. Section 1895(b)(4)(B) of the Act 
requires the establishment of an appropriate case-mix adjustment factor 
that explains a significant amount of the variation in cost among 
different units of services. Similarly, section 1895(b)(4)(C) of the 
Act requires the establishment of wage adjustment factors that reflect 
the relative level of wages and wage-related costs applicable to the 
furnishing of home health services in a geographic area compared to the 
national average applicable level. These wage-adjustment factors may be 
the factors used by the Secretary for the different area wage levels 
for purposes of section 1886(d)(3)(E) of the Act.
    Section 1895(b)(5) of the Act gives the Secretary the option to 
grant additions or adjustments to the payment amount otherwise made in 
the case of outliers because of unusual variations in the type or 
amount of medically necessary care. Total outlier payments in a given 
fiscal year cannot exceed 5 percent of total payments projected or 
estimated.

B. Updates

    On July 3, 2000, we published a final rule (65 FR 41128) in the 
Federal Register to implement the HH PPS legislation. That final rule 
established requirements for the new PPS for HHAs as required by 
section 4603 of the BBA, and as subsequently amended by section 5101 of 
the Omnibus Consolidated and Emergency Supplemental Appropriations Act 
(OCESAA) for Fiscal Year 1999, (Pub. L. 105-277), enacted on October 
21, 1998; and by sections 302, 305, and 306 of the Medicare, Medicaid, 
and SCHIP Balanced Budget Refinement Act (BBRA) of 1999, (Pub. L. 106-
113), enacted on November 29, 1999. The requirements include the 
implementation of a PPS for HHAs, consolidated billing requirements, 
and a number of other related changes. The PPS described in that rule 
replaced the retrospective reasonable-cost-based system that was used 
by Medicare for the payment of home health services under Part A and 
Part B.
    As required by section 1895(b)(3)(B) of the Act, we have 
historically updated the HH PPS rates annually in a separate Federal 
Register document.

C. System for Payment of Home Health Services

    Generally, Medicare makes payment under the HH PPS on the basis of 
a national standardized 60-day episode payment, adjusted for case mix 
and wage index. For episodes with four or fewer visits, Medicare pays 
on the basis of a national per-visit amount by discipline, referred to 
as a low utilization payment adjustment (LUPA). Medicare also adjusts 
the 60-day episode payment for certain intervening events that give 
rise to a partial episode payment adjustment (PEP adjustment) or a 
significant change in condition adjustment (SCIC). For certain cases 
that exceed a specific cost threshold, an outlier adjustment may also 
be

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available. For a complete and full description of the HH PPS as 
required by the BBA and as amended by OCESAA and BBRA, see the July 3, 
2000 HH PPS final rule (65 FR 41128).

D. Medicare Prescription Drug, Improvement, and Modernization Act of 
2003

    On December 8, 2003, the Congress enacted the Medicare Prescription 
Drug, Improvement, and Modernization Act (MMA) of 2003 (Pub. L. 108-
173). This new legislation affects our update to HH payment rates. 
Specifically, section 421 of MMA requires, for home health services 
furnished in a rural area (as defined in section 1886(d)(2)(D) of the 
Act), with respect to episodes or visits ending on or after April 1, 
2004 and before April 1, 2005, that the Secretary increase the payment 
amount that otherwise would have been made under section 1895 of the 
Act for the services by 5 percent.
    The statute waives budget neutrality for the purposes of this 
increase as it specifically states that the Secretary will not reduce 
the standard prospective payment amount (or amounts) under section 1895 
of the Act applicable to home health services furnished during a period 
to offset the increase in payments resulting in the application of this 
section of the statute.
    Section 701 of the MMA changes the yearly update cycle of the HH 
PPS rates from that of a fiscal year to a calendar year update cycle 
for 2004 and any subsequent year. Generally, section 701(a) of the MMA 
changes the references in the statute to refer to the calendar year for 
2004 and any subsequent year. The changes result in updates to the HH 
PPS rates described as ``fiscal year'' updates for 2002 and 2003 and as 
calendar ``year'' updates for 2004 and any subsequent year (section 
1895(b)(3)(B)(i) of the Act). In light of these provisions, we will not 
be updating the HH PPS rates on October 1, 2004 as HH PPS will now be 
updated on a calendar year update cycle.
    In addition to changing the update cycle for HH PPS rates, section 
701 of the MMA makes adjustments to the home health applicable increase 
percentage for 2004, 2005, and 2006. Specifically, section 701(a)(2)(D) 
of the MMA leaves unchanged the home health market basket increase for 
the last calendar year quarter of 2003 and the first calendar year 
quarter of 2004 (section 1895(b)(3)(B)(ii)(II) of the Act). 
Furthermore, section 701(b)(4) of the MMA sets the home health 
applicable percentage increase for the last 3 quarters of 2004 as the 
home health market basket (3.1 percent) minus 0.8 percentage points 
(section 1895(b)(3)(B)(ii)(III) of the Act). We implemented this 
provision through Pub. 100-20, One Time Notification, Transmittal 59, 
issued February 20, 2004. Section 701(b)(4) of the MMA also provides 
that updates for CY 2005 and CY 2006 will equal the applicable home 
health market basket percentage increase minus 0.8 percentage points. 
Lastly, section 701(b)(3) of the MMA revises the statute to provide 
that HH PPS rates for CY 2007 and any subsequent year will be updated 
by that year's home health market basket percentage increase (section 
1895(b)(3)(B)(ii)(IV) of the Act).

E. Requirements for Issuance of Regulations

    Section 902 of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA) amended section 1871(a) of the Act and 
requires the Secretary, in consultation with the Director of the Office 
of Management and Budget, to establish and publish timelines for the 
publication of Medicare final regulations based on the previous 
publication of a Medicare proposed or interim final regulation. Section 
902 of the MMA also states that the timelines for these regulations may 
vary but shall not exceed 3 years after publication of the preceding 
proposed or interim final regulation except under exceptional 
circumstances.
    This final rule finalizes provisions set forth in proposed rule 
published in the Federal Register (69 FR 31248) on June 2, 2004. In 
addition, this final rule has been published within the 3-year time 
limit imposed by section 902 of the MMA. Therefore, we believe that the 
final rule is in accordance with the Congress' intent to ensure timely 
publication of final regulations.

II. Provisions of the Proposed Regulations

    On June 2, 2004, we published a proposed rule in the Federal 
Register (69 FR 31248), proposing to update the 60-day national episode 
rates and the national per-visit amounts under the Medicare prospective 
payment system for home health agencies. We also proposed to rebase and 
revise the home health market basket to ensure it continues to 
adequately reflect the price changes of efficiently providing home 
health services. We also proposed to revise the fixed dollar loss 
ratio, which is used in the calculation of outlier payments.

A. National Standardized 60-Day Episode Rate

    Medicare HH PPS has been effective since October 1, 2000. As set 
forth in the final rule published July 3, 2000 in the Federal Register 
(65 FR 41128), the unit of payment under Medicare HH PPS is a national 
standardized 60-day episode rate. As set forth in 42 CFR 484.220, we 
adjust the national standardized 60-day episode rate by a case mix 
grouping and a wage index value based on the site of service for the 
beneficiary. The proposed CY 2005 HH PPS rates used the same case-mix 
methodology and application of the wage index adjustment to the labor 
portion of the HH PPS rates as set forth in the July 3, 2000 final 
rule. We multiplied the national 60-day episode rate by the patient's 
applicable case-mix weight. We divided the case-mix adjusted amount 
into a labor and non-labor portion. We multiplied the labor portion by 
the applicable wage index based on the site of service of the 
beneficiary.
    As required by section 1895(b)(3)(B) of the Act, we have updated 
the HH PPS rates annually in a separate Federal Register document. 
Section 484.225 sets forth the specific percentage update for fiscal 
years 2001, 2002, and 2003. To reflect the new statutory provisions 
enacted by section 701 of the MMA, in Sec.  484.225, we proposed to 
redesignate paragraph (d) as paragraph (g) and revise it to read as 
follows:
    (g) For 2007 and subsequent calendar years, the unadjusted national 
rate is equal to the rate for the previous calendar year increased by 
the applicable home health market basket index amount.
    We also proposed to add new paragraphs (d), (e), and (f) to read as 
follows:
    (d) For the last calendar quarter of 2003 and the first calendar 
quarter of 2004, the unadjusted national prospective 60-day episode 
payment rate is equal to the rate from the previous fiscal year (FY 
2003) increased by the applicable home health market basket index 
amount.
    (e) For the last 3 calendar quarters of 2004, the unadjusted 
national prospective 60-day episode payment rate is equal to the rate 
from the previous fiscal year (FY 2003) increased by the applicable 
home health market basket minus 0.8 percentage points.
    (f) For each of calendar years 2005 and 2006, the unadjusted 
national prospective 60-day episode payment rate is equal to the rate 
from the previous calendar year, increased by the applicable home 
health market basket minus 0.8 percentage points.

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    We also proposed to rebase and revise the home health market 
basket. As proposed, the labor related portion of the rebased and 
revised home health market basket would be 76.775 percent, and the non-
labor portion would be 23.225 percent. We added the wage-adjusted 
portion to the non-labor portion yielding the case-mix and wage-
adjusted 60-day episode rate subject to applicable adjustments.
    For CY 2005, we proposed to use again the design and case-mix 
methodology described in section III.G of the HH PPS July 3, 2000 final 
rule (65 FR 41192 through 41203). For CY 2005, we proposed to base the 
wage index adjustment to the labor portion of the PPS rates on the most 
recent pre-floor and pre-reclassified hospital wage index that does not 
apply the core-based statistical area (CBSA) policy. As discussed in 
the July 3, 2000 HH PPS final rule, for episodes with four or fewer 
visits, Medicare pays the national per-visit amount by discipline, 
referred to as a LUPA. We update the national per-visit amounts by 
discipline annually by the applicable home health market basket 
percentage. We adjust the national per-visit amount by the appropriate 
wage index based on the site of service for the beneficiary as set 
forth in Sec.  484.230. We proposed to adjust the labor portion of the 
updated national per-visit amounts by discipline used to calculate the 
LUPA by the most recent pre-floor and pre-reclassified hospital wage 
index that does not apply the CBSA policy.
    Medicare pays the 60-day case-mix and wage-adjusted episode payment 
on a split percentage payment approach. The split percentage payment 
approach includes an initial percentage payment and a final percentage 
payment as set forth in Sec.  484.205(b)(1) and (b)(2). We may base the 
initial percentage payment on the submission of a request for 
anticipated payment and the final percentage payment on the submission 
of the claim for the episode, as discussed in Sec.  409.43. The claim 
for the episode that the HHA submits for the final percentage payment 
determines the total payment amount for the episode and whether we make 
an applicable adjustment to the 60-day case-mix and wage-adjusted 
episode payment. The end date of the 60-day episode as reported on the 
claim determines the rate level at which Medicare will pay the claim 
for the fiscal period.
    We may also adjust the 60-day case-mix and wage-adjusted episode 
payment based on the information submitted on the claim to reflect the 
following:
    <bullet> A low utilization payment provided on a per-visit basis as 
set forth in Sec.  484.205(c) and Sec.  484.230.
    <bullet> A partial episode payment adjustment as set forth in Sec.  
484.205(d) and Sec.  484.235.
    <bullet> A significant change in condition adjustment as set forth 
in Sec.  484.205(e) and Sec.  484.237.
    <bullet> An outlier payment as set forth in Sec.  484.205(f) and 
Sec.  484.240.
    The proposed rule reflected the updated CY 2005 rates that would be 
effective January 1, 2005.

B. Rebasing and Revising of the Home Health Market Basket

    We also proposed to rebase and revise the home health market basket 
to ensure it continues to adequately reflect the price changes of 
efficiently providing home health services. In addition to rebasing the 
base year cost structure from FY 1993 to FY 2000, we also proposed to 
revise the market basket by modifying several categories in the market 
basket cost structure. The major revision to the proposed market basket 
was the combining of the Administrative and General and Other Expenses 
cost categories. [See 69 FR 31251 for a more complete explanation of 
the market basket cost structure]

C. Proposed CY 2005 Update to the Home Health Market Basket Index

    Section 1895(b)(3)(B) of the Act, as amended by section 701 of the 
MMA, requires for CY 2005 that the standard prospective payment amounts 
be increased by a factor equal to the applicable home health market 
basket increase minus 0.8 percentage points. We proposed to amend the 
regulations in Sec.  484.225 to reflect this requirement.
    <bullet> Proposed CY 2005 Adjustments.
    In calculating the annual update for the CY 2005 60-day episode 
rates, we proposed to first look at the CY 2004 rates as a starting 
point. The CY 2004 national 60-day episode rate, as modified by section 
701 of the MMA and implemented through Pub. 100-20 One Time 
Notification, Transmittal 59 issued February 20, 2004 is $2,213.37.
    In order to calculate the CY 2005 national 60-day episode rate, we 
proposed to multiply the CY 2004 national 60-day episode rate 
($2,213.37) by the applicable home health market basket update, at the 
time of publication of the proposed rule, of 3.3 percent for CY 2005 
minus 0.8 percentage points.
    We proposed to increase the CY 2004 60-day episode payment rate by 
the proposed home health market basket increase (3.3 percent) minus 0.8 
percentage points ($2,213.37 x 2.5 percent) to yield the proposed 
updated CY 2005 national 60-day episode rate ($2,268.70).
    <bullet> National Per-visit Amounts Used to Pay LUPAs and Compute 
Imputed Costs Used in Outlier Calculations.
    The policies governing the LUPAs and outlier calculations set forth 
in the July 3, 2000 HH PPS final rule will continue during CY 2005. In 
calculating the annual update for the CY 2005 national per-visit 
amounts we use to pay LUPAs and to compute the imputed costs in outlier 
calculations, we proposed to look again at the CY 2004 rates as a 
starting point. We then proposed to multiply those amounts by the 
proposed home health market basket increase minus 0.8 percentage points 
for CY 2005 to yield the updated per-visit amounts for each home health 
discipline for CY 2005. For details as to the specific LUPA rates that 
we proposed for CY 2005, see the proposed rule (69 FR 31256) published 
on June 2, 2004.

D. Proposed Update to the Outlier Fixed Dollar Loss Ratio

    Outlier payments are payments made in addition to regular 60-day 
case-mix and wage-adjusted episode payments for episodes that incur 
unusually large costs due to patient home health care needs. Outlier 
payments are made for episodes whose estimated cost exceeds a threshold 
amount. The episode's estimated cost is the sum of the national wage-
adjusted per-visit payment amounts for all visits delivered during the 
episode. The outlier threshold for each case-mix group, PEP adjustment, 
or total SCIC adjustment is defined as the 60-day episode payment 
amount, PEP adjustment, or total SCIC adjustment for that group plus a 
fixed dollar loss amount. Both components of the outlier threshold are 
wage-adjusted.
    The wage-adjusted fixed dollar loss amount (FDL) represents the 
amount of loss that an agency must bear before an episode becomes 
eligible for outlier payments. The FDL is computed by multiplying the 
wage-adjusted 60-day episode payment amount by the fixed dollar loss 
ratio, which is a proportion expressed in terms of the national 
standardized episode payment amount. The outlier payment is defined to 
be a proportion of the wage-adjusted estimated costs beyond the wage-
adjusted threshold. The proportion of additional costs paid as outlier 
payments is referred to as the loss-sharing ratio.
    Section 1895(b)(5) of the Act requires that estimated total outlier 
payments are no more than 5 percent of total estimated HH PPS payments. 
In response to the concerns about potential

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financial losses that might result from unusually expensive cases 
expressed in comments to the October 28, 1999 proposed rule (64 FR 
58133), the July 2000 final rule set the target for estimated outlier 
payments at the 5 percent level. The fixed dollar loss ratio and the 
loss-sharing ratio were then selected so that estimated total outlier 
payments would meet the 5 percent target.
    For a given level of outlier payments, there is a trade-off between 
the values selected for the fixed dollar loss ratio and the loss-
sharing ratio. A high fixed dollar loss ratio reduces the number of 
episodes that can receive outlier payments, but makes it possible to 
select a higher loss-sharing ratio and, therefore, increase outlier 
payments for outlier episodes. Alternatively, a lower fixed dollar loss 
ratio means that more episodes can qualify for outlier payments, but 
outlier payments per episode must be lower. As a result of public 
comments on the October 28, 1999 proposed rule, in our July 2000 final 
rule, we made the decision to attempt to cover a relatively high 
proportion of the costs of outlier cases for the most expensive 
episodes that would qualify for outlier payments within the 5 percent 
constraint.
    We chose a value of 0.80 for the loss-sharing ratio, which is 
relatively high, but which preserves incentives for agencies to attempt 
to provide care efficiently for outlier cases. It is also consistent 
with the loss-sharing ratios used in other Medicare PPS outlier 
policies. Having made this decision, we estimated the value of the 
fixed dollar loss ratio that would yield estimated total outlier 
payments that were projected to be no more than 5 percent of total home 
health PPS payments. The resulting value for the fixed dollar loss 
ratio was 1.13.
    Analysis of 100 percent of CY 2001 home health claims data 
reflected that outlier episodes represented approximately 3 percent of 
total episodes and 3 percent of total HH PPS payments. We proposed to 
make no change in the projected 5 percent target for outlier 
expenditures as a percent of total HH PPS payments. In addition, we 
proposed no change to the loss-sharing ratio of 0.80. Further, section 
1895(b)(3)(C) of the Act requires that the episode payment amounts be 
adjusted to effectively pay for outlier payments within the same level 
of estimated total spending. We proposed no change to the adjustment to 
the episode payment amounts for outlier payments. We proposed to change 
only the fixed dollar loss ratio, and in turn, the fixed dollar loss 
amount.
    For the proposed rule, we performed data analysis on CY 2001 HH PPS 
analytic data to update the fixed dollar loss ratio to enable the total 
estimated outlier payments to be 5 percent of total HH PPS payments. 
That analysis indicated that a fixed dollar loss ratio of 0.72 was 
consistent with the existing loss-sharing ratio of 0.80 and a target 
percentage of estimated outlier payments of the projected 5 percent. 
Consequently, we proposed to update the fixed dollar loss ratio from 
the current ratio of 1.13 to the fixed dollar loss ratio of 0.72. It 
was estimated that a fixed dollar loss ratio of 0.72 would allow 
approximately 6.5 percent of episodes to qualify for outlier payments. 
The estimated 6.5 percent outlier episodes is greater than the 3.0 
percent of episodes that currently qualify for outlier payments, and is 
about the same as the 6.8 percent for outlier episodes that we 
estimated in our July 2000 final rule.
    We believe that our proposed fixed dollar loss ratio of 0.72 
preserved a reasonable degree of cost sharing, while allowing a greater 
number of episodes to qualify for outlier payments. In our proposed 
rule, we indicated our plan to update our estimate of the fixed dollar 
loss ratio using the most current, complete year of HH PPS data 
available.

E. Rural Add-On as Required by the MMA

    Section 421 of the MMA requires, for home health services furnished 
in a rural area with respect to episodes and visits ending on or after 
April 1, 2004 and before April 1, 2005, that we increase by 5 percent 
the payment amount that otherwise would be made for these services. The 
statute waives budget neutrality related to this provision. By statute, 
the 5 percent rural add-on applies to home health services furnished in 
a rural area (as defined in section 1886(d)(2)(D) of the Act) for 
episodes and visits ending on or after April 1, 2004 and before April 
1, 2005. Therefore, the 5 percent rural add-on ends after the first 
quarter of CY 2005 for episodes and visits ending before April 1, 2005. 
After the rural add-on is determined, the applicable case-mix and wage 
index adjustment is then subsequently applied for the provision of home 
health services where the site of service is the non-Metropolitan 
Statistical Area (MSA) of the beneficiary. Similarly, the applicable 
wage index adjustment is subsequently applied to the LUPA per visit 
amounts adjusted for the provision of home health services where the 
site of service for the beneficiary is a non-MSA area. We implemented 
this provision for CY 2004 on April 1, 2004 through Pub. 100-20 One 
Time Notification, Transmittal 59 issued February 20, 2004. For further 
details as to the specific rates for HH PPS payments to beneficiaries 
in rural areas, see the proposed rule (69 FR 31259) published on June 
2, 2004.

F. Hospital Wage Index

    Sections 1895(b)(4)(A)(ii) and (b)(4)(C) of the Act require the 
Secretary to establish area wage adjustment factors that reflect the 
relative level of wages and wage-related costs applicable to the 
furnishing of home health services and to provide appropriate 
adjustments to the episode payment amounts under HH PPS to account for 
area wage differences. We applied the appropriate wage index value to 
the labor portion of the HH PPS rates based on the geographic area in 
which the beneficiary received home health services. We determined each 
HHA's labor market area based on definitions of Metropolitan 
Statistical Areas (MSAs) issued by the Office of Management and Budget 
(OMB). We recognize that on June 6, 2003, the Office of Management and 
Budget (OMB) issued OMB Bulletin No. 03-04, announcing revised 
definitions of Metropolitan Statistical Areas, and new definitions of 
Micropolitan Statistical Areas, and Combined Statistical Areas. A copy 
of the Bulletin may be obtained at the following Internet address: 
http://www.whitehouse.gov/omb/bulletins/b03-04.html. We indicated in 
our proposed rule, that these new definitions would not be applied to 
the CY 2005 wage index used in the proposed update to the HH payment 
rates.
    On May 18, 2004, we published a proposed rule entitled ``Medicare 
Program; Changes to the Hospital Inpatient Prospective Payment Systems 
and FY 2005 Rates'' (69 FR 28195), which discusses some of the issues 
associated with using these new definitions and proposes to use these 
new definitions for the Inpatient Hospital PPS for FY 2005. We 
indicated that we believed it would be appropriate to wait until the 
public comments on that proposed rule had been submitted and analyzed 
before we considered proposing any new labor market definitions in the 
home health context.
    As discussed previously and set forth in the July 3, 2000 final 
rule, the statute provides that the wage adjustment factors may be the 
factors used by the Secretary for purposes of section 1886(d)(3)(E) of 
the Act for hospital wage adjustment factors. Again, as discussed in 
the July 3, 2000 final rule,

[[Page 62128]]

we proposed to use the pre-floor and pre-reclassified hospital wage 
index to adjust the labor portion of the HH PPS rates based on the 
geographic area in which the beneficiary receives the home health 
services. We believe the use of the pre-floor and pre-reclassified 
hospital wage index results in the appropriate adjustment to the labor 
portion of the costs as required by statute. The most recent pre-floor 
and pre-reclassified hospital wage index available for this update of 
the CY 2005 home health rates was determined to be that of the 2005 
pre-floor and pre-reclassified hospital wage index. Due to the mandated 
change from a fiscal year update cycle to that of a calendar year 
update cycle, the most recent pre-floor and pre-reclassified hospital 
wage index available for this update of the CY 2005 home health payment 
rates was determined to be that of the 2005 pre-floor and pre-
reclassified hospital wage index.
    Under previous fiscal year updates, the most recent pre-floor and 
pre-reclassified hospital wage index available at the time of 
publication of the HH PPS fiscal year update was that of the previous 
year. Beginning with the CY 2005 update to home health payment rates, 
the most recent pre-floor and pre-reclassified hospital wage index 
available at the time of publication will be that of the current year. 
Consequently, for our proposed CY 2005 update to the home health 
payment rates, we proposed to continue to use the most recent pre-floor 
and pre-reclassified hospital wage index available at the time of 
publication. We recognized that this change to a calendar year update 
cycle results in using the current year's wage index values. We also 
note that for HH PPS rates addressed in the proposed rule, we 
inadvertently published the 2004 pre-floor and pre-reclassified 
hospital wage index. Consequently, we published a correction notice in 
the Federal Register on July 30, 2004 (69 FR 45640), replacing the 
inadvertently published 2004 pre-floor and pre-reclassified hospital 
wage index with a preliminary 2005 pre-floor and pre-reclassified 
hospital wage index that does not apply the CBSA policy.

III. Analysis of and Responses to Public Comments

    We received approximately 25 timely comments on the Home Health 
Prospective Payment System Rate Update for Calendar Year 2005 proposed 
rule (CMS-1265-P), published on June 2, 2004 (69 FR 31248). We have 
also received approximately 6 additional timely comments on the Home 
Health Prospective Payment System Rate Update for FY 2004 Notice (CMS-
1473-NC), published on July 2, 2003 (68 FR 39764). We received comments 
from HHAs and other health care providers, national industry 
associations, suppliers and practitioners, State associations, health 
care consulting firms, and private citizens. The comments centered on 
issues such as the wage index used to update rates, home health market 
basket analysis, metropolitan statistical areas as they relate to the 
wage index, reduction in the fixed dollar loss ratio for outlier 
episodes, home health resource group (HHRG) payment inadequacies, 
responsibility of and payment for supplies in the home health episode, 
cost reporting requirements, and finally refinements to the HH PPS in 
the areas of: Case mix, LUPAs, RAPs, SCICs, PEPs, outliers, supplies, 
and OASIS items (that is, M0175). We have considered all comments 
received during the 60-day public comment period on the June 2, 2004 
proposed rule, as well as from the July 2, 2003 notice. Our responses 
to the comments from both Federal Register publications, the June 2, 
2004 proposed rule and the July 2, 2003 notice are set forth in the 
following section.
    As noted in the proposed rule published in the Federal Register on 
June 2, 2004 (69 FR 31248), because of the large number of items of 
correspondence we normally receive on Federal Register documents 
published for comment, we are unable to respond to them individually. 
In this final rule, we address the concerns of the commenters that are 
related to the proposed rule and the notice with comment period 
published on July 2, 2003 (68 FR 39764). Summaries of the major 
concerns and our responses to these comments are set forth below.
Refinements
    Comment: There were several comments regarding refinement of the 
many different features of the HH PPS outside of the payment update 
such as outliers, supplies, PEPs, SCICs, LUPAs, and OASIS that make up 
the HH PPS, as well as other related issues such as dual-eligibles, 
long-term care patients, and telemedicine.
    Response: These comments were generally outside the scope of the 
proposed payment updates. Our ongoing research agenda on HH PPS 
refinements encompasses review of case mix adjustment and other payment 
adjustment provisions introduced as part of the PPS system. Our 
continuing work also includes review of overall system performance to 
the extent data permit analysis of this topic.
    We intend to address the aspects of the HH PPS that are subject to 
administrative revision when we initiate a refinement regulation. We 
believe it is prudent to avoid piecemeal revisions addressing one 
provision or another in isolation. Also, we believe it is common with 
new payment systems for providers to go through a period of adaptation. 
The adaptation process influences the data we use to study refinements, 
and those data lag by a year or more. We believe it is appropriate to 
base recommendations on data that reflect the end point of the provider 
adaptation process. Our study results will be more effective and 
provide a better basis for policy proposals when the data used in the 
studies reflect the end point of the adaptation period. Furthermore, we 
believe the best approach would be one that allows for analyzing 
interrelationships among payment features on the system in general. 
Moreover, it is more efficient to make numerous changes at the same 
time. Past experience with changes in systems and data collection for 
providers has shown that providers believe it is more burdensome when 
frequent changes are made to a payment system.
    Comment: There were a few comments requesting that ostomy supplies 
be exempt from the consolidated billing requirements because of their 
high cost.
    Response: The Medicare statute governing the home health PPS is 
specific to the type of items and services bundled to the HHA. Section 
1842(b)(6)(F) of the Act requires that all home health items and 
services, including medical supplies, furnished to a beneficiary under 
a plan of care are subject to consolidated billing. For example, if a 
patient is admitted for a condition that is related to a chronic 
condition which requires medical supplies (such as ostomy supplies), 
the HHA is required to provide those medical supplies while the patient 
is under a home health plan of care during an episode of care. We also 
note that costs of medical supplies are included in the HH PPS payment 
rate as the statute required that all services, including medical 
supplies, that would have been covered under the cost-based 
reimbursement system be bundled and paid under HH PPS.
    Comment: There were a few comments regarding supplies not covered 
under Part B, and a question was posed whether the HHAs are responsible 
to bundle these supplies

[[Page 62129]]

while a beneficiary is under a home health plan of care.
    Response: Section 1895(b)(1) of the Act specifies that under the HH 
PPS system, all services covered and paid for on a reasonable cost 
basis under the Medicare home health benefit as of the date of 
enactment of this section, including medical supplies, shall be paid 
for on the basis of a prospective payment amount determined under that 
subsection and applicable to the services involved. In the past, HH PPS 
home health agencies provided, and were reimbursed for, non-routine 
medical supplies for which Part B codes existed as well as for non-
routine medical supplies for which Part B codes did not exist. The 
costs of those supplies are included in the HH PPS rates, as those 
costs were built into the visit rates before the implementation of HH 
PPS and were part of the calculation of the base HH PPS rates. The 
implementation of the HH PPS did not change what home health agencies 
are required to provide to their beneficiaries under a plan of care.
    Comment: Some commenters requested clarification of the terms 
``significant change in condition'' and ``significant change in plan of 
care.''
    Response: As stated in 42 CFR 484.205(a)(3), a significant change 
in condition (SCIC) payment adjustment due to the intervening event is 
defined as a significant change in the patient's condition during an 
existing 60-day episode. The SCIC adjustment occurs when a beneficiary 
experiences a significant change in condition during a 60-day episode 
that was not envisioned in the original plan of care.
    Comment: One commenter asserted that the requirement to claim an 
SCIC with an improvement in an expected outcome of care would lead to a 
system that could result in having a lower payment despite a greater 
resource use.
    Response: As stated in our Pub. 100-2; Medicare Benefit Policy 
Manual, Chapter 7, ``Home Health Services'' 10.9 ``Significant Change 
in Condition (SCIC) Payment Adjustment'' the agency is not constrained 
to bill for a SCIC for a higher home health resource group (HHRG) if 
the net effect is a lower payment for the episode than if the SCIC had 
not occurred. Because the intent of the SCIC was not to lower the total 
episode payment when patients actually required more intensive 
services, the HHA is not forced to bill for an SCIC in this 
circumstance. However, where the SCIC reflects a lower HHRG due to 
unanticipated improvement in patient condition, the SCIC must be 
billed. This policy is restated in our Pub. 100-4; Medicare Claims 
Processing Manual, Chapter 10, ``Home Health Agency Billing'', 10.1.20 
``Adjustments of Episode Payment Significant Change in Condition 
(SCIC).''
    Comment: Commenters supported the adjustment of the outlier policy 
and encouraged us to regularly/annually monitor outlier expenditures so 
that further adjustments can be made promptly should the full amount of 
outlier funds not be used.
    Response: We plan to continue to monitor the outlier expenditures 
on a yearly basis and to make adjustments as necessary.
    Comment: A commenter requested that we conduct a thorough review of 
the PPS over the next year to improve its validity as outlier episodes 
were ``underpaid'' in previous years. The commenter also recommended 
that we increase the CY 2005 national 60-day episode rate and per visit 
amounts by 2 percent in light of the ``underpayments'' of outliers.
    Response: We will continue to closely monitor the outlier 
expenditures. In accordance with section 1895(b)(5) of the Act, we have 
set thresholds and ratios in the outlier calculations so that outlier 
payments for the year are projected to be no more than 5 percent of the 
total payments projected or estimated for the HH PPS. In doing so, we 
use the best Medicare data available.
    Many of the factors used to set prospective payment amounts for a 
given year are based on estimates. These factors include not only the 
outlier threshold, but also the market basket rate of increases used to 
establish the update factor to the HH PPS rates. We do not believe that 
the Congress intended that the standardized amounts for a given year 
should be adjusted (upward or downward) to reflect any difference 
between projected and actual outlier payments for a past year.
    Under the policy we have maintained since the inception of the HH 
PPS, we do not make retroactive adjustments to reconcile differences 
between the percentage of outlier payments projected before a given 
year and the ``actual'' outlier payments for that year.
Definition of Non-Metropolitan Statistical Area (MSA)/Wage Index
    Comment: In general, commenters appreciated that a change to the 
new CBSAs will not be undertaken for HH payments this year. Some 
commenters went so far as to express their opposition to ever adopting 
the CBSAs for HH PPS. There were also requests that if we were to 
implement CBSAs for HH PPS, we phase in the CBSAs in a similar fashion 
as is being done in the hospital setting. One commenter recommended 
using a blended wage index value, stating that HHAs in a given CBSA 
would receive the higher of either the wage index value based on data 
from hospitals in the new CBSA or the blended wage index value based on 
data from all hospitals in counties formerly included in the NECMA but 
now in separate CBSAs. The commenter believes that using such a blended 
wage index would also smooth out anomalies associated with an HHA 
serving patients in two or more different CBSAs. Commenters further 
urged us to postpone any change until the proposed IPPS wage index 
values could be evaluated.
    Response: We will review and analyze the comments to the proposed 
rule titled ``Medicare Program; Changes to the Hospital Inpatient 
Prospective Payment Systems and FY 2005 Rates'' (69 FR 28195) published 
on May 18, 2004 in which the new CBSAs are used before we consider 
adopting any new labor market definitions for HH PPS. In addition, we 
are currently analyzing the estimated impact that a move to CBSAs under 
the HH PPS would have on the home health industry. We plan to conduct a 
full study and consider the estimated impact that CBSAs would have on 
the home health industry before any revisions to the wage index are 
made.
    Comment: Commenters wished to see geographic area reclassification 
and wage index floors (such as those provided to hospitals) become 
available to HHAs. Commenters generally stated that the HHAs should be 
allowed to use the reclassified version of the wage index.
    Response: We continue to believe that the most recent available 
pre-floor and pre-reclassified hospital wage index data results in the 
appropriate adjustment to the labor portion of the costs as required by 
statute.
    Comment: Commenters supported using the most recent hospital wage 
index available for HH PPS in CY 2005.
    Response: We appreciate the commenters' support. As explained in 
the June 2, 2004 proposed rule, we have always used the most recent 
hospital wage index available in determining the HH PPS payment rates. 
However, as noted previously, the HH PPS update cycle was revised from 
that of a fiscal year update to a calendar year update, resulting in 
the most recent hospital wage index available at the time of 
publication being the current year's hospital wage index.
    Comment: One commenter urged us to use the 2004 pre-floor and pre-
reclassified wage index as opposed to using the current year's hospital 
wage

[[Page 62130]]

index data to provide a more equitable wage index transition and avoid 
abrupt changes due to skipping an update year.
    Response: As noted in the previous comment, we have always used the 
most recent available hospital wage index data in determining the HH 
PPS update. We continue to believe using the most recent available wage 
index better reflects current wages and salaries.
    Comment: Commenters supported creating a joint HH industry/CMS 
technical advisory group to explore the accuracy of the current wage 
index as well as options for a refined wage index that more accurately 
reflects the true wage costs experienced by the HH industry.
    Response: We appreciate the comment, however, we do not believe 
such a group is necessary. We have always received input from the 
industry on various aspects of our Medicare payment systems, and we 
anticipate this practice will continue into the future. More recently, 
the ``open-door'' forums, initiated by CMS, provide the public with an 
opportunity to provide input and comment on the wage index used in the 
HH PPS.
    Comment: Commenters wished to see a comprehensive impact analysis 
before instituting wage index changes. They believe that no changes in 
the wage index should be implemented without adequate (one full year's) 
notice.
    Response: To provide a more comprehensive impact analysis and one 
year's notice of wage index changes would necessitate that we not use 
the most recent available hospital wage index for HH PPS. As noted 
previously, we have always used the most recent available pre-floor and 
pre-reclassified hospital wage index at the time of publication as we 
believe it better reflects current wages and salaries.
    Comment: Commenters were concerned about the time to comment on the 
wage index that was published in the correction notice. One commenter 
suggested that the comment period be extended 30 days with respect to 
the wage index.
    Response: We believe commenters were given adequate notice to 
timely comment on the wage index. As stated in the proposed rule, the 
proposed wage indices were not final. The final wage index values are 
in the addendum to this final rule. The inadvertent inclusion of the 
wrong wage index was a technical error. We published the correct wage 
index on our Web site and as soon as possible thereafter in the Federal 
Register, once the inadvertent technical error was noted.
    Comment: Commenters are concerned about treatment of wage index 
values in Connecticut, and other parts of New England, and requested a 
reconsideration of the proposed decreases to the wage indices. The 
commenters were specifically concerned that we unilaterally changed the 
designation of three hospitals in Litchfield County from their 
placement in the Hartford MSA to the rural region, thereby lowering 
both regions' wage indices. Commenters requested that this be reversed 
and those three hospitals be designated to the Hartford MSA as per 
previous longstanding CMS policy. One commenter also suggested that the 
re-designation of hospitals in Hartford was done as part of our 
proposal for revised MSA definitions. If so, then this is in conflict 
with our stated intent not to apply expanded MSA definitions for HHAs 
in CY 2005.
    Response: We did not intend to implement any of the CBSA 
designations for CY 2005 in the HH PPS. Upon thorough review of the 
commenter's concern, we have determined that only Sharon Hospital of 
Litchfield County, Connecticut was inadvertently designated to the 
rural Connecticut area in our July 30, 2004 correction notice (69 FR 
45640). In this final rule, we are publishing an updated and corrected 
pre-floor and pre-reclassified hospital wage index that reflects Sharon 
Hospital's correct designation to the Hartford MSA (3283). In doing so, 
rural Connecticut's wage index value changes from 1.1586 in the 
proposed CY 2005 wage index published in the above correction notice, 
to 1.1917 in the final wage index published in this final rule. 
Conversely, the Hartford MSA wage index value changes from a value of 
1.1068 to 1.1055. In addition, our review determined that there were 
technical errors in the hospital wage index calculation process for FY 
2005 that had a slight overall impact to the wage index that we 
published in our correction notice (69 FR 45640). These technical 
errors have been corrected in the wage index published in this final 
rule.
    Comment: Commenters questioned how their wage index values could 
decrease so dramatically at a time when the wages they pay their staff 
have increased and their health insurance and dental insurance have 
increased. Commenters further requested to see our assessment of the 
impact of those declines, as agencies are already having trouble 
covering costs of serving isolated elders, as well as information as to 
how we arrived at the wage data used to compute the proposed wage index 
values.
    Response: As we noted in the final HH PPS rule on July 3, 2000 (65 
FR 41165), we do not have a home health specific wage index because of 
industry concerns with the methodology used to develop a HH specific 
wage index and the lack of applicable home health specific data. 
Accordingly, we use the hospital wage index as we believe it results in 
the most appropriate adjustment to the labor portion of the cost and 
best reflects the current wages and salaries.
    For the convenience of the public, we have recently published in 
the HH PPS rate updates, a comparison of wage index values from the 
current year to the upcoming year, as an illustration of the changes in 
the wage index from year to year. We are publishing a comparison table 
as part of this rule in Addendum C.
    For specifics regarding the information on the hospital wage data 
used in computing the hospital wage index, please refer to the August 
11, 2004 IPPS final rule (69 FR 48915).
    Comment: Commenters stated that a ``hold harmless'' provision 
should be available to HHAs to limit a wage index reduction 
(specifically to 2 percent from one year to the next) where there is a 
sudden reduction in the local wage index. Relief for providers that are 
negatively impacted should not come at the expense of providers that 
benefit from the changes.
    Response: Although we have sometimes implemented ``hold harmless'' 
provisions for groups of hospitals that are negatively impacted by 
significant changes in the wage index calculation or geographic 
classification, no such changes in methodology have taken place under 
the HH PPS. We note that, even for hospitals, there exists no precedent 
for a ``hold harmless'' provision based solely on percentage decreases 
in wage index values.
Home Health Market Basket
    Comment: Several commenters claimed the proposed rule had 
inadequate detail to evaluate the accuracy of the proposed changes. 
Specifically, they were unable to determine whether the market basket 
captures the costs of HIPAA compliance and outcome-based quality 
assurance activities and whether the blending of the price proxies 
accurately captures the growth of nursing wage costs.
    Response: We believe the detail provided in the proposed rule was 
adequate for the public to meaningfully comment on the proposed changes 
to the market basket. The proposed rule described the methodology, 
provided data sources, and discussed alternatives

[[Page 62131]]

considered for the proposed rebasing of the market basket.
    As for the HIPAA compliance and quality assurance activities, the 
HH market basket will only reflect these costs since they impact the 
rate of change in prices. For example, if there are overall increases 
in wage levels due to staffing changes associated with HIPAA compliance 
and/or quality assurance activities, these price changes may be 
reflected in the price proxies. However, costs associated with 
purchasing new equipment or hiring more staff for HIPAA compliance and/
or quality assurance activities will only be reflected in the base year 
weights when the index is rebased to reflect a year in which these 
costs were present.
    We also believe the blending of the price proxies accurately 
captures the growth of nursing wage costs. We continued to use a 50/50 
split of ECI for Professional Specialty & Technical Workers and 
Civilian Hospital Workers for both wages and benefits in order to 
reflect the competition between HHAs and hospitals for registered 
nurses, while still capturing the overall wage trends for professional 
and technical workers. We explained the need for this process as there 
is no specific wage or benefit measure for HHAs that holds skill mix 
constant. The increase in the Skilled Nursing & Therapist & Other 
Professional/Technical wages cost weight from the 1993-based (45.758 of 
the total wage cost category or 29.389 percent of the total index) to 
the proposed 2000-based HH market basket (53.816 percent of the wage 
cost category or 35.393 percent of the total index) is a reflection of 
the increase in skilled nursing, therapist, and other professional/
technical wage costs relative to other market basket costs. The blended 
home health wage proxy, composed of ECIs which keep the skill mix 
constant, increased 35 percent from 1995 through 2003, while the 
Average Hourly Earnings for Nonsupervisory Home Health Workers grew by 
24 percent.
    The market basket is an important component of the PPS system, but 
it is also important to review total provider reimbursement and costs 
when assessing the adequacy of Medicare payments. In April 2004, MedPAC 
reported that the Medicare margin for home health providers was 16.8 
percent in 2004, and recommended that no update be provided for 2005. 
The MMA, however, requires the market basket update minus 0.8 percent, 
which results in a 2.3 percent increase for 2005, which this final rule 
implements.
    Comment: Several commenters strongly supported the rebasing and 
revising of the home health market basket and hoped that CMS would be 
capable of rebasing more frequently.
    Response: Section 404 of the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003 (MMA) mandated that we study 
and report on the possibility of rebasing the Inpatient Prospective 
Payment System hospital market basket more often than once every 5 
years. After our report is completed, we plan to study the rebasing 
frequency for our other market baskets, such as the Skilled Nursing 
Facility and the Home Health market basket. We plan to use that 
information to determine an appropriate frequency for rebasing the home 
health market basket. It has always been our policy to rebase an index 
when appropriate. We will continue to monitor the home health market 
basket index to ensure it continues to adequately reflect the price of 
goods and services purchased by HHAs in providing an efficient level of 
home health care services.
    Comment: Some commenters questioned whether the home health market 
basket reflects current market forces. Specifically, they questioned 
whether the market basket captured the increase in worker's 
compensation, transportation, and professional liability insurance 
costs.
    Response: While all cost categories are not identified specifically 
and separately in the market basket, they are included in the weights, 
and the proxies attempt to reflect price changes associated with them. 
The price proxies are forecasted based on current price trends, thus 
reflecting current market forces. For the CY 2005 update, the 
forecasted price proxies include historical percent changes through 
2004, 2nd quarter.
    Comment: One commenter suggested that we convene a technical panel 
of industry and government experts in order to develop a more 
representative market basket. In addition, a few suggested that our use 
of the Medicare cost reports for home health agencies yields a flawed 
market basket and suggested combining cost report data and inputs from 
industry sources to develop the home health market basket.

    Response: In the past we have worked with industry, academic, 
government, and private sector experts on the development and update of 
the market basket, and we will continue to do so when necessary. When 
we rebase or revise the market, we generally provide a 60-day comment 
period for the rule which gives an opportunity for public input as do 
``open-door'' forums. We have always considered input from industry 
sources and evaluated them against other data sources based on our 
requirements of reliability, relevance, timeliness, and public 
availability.
    The Medicare cost reports provide actual cost share data for home 
health agencies serving Medicare patients. We believe that home health 
agencies understand the value we place upon accurate cost report data, 
and have provided us with reliable cost data, which aid our rebasing 
and revising of the home health market basket.
    Comment: Some commenters questioned if the market basket increase 
(in CY 2005 3.1 percent) is supposed to cover the costs of an efficient 
home health agency, then why is the HH PPS update equal to the home 
health market basket increase minus 0.8 percentage points.
    Response: The HH PPS update is dictated by statute. Section 701 of 
the MMA mandated that the CY 2005 HH PPS update be equal to the HH 
market basket increase minus 0.8 percentage points. Therefore, the 
update factor for CY 2005 was required to be reduced. While the 
deduction from the market basket increase is mandated in the MMA, we 
believe the market basket, as revised and rebased, is a technically 
accurate measure for price changes that reflect the true costs to a 
home health agency for efficiently providing services. This methodology 
is consistent with the market basket methodologies for Hospital, 
Skilled Nursing Facility, and Physician.
    Comment: A commenter was concerned about services such as 
telemonitoring/telehealth that are not included in the margin analysis. 
The commenter requested that the cost report be simplified to allow all 
costs associated with Medicare home care patients to be included in the 
cost report.
    Response: The instructions to Form 1728-94 were modified in June 
2001 to identify the direct and indirect costs of telemedicine services 
(including telemonitoring and telehealth) as a non-reimbursable cost 
center on the home health agency cost report to aide in trend analysis 
of telemedicine costs. However, as a non-reimbursable cost center these 
services are not a recognized visit or service under HH PPS. 
Specifically, in section 1895(e)(1)(B) of the Act, telecommunications 
services are not considered a home health visit for the purposes of 
eligibility or payment under this title.

[[Page 62132]]

Rural 5 Percent Rural Add-On
    Comment: Commenters questioned why the 5 percent increase is only 
for 1 year.
    Response: The statute is very specific as to the time frame for the 
rural add-on. Section 421 of the MMA requires, for home health services 
furnished in a rural area with respect to episodes and visits ending on 
or after April 1, 2004 and before April 1, 2005, an increase by 5 
percent of the payment amount that otherwise would be made for these 
services. Therefore, the 5 percent rural add-on ends after the first 
quarter of CY 2005, that is, for episodes and visits ending before 
April 1, 2005.
General Comments
    Comment: A commenter requested that we consider the issuance of 
public status reports regarding our efforts concerning the HH PPS, such 
as a rebasing of the HH PPS payment rates, revisions to the payment 
structure, and revisions to the HHRG case mix adjuster. This would 
provide an early opportunity for input and comment relative to the 
potential direction in that regard.
    Response: We appreciate the comment. Any significant changes to the 
HH PPS will continue to be provided with sufficient notice to the 
public. In addition, our ``open door'' forum is an opportunity for the 
public to express concerns and have issues addressed.
IPPS-Related Comments
    Comment: We received a small number of comments that were 
particular to the Inpatient Hospital PPS proposed rule of May 18, 2004 
(69 FR 28196). Issues ranged from expanded wage areas that would change 
status due to the redefinition of rural and urban areas, to suggestions 
of modernizing the geographic reclassification criteria to protect 
providers when they are ``redistricted'' out of a high wage area, to 
issues regarding Critical Access Hospital status and the applicable 
wage index calculation.
    Response: These comments are specific to IPPS and outside the scope 
of the HH PPS update.
Comments on Home Health Prospective Payment System Rate Update for FY 
2004 Notice, Published on July 2, 2003 (68 FR 39764)
    As noted previously, we received 6 comments on the 2004 update 
notice for HH PPS. A summary of those comments and our responses are 
noted below.
    Comment: Commenters requested that we publish the pre-floor and 
pre-reclassified hospital wage index annually as part of the notice and 
comment rulemaking for inpatient hospital PPS. This would allow for 
prior public comment on the wage index applied to HHAs.
    Response: The methodology as to how wage indicies are used in the 
calculation of the HH PPS payment rates has not changed since the 
implementation of the HH PPS. Because it is only the updating of data 
used to determine the wage index values between versions of a 
particular year's wage index file, and not the changing of methodology, 
we do not believe that prior public notice or a separate publication 
(outside the publication of the HH PPS update) is warranted. As to the 
specific wage index tables for the HH PPS for a given year, although it 
applies a rural floor and reclassifications, generally the hospital 
wage index files published in the IPPS rules, (which are published 
before the HH PPS update) would provide a good indication of the wage 
index used in a HH PPS update.
    Comment: One commenter had several comments on potential 
legislation, including urging us to assert to Congressional leadership 
that HHAs need to receive the full market basket increase of 3.3 
percent. The commenter also criticized the loss of the rural add-on and 
the threat of copayments.
    Response: We note that recently passed legislation addresses the 
commenters' concerns regarding market basket updates and the rural add-
on. The MMA addresses the market basket increase in section 701. 
Specifically, section 701(b) of the MMA states that for the last 3 
calendar quarters of 2004, the unadjusted prospective 60-day episode 
payment rate is equal to the rate from the previous fiscal year (FY 
2003) increased by the applicable home health market basket minus 0.8 
percentage points. For each of calendar years 2005 and 2006, the 
unadjusted national prospective 60-day episode payment rate is equal to 
the rate from the previous calendar year, increased by the applicable 
home health market basket minus 0.8 percentage points. Regarding the 
rural add-on, section 421 of the MMA requires, for home health services 
furnished in a rural area with respect to episodes and visits ending on 
or after April 1, 2004 and before April 1, 2005, that we increase by 5 
percent the payment amount that otherwise would be made for the 
services. The MMA did not include copayments for Medicare home health 
services.

IV. Provisions of the Final Regulations

    This final rule incorporates the provisions of the regulations text 
of the proposed rule [69 FR 31248]. We have adopted the proposed 
changes from the above captioned proposed rule with regards to the 
rebasing and revising of the home health market basket, differing only 
in that through the use of updated data, the final CY 2005 market 
basket increase is 3.1 percent, as compared to 3.3 percent in the 
proposed rule. Consequently, we will update the national 60-day episode 
rate and the per-visit payment amounts per discipline for CY 2005 for 
LUPAs by the final determined market basket percentage of 3.1 percent 
minus 0.8 percentage points for an update to the HH PPS rates of 2.3 
percent. In addition, we will update, by 5 percent, the 60-day episode 
payment amounts and the LUPA, per-visit payment amounts for services 
furnished in a rural area with respect to episodes and visits ending on 
or after April 1, 2004 and before April 1, 2005. We have also updated 
the fixed dollar loss (FDL) ratio, used in the determination of outlier 
payments, from the proposed ratio of 0.72 in the proposed rule to 0.70, 
using the most recent available HH PPS data. Finally, this final rule 
includes the most recent version of the pre-floor and pre-reclassified 
hospital wage index, that does not apply the CBSA policy, used by the 
HH PPS.

A. Rebasing and Revising of the Home Health Market Basket

1. Rebasing Results
    Section 1895(b)(3)(B) of the Act, as amended by the MMA, requires 
the standard prospective payment amounts to be paid on a calendar year 
basis for 2004 and any subsequent year. Previous market basket updates 
were calculated on a fiscal year basis. Table 1 shows that the 
forecasted rate of growth for CY 2005, beginning January 1, 2005, for 
the rebased and revised home health market basket is 3.1 percent, while 
the forecasted rate of growth for the current 1993-based home health 
market basket is also 3.1 percent. This final update for CY 2005 is 
based on the Global Insight, Inc 2004, 3rd quarter forecast with 
historical data through 2004, 2nd quarter. The proposed CY 2005 update 
was based on a forecast with historical data through 2003, 3rd quarter. 
As previously mentioned, we rebase the home health market basket 
periodically so the cost category weights continue to reflect changes 
in the mix of goods and services that HHAs purchase in furnishing home 
health care.

[[Page 62133]]



 
     Table 1.--Forecasted Annual Percent Change in the 1993-Based and 2000-Based Home Health Market Baskets
----------------------------------------------------------------------------------------------------------------
                                                                                                    Difference
                                                                 Home health      Home health      (2000-based
              Calendar year beginning January 1                 market basket,   market basket,     less 1993-
                                                                  1993-based       2000-based         based)
----------------------------------------------------------------------------------------------------------------
January 2005, CY 2005........................................             3.1              3.1             0.0
----------------------------------------------------------------------------------------------------------------
 Source: Global Insight, Inc, 3rd Qtr, 2004; @USMACRO/CONTROL0804 @CISSIM/TL0804.SIM.

    Table 2 shows the percent changes for CY 2005 based on the 2004, 
3rd quarter forecast for each cost category in the home health market 
basket.

 Table 2.--CY 2005 Forecasted Annual Percent Change for All Cost Categories in the 2000-Based Home Health Market
                                                     Basket
----------------------------------------------------------------------------------------------------------------
                                                                                                    Forecasted
                                                                                                  annual percent
              Cost categories                    Weight                  Price proxy              change for  CY
                                                                                                       2005
----------------------------------------------------------------------------------------------------------------
Total......................................         100.000  ...................................             3.1
Compensation...............................          76.775  ...................................             3.3
    Wages and Salaries.....................          65.766  Home Health Occupational Wage Index             3.0
    Employee Benefits......................          11.009  Home Health Occupational Benefits               5.0
                                                              Index.
Operations & Maintenance...................           0.825  CPI Fuel & Other Utilities.........             2.8
Administrative & General & Other Expenses..          16.633  ...................................             2.6
    Telephone..............................           0.850  CPI Telephone Services.............             0.9
    Postage................................           0.563  CPI Postage........................             2.0
    Professional Fees*.....................           1.405  ECI for Compensation for                        3.6
                                                              Professional and Technical Workers.
    Other Products*........................           6.419  CPI All Items Less Food and Energy.             2.1
    Other Services*........................           7.396  ECI for Compensation for Service                3.1
                                                              Workers.
Transportation.............................           2.744  CPI Private Transportation.........             0.3
Capital-Related............................           3.023  ...................................             2.5
    Insurance..............................           0.275  CPI Household Insurance............             3.3
    Fixed Capital..........................           1.777  CPI Owner's Equivalent Rent........             3.1
    Movable Capital........................           0.971  PPI Machinery & Equipment..........            1.0
----------------------------------------------------------------------------------------------------------------
*New break-out in cost structure when compared with the 1993-based home health market basket.
Source: Global Insight, Inc, 3rd Qtr, 2004; @USMACRO/CONTROL0804 @CISSIM/TL0804.SIM.

B. CY 2005 Update to the Home Health Market Basket Index

    Section 1895(b)(3)(B) of the Act, as amended by section 701 of the 
MMA, requires for CY 2005 that the standard prospective payment amounts 
be increased by a factor equal to the applicable home health market 
basket increase minus 0.8 percentage points. As previously noted, we 
are amending the regulations in Sec.  484.225 to reflect this 
requirement.

CY 2005 Adjustments

    To calculate the CY 2005 national 60-day episode rate, we multiply 
the CY 2004 (as of April 1, 2004) national 60-day episode rate 
($2,213.37) by the applicable home health market basket update of 3.1 
percent for CY 2005 minus 0.8 percentage points.
    We increase the CY 2004 60-day episode payment rate by the proposed 
home health market basket increase (3.1 percent) minus 0.8 percentage 
points ($2,213.37 x 2.3 percent) to yield the updated CY 2005 national 
60-day episode rate ($2,264.28) (see Table 4 below).

Table 4.--National 60-Day Episode Amounts Updated by the Applicable Home
 Health Market Basket CY 2005, Minus 0.8 Percentage Points, Before Case-
 Mix Adjustment, Wage Index Adjustment Based on the Site of Service for
            the Beneficiary or Applicable Payment Adjustment
------------------------------------------------------------------------
                                  Multiply by the
                                  applicable home
   Total prospective payment       health market       CY 2005 updated
 amount per 60-day episode for    basket increase      national 60-day
   CY 2004 (as of 04/01/04)     (3.1 percent) minus      episode rate
                                   0.8 percentage
                                       points
------------------------------------------------------------------------
$2,213.37.....................             x 1.023            $2,264.28
------------------------------------------------------------------------


[[Page 62134]]

C. National Per-Visit Amounts Used To Pay LUPAs and Compute Imputed 
Costs Used in Outlier Calculations

    As discussed previously in this final rule, the policies governing 
the LUPAs and outlier calculations set forth in the July 3, 2000 HH PPS 
final rule will continue during CY 2005. In calculating the annual 
update for the CY 2005 national per-visit amounts we use to pay LUPAs 
and to compute the imputed costs in outlier calculations, we look again 
at the CY 2004 (as of April 1, 2004) rates as a starting point. We then 
multiply those amounts by the home health market basket increase minus 
0.8 percentage points for CY 2005 to yield the updated per-visit 
amounts for each home health discipline for CY 2005. (See Table 5 
below.)

  Table 5.--National Per-Visit Amounts for LUPAs and Outlier Calculations Updated by the Applicable Home Health
 Market Basket Increase for CY 2005, Minus 0.8 Percentage Points, Before Wage Index Adjustment Based on the Site
                                         of Service for the Beneficiary
----------------------------------------------------------------------------------------------------------------
                                                                               Multiply by the
                                                             Final per-visit   applicable home      Per-visit
                                                            amounts per  60-    health market    payment amount
                Home health discipline type                  day episode for    basket  (3.1     per  discipline
                                                              CY 2004  for     percent)  minus   for CY 2005 for
                                                            LUPAs  (as of 04/  0.8  percentage        LUPAs
                                                                 01/04)            points
----------------------------------------------------------------------------------------------------------------
Home Health Aide..........................................            $43.75           x 1.023            $44.76
Medical Social Services...................................            154.89           x 1.023            158.45
Occupational Therapy......................................            106.36           x 1.023            108.81
Physical Therapy..........................................            105.65           x 1.023            108.08
Skilled Nursing...........................................             96.63           x 1.023             98.85
Speech-Language Pathology.................................            114.80           x 1.023            117.44
----------------------------------------------------------------------------------------------------------------

D. Update to the Outlier Fixed Dollar Loss Ratio

    For the rule, we performed analysis of CY 2001 home health claims 
data. The results of that analysis reflected that outlier episodes 
represented approximately 3 percent of total episodes and 3 percent of 
total HH PPS payments. For this final rule, we have performed the same 
analysis on CY 2002 and CY 2003 home health claims data and have found 
the number of outlier episodes and payments to continue to hold at 
approximately 3 percent of total episodes and total HH PPS payments, 
respectively.
    In the rule, we also performed data analysis on CY 2001 HH PPS 
analytic data to update the fixed dollar loss (FDL) ratio to enable the 
total estimated outlier payments to be a projected 5 percent of total 
HH PPS payments. The results of that analysis indicated that a fixed 
dollar loss ratio of 0.72 was consistent with the existing loss-sharing 
ratio of 0.80 and a projected target percentage of estimated outlier 
payments of 5 percent. For this final rule, we have performed the same 
analysis on CY 2003 HH PPS analytic data to update the fixed dollar 
loss ratio. The results of this analysis indicate that a fixed dollar 
loss ratio of 0.70 is consistent with the existing loss-sharing ratio 
of 0.80 and a projected target percentage of estimated outlier payments 
of 5 percent. Consequently, we are updating the fixed dollar loss ratio 
from the current ratio of 1.13 to the fixed dollar loss ratio of 0.70. 
Our analysis shows that reducing the fixed dollar loss ratio from 1.13 
to 0.70 will allow approximately 5.9 percent of episodes to qualify for 
outlier payments. The estimated 5.9 percent outlier episodes are 
greater than the 3.0 percent of episodes that currently qualify for 
outlier payments.
    Expressed in terms of a fixed dollar loss amount, the fixed dollar 
loss ratio of 0.70 implies that providers would absorb approximately 
$1,585 of their costs (before wage adjustment), in addition to their 
loss-sharing portion of the estimated cost in excess of the outlier 
threshold. This fixed dollar loss amount of approximately $1,585 is 
computed by multiplying the standard 60-day episode payment amount 
($2,264.28) by the fixed dollar loss ratio (0.70). Using the current 
fixed dollar loss ratio (1.13), the fixed dollar loss amount would be 
approximately $2,558 ($2,264.28 x 1.13).
    We believe that a fixed dollar loss ratio of 0.70 preserves a 
reasonable degree of cost sharing, while allowing a greater number of 
episodes to qualify for outlier payments.
    The following analytical Tables 6-a through 6-d, derived from 
analysis of CY 2003 HH PPS claims data, characterize outlier episodes, 
and estimate how different types of providers and providers in 
different parts of the country will do under an outlier scenario that 
employs a fixed dollar loss ratio of 0.70 as compared to the current 
fixed dollar loss ratio of 1.13.
    The new FDL of 0.70 will increase outlier payments to all types of 
home health providers in all areas of the country. Generally speaking, 
it has been estimated that, under a scenario where the FDL is equal to 
0.70, for home health providers whose outlier payments are historically 
a lesser percentage of their total HH PPS payments, their outlier 
payments will increase at a greater rate than will outlier payments for 
home health providers whose outlier payments are historically of a 
greater percentage of their total HH PPS payments.
    For example, non-profit home health agencies were estimated to 
receive outlier payments equal to approximately 1.9 percent of their 
total HH PPS payments under the current scenario where the FDL = 1.13. 
Under the same scenario, for-profit home health agencies were estimated 
to receive outlier payments equal to approximately 5.1 percent of their 
total HH PPS payments. While a scenario where the FDL = 0.70 increases 
the percentage of outlier payments to total HH PPS payments, the 
overall increase in outlier payments to non-profit home health agencies 
increases by an estimated 77.6 percent while the outlier payments for 
for-profit home health agencies increase by approximately 33.8 percent.
    Similarly, while outlier payments to both provider-based and free-
standing home health agencies will increase under a scenario where FDL 
= 0.70, outlier payments to provider-based home health agencies are 
estimated to increase by approximately 97.3 percent, while payments to 
free-standing home health agencies are estimated to increase

[[Page 62135]]

by approximately 41 percent. For areas of the county where outlier 
payments are estimated to be of a lesser percentage to their total HH 
PPS payments, their overall percentage increase in outlier payments is 
estimated to be greater than for those areas of the country where 
outlier payments have been estimated to be of a greater percentage of 
their total HH PPS payments. Finally, while both urban and rural 
providers will benefit from increased outlier payments under the FDL of 
0.70 scenario, rural providers will see their outlier payments increase 
by an estimated 81.5 percent, while urban providers will see an 
estimated increase of approximately 43.2 percent.

 Table 6-a.--Comparison of Estimated Outlier Payments as a Percentage of Total HH PPS Payments Under the Current
 FDL = 1.13 to Estimated Outlier Payments as Percentage of Total HH PPS Under the FDL = 0.70 by Type of Control
----------------------------------------------------------------------------------------------------------------
                                                             Percentage of outlier payments to   Percent change
                                                                   total HH PPS payments           in outlier
                      Type of control                      ------------------------------------   payments from
                                                                                                  FDL = 1.13 to
                                                               FDL = 1.13        FDL = 0.70        FDL = 0.70
----------------------------------------------------------------------------------------------------------------
Non-Profit................................................               1.9               3.4              77.6
Profit....................................................               5.1               6.7              33.8
Government................................................               2.1               3.1              77.5
----------------------------------------------------------------------------------------------------------------


 Table 6-b.--Comparison of Estimated Outlier Payments as a Percentage of Total HH PPS Payments Under the Current
 FDL = 1.13 to Estimated Outlier Payments as Percentage of Total HH PPS Under the FDL = 0.70 by Type of Facility
----------------------------------------------------------------------------------------------------------------
                                                             Percentage of outlier payments to   Percent change
                                                                   total HH PPS payments           in outlier
                      Type of control                      ------------------------------------   payments from
                                                                                                  FDL = 1.13 to
                                                               FDL = 1.13        FDL = 0.70        FDL = 0.70
----------------------------------------------------------------------------------------------------------------
Free Standing.............................................               4.1               5.7              41.0
Provider Based............................................               1.4               2.7              97.3
----------------------------------------------------------------------------------------------------------------


 Table 6-c.--Comparison of Estimated Outlier Payments as a Percentage of Total HH PPS Payments Under the Current
      FDL = 1.13 to Estimated Outlier Payments as Percentage of Total HH PPS Under the FDL = 0.70 by Region
----------------------------------------------------------------------------------------------------------------
                                                             Percentage of outlier payments to   Percent change
                                                                   total HH PPS payments           in outlier
                          Region                           ------------------------------------   payments from
                                                                                                  FDL = 1.13 to
                                                               FDL = 1.13        FDL = 0.70        FDL = 0.70
----------------------------------------------------------------------------------------------------------------
Region I: Boston..........................................               2.8               4.9              76.6
Region II: New York.......................................               3.3               5.4              66.6
Region III: Philadelphia..................................               1.0               2.0              97.5
Region IV: Atlanta........................................               3.5               4.9              43.6
Region V: Chicago.........................................               1.1               2.1              96.9
Region VI: Dallas.........................................               3.7               5.2              41.5
Region VII: Kansas City...................................               1.2               2.3             102.5
Region VIII: Denver.......................................               3.5               5.1              47.6
Region IX: San Francisco..................................               9.9              12.0              24.6
Region X: Seattle.........................................               0.5               1.3             151.7
----------------------------------------------------------------------------------------------------------------


 Table 6-d.--Comparison of Estimated Outlier Payments as a Percentage of Total HH PPS Payments Under the Current
   FDL = 1.13 to Estimated Outlier Payments as Percentage of Total HH PPS Under the FDL = 0.70 by Urban/Rural
----------------------------------------------------------------------------------------------------------------
                                                             Percentage of outlier payments to   Percent change
                                                                   total HH PPS payments           in outlier
                        Urban/rural                        ------------------------------------   payments from
                                                                                                  FDL = 1.13 to
                                                               FDL = 1.13        FDL = 0.70        FDL = 0.70
----------------------------------------------------------------------------------------------------------------
Urban.....................................................               4.0               5.6              43.2
Rural.....................................................               1.4               2.5              81.5
----------------------------------------------------------------------------------------------------------------


[[Page 62136]]

E. Rural Add-On as Required by MMA

    As discussed in the proposed rule, section 421 of the MMA requires, 
for home health services furnished in a rural area with respect to 
episodes and visits ending on or after April 1, 2004 and before April 
1, 2005, that we increase by 5 percent the payment amount that 
otherwise would be made for the services.
    The CY 2005 5 percent rural add-on to the 60-day episode 
standardized payment and the per-visit LUPA payments, as required by 
section 421 of the MMA, is noted in tables 7 and 8 below.

 Table 7.--CY 2005 Rural Add-On to 60-Day Episode Payment Amounts Ending
on or After April 1, 2004 and Before April 1, 2005 for Beneficiaries Who
     Reside in a Non-MSA Area Before Case-Mix Adjustment, Wage Index
     Adjustment Based on the Site of Service for the Beneficiary or
                      Applicable Payment Adjustment
------------------------------------------------------------------------
                                                          CY 2005 final
                                                         payment amount
                                                           per 60-day
                                                         episode ending
Total prospective payment amount per   5 percent rural   before April 1,
     60-day episode for CY 2005            add-on          2005 for a
                                                         beneficiary who
                                                        resides in a Non-
                                                            MSA area
------------------------------------------------------------------------
$2,264.28...........................            x 1.05         $2,377.49
------------------------------------------------------------------------


 Table 8.--CY 2005 Add-On to LUPA Per-Visit Amounts for Visits Ending on or After April 1, 2004 and Before April
 1, 2005, Before Wage Index Adjustment Based on the Site of Service of the Beneficiary Who Resides in a Non-MSA
                                      Area or Payment Applicable Adjustment
----------------------------------------------------------------------------------------------------------------
                                                                                                  CY 2005 per-
                                                                                                  visit payment
                                                                                                amounts per  60-
                                                                Per-visit                          day episode
                                                             payment amounts   5 percent rural    ending before
                Home health discipline type                    per 60-day          add-on         April 1, 2005
                                                             episode for CY                      for LUPAs for a
                                                             2005 for LUPAs                      beneficiary who
                                                                                                  resides in a
                                                                                                  non-MSA area
----------------------------------------------------------------------------------------------------------------
Home Health Aide..........................................            $44.76            x 1.05            $47.00
Medical Social Services...................................            158.45            x 1.05            166.37
Occupational Therapy......................................            108.81            x 1.05            114.25
Physical Therapy..........................................            108.08            x 1.05            113.48
Skilled Nursing...........................................             98.85            x 1.05            103.79
Speech-Language Pathology.................................            117.44            x 1.05            123.31
----------------------------------------------------------------------------------------------------------------

F. Hospital Wage Index

    Sections 1895(b)(4)(A)(ii) and (b)(4)(C) of the Act require the 
Secretary to establish area wage adjustment factors that reflect the 
relative level of wages and wage-related costs applicable to the 
furnishing of home health services and to provide appropriate 
adjustments to the episode payment amounts under HH PPS to account for 
area wage differences. We have consistently used the most recent pre-
floor and pre-reclassified hospital wage index available in determining 
HH PPS updates.
    In our June 2, 2004 proposed rule (69 FR 31260), we proposed to 
continue to use the most recent pre-floor and pre-reclassified hospital 
wage index available at the time of the final rule. At the time of 
publication of the proposed rule, only preliminary versions of the wage 
index used by HH PPS were available. We indicated in the proposed rule 
that we would incorporate updated wage data for the wage index to be 
used in the final rule for the CY 2005 HH PPS update. Subsequent to the 
proposed rule, we published a correction notice on July 30, 2004 (69 FR 
45640) in which we indicated that in our publishing of the proposed 
rule, we inadvertently published the 2004 pre-floor and pre-
reclassified wage index tables instead of the intended 2005 pre-floor 
and pre-reclassified wage index tables. As part of that correction 
notice, we published the appropriate 2005 pre-floor and pre-
reclassified wage index tables.
    Since the publication of the correction notice, we have determined 
that there exists some labeling and other technical errors in the 
proposed wage index.
    We note a labeling error in the wage index tables used in the HH 
PPS. That labeling error is the listing of Stanly County, NC as one of 
the areas under MSA 1520 when, in fact, we consider Stanly County, NC 
to be a rural area in North Carolina. Stanly County wage data have 
always been correctly treated as rural in the actual creation of the 
home health wage index values, and it has only been the listing of 
Stanly County under MSA 1520 that was in error. Consequently, the wage 
index table in this final rule correctly removes Stanly County from the 
list of areas that fall under the MSA 1520 wage index. As this is 
strictly a labeling correction that does not affect the actual 
computation of the wage index values, home health providers in Stanly 
County, NC will continue to fall under, and use, the wage index for 
rural North Carolina.
    In addition, we have determined that Sharon Hospital of Litchfield 
County, Connecticut was inadvertently designated to the rural 
Connecticut area in our July 30, 2004 correction notice (69 FR 45640). 
Consequently, the updated CY 2005 pre-floor and pre-reclassified 
hospital wage index published in this final rule correctly designates 
Sharon Hospital to the

[[Page 62137]]

Hartford MSA (3283). In doing so, rural Connecticut's wage index value 
increases from 1.1586 in the proposed CY 2005 wage index to 1.1917 in 
the final CY 2005 wage index published in this final rule. Conversely, 
the Hartford MSA wage index value changes from a value of 1.1068 to 
1.1055. In addition, our review determined that there were technical 
errors in the hospital wage index calculation process for FY 2005 that 
had a slight overall impact to the wage index that we published in our 
correction notice (69 FR 45640). These technical errors have been 
corrected in the wage index published in this final rule.
    See Addenda A and B of this final rule, respectively, for the rural 
and urban hospital wage indexes. Furthermore, we have added an Addendum 
C that shows a side-by-side comparison of the FY 2003 pre-floor and 
pre-reclassified hospital wage index and the CY 2005 pre-floor and pre-
reclassified hospital wage index, that does not apply the CBSA policy, 
for CY 2005 HH PPS.

V. Collection of Information Requirements

    This document does not impose information collection and record-
keeping requirements. Consequently, it need not be reviewed by the 
Office of Management and Budget under the authority of the Paperwork 
Reduction Act of 1995 (44 U.S.C. 3501 et seq.).

VI. Regulatory Impact Analysis

A. Overall Impact

    We have examined the impacts of this rule as required by Executive 
Order 12866 (September 1993, Regulatory Planning and Review), the 
Regulatory Flexibility Act (RFA) (September 16, 1980, Pub. L. 96-354), 
section 1102(b) of the Social Security Act, the Unfunded Mandates 
Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.
    Executive Order 12866 (as amended by Executive Order 13258, which 
merely reassigns responsibility of duties) directs agencies to assess 
all costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, distributive impacts, and equity). A 
regulatory impact analysis (RIA) must be prepared for major rules with 
economically significant effects ($100 million or more in any 1 year). 
The update set forth in this final rule would apply to Medicare 
payments under HH PPS in CY 2005. Accordingly, the following analysis 
describes the impact in CY 2005 only. We estimate that there will be an 
additional $250 million in CY 2005 expenditures attributable to the CY 
2005 market basket (3.1 percent), minus 0.8 percentage points, an 
estimated increase of 2.3 percent.
    Section 421 of the MMA provides for a 5 percent increase in home 
health payments to rural providers for episodes and visits ending after 
April 1, 2004 and before April 1, 2005. This increase is not subject to 
budget neutrality. Consequently, this increase in payments to rural 
providers will result in an estimated increase in expenditures of $50 
million in CY 2004 and $60 million in CY 2005.
    Section 701 of the MMA includes a provision that changes the update 
cycle for HH PPS, and thus the home health market basket update, from a 
fiscal year basis to that of a calendar year basis in 2004. This 
results in a projected reduction in expenditures of approximately $90 
million in FY 2005.
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses. For purposes of the RFA, small entities include 
small businesses, nonprofit organizations, and government agencies. 
Most hospitals and most other providers and suppliers are small 
entities, either by nonprofit status or by having revenues of $6 
million to $29 million or less annually (for details, see the Small 
Business Administration's regulation that set forth size standards for 
health care industries at 65 FR 69432). For purposes of the RFA, 
approximately 75 percent of HHAs are considered small businesses 
according to the Small Business Administration's size standards with 
total revenues of $11.5 million or less in 1 year. Individuals and 
States are not included in the definition of a small entity. As stated 
above, this final rule updates all of the HHAs for CY 2005 as required 
by statute. This rule will have a significant positive effect upon 
small entities.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis if a rule may have a significant impact on 
the operations of a substantial number of small rural hospitals. This 
analysis must conform to the provisions of section 603 of the RFA. For 
purposes of section 1102(b) of the Act, we define a small rural 
hospital as a hospital that is located outside of a metropolitan 
statistical area (MSA) and has fewer than 100 beds. We have determined 
that this final rule would not have a significant economic impact on 
the operations of a substantial number of small rural hospitals.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule that may result in expenditure in any 1 year by State, 
local, or tribal governments, in the aggregate, or by the private 
sector, of $110 million. We believe that this final rule would not 
mandate expenditures in that amount.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. We have reviewed this rule under the threshold criteria 
of Executive Order 13132, Federalism. We have determined that this 
final rule would not have substantial direct effects on the rights, 
roles, and responsibilities of States.

B. Anticipated Effects

    In accordance with the requirements of section 1895(b)(3) of the 
Act, we publish an update for each subsequent fiscal year that will 
provide an update to the payment rates. Section 1895(b)(3)(B) of the 
Act, as amended by section 701 of the MMA, requires us, for CY 2005, to 
increase the prospective payment amounts by the applicable home health 
market basket increase minus 0.8 percentage points. We estimate that 
with a home health market basket of 3.1 percent minus 0.8 percentage 
points, the increase for CY 2005 is 2.3 percent.
1. Effects on the Medicare Program
    This final rule provides a percentage update to all Medicare HHAs. 
Therefore, we have not furnished any impact tables. We increased the 
payment to each Medicare HHA equally by the home health market basket 
update for CY 2005, minus 0.8 percentage points, as required by 
statute. There is no differential impact among provider types. The 
impact is in the aggregate. We can show the impact that the CY 2005 
wage index would have on providers. Addendum C shows a side-by-side 
comparison of the FY 2003 pre-floor and pre-reclassified hospital wage 
index and the CY 2005 pre-floor and pre-reclassified hospital wage 
index, that does not apply the CBSA policy, for the CY 2005 HH PPS 
update final rule. We estimate that there would be an additional $250 
million in CY 2005 expenditures attributable to the CY 2005 market 
basket (3.1 percent), minus 0.8 percentage points, resulting in a 2.3 
percent increase. Thus, the anticipated expenditures outlined in this 
final rule

[[Page 62138]]

would exceed the $100 million annual threshold for a major rule as 
defined in Title 5, U.S.C., section 804(2).
    The applicable home health market basket (minus 0.8 percentage 
points) increase of 2.3 percent for CY 2005 applies to all Medicare-
participating HHAs. We do not believe there is a differential impact 
due to the aggregate nature of the update.

                                 Table 9
------------------------------------------------------------------------
                                                         Additional CY
                                                         2005 Medicare
                                                          Home Health
 CY 2005 update to Home Health PPS rates required by       estimated
                       the Act                          expenditures due
                                                       to  annual update
                                                         required by law
------------------------------------------------------------------------
Section 1895(b)(3)(B) of the Act requires HH PPS          $250 Million.
 rates increased by applicable home health market
 basket increase (3.1 percent) minus 0.8 percentage
 points, yielding 2.3 percent........................
------------------------------------------------------------------------
Source: President's FY 2004 Budget.

2. Effects on Providers
    We believe that this rule would have a positive effect on providers 
of Medicare home health services by increasing their rate of Medicare 
payments. We do not anticipate specific effects on other providers. 
This final rule reflects the statutorily required annual update to the 
HH PPS rates. We do not believe there is a differential impact due to 
the consistent and aggregate nature of the update.

C. Alternatives Considered

    This final rule reflects an annual update to the HH PPS rates as 
required by statute. We believe that the statute provides no latitude 
for alternatives other than the approach set forth in this final rule 
reflecting the CY 2005 annual update to the HH PPS rates. Other than 
the positive effect of the market basket increase, this final rule 
would not have a significant economic impact nor would it impose an 
additional burden on small entities. When a regulation or notice 
imposes additional burden on small entities, we are required under the 
RFA to examine alternatives for reducing burden.
    This final rule rebases and revises the home health market basket 
by moving the base year from FY 1993 to FY 2000 to reflect the latest 
available, thorough data on the structure of HHA costs. We periodically 
rebase and revise market baskets for multiple types of health care 
providers, generally on a 5-year cycle. We continue to believe that by 
rebasing and revising the home health market basket periodically, cost 
category weights will better reflect changes in the mix of goods and 
services that HHAs purchase in furnishing home health care. The 
alternative to not rebase and revise the market basket would be to 
delay the inevitable task of rebasing and revising the home health 
market basket to some later date. For this final rule, the forecasted 
rate of growth for CY 2005 for both the rebased and revised home health 
market basket and the current 1993-based home health market basket is 
3.1 percent (see Table 1 of this rule). Future updates will be better 
served by using a more up-to-date cost structure, as is accomplished in 
the revised and rebased home health market basket.
    Section 1895(b)(5) of the Act states that the total amount of 
payments for outliers, under HH PPS, may not exceed 5 percent of the 
total payments projected or estimated to be made for a given fiscal 
year or year. As discussed in section IV, ``Provisions of the Final 
Regulations'', we are reducing the fixed dollar loss ratio used in the 
formula to determine outlier cases in HH PPS, from that of 1.13 to 
0.70. Analysis indicates that a fixed dollar loss ratio of 0.70 is 
consistent with the existing loss-sharing ratio of 0.80 and our target 
percentage of estimated outlier payments of 5 percent of total home 
health payments. Other alternatives considered in the updating of the 
formula for determining outlier cases included updating/changing the 
loss-sharing ratio from that of 0.80 as well as changing the outlier 
payment target of to less than 5 percent of total home health payments. 
We believe that a value of 0.80 for the loss-sharing ratio is 
appropriate in that it preserves incentives for agencies to provide 
care efficiently for outlier cases. Similarly, we continue to believe 
that the total outlier payment target of 5 percent of total home health 
payments appropriately targets the most costly cases under HH PPS.

D. Conclusion

    We have examined the economic impact of this final rule on small 
entities and have determined that the economic impact is positive, 
significant, and that all HHAs would be affected. To the extent that 
small rural hospitals are affiliated with HHAs, the impact on these 
facilities would also be positive. Finally, we have determined that the 
economic effects described above are largely the result of the specific 
statutory provisions, which this final rule serves to announce.
    In accordance with the provisions of Executive Order 12866, this 
regulation was reviewed by the Office of Management and Budget.

List of Subjects in 42 CFR Part 484

    Health facilities, Health professions, Medicare, Reporting and 
record-keeping requirements.


0
For the reasons set forth in the preamble, the Centers for Medicare & 
Medicaid Services amends 42 CFR chapter IV as set forth below:

PART 484--HOME HEALTH SERVICES

0
1. The authority citation for part 484 continues to read as follows:

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


0
2. Section 484.225 is amended as follow:
0
A. Paragraph (d) is redesignated as paragraph (g) and is revised.
0
B. New paragraph (d) is added.
0
C. New paragraph (e) is added.
0
D. New paragraph (f) is added.
    The revisions and additions read as follows:


Sec.  484.225  Annual update of the unadjusted national prospective 60-
day episode payment rate.

* * * * *
    (d) For the last calendar quarter of 2003 and the first calendar 
quarter of 2004, the unadjusted national prospective 60-day episode 
payment rate is equal to the rate from the previous fiscal year (FY 
2003) increased by the applicable home health market basket index 
amount.
    (e) For the last the 3 calendar quarters of 2004, the unadjusted 
national

[[Page 62139]]

prospective 60-day episode payment rate is equal to the rate from the 
previous fiscal year (FY 2003) increased by the applicable home health 
market basket minus 0.8 percentage points.
    (f) For each calendar year of 2005 and 2006, the unadjusted 
national prospective 60-day episode payment rate is equal to the rate 
from the previous calendar year, increased by the applicable home 
health market basket minus 0.8 percentage points.
    (g) For 2007 and subsequent calendar years, the unadjusted national 
rate is equal to the rate for the previous calendar year increased by 
the applicable home health market basket index amount.

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

    Dated: September 14, 2004.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
    Dated: October 7, 2004.
Tommy G. Thompson,
Secretary.

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


  Addendum A.--Wage Index for Rural Areas-Applicable Pre-Floor and Pre-
                    Reclassified Hospital Wage Index
                                [CY 2005]
------------------------------------------------------------------------
                                                                  Wage
                           MSA name                              index
------------------------------------------------------------------------
Alabama......................................................     0.7637
Alaska.......................................................     1.1637
Arizona......................................................     0.9140
Arkansas.....................................................     0.7704
California...................................................     1.0297
Colorado.....................................................     0.9368
Connecticut..................................................     1.1917
Delaware.....................................................     0.9504
Florida......................................................     0.8789
Georgia......................................................     0.8247
Guam.........................................................     0.9611
Hawaii.......................................................     1.0522
Idaho........................................................     0.8826
Illinois.....................................................     0.8341
Indiana......................................................     0.8736
Iowa.........................................................     0.8550
Kansas.......................................................     0.8088
Kentucky.....................................................     0.7844
Louisiana....................................................     0.7291
Maine........................................................     0.9039
Maryland.....................................................     0.9179
Massachusetts................................................     1.0217
Michigan.....................................................     0.8741
Minnesota....................................................     0.9339
Mississippi..................................................     0.7583
Missouri.....................................................     0.7829
Montana......................................................     0.8701
Nebraska.....................................................     0.9035
Nevada.......................................................     0.9833
New Hampshire................................................     0.9940
New Jersey \1\...............................................  .........
New Mexico...................................................     0.8529
New York.....................................................     0.8403
North Carolina...............................................     0.8501
North Dakota.................................................     0.7743
Ohio.........................................................     0.8760
Oklahoma.....................................................     0.7537
Oregon.......................................................     1.0050
Pennsylvania.................................................     0.8348
Puerto Rico..................................................     0.4047
Rhode Island \1\.............................................  .........
South Carolina...............................................     0.8640
South Dakota.................................................     0.8393
Tennessee....................................................     0.7876
Texas........................................................     0.7910
Utah.........................................................     0.8843
Vermont......................................................     0.9375
Virginia.....................................................     0.8480
Virgin Islands...............................................     0.7457
Washington...................................................     1.0072
West Virginia................................................     0.8084
Wisconsin....................................................     0.9498
Wyoming......................................................    0.9182
------------------------------------------------------------------------
\1\ All counties within the State are classified urban.


   Addendum B.--CY 2005 Wage Index for Urban Areas Pre-Floor and Pre-
                    Reclassified Hospital Wage Index
------------------------------------------------------------------------
                                    Urban area (constituent
              MSA                     counties or county          Wage
                                         equivalents)             index
------------------------------------------------------------------------
0040..........................  Abilene, TX...................    0.8009
                                Taylor, TX
0060..........................  Aguadilla, PR.................    0.4294
                                Aguada, PR
                                Aguadilla, PR
                                Moca, PR
0080..........................  Akron, OH.....................    0.9055
                                Portage, OH
                                Summit, OH
0120..........................  Albany, GA....................    1.1266
                                Dougherty, GA
                                Lee, GA
0160..........................  Albany-Schenectady-Troy, NY...    0.8570
                                Albany, NY
                                Montgomery, NY
                                Rensselaer, NY
                                Saratoga, NY
                                Schenectady, NY
                                Schoharie, NY
0200..........................  Albuquerque, NM...............    1.0485
                                Bernalillo, NM
                                Sandoval, NM
                                Valencia, NM
0220..........................  Alexandria, LA................    0.8171
                                Rapides, LA
0240..........................  Allentown-Bethlehem-Easton, PA    0.9536
                                Carbon, PA
                                Lehigh, PA
                                Northampton, PA
0280..........................  Altoona, PA...................    0.8462
                                Blair, PA
0320..........................  Amarillo, TX..................    0.9178

[[Page 62140]]

 
                                Potter, TX
                                Randall, TX
0380..........................  Anchorage, AK.................    1.2109
                                Anchorage, AK
0440..........................  Ann Arbor, MI.................    1.0817
                                Lenawee, MI
                                Livingston, MI
                                Washtenaw, MI
0450..........................  Anniston,AL...................    0.7881
                                Calhoun, AL
0460..........................  Appleton-Oshkosh-Neenah, WI...    0.9115
                                Calumet, WI
                                Outagamie, WI
                                Winnebago, WI
0470..........................  Arecibo, PR...................    0.3757
                                Arecibo, PR
                                Camuy, PR
                                Hatillo, PR
0480..........................  Asheville, NC.................    0.9502
                                Buncombe, NC
                                Madison, NC
0500..........................  Athens, GA....................    1.0203
                                Clarke, GA
                                Madison, GA
                                Oconee, GA
0520..........................  Atlanta, GA...................    0.9971
                                Barrow, GA
                                Bartow, GA
                                Carroll, GA
                                Cherokee, GA
                                Clayton, GA
                                Cobb, GA
                                Coweta, GA
                                De Kalb, GA
                                Douglas, GA
                                Fayette, GA
                                Forsyth, GA
                                Fulton, GA
                                Gwinnett, GA
                                Henry, GA
                                Newton, GA
                                Paulding, GA
                                Pickens, GA
                                Rockdale, GA
                                Spalding, GA
                                Walton, GA
0560..........................  Atlantic City-Cape May, NJ....    1.0907
                                Atlantic City, NJ
                                Cape May, NJ
0580..........................  Auburn-Opelika, AL............    0.8215
                                Lee, AL
0600..........................  Augusta-Aiken, GA-SC..........    0.9208
                                Columbia, GA
                                McDuffie, GA
                                Richmond, GA
                                Aiken, SC
                                Edgefield, SC
0640..........................  Austin-San Marcos, TX.........    0.9596
                                Bastrop, TX
                                Caldwell, TX
                                Hays, TX
                                Travis, TX
                                Williamson, TX
0680..........................  Bakersfield, CA...............    1.0036
                                Kern, CA
0720..........................  Baltimore, MD.................    0.9908
                                Anne Arundel, MD
                                Baltimore, MD
                                Baltimore City, MD
                                Carroll, MD

[[Page 62141]]

 
                                Harford, MD
                                Howard, MD
                                Queen Annes, MD
0733..........................  Bangor, ME....................    0.9955
                                Penobscot, ME
0743..........................  Barnstable-Yarmouth, MA.......    1.2335
                                Barnstable, MA
0760..........................  Baton Rouge, LA...............    0.8354
                                Ascension, LA
                                East Baton Rouge
                                Livingston, LA
                                West Baton Rouge, LA
0840..........................  Beaumont-Port Arthur, TX......    0.8616
                                Hardin, TX
                                Jefferson, TX
                                Orange, TX
0860..........................  Bellingham, WA................    1.1643
                                Whatcom, WA
0870..........................  Benton Harbor, MI.............    0.8847
                                Berrien, MI
0875..........................  Bergen-Passaic, NJ............    1.1967
                                Bergen, NJ
                                Passaic, NJ
0880..........................  Billings, MT..................    0.8961
                                Yellowstone, MT
0920..........................  Biloxi-Gulfport-Pascagoula, MS    0.8649
                                Hancock, MS
                                Harrison, MS
                                Jackson, MS
0960..........................  Binghamton, NY................    0.8447
                                Broome, NY
                                Tioga, NY
1000..........................  Birmingham, AL................    0.9199
                                Blount, AL
                                Jefferson, AL
                                St. Clair, AL
                                Shelby, AL
1010..........................  Bismarck, ND..................    0.7505
                                Burleigh, ND
                                Morton, ND
1020..........................  Bloomington, IN...............    0.8588
                                Monroe, IN
1040..........................  Bloomington-Normal, IL........    0.9111
                                McLean, IL
1080..........................  Boise City, ID................    0.9352
                                Ada, ID
                                Canyon, ID
1123..........................  Boston-Worcester-Lawrence-        1.1291
                                 Lowell-Brockton, MA-NH.
                                Bristol, MA
                                Essex, MA
                                Middlesex, MA
                                Norfolk, MA
                                Plymouth, MA
                                Suffolk, MA
                                Worcester, MA
                                Hillsborough, NH
                                Merrimack, NH
                                Rockingham, NH
                                Strafford, NH
1125..........................  Boulder-Longmont, CO..........    1.0046
                                Boulder, CO
1145..........................  Brazoria, TX..................    0.8525
                                Brazoria, TX
1150..........................  Bremerton, WA.................    1.0614
                                Kitsap, WA
1240..........................  Brownsville-Harlingen-San         1.0125
                                 Benito, TX.
                                Cameron, TX
1260..........................  Bryan-College Station, TX.....    0.9219
                                Brazos, TX
1280..........................  Buffalo-Niagara Falls, NY.....    0.9339

[[Page 62142]]

 
                                Erie, NY
                                Niagara, NY
1303..........................  Burlington, VT................    0.9322
                                Chittenden, VT
                                Franklin, VT
                                Grand Isle, VT
1310..........................  Caguas, PR....................    0.4061
                                Caguas, PR
                                Cayey, PR
                                Cidra, PR
                                Gurabo, PR
                                San Lorenzo, PR
1320..........................  Canton-Massillon, OH..........    0.8895
                                Carroll, OH
                                Stark, OH
1350..........................  Casper, WY....................    0.9244
                                Natrona, WY
1360..........................  Cedar Rapids, IA..............    0.8975
                                Linn, IA
1400..........................  Champaign-Urbana, IL..........    0.9527
                                Champaign, IL
1440..........................  Charleston-North Charleston,      0.9420
                                 SC.
                                Berkeley, SC
                                Charleston, SC
                                Dorchester, SC
1480..........................  Charleston, WV................    0.8876
                                Kanawha, WV
                                Putnam, WV
1520..........................  Charlotte-Gastonia-Rock Hill,     0.9712
                                 NC-SC.
                                Cabarrus, NC
                                Gaston, NC
                                Lincoln, NC
                                Mecklenburg, NC
                                Rowan, NC
                                Union, NC
                                York, SC
1540..........................  Charlottesville, VA...........    1.0295
                                Albemarle, VA
                                Charlottesville City, VA
                                Fluvanna, VA
                                Greene, VA
1560..........................  Chattanooga, TN-GA............    0.9207
                                Catoosa, GA
                                Dade, GA
                                Walker, GA
                                Hamilton, TN
                                Marion, TN
1580..........................  Cheyenne, WY..................    0.8980
                                Laramie, WY
1600..........................  Chicago, IL...................    1.0852
                                Cook, IL
                                De Kalb, IL
                                Du Page, IL
                                Grundy, IL
                                Kane, IL
                                Kendall, IL
                                Lake, IL
                                McHenry, IL
                                Will, IL
1620..........................  Chico-Paradise, CA............    1.0543
                                Butte, CA
1640..........................  Cincinnati, OH-KY-IN..........    0.9595
                                Dearborn, IN
                                Ohio, IN
                                Boone, KY
                                Campbell, KY
                                Gallatin, KY
                                Grant, KY
                                Kenton, KY
                                Pendleton, KY

[[Page 62143]]

 
                                Brown, OH
                                Clermont, OH
                                Hamilton, OH
                                Warren, OH
1660..........................  Clarksville-Hopkinsville, TN-     0.8022
                                 KY.
                                Christian, KY
                                Montgomery, TN
1680..........................  Cleveland-Lorain-Elyria, OH...    0.9626
                                Ashtabula, OH
                                Geauga, OH
                                Cuyahoga, OH
                                Lake, OH
                                Lorain, OH
                                Medina, OH
1720..........................  Colorado Springs, CO..........    0.9793
                                El Paso, CO
1740..........................  Columbia MO...................    0.8396
                                Boone, MO
1760..........................  Columbia, SC..................    0.9450
                                Lexington, SC
                                Richland, SC
1800..........................  Columbus, GA-AL...............    0.8690
                                Russell,AL
                                Chattanoochee, GA
                                Harris, GA
                                Muscogee, GA
1840..........................  Columbus, OH..................    0.9753
                                Delaware, OH
                                Fairfield, OH
                                Franklin, OH
                                Licking, OH
                                Madison, OH
                                Pickaway, OH
1880..........................  Corpus Christi, TX............    0.8647
                                Nueces, TX
                                San Patricio, TX
1890..........................  Corvallis, OR.................    1.0545
                                Benton, OR
1900..........................  Cumberland, MD-WV.............    0.8662
                                Allegany MD
                                Mineral WV
1920..........................  Dallas, TX....................    1.0049
                                Collin, TX
                                Dallas, TX
                                Denton, TX
                                Ellis, TX
                                Henderson, TX
                                Hunt, TX
                                Kaufman, TX
                                Rockwall, TX
1950..........................  Danville, VA..................    0.8643
                                Danville City, VA
                                Pittsylvania, VA
1960..........................  Davenport-Moline-Rock Island,     0.8774
                                 IA-IL.
                                Scott, IA
                                Henry, IL
                                Rock Island, IL
2000..........................  Dayton-Springfield, OH........    0.9232
                                Clark, OH
                                Greene, OH
                                Miami, OH
                                Montgomery, OH
2020..........................  Daytona Beach, FL.............    0.8900
                                Flagler, FL
                                Volusia, FL
2030..........................  Decatur, AL...................    0.8894
                                Lawrence, AL
                                Morgan, AL
2040..........................  Decatur, IL...................    0.8122
                                Macon, IL

[[Page 62144]]

 
2080..........................  Denver, CO....................    1.0905
                                Adams, CO
                                Arapahoe, CO
                                Broomfield, CO
                                Denver, CO
                                Douglas, CO
                                Jefferson, CO
2120..........................  Des Moines, IA................    0.9267
                                Dallas, IA
                                Polk, IA
                                Warren, IA
2160..........................  Detroit, MI...................    1.0227
                                Lapeer, MI
                                Macomb, MI
                                Monroe, MI
                                Oakland, MI
                                St. Clair, MI
                                Wayne, MI
2180..........................  Dothan, AL....................    0.7597
                                Dale, AL
                                Houston, AL
2190..........................  Dover, DE.....................    0.9825
                                Kent, DE
2200..........................  Dubuque, IA...................    0.8748
                                Dubuque, IA
2240..........................  Duluth-Superior, MN-WI........    1.0356
                                St. Louis, MN
                                Douglas, WI
2281..........................  Dutchess County, NY...........    1.1658
                                Dutchess, NY
2290..........................  Eau Claire, WI................    0.9139
                                Chippewa, WI
                                Eau Claire, WI
2320..........................  El Paso, TX...................    0.9065
                                El Paso, TX
2330..........................  Elkhart-Goshen, IN............    0.9279
                                Elkhart, IN
2335..........................  Elmira, NY....................    0.8445
                                Chemung, NY
2340..........................  Enid, OK......................    0.9001
                                Garfield, OK
2360..........................  Erie, PA......................    0.8699
                                Erie, PA
2400..........................  Eugene-Springfield, OR........    1.0940
                                Lane, OR
2440..........................  Evansville-Henderson, IN-KY...    0.8395
                                Posey, IN
                                Vanderburgh, IN
                                Warrick, IN
                                Henderson, KY
2520..........................  Fargo-Moorhead, ND-MN.........    0.9115
                                Clay, MN
                                Cass, ND
2560..........................  Fayetteville, NC..............    0.9363
                                Cumberland, NC
2580..........................  Fayetteville-Springdale-          0.8637
                                 Rogers, AR.
                                Benton, AR
                                Washington, AR
2620..........................  Flagstaff, AZ-UT..............    1.0611
                                Coconino, AZ
                                Kane, UT
2640..........................  Flint, MI.....................    1.1178
                                Genesee, MI
2650..........................  Florence, AL..................    0.7883
                                Colbert, AL
                                Lauderdale, AL
2655..........................  Florence, SC..................    0.8961
                                Florence, SC
2670..........................  Fort Collins-Loveland, CO.....    1.0219
                                Larimer, CO

[[Page 62145]]

 
2680..........................  Ft. Lauderdale, FL............    1.0165
                                Broward, FL
2700..........................  Fort Myers-Cape Coral, FL.....    0.9372
                                Lee, FL
2710..........................  Fort Pierce-Port St. Lucie, FL    1.0046
                                Martin, FL
                                St. Lucie, FL
2720..........................  Fort Smith, AR-OK.............    0.8303
                                Crawford, AR
                                Sebastian, AR
                                Sequoyah, OK
2750..........................  Fort Walton Beach, FL.........    0.8786
                                Okaloosa, FL
2760..........................  Fort Wayne, IN................    0.9737
                                Adams, IN
                                Allen, IN
                                De Kalb, IN
                                Huntington, IN
                                Wells, IN
                                Whitley, IN
2800..........................  Forth Worth-Arlington, TX.....    0.9538
                                Hood, TX
                                Johnson, TX
                                Parker, TX
                                Tarrant, TX
2840..........................  Fresno, CA....................    1.0408
                                Fresno, CA
                                Madera, CA
2880..........................  Gadsden, AL...................    0.8049
                                Etowah, AL
2900..........................  Gainesville, FL...............    0.9459
                                Alachua, FL
2920..........................  Galveston-Texas City, TX......    0.9403
                                Galveston, TX
2960..........................  Gary, IN......................    0.9343
                                Lake, IN
                                Porter, IN
2975..........................  Glens Falls, NY...............    0.8467
                                Warren, NY
                                Washington, NY
2980..........................  Goldsboro, NC.................    0.8779
                                Wayne, NC
2985..........................  Grand Forks, ND-MN............    0.9092
                                Polk, MN
                                Grand Forks, ND
2995..........................  Grand Junction, CO............    0.9900
                                Mesa, CO
3000..........................  Grand Rapids-Muskegon-Holland,    0.9520
                                 MI.
                                Allegan, MI
                                Kent, MI
                                Muskegon, MI
                                Ottawa, MI
3040..........................  Great Falls, MT...............    0.8810
                                Cascade, MT
3060..........................  Greeley, CO...................    0.9444
                                Weld, CO
3080..........................  Green Bay, WI.................    0.9586
                                Brown, WI
3120..........................  Greensboro-Winston-Salem-High     0.9312
                                 Point, NC.
                                Alamance, NC
                                Davidson, NC
                                Davie, NC
                                Forsyth, NC
                                Guilford, NC
                                Randolph, NC
                                Stokes, NC
                                Yadkin, NC
3150..........................  Greenville, NC................    0.9183
                                Pitt, NC
3160..........................  Greenville-Spartanburg-           0.9400
                                 Anderson, SC.

[[Page 62146]]

 
                                Anderson, SC
                                Cherokee, SC
                                Greenville, SC
                                Pickens, SC
                                Spartanburg, SC
3180..........................  Hagerstown, MD................    0.9940
                                Washington, MD
3200..........................  Hamilton-Middletown, OH.......    0.9066
                                Butler, OH
3240..........................  Harrisburg-Lebanon-Carlisle,      0.9286
                                 PA.
                                Cumberland, PA
                                Dauphin, PA
                                Lebanon, PA
                                Perry, PA
3283..........................  Hartford, CT..................    1.1055
                                Hartford, CT
                                Litchfield, CT
                                Middlesex, CT
                                Tolland, CT
3285..........................  Hattiesburg, MS...............    0.7362
                                Forrest, MS
                                Lamar, MS
3290..........................  Hickory-Morganton-Lenoir, NC..    0.9502
                                Alexander, NC
                                Burke, NC
                                Caldwell, NC
                                Catawba, NC
3320..........................  Honolulu, HI..................    1.1014
                                Honolulu, HI
3350..........................  Houma, LA.....................    0.7721
                                Lafourche, LA
                                Terrebonne, LA
3360..........................  Houston, TX...................    1.0117
                                Chambers, TX
                                Fort Bend, TX
                                Harris, TX
                                Liberty, TX
                                Montgomery, TX
                                Waller, TX
3400..........................  Huntington-Ashland, WV-KY-OH..    0.9565
                                Boyd, KY
                                Carter, KY
                                Greenup, KY
                                Lawrence, OH
                                Cabell, WV
                                Wayne, WV
3440..........................  Huntsville, AL................    0.8851
                                Limestone, AL
                                Madison, AL
3480..........................  Indianapolis, IN..............    1.0039
                                Boone, IN
                                Hamilton, IN
                                Hancock, IN
                                Hendricks, IN
                                Johnson, IN
                                Madison, IN
                                Marion, IN
                                Morgan, IN
                                Shelby, IN
3500..........................  Iowa City, IA.................    0.9655
                                Johnson, IA
3520..........................  Jackson, MI...................    0.9146
                                Jackson, MI
3560..........................  Jackson, MS...................    0.8406
                                Hinds, MS
                                Madison, MS
                                Rankin, MS
3580..........................  Jackson, TN...................    0.8900
                                Chester, TN
                                Madison, TN

[[Page 62147]]

 
3600..........................  Jacksonville, FL..............    0.9548
                                Clay, FL
                                Duval, FL
                                Nassau, FL
                                St. Johns, FL
3605..........................  Jacksonville, NC..............    0.8402
                                Onslow, NC
3610..........................  Jamestown, NY.................    0.7589
                                Chautaqua, NY
3620..........................  Janesville-Beloit, WI.........    0.9583
                                Rock, WI
3640..........................  Jersey City, NJ...............    1.0923
                                Hudson, NJ
3660..........................  Johnson City-Kingsport-           0.8203
                                 Bristol, TN-VA.
                                Carter, TN
                                Hawkins, TN
                                Sullivan, TN
                                Unicoi, TN
                                Washington, TN
                                Bristol City, VA
                                Scott, VA
                                Washington, VA
3680..........................  Johnstown, PA.................    0.7981
                                Cambria, PA
                                Somerset, PA
3700..........................  Jonesboro, AR.................    0.7934
                                Craighead, AR
3710..........................  Joplin, MO....................    0.8721
                                Jasper, MO
                                Newton, MO
3720..........................  Kalamazoo-Battlecreek, MI.....    1.0350
                                Calhoun, MI
                                Kalamazoo, MI
                                Van Buren, MI
3740..........................  Kankakee, IL..................    1.0603
                                Kankakee, IL
3760..........................  Kansas City, KS-MO............    0.9642
                                Johnson, KS
                                Leavenworth, KS
                                Miami, KS
                                Wyandotte, KS
                                Cass, MO
                                Clay, MO
                                Clinton, MO
                                Jackson, MO
                                Lafayette, MO
                                Platte, MO
                                Ray, MO
3800..........................  Kenosha, WI...................    0.9772
                                Kenosha, WI
3810..........................  Killeen-Temple, TX............    0.9242
                                Bell, TX
                                Coryell, TX
3840..........................  Knoxville, TN.................    0.8509
                                Anderson, TN
                                Blount, TN
                                Knox, TN
                                Loudon, TN
                                Sevier, TN
                                Union, TN
3850..........................  Kokomo, IN....................    0.8986
                                Howard, IN
                                Tipton, IN
3870..........................  La Crosse, WI-MN..............    0.9290
                                Houston, MN
                                La Crosse, WI
3880..........................  Lafayette, LA.................    0.8105
                                Acadia, LA
                                Lafayette, LA
                                St. Landry, LA

[[Page 62148]]

 
                                St. Martin, LA
3920..........................  Lafayette, IN.................    0.9068
                                Clinton, IN
                                Tippecanoe, IN
3960..........................  Lake Charles, LA..............    0.7959
                                Calcasieu, LA
3980..........................  Lakeland-Winter Haven, FL.....    0.8931
                                Polk, FL
4000..........................  Lancaster, PA.................    0.9883
                                Lancaster, PA
4040..........................  Lansing-East Lansing, MI......    0.9659
                                Clinton, MI
                                Eaton, MI
                                Ingham, MI
4080..........................  Laredo, TX....................    0.8747
                                Webb, TX
4100..........................  Las Cruces, NM................    0.8784
                                Dona Ana, NM
4120..........................  Las Vegas, NV-AZ..............    1.1121
                                Mohave, AZ
                                Clark, NV
                                Nye, NV
4150..........................  Lawrence, KS..................    0.8644
                                Douglas, KS
4200..........................  Lawton, OK....................    0.8212
                                Comanche, OK
4243..........................  Lewiston-Auburn, ME...........    0.9562
                                Androscoggin, ME
4280..........................  Lexington, KY.................    0.8053
                                Bourbon, KY
                                Clark, KY
                                Fayette, KY
                                Jessamine, KY
                                Madison, KY
                                Scott, KY
                                Woodford, KY
4320..........................  Lima, OH......................    0.9258
                                Allen, OH
                                Auglaize, OH
4360..........................  Lincoln, NE...................    1.0208
                                Lancaster, NE
4400..........................  Little Rock-North Little, AR..    0.8827
                                Faulkner, AR
                                Lonoke, AR
                                Pulaski, AR
                                Saline, AR
4420..........................  Longview-Marshall, TX.........    0.8739
                                Gregg, TX
                                Harrison, TX
                                Upshur, TX
4480..........................  Los Angeles-Long Beach, CA....    1.1732
                                Los Angeles, CA
4520..........................  Louisville, KY-IN.............    0.9163
                                Clark, IN
                                Floyd, IN
                                Harrison, IN
                                Scott, IN
                                Bullitt, KY
                                Jefferson, KY
                                Oldham, KY
4600..........................  Lubbock, TX...................    0.8777
                                Lubbock, TX
4640..........................  Lynchburg, VA.................    0.9018
                                Amherst, VA
                                Bedford City, VA
                                Bedford, VA
                                Campbell, VA
                                Lynchburg City, VA
4680..........................  Macon, GA.....................    0.9596
                                Bibb, GA

[[Page 62149]]

 
                                Houston, GA
                                Jones, GA
                                Peach, GA
                                Twiggs, GA
4720..........................  Madison, WI...................    1.0395
                                Dane, WI
4800..........................  Mansfield, OH.................    0.9105
                                Crawford, OH
                                Richland, OH
4840..........................  Mayaguez, PR..................    0.4769
                                Anasco, PR
                                Cabo Rojo, PR
                                Hormigueros, PR
                                Mayaguez, PR
                                Sabana Grande, PR
                                San German, PR
4880..........................  McAllen-Edinburg-Mission, TX..    0.8602
                                Hidalgo, TX
4890..........................  Medford-Ashland, OR...........    1.0534
                                Jackson, OR
4900..........................  Melbourne-Titusville-Palm Bay,    0.9633
                                 FL.
                                Brevard, FL
4920..........................  Memphis, TN-AR-MS.............    0.9234
                                Crittenden, AR
                                De Soto, MS
                                Fayette, TN
                                Shelby, TN
                                Tipton, TN
4940..........................  Merced, CA....................    1.0576
                                Merced, CA
5000..........................  Miami, FL.....................    1.0026
                                Dade, FL
5015..........................  Middlesex-Somerset-Hunterdon,     1.1360
                                 NJ.
                                Hunterdon, NJ
                                Middlesex, NJ
                                Somerset, NJ
5080..........................  Milwaukee-Waukesha, WI........    1.0076
                                Milwaukee, WI
                                Ozaukee, WI
                                Washington, WI
                                Waukesha, WI
5120..........................  Minneapolis-St. Paul, MN-WI...    1.1067
                                Anoka, MN
                                Carver, MN
                                Chisago, MN
                                Dakota, MN
                                Hennepin, MN
                                Isanti, MN
                                Ramsey, MN
                                Scott, MN
                                Sherburne, MN
                                Washington, MN
                                Wright, MN
                                Pierce, WI
                                St. Croix, WI
5140..........................  Missoula, MT..................    0.9618
                                Missoula, MT
5160..........................  Mobile, AL....................    0.7933
                                Baldwin, AL
                                Mobile, AL
5170..........................  Modesto, CA...................    1.1966
                                Stanislaus, CA
5190..........................  Monmouth-Ocean, NJ............    1.0889
                                Monmouth, NJ
                                Ocean, NJ
5200..........................  Monroe, LA....................    0.7913
                                Ouachita, LA
5240..........................  Montgomery, AL................    0.8300
                                Autauga, AL
                                Elmore, AL

[[Page 62150]]

 
                                Montgomery, AL
5280..........................  Muncie, IN....................    0.8580
                                Delaware, IN
5330..........................  Myrtle Beach, SC..............    0.9022
                                Horry, SC
5345..........................  Naples, FL....................    1.0596
                                Collier, FL
5360..........................  Nashville, TN.................    1.0108
                                Cheatham, TN
                                Davidson, TN
                                Dickson, TN
                                Robertson, TN
                                Rutherford, TN
                                Sumner, TN
                                Williamson, TN
                                Wilson, TN
5380..........................  Nassau-Suffolk, NY............    1.2921
                                Nassau, NY
                                Suffolk, NY
5483..........................  New Haven-Bridgeport-Stamford-    1.2254
                                 Waterbury-Danbury, CT.
                                Fairfield, CT
                                New Haven, CT
5523..........................  New London-Norwich, CT........    1.1596
                                New London, CT
5560..........................  New Orleans, LA...............    0.9103
                                Jefferson, LA
                                Orleans, LA
                                Plaquemines, LA
                                St. Bernard, LA
                                St. Charles, LA
                                St. James, LA
                                St. John The Baptist, LA
                                St. Tammany, LA
5600..........................  New York, NY..................    1.3588
                                Bronx, NY
                                Kings, NY
                                New York, NY
                                Putnam, NY
                                Queens, NY
                                Richmond, NY
                                Rockland, NY
                                Westchester, NY
5640..........................  Newark, NJ....................    1.1625
                                Essex, NJ
                                Morris, NJ
                                Sussex, NJ
                                Union, NJ
                                Warren, NJ
5660..........................  Newburgh, NY-PA...............    1.1171
                                Orange, NY
                                Pike, PA
5720..........................  Norfolk-Virginia Beach-Newport    0.8895
                                 News, VA-NC.
                                Currituck, NC
                                Chesapeake City, VA
                                Gloucester, VA
                                Hampton City, VA
                                Isle of Wight, VA
                                James City, VA
                                Mathews, 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
5775..........................  Oakland, CA...................    1.5221
                                Alameda, CA
                                Contra Costa, CA

[[Page 62151]]

 
5790..........................  Ocala, FL.....................    0.9153
                                Marion, FL
5800..........................  Odessa-Midland, TX............    0.9632
                                Ector, TX
                                Midland, TX
5880..........................  Oklahoma City, OK.............    0.8966
                                Canadian, OK
                                Cleveland, OK
                                Logan, OK
                                McClain, OK
                                Oklahoma, OK
                                Pottawatomie, OK
5910..........................  Olympia, WA...................    1.1007
                                Thurston, WA
5920..........................  Omaha, NE-IA..................    0.9754
                                Pottawattamie, IA
                                Cass, NE
                                Douglas, NE
                                Sarpy, NE
                                Washington, NE
5945..........................  Orange County, CA.............    1.1612
                                Orange, CA
5960..........................  Orlando, FL...................    0.9742
                                Lake, FL
                                Orange, FL
                                Osceola, FL
                                Seminole, FL
5990..........................  Owensboro, KY.................    0.8434
                                Daviess, KY
6015..........................  Panama City, FL...............    0.8124
                                Bay, FL
6020..........................  Parkersburg-Marietta, WV-OH...    0.8288
                                Washington, OH
                                Wood, WV
6080..........................  Pensacola, FL.................    0.8306
                                Escambia, FL
                                Santa Rosa, FL
6120..........................  Peoria-Pekin, IL..............    0.8886
                                Peoria, IL
                                Tazewell, IL
                                Woodford, IL
6160..........................  Philadelphia, PA-NJ...........    1.0824
                                Burlington, NJ
                                Camden, NJ
                                Gloucester, NJ
                                Salem, NJ
                                Bucks, PA
                                Chester, PA
                                Delaware, PA
                                Montgomery, PA
                                Philadelphia, PA
6200..........................  Phoenix-Mesa, AZ..............    0.9982
                                Maricopa, AZ
                                Pinal, AZ
6240..........................  Pine Bluff, AR................    0.8673
                                Jefferson, AR
6280..........................  Pittsburgh, PA................    0.8756
                                Allegheny, PA
                                Beaver, PA
                                Butler, PA
                                Fayette, PA
                                Washington, PA
                                Westmoreland, PA
6323..........................  Pittsfield, MA................    1.0439
                                Berkshire, MA
6340..........................  Pocatello, ID.................    0.9602
                                Bannock, ID
6360..........................  Ponce, PR.....................    0.4954
                                Guayanilla, PR
                                Juana Diaz, PR

[[Page 62152]]

 
                                Penuelas, PR
                                Ponce, PR
                                Villalba, PR
                                Yauco, PR
6403..........................  Portland, ME..................    1.0112
                                Cumberland, ME
                                Sagadahoc, ME
                                York, ME
6440..........................  Portland-Vancouver, OR-WA.....    1.1403
                                Clackamas, OR
                                Columbia, OR
                                Multnomah, OR
                                Washington, OR
                                Yamhill, OR
                                Clark, WA
6483..........................  Providence-Warwick-Pawtucket,     1.1062
                                 RI.
                                Bristol, RI
                                Kent, RI
                                Newport, RI
                                Providence, RI
                                Washington, RI
6520..........................  Provo-Orem, UT................    0.9613
                                Utah, UT
6560..........................  Pueblo, CO....................    0.8752
                                Pueblo, CO
6580..........................  Punta Gorda, FL...............    0.9441
                                Charlotte, FL
6600..........................  Racine, WI....................    0.9045
                                Racine, WI
6640..........................  Raleigh-Durham-Chapel Hill, NC    1.0258
                                Chatham, NC
                                Durham, NC
                                Franklin, NC
                                Johnston, NC
                                Orange, NC
                                Wake, NC
6660..........................  Rapid City, SD................    0.8912
                                Pennington, SD
6680..........................  Reading, PA...................    0.9216
                                Berks, PA
6690..........................  Redding, CA...................    1.1835
                                Shasta, CA
6720..........................  Reno, NV......................    1.0456
                                Washoe, NV
6740..........................  Richland-Kennewick-Pasco, WA..    1.0520
                                Benton, WA
                                Franklin, WA
6760..........................  Richmond-Petersburg, VA.......    0.9398
                                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..    1.0975
                                Riverside, CA
                                San Bernardino, CA
6800..........................  Roanoke, VA...................    0.8429
                                Botetourt, VA
                                Roanoke, VA
                                Roanoke City, VA
                                Salem City, VA
6820..........................  Rochester, MN.................    1.1504

[[Page 62153]]

 
                                Olmsted, MN
6840..........................  Rochester, NY.................    0.9196
                                Genesee, NY
                                Livingston, NY
                                Monroe, NY
                                Ontario, NY
                                Orleans, NY
                                Wayne, NY
6880..........................  Rockford, IL..................    0.9626
                                Boone, IL
                                Ogle, IL
                                Winnebago, IL
6895..........................  Rocky Mount, NC...............    0.8998
                                Edgecombe, NC
                                Nash, NC
6920..........................  Sacramento, CA................    1.1849
                                El Dorado, CA
                                Placer, CA
                                Sacramento, CA
6960..........................  Saginaw-Bay City-Midland, MI..    0.9696
                                Bay, MI
                                Midland, MI
                                Saginaw, MI
6980..........................  St. Cloud, MN.................    1.0215
                                Benton, MN
                                Stearns, MN
7000..........................  St. Joseph, MO................    1.0013
                                Andrews, MO
                                Buchanan, MO
7040..........................  St. Louis, MO-IL..............    0.9081
                                Clinton, IL
                                Jersey, IL
                                Madison, IL
                                Monroe, IL
                                St. Clair, IL
                                Franklin, MO
                                Jefferson, MO
                                Lincoln, MO
                                St. Charles, MO
                                St. Louis, MO
                                St. Louis City, MO
                                Warren, MO
                                Sullivan City, MO
7080..........................  Salem, OR.....................    1.0557
                                Marion, OR
                                Polk, OR
7120..........................  Salinas, CA...................    1.3823
                                Monterey, CA
7160..........................  Salt Lake City-Ogden, UT......    0.9487
                                Davis, UT
                                Salt Lake, UT
                                Weber, UT
7200..........................  San Angelo, TX................    0.8168
                                Tom Green, TX
7240..........................  San Antonio, TX...............    0.9023
                                Bexar, TX
                                Comal, TX
                                Guadalupe, TX
                                Wilson, TX
7320..........................  San Diego, CA.................    1.1267
                                San Diego, CA
7360..........................  San Francisco, CA.............    1.4712
                                Marin, CA
                                San Francisco, CA
                                San Mateo, CA
7400..........................  San Jose, CA..................    1.4744
                                Santa Clara, CA
7440..........................  San Juan-Bayamon, PR..........    0.4802
                                Aguas Buenas, PR
                                Barceloneta, PR

[[Page 62154]]

 
                                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-       1.1118
                                 Paso Robles, CA.
                                San Luis Obispo, CA
7480..........................  Santa Barbara-Santa Maria-        1.0771
                                 Lompoc, CA.
                                Santa Barbara, CA
7485..........................  Santa Cruz-Watsonville, CA....    1.4780
                                Santa Cruz, CA
7490..........................  Santa Fe, NM..................    1.0590
                                Los Alamos, NM
                                Santa Fe, NM
7500..........................  Santa Rosa, CA................    1.2962
                                Sonoma, CA
7510..........................  Sarasota-Bradenton, FL........    0.9630
                                Manatee, FL
                                Sarasota, FL
7520..........................  Savannah, GA..................    0.9460
                                Bryan, GA
                                Chatham, GA
                                Effingham, GA
7560..........................  Scranton--Wilkes-Barre--          0.8523
                                 Hazleton, PA.
                                Columbia, PA
                                Lackawanna, PA
                                Luzerne, PA
                                Wyoming, PA
7600..........................  Seattle-Bellevue-Everett, WA..    1.1479
                                Island, WA
                                King, WA
                                Snohomish, WA
7610..........................  Sharon, PA....................    0.7881
                                Mercer, PA
7620..........................  Sheboygan, WI.................    0.8949
                                Sheboygan, WI
7640..........................  Sherman-Denison, TX...........    0.9617
                                Grayson, TX
7680..........................  Shreveport-Bossier City, LA...    0.9112
                                Bossier, LA
                                Caddo, LA
                                Webster, LA
7720..........................  Sioux City, IA-NE.............    0.9094
                                Woodbury, IA
                                Dakota, NE
7760..........................  Sioux Falls, SD...............    0.9441
                                Lincoln, SD

[[Page 62155]]

 
                                Minnehaha, SD
7800..........................  South Bend, IN................    0.9447
                                St. Joseph, IN
7840..........................  Spokane, WA...................    1.0661
                                Spokane, WA
7880..........................  Springfield, IL...............    0.8738
                                Menard, IL
                                Sangamon, IL
7920..........................  Springfield, MO...............    0.8597
                                Christian, MO
                                Greene, MO
                                Webster, MO
8003..........................  Springfield, MA...............    1.0174
                                Hampden, MA
                                Hampshire, MA
8050..........................  State College, PA.............    0.8462
                                Centre, PA
8080..........................  Steubenville-Weirton, OH-WV...    0.8281
                                Jefferson, OH
                                Brooke, WV
                                Hancock, WV
8120..........................  Stockton-Lodi, CA.............    1.0564
                                San Joaquin, CA
8140..........................  Sumter, SC....................    0.8520
                                Sumter, SC
8160..........................  Syracuse, NY..................    0.9394
                                Cayuga, NY
                                Madison, NY
                                Onondaga, NY
                                Oswego, NY
8200..........................  Tacoma, WA....................    1.1078
                                Pierce, WA
8240..........................  Tallahassee, FL...............    0.8656
                                Gadsden, FL
                                Leon, FL
8280..........................  Tampa-St. Petersburg-             0.9024
                                 Clearwater, FL.
                                Hernando, FL
                                Hillsborough, FL
                                Pasco, FL
                                Pinellas, FL
8320..........................  Terre Haute, IN...............    0.8582
                                Clay, IN
                                Vermillion, IN
                                Vigo, IN
8360..........................  Texarkana, AR-Texarkana, TX...    0.8414
                                Miller, AR
                                Bowie, TX
8400..........................  Toledo, OH....................    0.9525
                                Fulton, OH
                                Lucas, OH
                                Wood, OH
8440..........................  Topeka, KS....................    0.8904
                                Shawnee, KS
8480..........................  Trenton, NJ...................    1.0276
                                Mercer, NJ
8520..........................  Tucson, AZ....................    0.8926
                                Pima, AZ
8560..........................  Tulsa, OK.....................    0.8729
                                Creek, OK
                                Osage, OK
                                Rogers, OK
                                Tulsa, OK
                                Wagoner, OK
8600..........................  Tuscaloosa, AL................    0.8440
                                Tuscaloosa, AL
8640..........................  Tyler, TX.....................    0.9502
                                Smith, TX
8680..........................  Utica-Rome, NY................    0.8295
                                Herkimer, NY
                                Oneida, NY

[[Page 62156]]

 
8720..........................  Vallejo-Fairfield-Napa, CA....    1.3517
                                Napa, CA
                                Solano, CA
8735..........................  Ventura, CA...................    1.1105
                                Ventura, CA
8750..........................  Victoria, TX..................    0.8469
                                Victoria, TX
8760..........................  Vineland-Millville-Bridgeton,     1.0573
                                 NJ.
                                Cumberland, NJ
8780..........................  Visalia-Tulare-Porterville, CA    0.9964
                                Tulare, CA
8800..........................  Waco, TX......................    0.8146
                                McLennan, TX
8840..........................  Washington, DC-MD-VA-WV.......    1.0971
                                District of Columbia, DC
                                Calvert, MD
                                Charles, MD
                                Frederick, MD
                                Montgomery, MD
                                Prince Georges, MD
                                Alexandria City, VA
                                Arlington, VA
                                Clarke, VA
                                Culpepper, VA
                                Fairfax, VA
                                Fairfax City, VA
                                Falls Church City, VA
                                Fauquier, VA
                                Fredericksburg City, VA
                                King George, VA
                                Loudoun, VA
                                Manassas City, VA
                                Manassas Park City, VA
                                Prince William, VA
                                Spotsylvania, VA
                                Stafford, VA
                                Warren, VA
                                Berkeley, WV
                                Jefferson, WV
8920..........................  Waterloo-Cedar Falls, IA......    0.8633
                                Black Hawk, IA
8940..........................  Wausau, WI....................    0.9570
                                Marathon, WI
8960..........................  West Palm Beach-Boca Raton, FL    1.0059
                                Palm Beach, FL
9000..........................  Wheeling, OH-WV...............    0.7449
                                Belmont, OH
                                Marshall, WV
                                Ohio, WV
9040..........................  Wichita, KS...................    0.9473
                                Butler, KS
                                Harvey, KS
                                Sedgwick, KS
9080..........................  Wichita Falls, TX.............    0.8395
                                Archer, TX
                                Wichita, TX
9140..........................  Williamsport, PA..............    0.8486
                                Lycoming, PA
9160..........................  Wilmington-Newark, DE-MD......    1.1121
                                New Castle, DE
                                Cecil, MD
9200..........................  Wilmington, NC................    0.9237
                                New Hanover, NC
                                Brunswick, NC
9260..........................  Yakima, WA....................    1.0323
                                Yakima, WA
9270..........................  Yolo, CA......................    0.9378
                                Yolo, CA
9280..........................  York, PA......................    0.9150
                                York, PA

[[Page 62157]]

 
9320..........................  Youngstown-Warren, OH.........    0.9518
                                Columbiana, OH
                                Mahoning, OH
                                Trumbull, OH
9340..........................  Yuba City, CA.................    1.0364
                                Sutter, CA
                                Yuba, CA
9360..........................  Yuma, AZ......................    0.8871
                                Yuma, AZ
------------------------------------------------------------------------


      Addendum C.--Comparison of Pre-Floor and Pre-Reclassified Hospital Wage Index for FY 2003 and CY 2005
----------------------------------------------------------------------------------------------------------------
                                                            FY 2003 Wage       CY 2005 Wage     Percent change,
                       Rural area                              index              index         FY 2003-CY 2005
----------------------------------------------------------------------------------------------------------------
ALABAMA................................................             0.7660             0.7637              -0.30
ALASKA.................................................             1.2293             1.1637              -5.34
ARIZONA................................................             0.8493             0.9140               7.62
ARKANSAS...............................................             0.7666             0.7704               0.50
CALIFORNIA.............................................             0.9840             1.0297               4.64
COLORADO...............................................             0.9015             0.9368               3.92
CONNECTICUT............................................             1.2394             1.1917              -3.85
DELAWARE...............................................             0.9128             0.9504               4.12
FLORIDA................................................             0.8814             0.8789              -0.28
GEORGIA................................................             0.8230             0.8247               0.21
GUAM...................................................             0.9611             0.9611               0.00
HAWAII.................................................             1.0255             1.0522               2.60
IDAHO..................................................             0.8747             0.8826               0.90
ILLINOIS...............................................             0.8204             0.8341               1.67
INDIANA................................................             0.8755             0.8736              -0.22
IOWA...................................................             0.8315             0.8550               2.83
KANSAS.................................................             0.7923             0.8088               2.08
KENTUCKY...............................................             0.8079             0.7844              -2.91
LOUISIANA..............................................             0.7567             0.7291              -3.65
MAINE..................................................             0.8874             0.9039               1.86
MARYLAND...............................................             0.8946             0.9179               2.60
MASSACHUSETTS..........................................             1.1288             1.0217              -9.49
MICHIGAN...............................................             0.9000             0.8741              -2.88
MINNESOTA..............................................             0.9151             0.9339               2.05
MISSISSIPPI............................................             0.7680             0.7583              -1.26
MISSOURI...............................................             0.8021             0.7829              -2.39
MONTANA................................................             0.8481             0.8701               2.59
NEBRASKA...............................................             0.8204             0.9035              10.13
NEVADA.................................................             0.9577             0.9833               2.67
NEW HAMPSHIRE..........................................             0.9796             0.9940               1.47
New Jersey.............................................  .................  .................  .................
NEW MEXICO.............................................             0.8872             0.8529              -3.87
NEW YORK...............................................             0.8542             0.8403              -1.63
NORTH CAROLINA.........................................             0.8666             0.8501              -1.90
NORTH DAKOTA...........................................             0.7788             0.7743              -0.58
OHIO...................................................             0.8613             0.8760               1.71
OKLAHOMA...............................................             0.7590             0.7537              -0.70
OREGON.................................................             1.0303             1.0050              -2.46
PENNSYLVANIA...........................................             0.8462             0.8348              -1.35
PUERTO RICO............................................             0.4356             0.4047              -7.09
RHODE ISLAND...........................................  .................  .................  .................
SOUTH CAROLINA.........................................             0.8607             0.8640               0.38
SOUTH DAKOTA...........................................             0.7815             0.8393               7.40
TENNESSEE..............................................             0.7877             0.7876              -0.01
TEXAS..................................................             0.7821             0.7910               1.14
UTAH...................................................             0.9312             0.8843              -5.04
VERMONT................................................             0.9345             0.9375               0.32
VIRGINIA...............................................             0.8504             0.8480              -0.28
VIRGIN ISLANDS.........................................             0.7845             0.7457              -4.95
WASHINGTON.............................................             1.0179             1.0072              -1.05
WEST VIRGINIA..........................................             0.7975             0.8084               1.37
WISCONSIN..............................................             0.9162             0.9498               3.67
WYOMING................................................             0.9007             0.9182               1.94
----------------------------------------------------------------------------------------------------------------


[[Page 62158]]


----------------------------------------------------------------------------------------------------------------
                                                            FY 2003 wage       CY 2005 wage     Percent change,
                       Urban MSA                               index              index         FY 2003-CY 2005
----------------------------------------------------------------------------------------------------------------
0040...................................................             0.7792             0.8009               2.78
0060...................................................             0.4587             0.4294              -6.39
0080...................................................             0.9600             0.9055              -5.68
0120...................................................             1.0594             1.1266               6.34
0160...................................................             0.8384             0.8570               2.22
0200...................................................             0.9315             1.0485              12.56
0220...................................................             0.7859             0.8171               3.97
0240...................................................             0.9735             0.9536              -2.04
0280...................................................             0.9225             0.8462              -8.27
0320...................................................             0.9034             0.9178               1.59
0380...................................................             1.2358             1.2109              -2.01
0440...................................................             1.1103             1.0817              -2.58
0450...................................................             0.8044             0.7881              -2.03
0460...................................................             0.8997             0.9115               1.31
0470...................................................             0.4337             0.3757             -13.37
0480...................................................             0.9876             0.9502              -3.79
0500...................................................             1.0211             1.0203              -0.08
0520...................................................             0.9991             0.9971              -0.20
0560...................................................             1.1017             1.0907              -1.00
0580...................................................             0.8325             0.8215              -1.32
0600...................................................             1.0264             0.9208             -10.29
0640...................................................             0.9637             0.9596              -0.43
0680...................................................             0.9899             1.0036               1.38
0720...................................................             0.9929             0.9908              -0.21
0733...................................................             0.9664             0.9955               3.01
0743...................................................             1.3202             1.2335              -6.57
0760...................................................             0.8294             0.8354               0.72
0840...................................................             0.8324             0.8616               3.51
0860...................................................             1.2282             1.1643              -5.20
0870...................................................             0.9042             0.8847              -2.16
0875...................................................             1.2150             1.1967              -1.51
0880...................................................             0.9022             0.8961              -0.68
0920...................................................             0.8757             0.8649              -1.23
0960...................................................             0.8341             0.8447               1.27
1000...................................................             0.9222             0.9199              -0.25
1010...................................................             0.7972             0.7505              -5.86
1020...................................................             0.8907             0.8588              -3.58
1040...................................................             0.9109             0.9111               0.02
1080...................................................             0.9310             0.9352               0.45
1123...................................................             1.1235             1.1291               0.50
1125...................................................             0.9689             1.0046               3.68
1145...................................................             0.8535             0.8525              -0.12
1150...................................................             1.0944             1.0614              -3.02
1240...................................................             0.8880             1.0125              14.02
1260...................................................             0.8821             0.9219               4.51
1280...................................................             0.9365             0.9339              -0.28
1303...................................................             1.0052             0.9322              -7.26
1310...................................................             0.4371             0.4061              -7.09
1320...................................................             0.8932             0.8895              -0.41
1350...................................................             0.9690             0.9244              -4.60
1360...................................................             0.9056             0.8975              -0.89
1400...................................................             1.0635             0.9527             -10.42
1440...................................................             0.9235             0.9420               2.00
1480...................................................             0.8898             0.8876              -0.25
1520...................................................             0.9850             0.9712              -1.40
1540...................................................             1.0438             1.0295              -1.37
1560...................................................             0.8976             0.9207               2.57
1580...................................................             0.8628             0.8980               4.08
1600...................................................             1.1044             1.0852              -1.74
1620...................................................             0.9745             1.0543               8.19
1640...................................................             0.9381             0.9595               2.28
1660...................................................             0.8406             0.8022              -4.57
1680...................................................             0.9670             0.9626              -0.46
1720...................................................             0.9916             0.9793              -1.24
1740...................................................             0.8496             0.8396              -1.18
1760...................................................             0.9307             0.9450               1.54
1800...................................................             0.8374             0.8690               3.77
1840...................................................             0.9751             0.9753               0.02
1880...................................................             0.8729             0.8647              -0.94
1890...................................................             1.1453             1.0545              -7.93
1900...................................................             0.7847             0.8662              10.39
1920...................................................             0.9998             1.0049               0.51
1950...................................................             0.8859             0.8643              -2.44

[[Page 62159]]

 
1960...................................................             0.8835             0.8774              -0.69
2000...................................................             0.9282             0.9232              -0.54
2020...................................................             0.9062             0.8900              -1.79
2030...................................................             0.8973             0.8894              -0.88
2040...................................................             0.8055             0.8122               0.83
2080...................................................             1.0601             1.0905               2.87
2120...................................................             0.8791             0.9267               5.41
2160...................................................             1.0448             1.0227              -2.12
2180...................................................             0.8137             0.7597              -6.64
2190...................................................             0.9356             0.9825               5.01
2200...................................................             0.8795             0.8748              -0.53
2240...................................................             1.0368             1.0356              -0.12
2281...................................................             1.0684             1.1658               9.12
2290...................................................             0.8952             0.9139               2.09
2320...................................................             0.9265             0.9065              -2.16
2330...................................................             0.9722             0.9279              -4.56
2335...................................................             0.8416             0.8445               0.34
2340...................................................             0.8376             0.9001               7.46
2360...................................................             0.8925             0.8699              -2.53
2400...................................................             1.0944             1.0940              -0.04
2440...................................................             0.8177             0.8395               2.67
2520...................................................             0.9684             0.9115              -5.88
2560...................................................             0.8889             0.9363               5.33
2580...................................................             0.8100             0.8637               6.63
2620...................................................             1.0682             1.0611              -0.66
2640...................................................             1.1135             1.1178               0.39
2650...................................................             0.7792             0.7883               1.17
2655...................................................             0.8780             0.8961               2.06
2670...................................................             1.0066             1.0219               1.52
2680...................................................             1.0297             1.0165              -1.28
2700...................................................             0.9680             0.9372              -3.18
2710...................................................             0.9823             1.0046               2.27
2720...................................................             0.7895             0.8303               5.17
2750...................................................             0.9693             0.8786              -9.36
2760...................................................             0.9457             0.9737               2.96
2800...................................................             0.9446             0.9538               0.97
2840...................................................             1.0216             1.0408               1.88
2880...................................................             0.8505             0.8049              -5.36
2900...................................................             0.9871             0.9459              -4.17
2920...................................................             0.9465             0.9403              -0.66
2960...................................................             0.9584             0.9343              -2.51
2975...................................................             0.8281             0.8467               2.25
2980...................................................             0.8892             0.8779              -1.27
2985...................................................             0.8897             0.9092               2.19
2995...................................................             0.9456             0.9900               4.70
3000...................................................             0.9525             0.9520              -0.05
3040...................................................             0.8950             0.8810              -1.56
3060...................................................             0.9237             0.9444               2.24
3080...................................................             0.9502             0.9586               0.88
3120...................................................             0.9282             0.9312               0.32
3150...................................................             0.9100             0.9183               0.91
3160...................................................             0.9122             0.9400               3.05
3180...................................................             0.9268             0.9940               7.25
3200...................................................             0.9418             0.9066              -3.74
3240...................................................             0.9223             0.9286               0.68
3283...................................................             1.1549             1.1055              -4.28
3285...................................................             0.7659             0.7362              -3.88
3290...................................................             0.9028             0.9502               5.25
3320...................................................             1.1457             1.1014              -3.87
3350...................................................             0.8385             0.7721              -7.92
3360...................................................             0.9892             1.0117               2.27
3400...................................................             0.9636             0.9565              -0.74
3440...................................................             0.8903             0.8851              -0.58
3480...................................................             0.9717             1.0039               3.31
3500...................................................             0.9587             0.9655               0.71
3520...................................................             0.9532             0.9146              -4.05
3560...................................................             0.8607             0.8406              -2.34
3580...................................................             0.9275             0.8900              -4.04
3600...................................................             0.9381             0.9548               1.78
3605...................................................             0.8239             0.8402               1.98
3610...................................................             0.7976             0.7589              -4.85
3620...................................................             0.9849             0.9583              -2.70
3640...................................................             1.1190             1.0923              -2.39

[[Page 62160]]

 
3660...................................................             0.8268             0.8203              -0.79
3680...................................................             0.8329             0.7981              -4.18
3700...................................................             0.7749             0.7934               2.39
3710...................................................             0.8613             0.8721               1.25
3720...................................................             1.0595             1.0350              -2.31
3740...................................................             1.0790             1.0603              -1.73
3760...................................................             0.9736             0.9642              -0.97
3800...................................................             0.9686             0.9772               0.89
3810...................................................             1.0399             0.9242             -11.13
3840...................................................             0.8970             0.8509              -5.14
3850...................................................             0.8971             0.8986               0.17
3870...................................................             0.9400             0.9290              -1.17
3880...................................................             0.8475             0.8105              -4.37
3920...................................................             0.9278             0.9068              -2.26
3960...................................................             0.7965             0.7959              -0.08
3980...................................................             0.9357             0.8931              -4.55
4000...................................................             0.9078             0.9883               8.87
4040...................................................             0.9726             0.9659              -0.69
4080...................................................             0.8472             0.8747               3.25
4100...................................................             0.8745             0.8784               0.45
4120...................................................             1.1521             1.1121              -3.47
4150...................................................             0.7923             0.8644               9.10
4200...................................................             0.8315             0.8212              -1.24
4243...................................................             0.9179             0.9562               4.17
4280...................................................             0.8581             0.8053              -6.15
4320...................................................             0.9483             0.9258              -2.37
4360...................................................             0.9892             1.0208               3.19
4400...................................................             0.9097             0.8827              -2.97
4420...................................................             0.8629             0.8739               1.27
4480...................................................             1.2001             1.1732              -2.24
4520...................................................             0.9276             0.9163              -1.22
4600...................................................             0.9646             0.8777              -9.01
4640...................................................             0.9219             0.9018              -2.18
4680...................................................             0.9204             0.9596               4.26
4720...................................................             1.0467             1.0395              -0.69
4800...................................................             0.8900             0.9105               2.30
4840...................................................             0.4914             0.4769              -2.95
4880...................................................             0.8428             0.8602               2.06
4890...................................................             1.0498             1.0534               0.34
4900...................................................             1.0253             0.9633              -6.05
4920...................................................             0.8920             0.9234               3.52
4940...................................................             0.9837             1.0576               7.51
5000...................................................             0.9802             1.0026               2.29
5015...................................................             1.1213             1.1360               1.31
5080...................................................             0.9893             1.0076               1.85
5120...................................................             1.0903             1.1067               1.50
5140...................................................             0.9157             0.9618               5.03
5160...................................................             0.8108             0.7933              -2.16
5170...................................................             1.0498             1.1966              13.98
5190...................................................             1.0674             1.0889               2.01
5200...................................................             0.8137             0.7913              -2.75
5240...................................................             0.7734             0.8300               7.32
5280...................................................             0.9284             0.8580              -7.58
5330...................................................             0.8976             0.9022               0.51
5345...................................................             0.9754             1.0596               8.63
5360...................................................             0.9578             1.0108               5.53
5380...................................................             1.3357             1.2921              -3.26
5483...................................................             1.2408             1.2254              -1.24
5523...................................................             1.1767             1.1596              -1.45
5560...................................................             0.9046             0.9103               0.63
5600...................................................             1.4414             1.3588              -5.73
5640...................................................             1.1381             1.1625               2.14
5660...................................................             1.1387             1.1171              -1.90
5720...................................................             0.8574             0.8895               3.74
5775...................................................             1.5072             1.5221               0.99
5790...................................................             0.9402             0.9153              -2.65
5800...................................................             0.9397             0.9632               2.50
5880...................................................             0.8900             0.8966               0.74
5910...................................................             1.0960             1.1007               0.43
5920...................................................             0.9978             0.9754              -2.24
5945...................................................             1.1474             1.1612               1.20
5960...................................................             0.9640             0.9742               1.06
5990...................................................             0.8344             0.8434               1.08

[[Page 62161]]

 
6015...................................................             0.8865             0.8124              -8.36
6020...................................................             0.8127             0.8288               1.98
6080...................................................             0.8645             0.8306              -3.92
6120...................................................             0.8739             0.8886               1.68
6160...................................................             1.0713             1.0824               1.04
6200...................................................             0.9820             0.9982               1.65
6240...................................................             0.7962             0.8673               8.93
6280...................................................             0.9365             0.8756              -6.50
6323...................................................             1.0235             1.0439               1.99
6340...................................................             0.9372             0.9602               2.45
6360...................................................             0.5169             0.4954              -4.16
6403...................................................             0.9794             1.0112               3.25
6440...................................................             1.0667             1.1403               6.90
6483...................................................             1.0854             1.1062               1.92
6520...................................................             0.9984             0.9613              -3.72
6560...................................................             0.8820             0.8752              -0.77
6580...................................................             0.9218             0.9441               2.42
6600...................................................             0.9334             0.9045              -3.10
6640...................................................             0.9990             1.0258               2.68
6660...................................................             0.8846             0.8912               0.75
6680...................................................             0.9295             0.9216              -0.85
6690...................................................             1.1135             1.1835               6.29
6720...................................................             1.0648             1.0456              -1.80
6740...................................................             1.1491             1.0520              -8.45
6760...................................................             0.9477             0.9398              -0.83
6780...................................................             1.1365             1.0975              -3.43
6800...................................................             0.8614             0.8429              -2.15
6820...................................................             1.2139             1.1504              -5.23
6840...................................................             0.9194             0.9196               0.02
6880...................................................             0.9625             0.9626               0.01
6895...................................................             0.9228             0.8998              -2.49
6920...................................................             1.1500             1.1849               3.03
6960...................................................             0.9650             0.9696               0.48
6980...................................................             0.9700             1.0215               5.31
7000...................................................             0.8021             1.0013              24.83
7040...................................................             0.8855             0.9081               2.55
7080...................................................             1.0367             1.0557               1.83
7120...................................................             1.4623             1.3823              -5.47
7160...................................................             0.9945             0.9487              -4.61
7200...................................................             0.8374             0.8168              -2.46
7240...................................................             0.8753             0.9023               3.08
7320...................................................             1.1131             1.1267               1.22
7360...................................................             1.4142             1.4712               4.03
7400...................................................             1.4145             1.4744               4.23
7440...................................................             0.4741             0.4802               1.29
7460...................................................             1.1271             1.1118              -1.36
7480...................................................             1.0481             1.0771               2.77
7485...................................................             1.3646             1.4780               8.31
7490...................................................             1.0712             1.0590              -1.14
7500...................................................             1.3046             1.2962              -0.64
7510...................................................             0.9425             0.9630               2.18
7520...................................................             0.9376             0.9460               0.90
7560...................................................             0.8599             0.8523              -0.88
7600...................................................             1.1474             1.1479               0.04
7610...................................................             0.7869             0.7881               0.15
7620...................................................             0.8697             0.8949               2.90
7640...................................................             0.9255             0.9617               3.91
7680...................................................             0.8987             0.9112               1.39
7720...................................................             0.9046             0.9094               0.53
7760...................................................             0.9257             0.9441               1.99
7800...................................................             0.9802             0.9447              -3.62
7840...................................................             1.0852             1.0661              -1.76
7880...................................................             0.8659             0.8738               0.91
7920...................................................             0.8424             0.8597               2.05
8003...................................................             1.0927             1.0174              -6.89
8050...................................................             0.8941             0.8462              -5.36
8080...................................................             0.8804             0.8281              -5.94
8120...................................................             1.0506             1.0564               0.55
8140...................................................             0.8273             0.8520               2.99
8160...................................................             0.9714             0.9394              -3.29
8200...................................................             1.0940             1.1078               1.26
8240...................................................             0.8504             0.8656               1.79
8280...................................................             0.9065             0.9024              -0.45

[[Page 62162]]

 
8320...................................................             0.8599             0.8582              -0.20
8360...................................................             0.8088             0.8414               4.03
8400...................................................             0.9810             0.9525              -2.91
8440...................................................             0.9199             0.8904              -3.21
8480...................................................             1.0432             1.0276              -1.50
8520...................................................             0.8911             0.8926               0.17
8560...................................................             0.8332             0.8729               4.76
8600...................................................             0.8130             0.8440               3.81
8640...................................................             0.9521             0.9502              -0.20
8680...................................................             0.8465             0.8295              -2.01
8720...................................................             1.3354             1.3517               1.22
8735...................................................             1.1096             1.1105               0.08
8750...................................................             0.8756             0.8469              -3.28
8760...................................................             1.0031             1.0573               5.40
8780...................................................             0.9429             0.9964               5.67
8800...................................................             0.8073             0.8146               0.90
8840...................................................             1.0851             1.0971               1.11
8920...................................................             0.8069             0.8633               6.99
8940...................................................             0.9782             0.9570              -2.17
8960...................................................             0.9939             1.0059               1.21
9000...................................................             0.7670             0.7449              -2.88
9040...................................................             0.9520             0.9473              -0.49
9080...................................................             0.8498             0.8395              -1.21
9140...................................................             0.8544             0.8486              -0.68
9160...................................................             1.1173             1.1121              -0.47
9200...................................................             0.9640             0.9237              -4.18
9260...................................................             1.0569             1.0323              -2.33
9270...................................................             0.9434             0.9378              -0.59
9280...................................................             0.9026             0.9150               1.37
9320...................................................             0.9358             0.9518               1.71
9340...................................................             1.0276             1.0364               0.86
9360...................................................             0.8589             0.8871               3.28
----------------------------------------------------------------------------------------------------------------

[FR Doc. 04-23440 Filed 10-15-04; 4:00 pm]
BILLING CODE 4120-01-P