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[Federal Register Volume 78, Number 148 (Thursday, August 1, 2013)]
[Notices]
[Pages 46733-46777]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2013-18445]

[[Page 46733]]

Vol. 78

Thursday,

No. 148

August 1, 2013

Part III

Department of Health and Human Services

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Centers for Medicare & Medicaid Services

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Medicare Program; Inpatient Psychiatric Facilities Prospective Payment 
System--Update for Fiscal Year Beginning October 1, 2013 (FY 2014); 
Notice

Federal Register / Vol. 78, No. 148 / Thursday, August 1, 2013 / 
Notices

[[Page 46734]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-1447-N]
RIN 0938-AR63

Medicare Program; Inpatient Psychiatric Facilities Prospective 
Payment System--Update for Fiscal Year Beginning October 1, 2013 (FY 
2014)

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

ACTION: Notice.

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SUMMARY: This notice updates the prospective payment rates for Medicare 
inpatient hospital services provided by inpatient psychiatric 
facilities (IPFs). These changes are applicable to IPF discharges 
occurring during the fiscal year (FY) beginning October 1, 2013 through 
September 30, 2014.

DATES: Effective Date: The updated IPF prospective payment rates are 
effective for discharges occurring on or after October 1, 2013 through 
September 30, 2014.

FOR FURTHER INFORMATION CONTACT: Dorothy Myrick or Jana Lindquist, 
(410) 786-4533, for general information. Hudson Osgood, (410) 786-7897 
or Bridget Dickensheets, (410) 786-8670, for information regarding the 
market basket and labor-related share. Theresa Bean, (410) 786-2287, 
for information regarding the regulatory impact analysis.

SUPPLEMENTARY INFORMATION:

Table of Contents

    To assist readers in referencing sections contained in this 
document, we are providing the following table of contents.
I. Executive Summary
    A. Purpose
    B. Summary of the Major Provisions
    C. Summary of Costs and Benefits
II. Background
    A. Annual Requirements for Updating the IPF PPS
    B. Overview of the Legislative Requirements of the IPF PPS
    C. General Overview of the IPF PPS
III. Transition Period for Implementation of the IPF PPS
IV. Changing the IPF PPS Payment Rate Update Period from a Rate Year 
to a Fiscal Year
V. Market Basket for the IPF PPS
    A. Background
    B. FY 2014 Market Basket Update
    C. Labor-Related Share
VI. Updates to the IPF PPS for FY Beginning October 1, 2013
    A. Determining the Standardized Budget-Neutral Federal Per Diem 
Base Rate
    1. Standardization of the Federal Per Diem Base Rate and 
Electroconvulsive Therapy (ECT) Rate
    2. Calculation of the Budget Neutrality Adjustment
    a. Outlier Adjustment
    b. Stop-Loss Provision Adjustment
    c. Behavioral Offset
    B. Update of the Federal Per Diem Base Rate and 
Electroconvulsive Therapy Rate
VII. Update of the IPF PPS Adjustment Factors
    A. Overview of the IPF PPS Adjustment Factors
    B. Patient-Level Adjustments
    1. Adjustment for MS-DRG Assignment
    2. Payment for Comorbid Conditions
    3. Patient Age Adjustments
    4. Variable Per Diem Adjustments
    C. Facility-Level Adjustments
    1. Wage Index Adjustment
    a. Background
    b. Wage Index for FY 2014
    c. OMB Bulletins
    2. Adjustment for Rural Location
    3. Teaching Adjustment
    a. FTE Intern and Resident Cap Adjustment
    b. Temporary Adjustment to the FTE Cap to Reflect Residents 
Added Due to Hospital Closure
    c. Temporary Adjustment to FTE Cap to Reflect Residents Affected 
By Residency Program Closure
    i. Receiving IPF
    ii. IPF That Closed Its Program
    4. Cost of Living Adjustment for IPFs Located in Alaska and 
Hawaii
    5. Adjustment for IPFs with a Qualifying Emergency Department 
(ED)
    D. Other Payment Adjustments and Policies
    1. Outlier Payments
    a. Update to the Outlier Fixed Dollar Loss Threshold Amount
    b. Update to IPF Cost-to-Charge Ratio Ceilings
    2. Expiration of the Stop-Loss Provision
    3. Future Refinements
VIII. Secretary's Recommendations
IX. Waiver of Notice and Comment
X. Collection of Information Requirements
XI. Regulatory Impact Analysis
    Addenda

Acronyms

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

    BBRA Medicare, Medicaid and SCHIP [State Children's Health 
Insurance Program] Balanced Budget Refinement Act of 1999, (Pub. L. 
106-113)
CBSA Core-Based Statistical Area
CCR Cost-to-charge ratio
CAH Critical access hospital
DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders 
Fourth Edition--Text Revision
DRGs Diagnosis-related groups
FY Federal fiscal year (October 1 through September 30)
ICD-9-CM International Classification of Diseases, 9th Revision, 
Clinical Modification
IPFs Inpatient psychiatric facilities
IRFs Inpatient rehabilitation facilities
LTCHs Long-term care hospitals
MedPAR Medicare provider analysis and review file
RPL Rehabilitation, Psychiatric, and Long-Term Care
RY Rate Year (July 1 through June 30)
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, (Pub. L. 97-
248)

I. Executive Summary

A. Purpose

    This notice updates the prospective payment rates for Medicare 
inpatient hospital services provided by inpatient psychiatric 
facilitates for discharges occurring during the fiscal year (FY) 
beginning October 1, 2013 through September 30, 2014.

B. Summary of the Major Provisions

    In this notice, we update the IPF PPS, as specified in 42 CFR 
412.428. The updates include the following:
     The FY 2008-based Rehabilitation, Psychiatric, and Long 
Term Care (RPL) market basket update of 2.6 percent adjusted by a 0.1 
percentage point reduction as required by section 1886(s)(2)(A)(ii) of 
the Social Security Act (the Act) and a 0.5 percentage point reduction 
for economy-wide productivity as required by 1886(s)(2)(A)(i) of the 
Act.
     The fixed dollar loss threshold amount in order to 
maintain the appropriate outlier percentage.
     The electroconvulsive therapy payment by a factor 
specified by CMS.
     The national urban and rural cost-to-charge ratio medians 
and ceilings.
     The cost of living adjustment factors for IPFs located in 
Alaska and Hawaii, if appropriate.
     Description of the ICD-9-CM and MS-DRG classification 
changes discussed in the annual update to the hospital inpatient PPS 
regulations.
     Use of the best available hospital wage index and 
information regarding whether an adjustment to the Federal per diem 
base rate is needed to maintain budget neutrality.
     The MS-DRG listing and comorbidity categories to reflect 
the ICD-9-CM revisions effective October 1, 2013.
     Retaining the 17 percent adjustment for IPFs located in 
rural areas, the 1.31 adjustment factor for IPFs with a qualifying 
emergency department, the coefficient value of 0.5150 for the teaching 
adjustment to the Federal per diem rate, the MS-DRG adjustment factors 
and comorbidity adjustment factors currently being paid to IPFs for FY 
2013.

[[Page 46735]]

C. Summary of Transfers

------------------------------------------------------------------------
         Provision description                   Total transfers
------------------------------------------------------------------------
FY 2014 IPF PPS payment rate update....  The overall economic impact of
                                          this notice is an estimated
                                          $115 million in increased
                                          payments to IPFs during FY
                                          2014.
------------------------------------------------------------------------

II. Background

A. Annual Requirements for Updating the IPF PPS

    In November 2004, we implemented the inpatient psychiatric 
facilities (IPF) prospective payment system (PPS) in a final rule that 
appeared in the November 15, 2004 Federal Register (69 FR 66922). In 
developing the IPF PPS, in order to ensure that the IPF PPS is able to 
account adequately for each IPF's case-mix, we performed an extensive 
regression analysis of the relationship between the per diem costs and 
certain patient and facility characteristics to determine those 
characteristics associated with statistically significant cost 
differences on a per diem basis. For characteristics with statistically 
significant cost differences, we used the regression coefficients of 
those variables to determine the size of the corresponding payment 
adjustments.
    In that final rule, we explained that we believe it is important to 
delay updating the adjustment factors derived from the regression 
analysis until we have IPF PPS data that include as much information as 
possible regarding the patient-level characteristics of the population 
that each IPF serves. Therefore, we indicated that we did not intend to 
update the regression analysis and recalculate the Federal per diem 
base rate and the patient-and facility-level adjustments until we 
complete that analysis. Until that analysis is complete, we stated our 
intention to publish a notice in the Federal Register each spring to 
update the IPF PPS (71 FR 27041). In the May 6, 2011 IPF PPS final rule 
(76 FR 26432), we changed the payment rate update period to a rate year 
(RY) that coincides with a fiscal year (FY) update. Therefore, update 
notices are now published in the Federal Register in the summer to be 
effective on October 1. For further discussion on changing the IPF PPS 
payment rate update period to a RY that coincides with a FY, see the 
IPF PPS final rule published in the Federal Register on May 6, 2011 (76 
FR 26434 through 26435).
    Updates to the IPF PPS, as specified in 42 CFR Sec.  412.428, 
include the following:
     A description of the methodology and data used to 
calculate the updated Federal per diem base payment amount.
     The rate of increase factor as described in Sec.  
412.424(a)(2)(iii), which is based on the Excluded Hospital with 
Capital market basket under the update methodology of section 
1886(b)(3)(B)(ii) of the Act for each year (effective from the 
implementation period until June 30, 2006).
     For discharges occurring on or after July 1, 2006, the 
rate of increase factor for the Federal portion of the IPF's payment, 
which is based on the Rehabilitation, Psychiatric, and Long-Term Care 
(RPL) market basket.
     The best available hospital wage index and information 
regarding whether an adjustment to the Federal per diem base rate is 
needed to maintain budget neutrality.
     Updates to the fixed dollar loss threshold amount in order 
to maintain the appropriate outlier percentage.
     Description of the International Classification of 
Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding and 
diagnosis-related groups (DRGs) classification changes discussed in the 
annual update to the hospital inpatient prospective payment system 
(IPPS) regulations.
     Update to the electroconvulsive therapy (ECT) payment by a 
factor specified by CMS.
     Update to the national urban and rural cost-to-charge 
ratio medians and ceilings.
     Update to the cost of living adjustment factors for IPFs 
located in Alaska and Hawaii, if appropriate.
    Our most recent IPF PPS annual update occurred in the August 7, 
2012 Federal Register notice (77 FR 47224) (hereinafter referred to as 
the August 2012 IPF PPS notice) that set forth updates to the IPF PPS 
payment rates for FY 2013. That notice updated the IPF PPS per diem 
payment rates that were published in the May 2011 IPF PPS final rule in 
accordance with our established policies.
    Since implementation of the IPF PPS, we have explained that we 
believe it is important to delay updating the adjustment factors 
derived from the regression analysis until we have IPF PPS data that 
include as much information as possible regarding the patient-level 
characteristics of the population that each IPF serves. Because we are 
now approximately 8 years into the system, we believe that we have 
enough data to begin that process. Therefore, we have begun the 
necessary analysis to make future refinements. While we do not propose 
to make refinements in this notice, as explained in section V.D.3 
below, we expect that in future rulemaking, for FY 2015, we will be 
ready to propose potential refinements.

B. Overview of the Legislative Requirements of the IPF PPS

    Section 124 of the Medicare, Medicaid, and SCHIP (State Children's 
Health Insurance Program) Balanced Budget Refinement Act of 1999 (BBRA) 
(Pub. L. 106-113) required the establishment and implementation of an 
IPF PPS. Specifically, section 124 of the BBRA mandated that the 
Secretary develop a per diem PPS for inpatient hospital services 
furnished in psychiatric hospitals and psychiatric units including an 
adequate patient classification system that reflects the differences in 
patient resource use and costs among psychiatric hospitals and 
psychiatric units.
    Section 405(g)(2) of the Medicare Prescription Drug, Improvement, 
and Modernization Act of 2003 (MMA) (Pub. L. 108-173) extended the IPF 
PPS to distinct part psychiatric units of critical access hospitals 
(CAHs).
    Section 3401(f) of the Patient Protection and Affordable Care Act 
(Pub. L. 111-148) as amended by section 10319(e) of that Act and by 
section 1105(d) of the Health Care and Education Reconciliation Act of 
2010 (Pub. L. 111-152) (hereafter referred to as ``the Affordable Care 
Act'') added subsection (s) to section 1886 of the Act.
    Section 1886(s)(1) is titled ``Reference to Establishment and 
Implementation of System'' and it refers to section 124 of the 
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, 
which relates to the establishment of the IPF PPS.
    Section 1886(s)(2)(A)(i) of the Act requires the application of the 
productivity adjustment described in section 1886(b)(3)(B)(xi)(II) of 
the Act to the IPF PPS for the RY beginning in 2012 (that is, a RY that 
coincides with a FY) and each subsequent RY. For the RY beginning in 
2013 (that is, FY 2014), the productivity adjustment is equal to 0.5 
percentage point, which we are implementing in this notice. Section 
1886(s)(2)(A)(ii) of the Act requires the application of an ``other 
adjustment'' that reduces any update to an IPF PPS base rate by 
percentages specified in section 1886(s)(3) of the Act for the RY 
beginning in 2010 through the RY beginning in 2019. For the RY 
beginning in 2013 (that is, FY 2014), section 1886(s)(3)(B) of the Act 
requires the reduction to be 0.1 percentage point. We are implementing 
that provision in this FY 2014 IPF PPS notice.

[[Page 46736]]

    Section 1886(s)(4) of the Act requires the establishment of a 
quality data reporting program for the IPF PPS beginning in RY 2014. We 
proposed and finalized new requirements for quality reporting for IPFs 
in the ``Hospital Inpatient Prospective Payment System for Acute Care 
Hospitals and the Long Term Care Hospital Prospective Payment System 
and Fiscal Year 2013 Rates'' proposed rule (May 11, 2012) (77 FR 27870, 
28105 through 28116) and final rule (August 31, 2012) (77 FR 53258, 
53644 through 53360).
    To implement and periodically update these provisions, we have 
published various proposed and final rules in the Federal Register. For 
more information regarding these rules, see the CMS Web site at http://www.cms.hhs.gov/InpatientPsychFacilPPS/.

C. General Overview of the IPF PPS

    The November 2004 IPF PPS final rule (69 FR 66922) established the 
IPF PPS, as authorized under section 124 of the BBRA and codified at 
subpart N of part 412 of the Medicare regulations. The November 2004 
IPF PPS final rule set forth the per diem Federal rates for the 
implementation year (the 18-month period from January 1, 2005 through 
June 30, 2006), and it provided payment for the inpatient operating and 
capital costs to IPFs for covered psychiatric services they furnish 
(that is, routine, ancillary, and capital costs, but not costs of 
approved educational activities, bad debts, and other services or items 
that are outside the scope of the IPF PPS). Covered psychiatric 
services include services for which benefits are provided under the 
fee-for-service Part A (Hospital Insurance Program) Medicare program.
    The IPF PPS established the Federal per diem base rate for each 
patient day in an IPF derived from the national average daily routine 
operating, ancillary, and capital costs in IPFs in FY 2002. The average 
per diem cost was updated to the midpoint of the first year under the 
IPF PPS, standardized to account for the overall positive effects of 
the IPF PPS payment adjustments, and adjusted for budget neutrality.
    The Federal per diem payment under the IPF PPS is comprised of the 
Federal per diem base rate described above and certain patient- and 
facility-level payment adjustments that were found in the regression 
analysis to be associated with statistically significant per diem cost 
differences.
    The patient-level adjustments include age, DRG assignment, 
comorbidities, and variable per diem adjustments to reflect higher per 
diem costs in the early days of an IPF stay. Facility-level adjustments 
include adjustments for the IPF's wage index, rural location, teaching 
status, a cost of living adjustment for IPFs located in Alaska and 
Hawaii, and presence of a qualifying emergency department (ED).
    The IPF PPS provides additional payment policies for: Outlier 
cases; stop-loss protection (which was applicable only during the IPF 
PPS transition period); interrupted stays; and a per treatment 
adjustment for patients who undergo ECT.
    A complete discussion of the regression analysis appears in the 
November 2004 IPF PPS final rule (69 FR 66933 through 66936).
    Section 124 of BBRA did not specify an annual update rate strategy 
for the IPF PPS and was broadly written to give the Secretary 
discretion in establishing an update methodology. Therefore, in the 
November 2004 IPF PPS final rule, we implemented the IPF PPS using the 
following update strategy:
     Calculate the final Federal per diem base rate to be 
budget neutral for the 18-month period of January 1, 2005 through June 
30, 2006.
     Use a July 1 through June 30 annual update cycle.
     Allow the IPF PPS first update to be effective for 
discharges on or after July 1, 2006 through June 30, 2007.

III. Transition Period for Implementation of the IPF PPS

    In the November 2004 IPF PPS final rule, we provided for a 3-year 
transition period. During this 3-year transition period, an IPF's total 
payment under the PPS was based on an increasing percentage of the 
Federal rate with a corresponding decreasing percentage of the IPF PPS 
payment that was based on reasonable cost concepts. However, effective 
for cost reporting periods beginning on or after January 1, 2008, IPF 
PPS payments were based on 100 percent of the Federal rate.

IV. Changing the IPF PPS Payment Rate Update Period From a Rate Year to 
a Fiscal Year

    Prior to RY 2012, the IPF PPS was updated on a July 1st through 
June 30th annual update cycle. Effective with RY 2012, we switched the 
IPF PPS payment rate update from a rate year that begins on July 1st 
ending on June 30th to a period that coincides with a fiscal year. In 
order to transition from a RY to a FY, the IPF PPS RY 2012 covered a 15 
month period from July 1st through September 30th. As proposed and 
finalized, after RY 2012, the rate update period for the IPF PPS 
payment rates and other policy changes begin on October 1 through 
September 30. Therefore, the update cycle for FY 2014 will be October 
1, 2013 through September 30, 2014.
    For further discussion of the 15-month market basket update for RY 
2012 and changing the payment rate update period from a RY to a FY, we 
refer readers to the RY 2012 IPF PPS proposed rule (76 FR 4998) and the 
RY 2012 IPF PPS final rule (76 FR 26432).

V. Market Basket for the IPF PPS

A. Background

    The input price index (that is, the market basket) that was used to 
develop the IPF PPS was the Excluded Hospital with Capital market 
basket. This market basket was based on 1997 Medicare cost report data 
and included data for Medicare participating IPFs, inpatient 
rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), 
cancer hospitals, and children's hospitals. Although ``market basket'' 
technically describes the mix of goods and services used in providing 
hospital care, this term is also commonly used to denote the input 
price index (that is, cost category weights and price proxies combined) 
derived from that market basket. Accordingly, the term ``market 
basket'' as used in this document refers to a hospital input price 
index.
    Beginning with the May 2006 IPF PPS final rule (71 FR 27046 through 
27054), IPF PPS payments were updated using a FY 2002-based market 
basket reflecting the operating and capital cost structures for IRFs, 
IPFs, and LTCHs (hereafter referred to as the Rehabilitation, 
Psychiatric, and Long-Term Care (RPL) market basket).
    We excluded cancer and children's hospitals from the RPL market 
basket because these hospitals are not reimbursed through a PPS; 
rather, their payments are based entirely on reasonable costs subject 
to rate-of-increase limits established under the authority of section 
1886(b) of the Act, which are implemented in regulations at Sec.  
413.40. Moreover, the FY 2002 cost structures for cancer and children's 
hospitals are noticeably different than the cost structures of the 
IRFs, IPFs, and LTCHs. A complete discussion of the FY 2002-based RPL 
market basket appears in the May 2006 IPF PPS final rule (71 FR 27046 
through 27054).
    In the May 1, 2009 IPF PPS notice (74 FR 20362), we expressed our 
interest in exploring the possibility of creating a stand-alone IPF 
market basket that reflects the cost structures of only IPF providers. 
We noted that, of the available options, one would be to join the 
Medicare cost report data from

[[Page 46737]]

freestanding IPF providers (presently incorporated into the RPL market 
basket) with data from hospital-based IPF providers (not currently 
incorporated in any market basket cost weights). We indicated that an 
examination of the Medicare cost report data comparing freestanding and 
hospital-based IPFs revealed considerable differences between the two 
with respect to cost levels and cost structures. At that time, we were 
unable to fully understand the differences between these two types of 
IPF providers. As a result, we felt that further research was required; 
therefore we solicited public comment for additional information that 
might help us to better understand the reasons for the variations in 
costs and cost structures, as indicated by the cost report data, 
between freestanding and hospital-based IPFs (74 FR 20376).
    We summarized the public comments received and our responses in the 
April 2010 IPF PPS notice (75 FR 23111 through 23113). Despite 
receiving comments from the public on this issue, we were unable to 
explain the observed differences in costs and cost structures between 
hospital-based and freestanding IPFs. Therefore, we did not believe it 
was appropriate, at the time, to incorporate data from hospital-based 
IPFs with those of freestanding IPFs to create a stand-alone IPF market 
basket.
    In the RY 2012 IPF PPS proposed rule (76 FR 4998) and final rule 
(76 FR 26432), we proposed and finalized the use of a rebased and 
revised FY 2008-based RPL market basket to update IPF payments. In the 
RY 2012 IPF PPS proposed rule (76 FR 5001), we also welcomed public 
comment on the possibility of using a rehabilitation and psychiatric 
(RP) market basket to update IPF payments in the future. Comments 
received and our responses are summarized in the RY 2012 final rule (76 
FR 26436).
    We continue to explore the viability of creating separate market 
baskets from the current RPL market basket. In the FY 2013 IPPS/LTCH 
final rule (77 FR 53468 through 53476), we adopted the newly created FY 
2009-based LTCH-specific market basket for use under the LTCH PPS 
beginning in FY 2013. We continue to investigate the use of an 
alternative market basket to update IPF PPS payments; however, for the 
FY 2014 IPF PPS update, we continue to use (as was done for the FY 2013 
update) the percentage increase in the FY 2008-based RPL market basket 
to determine the IPF PPS market basket update. We still have concerns 
about cost differences between freestanding and hospital-based 
providers, which remain unexplained even when looking at more recent 
data. However, we remain interested in researching this topic further 
to determine if these data quality and representativeness concerns can 
be overcome, and have plans to conduct more analysis into the claims 
and cost data for IPFs. Any possible changes to the market basket used 
to update IPF payments would appear in a future rulemaking and be 
subject to public comment.

B. FY 2014 Market Basket Update

    The FY 2014 update for the IPF PPS using the FY 2008-based RPL 
market basket and IHS Global Insight's second quarter 2013 forecast of 
the market basket components is 2.6 percent (prior to the application 
of any statutory adjustments). This includes increases in both the 
operating and the capital components for FY 2014 (that is, October 1, 
2013 through September 30, 2014). IHS Global Insight, Inc. is a 
nationally recognized economic and financial forecasting firm that 
contracts with CMS to forecast the components of the market baskets.
    As previously described in section I.B, section 1886(s)(2)(A)(i) of 
the Act requires the application of the productivity adjustment 
described in section 1886(b)(3)(B)(xi)(II) of the Act to the IPF PPS 
for the RY beginning in 2012 and each subsequent RY. The statute 
defines the productivity adjustment to be equal to the 10-year moving 
average of changes in annual economy-wide private nonfarm business 
multifactor productivity (MFP) (as projected by the Secretary for the 
10-year period ending with the applicable FY, year, cost reporting 
period, or other annual period) (the ``MFP adjustment'').
    The Bureau of Labor Statistics (BLS) is the agency that publishes 
the official measure of private non-farm business MFP. We refer readers 
to the BLS Web site at http://www.bls.gov/mfp to obtain the BLS 
historical published MFP data. The MFP adjustment for FY 2014 
applicable to the IPF PPS is derived using a projection of MFP that is 
currently produced by IHS Global Insight, Inc. For a detailed 
description of the model currently used by IHS Global Insight, Inc. to 
project MFP, as well as a description of how the MFP adjustment is 
calculated, we refer readers to the FY 2012 IPPS/LTCH final rule (76 FR 
51690 through 51692). Based on IHS Global Insight, Inc.'s 2013 second 
quarter forecast, the productivity adjustment for FY 2014 is 0.5 
percentage point. Section 1886(s)(2)(A)(ii) of the Act also requires 
the application of an ``other adjustment'' that reduces any update to 
an IPF PPS base rate by percentages specified in section 1886(s)(3) of 
the Act for rate years beginning in 2010 through the RY beginning in 
2019. For the RY beginning in 2013 (that is, FY 2014), the reduction is 
0.1 percentage point. We are implementing the productivity adjustment 
and ``other adjustment'' in this FY 2014 IPF PPS notice.

C. Labor-Related Share

    Due to variations in geographic wage levels and other labor-related 
costs, we believe that payment rates under the IPF PPS should continue 
to be adjusted by a geographic wage index, which would apply to the 
labor-related portion of the Federal per diem base rate (hereafter 
referred to as the labor-related share).
    The labor-related share is determined by identifying the national 
average proportion of total costs that are related to, influenced by, 
or vary with the local labor market. We classify a cost category as 
labor-related if the costs are labor-intensive and vary with the local 
labor market. Based on our definition of the labor-related share, we 
include in the labor-related share the sum of the relative importance 
of Wages and Salaries, Employee Benefits, Professional Fees: Labor-
related, Administrative and Business Support Services, All Other: 
Labor-related Services, and a portion of the Capital-Related cost 
weight.
    Therefore, to determine the labor-related share for the IPF PPS for 
FY 2014, we used the FY 2008-based RPL market basket cost weights 
relative importance to determine the labor-related share for the IPF 
PPS. This estimate of the FY 2014 labor-related share is based on IHS 
Global Insight Inc.'s second quarter 2013 forecast, which is the same 
forecast used to derive the FY 2014 market basket update.
    Table 1 below shows the FY 2014 relative importance labor-related 
share using the FY 2008-based RPL market basket along with the FY 2013 
relative importance labor-related share.

[[Page 46738]]

Table 1--FY 2014 Relative Importance Labor-Related Share and the FY 2013
 Relative Importance Labor-Related Share Based on the FY 2008-Based RPL
                              Market Basket
------------------------------------------------------------------------
                                           FY 2013           FY 2014
                                          relative          relative
                                      importance labor- importance labor-
                                        related share     related share
                                             \1\               \2\
------------------------------------------------------------------------
Wages and Salaries..................            48.796            48.394
Employee Benefits...................            13.021            12.963
Professional Fees: Labor-Related....             2.070             2.065
Administrative and Business Support              0.417             0.415
 Services...........................
All Other: Labor-Related Services...             2.077             2.080
Subtotal............................            66.381            65.917
Labor-Related Portion of Capital                 3.600             3.577
 Costs (46%)........................
                                     -----------------------------------
    Total Labor-Related Share.......            69.981            69.494
------------------------------------------------------------------------
1. Published in the FY 2013 IPF PPS notice (77 FR 47228) and based on
  IHS Global Insight, Inc.'s second quarter 2012 forecast of the FY 2008-
  based RPL market basket.
2. Based on IHS Global Insight, Inc.'s second quarter 2013 forecast of
  the FY 2008-based RPL market basket.

    The labor-related share for FY 2014 is the sum of the FY 2014 
relative importance of each labor-related cost category, and would 
reflect the different rates of price change for these cost categories 
between the base year (FY 2008) and FY 2014. The sum of the relative 
importance for FY 2014 for operating costs (Wages and Salaries, 
Employee Benefits, Professional Fees: Labor-Related, Administrative and 
Business Support Services, and All Other: Labor-related Services) is 
65.917 percent, as shown in Table 1 above. The portion of Capital-
related cost that is influenced by the local labor market is estimated 
to be 46 percent. Since the relative importance for Capital-Related 
Costs is 7.776 percent of the FY 2008-based RPL market basket in FY 
2014, we take 46 percent of 7.776 percent to determine the labor-
related share of Capital-related cost for FY 2014. The result is 3.577 
percent, which we add to 65.917 percent for the operating cost amount 
to determine the total labor-related share for FY 2014. Therefore, the 
labor-related share for the IPF PPS in FY 2014 is 69.494 percent. This 
labor-related share is determined using the same general methodology as 
employed in calculating all previous IPF labor-related shares (see, for 
example, 69 FR 66952 through 66953). The wage index and the labor-
related share are reflected in budget neutrality adjustments.

VI. Updates to the IPF PPS for FY Beginning October 1, 2013

    The IPF PPS is based on a standardized Federal per diem base rate 
calculated from the IPF average per diem costs and adjusted for budget-
neutrality in the implementation year. The Federal per diem base rate 
is used as the standard payment per day under the IPF PPS and is 
adjusted by the patient- and facility-level adjustments that are 
applicable to the IPF stay. A detailed explanation of how we calculated 
the average per diem cost appears in the November 2004 IPF PPS final 
rule (69 FR 66926).

A. Determining the Standardized Budget-Neutral Federal Per Diem Base 
Rate

    Section 124(a)(1) of the BBRA required that we implement the IPF 
PPS in a budget neutral manner. In other words, the amount of total 
payments under the IPF PPS, including any payment adjustments, must be 
projected to be equal to the amount of total payments that would have 
been made if the IPF PPS were not implemented. Therefore, we calculated 
the budget-neutrality factor by setting the total estimated IPF PPS 
payments to be equal to the total estimated payments that would have 
been made under the Tax Equity and Fiscal Responsibility Act of 1982 
(TEFRA) (Pub. L. 97-248) methodology had the IPF PPS not been 
implemented.
    Under the IPF PPS methodology, we calculated the final Federal per 
diem base rate to be budget neutral during the IPF PPS implementation 
period (that is, the 18-month period from January 1, 2005 through June 
30, 2006) using a July 1 update cycle. We updated the average cost per 
day to the midpoint of the IPF PPS implementation period (that is, 
October 1, 2005), and this amount was used in the payment model to 
establish the budget-neutrality adjustment.
    A step-by-step description of the methodology used to estimate 
payments under the TEFRA payment system appears in the November 2004 
IPF PPS final rule (69 FR 66926).
1. Standardization of the Federal Per Diem Base Rate and 
Electroconvulsive Therapy (ECT) Rate
    In the November 2004 IPF PPS final rule, we describe how we 
standardized the IPF PPS Federal per diem base rate to account for the 
overall positive effects of the IPF PPS payment adjustment factors. To 
standardize the IPF PPS payments, we compared the IPF PPS payment 
amounts calculated from the FY 2002 Medicare Provider Analysis and 
Review (MedPAR) file to the projected TEFRA payments from the FY 2002 
cost report file updated to the midpoint of the IPF PPS implementation 
period (that is, October 2005). The standardization factor was 
calculated by dividing total estimated payments under the TEFRA payment 
system by estimated payments under the IPF PPS. The standardization 
factor was calculated to be 0.8367.
    As described in detail in the May 2006 IPF PPS final rule (71 FR 
27045), in reviewing the methodology used to simulate the IPF PPS 
payments used for the November 2004 IPF PPS final rule, we discovered 
that due to a computer code error, total IPF PPS payments were 
underestimated by about 1.36 percent. Since the IPF PPS payment total 
should have been larger than the estimated figure, the standardization 
factor should have been smaller (0.8254 vs. 0.8367). In turn, the 
Federal per diem base rate and the ECT rate should have been reduced by 
0.8254 instead of 0.8367.
    To resolve this issue, in RY 2007, we amended the Federal per diem 
base rate and the ECT payment rate prospectively. Using the 
standardization factor of 0.8254, the average cost per day was 
effectively reduced by 17.46 percent (100 percent minus 82.54 percent = 
17.46 percent).

[[Page 46739]]

2. Calculation of the Budget Neutrality Adjustment
    To compute the budget neutrality adjustment for the IPF PPS, we 
separately identified each component of the adjustment, that is, the 
outlier adjustment, stop-loss adjustment, and behavioral offset.
    A complete discussion of how we calculate each component of the 
budget neutrality adjustment appears in the November 2004 IPF PPS final 
rule (69 FR 66932 through 66933) and in the May 2006 IPF PPS final rule 
(71 FR 27044 through 27046).
a. Outlier Adjustment
    Since the IPF PPS payment amount for each IPF includes applicable 
outlier amounts, we reduced the standardized Federal per diem base rate 
to account for aggregate IPF PPS payments estimated to be made as 
outlier payments. The outlier adjustment was calculated to be 2 
percent. As a result, the standardized Federal per diem base rate was 
reduced by 2 percent to account for projected outlier payments.
b. Stop-Loss Provision Adjustment
    As explained in the November 2004 IPF PPS final rule, we provided a 
stop-loss payment during the transition from cost-based reimbursement 
to the per diem payment system to ensure that an IPF's total PPS 
payments were no less than a minimum percentage of their TEFRA payment, 
had the IPF PPS not been implemented. We reduced the standardized 
Federal per diem base rate by the percentage of aggregate IPF PPS 
payments estimated to be made for stop-loss payments. As a result, the 
standardized Federal per diem base rate was reduced by 0.39 percent to 
account for stop-loss payments. Since the transition was completed in 
RY 2009, the stop-loss provision is no longer applicable, and for cost 
reporting periods beginning on or after January 1, 2008, IPFs were paid 
100 percent PPS rates.
c. Behavioral Offset
    As explained in the November 2004 IPF PPS final rule, 
implementation of the IPF PPS may result in certain changes in IPF 
practices, especially with respect to coding for comorbid medical 
conditions. As a result, Medicare may make higher payments than assumed 
in our calculations. Accounting for these effects through an adjustment 
is commonly known as a behavioral offset.
    Based on accepted actuarial practices and consistent with the 
assumptions made in other PPSs, we assumed in determining the 
behavioral offset that IPFs would regain 15 percent of potential 
``losses'' and augment payment increases by 5 percent. We applied this 
actuarial assumption, which is based on our historical experience with 
new payment systems, to the estimated ``losses'' and ``gains'' among 
the IPFs. The behavioral offset for the IPF PPS was calculated to be 
2.66 percent. As a result, we reduced the standardized Federal per diem 
base rate by 2.66 percent to account for behavioral changes. As 
indicated in the November 2004 IPF PPS final rule, we do not plan to 
change adjustment factors or projections until we analyze IPF PPS data.
    If we find that an adjustment is warranted, the percent difference 
may be applied prospectively to the established PPS rates to ensure the 
rates accurately reflect the payment level. In conducting this 
analysis, we will be interested in the extent to which improved coding 
of patients' principal and other diagnoses, which may not reflect real 
increases in underlying resource demands, has occurred under the PPS.

B. Update of the Federal Per Diem Base Rate and Electroconvulsive 
Therapy Rate

    As described in the November 2004 IPF PPS final rule (69 FR 66931), 
the average per diem cost was updated to the midpoint of the 
implementation year. This updated average per diem cost of $724.43 was 
reduced by--(1) 17.46 percent to account for standardization to 
projected TEFRA payments for the implementation period; (2) 2 percent 
to account for outlier payments; (3) 0.39 percent to account for stop-
loss payments; and (4) 2.66 percent to account for the behavioral 
offset. The Federal per diem base rate in the implementation year was 
$575.95. The increase in the per diem base rate for RY 2009 included 
the 0.39 percent increase due to the removal of the stop-loss 
provision. We indicated in the November 2004 IPF PPS final rule (69 FR 
66932) that we would remove this 0.39 percent reduction to the Federal 
per diem base rate after the transition. As discussed in section 
IV.D.2. of the May 2008 IPF PPS notice, we increased the Federal per 
diem base rate and the ECT base rate by 0.39 percent in RY 2009. 
Therefore for RY 2009 and beyond, the stop-loss provision has ended and 
is no longer a part of budget neutrality.
    In accordance with section 1886(s)(2)(A)(ii) of the Act, which 
requires the application of an ``other adjustment,'' described in 
section 1886(s)(3) of the Act (specifically, section 1886(s)(3)(B)) for 
RYs 2013 and 2014 that reduces the update to the IPF PPS base rate for 
the FY beginning in Calendar Year (CY) 2013, we are adjusting the IPF 
PPS update by a 0.1 percentage point reduction for FY 2014. In 
addition, in accordance with section 1886(s)(2)(A)(i) of the Act, which 
requires the application of the productivity adjustment that reduces 
the update to the IPF PPS base rate for the FY beginning in CY 2013, we 
are adjusting the IPF PPS update by a 0.5 percentage point reduction 
for FY 2014.
    For this notice, we are applying an annual update of 2.0 percent 
(that is the FY 2008-based RPL market basket increase for FY 2014 of 
2.6 percent less the productivity adjustment of 0.5 percentage point 
less the 0.1 percentage point required under section1886(s)(3)(B) of 
the Act), and the wage index budget neutrality factor of 1.0010 to the 
FY 2013 Federal per diem base rate of $698.51, yielding a Federal per 
diem base rate of $713.19 for FY 2014. Similarly, we are applying the 
2.0 percent payment update, and the 1.0010 wage index budget neutrality 
factor to the FY 2013 ECT base rate, yielding an ECT base rate of 
$307.04 for FY 2014.
    As noted above, section 1886(s)(4) of the Act requires the 
establishment of a quality data reporting program for the IPF PPS 
beginning in RY 2014. We finalized new requirements for quality 
reporting for IPFs in the ``Hospital Inpatient Prospective Payment 
System for Acute Care Hospitals and the Long Term Care Hospital 
Prospective Payment System and Fiscal Year 2013 Rates'' final rule 
(August 31, 2012) (77 FR 53258, 53644 through 53360). Section 
1886(s)(4)(A)(i) of the Act requires that, for RY 2014 and each 
subsequent rate year, the Secretary shall reduce any annual update to a 
standard Federal rate for discharges occurring during the rate year by 
2.0 percentage points for any IPF that does not comply with the quality 
data submission requirements with respect to an applicable year. 
Therefore, we are applying a 2.0 percentage point reduction to the 
federal per diem base rate and the ECT base rate as follows.
    For IPFs that fail to submit quality reporting data under the IPFQR 
program, we are applying a 0 percent annual update (that is 2 percent 
reduced by 2 percentage points in accordance with section 
1886(s)(4)(A)(ii) of the Act) and the wage index budget neutrality 
factor of 1.0010 to the FY 2013 Federal per diem base rate of $698.51, 
yielding a Federal per diem base rate of $699.21 for FY 2014.
    Similarly, we are applying the 0 percent annual update and the 
1.0010 wage index budget neutrality factor to

[[Page 46740]]

the FY 2013 ECT base rate of $300.72, yielding an ECT base rate of 
$301.02 for FY 2014.
    In the FY 2014 IPPS/LTCH PPS final rule (78 FR 27485), we are 
adopting two new measures for the FY 2016 payment determination and 
subsequent years for the IPFQR Program. We are also finalizing a 
request for voluntary information whereby IPFs will be asked to provide 
information on the patient experience of care survey they use.

VII. Update of the IPF PPS Adjustment Factors

A. Overview of the IPF PPS Adjustment Factors

    The IPF PPS payment adjustments were derived from a regression 
analysis of 100 percent of the FY 2002 MedPAR data file, which 
contained 483,038 cases. For this notice, we used the same results of 
the regression analysis used to implement the November 2004 IPF PPS 
final rule. For a more detailed description of the data file used for 
the regression analysis, see the November 2004 IPF PPS final rule (69 
FR 66935 through 66936). While we have since used more recent claims 
data to set the fixed dollar loss threshold amount, we used the same 
results of this regression analysis to update the IPF PPS for FY 2013 
and for FY 2014. Now that we are approximately 8 years into the IPF 
PPS, we believe that we have enough data to begin looking at the 
process of refining the IPF PPS as appropriate. We expect that in 
future rulemaking, we may propose potential refinements to the system.
    As we stated previously, we do not plan to update the regression 
analysis until we are able to analyze IPF PPS claims and cost report 
data. However, we continue to monitor claims and payment data 
independently from cost report data to assess issues, to determine 
whether changes in case-mix or payment shifts have occurred among 
freestanding governmental, non-profit and private psychiatric 
hospitals, and psychiatric units of general hospitals, and CAHs and 
other issues of importance to IPFs.

B. Patient-Level Adjustments

    In the August 2012 IPF PPS notice (77 FR 47230 through 47233) we 
announced payment adjustments for the following patient-level 
characteristics: Medicare Severity diagnosis related groups (MS-DRGs) 
assignment of the patient's principal diagnosis, selected 
comorbidities, patient age, and the variable per diem adjustments.
1. Adjustment for MS-DRG Assignment
    The IPF PPS includes payment adjustments for designated psychiatric 
DRGs assigned to the claim based on each patient's principal diagnosis. 
As we did in FY 2013 (77 FR 47231), for FY 2014, we will make a payment 
adjustment for psychiatric diagnoses that group to one of the 17 MS-
IPF-DRGs listed in Table 2. The DRG adjustment factors were expressed 
relative to the most frequently reported psychiatric DRG in FY 2002, 
that is, DRG 430 (psychoses). The coefficient values and adjustment 
factors were derived from the regression analysis.
    In accordance with Sec.  412.27(a), payment under the IPF PPS is 
conditioned on IPFs admitting ``only patients whose admission to the 
unit is required for active treatment, of an intensity that can be 
provided appropriately only in an inpatient hospital setting, of a 
psychiatric principal diagnosis that is listed in Chapter Five (`Mental 
Disorders') of the International Classification of Diseases, Ninth 
Revision, Clinical Modification (ICD-9-CM)'' or in the Fourth Edition, 
Text Revision of the American Psychiatric Association's Diagnostic and 
Statistical Manual, (DSM-IV-TR). IPF claims with a principal diagnosis 
included in Chapter Five of the ICD-9-CM or the DSM-IV-TR are paid the 
Federal per diem base rate under the IPF PPS and all other applicable 
adjustments, including any applicable DRG adjustment. Psychiatric 
principal diagnoses that do not group to one of the 17 designated DRGs 
will still receive the Federal per diem base rate and all other 
applicable adjustments, but the payment will not include a DRG 
adjustment.
    The Standards for Electronic Transaction final rule published in 
the Federal Register on August 17, 2000 (65 FR 50312), adopted ICD-9-CM 
as the designated code set for reporting diseases, injuries, 
impairments, other health related problems, their manifestations, and 
causes of injury, disease, impairment, or other health related 
problems. Therefore, we use ICD-9-CM as the designated code set for the 
IPF PPS.
    We believe that it is important to maintain the same diagnostic 
coding and DRG classification for IPFs that are used under the IPPS for 
providing psychiatric care. Therefore, when the IPF PPS was implemented 
for cost reporting periods beginning on or after January 1, 2005, we 
adopted the same diagnostic code set and DRG patient classification 
system (that is, the CMS DRGs) that were utilized at the time under the 
hospital inpatient IPPS. Since the inception of the IPF PPS, the DRGs 
used as the patient classification system under the IPF PPS have 
corresponded exactly with the CMS DRGs applicable under the IPPS for 
acute care hospitals.
    Every year, changes to the ICD-9-CM coding system are addressed in 
the IPPS proposed and final rules. The changes to the codes are 
effective October 1 of each year and must be used by acute care 
hospitals as well as other providers to report diagnostic and procedure 
information. The IPF PPS has always incorporated ICD-9-CM coding 
changes made in the annual IPPS update. We publish coding changes in a 
Transmittal/Change Request, similar to how coding changes are announced 
by the IPPS and LTCH PPS. Those ICD-9-CM coding changes are also 
published in the following IPF PPS FY update, in either the IPF PPS 
proposed and final rules, or in an IPF PPS update notice.
    In the May 2008 IPF PPS notice (73 FR 25709), we discussed CMS' 
effort to better recognize resource use and the severity of illness 
among patients. CMS adopted the new MS-DRGs for the IPPS in the FY 2008 
IPPS final rule with comment period (72 FR 47130). A crosswalk, to 
reflect changes that were made to the DRGs under the IPF PPS to the new 
MS-DRGs, was provided (73 FR 25716). We believe by better accounting 
for patients' severity of illness in Medicare payment rates, the MS-
DRGs encourage hospitals to improve their coding and documentation of 
patient diagnoses. The MS-DRGs, which are based on the IPPS MS-DRGs, 
represent a significant increase in the number of DRGs (from 538 to 
745, an increase of 207). For a full description of the development and 
implementation of the MS-DRGs, see the FY 2008 IPPS final rule with 
comment period (72 FR 47141 through 47175).
    All of the ICD-9-CM coding changes are reflected in the FY 2013 
GROUPER, Version 31.0, effective for IPPS discharges occurring on or 
after October 1, 2013 through September 30, 2014. The GROUPER Version 
31.0 software package assigns each case to an MS-DRG on the basis of 
the diagnosis and procedure codes and demographic information (that is, 
age, sex, and discharge status). The Medicare Code Editor (MCE) 31.0 
uses the new ICD-9-CM codes to validate coding for IPPS discharges on 
or after October 1, 2013. The complete documentation of the GROUPER 
logic is available from 3M/Health Information System (HIS), which, 
under contract with CMS, is responsible for updating and maintaining 
the GROUPER program. The current MS-DRG Definitions

[[Page 46741]]

Manual, version 30.0, is available on a CD for $225.00. Version 31.0 of 
this manual, which will include the final FY 2014 MS-DRG changes, will 
be available on CD for $225.00. These manuals may be obtained by 
writing to 3M/HIS at the following address: 100 Barnes Road, 
Wallingford, CT 06492; or by calling (203) 949-0303, or by obtaining an 
order form at the Web site: http://www.3MHIS.com. The IPF PPS has 
always used the same GROUPER and Code Editor as the IPPS. Therefore, 
the ICD-9-CM changes, which were reflected in the GROUPER Version 31.0 
and MCE 31.0 on October 1, 2013, also became effective for the IPF PPS 
for discharges occurring on or after October 1, 2013.
    The impact of the new MS-DRGs on the IPF PPS was negligible. 
Mapping to the MS-DRGs resulted in the current 17 MS-DRGs, instead of 
the original 15, for which the IPF PPS provides an adjustment. Although 
the code set is updated, the same associated adjustment factors apply 
now that have been in place since implementation of the IPF PPS, with 
one exception that is unrelated to the update to the codes. When DRGs 
521 and 522 were consolidated into MS-DRG 895, we carried over the 
adjustment factor of 1.02 from DRG 521 to the newly consolidated MS-
DRG. This was done to reflect the higher claims volume under DRG 521, 
with more than eight times the number of claims than billed under DRG 
522. For a detailed description of the mapping changes from the 
original DRG adjustment categories to the current MS-DRG adjustment 
categories, we refer readers to the May 2008 IPF PPS notice (73 FR 
25714).
    The official version of the ICD-9-CM is available on CD-ROM from 
the U.S. Government Printing Office. The FY 2012 version can be ordered 
by contacting the Superintendent of Documents, U.S. Government Printing 
Office, Department 50, Washington, DC 20402-9329, telephone number 
(202) 512-1800. Questions concerning the ICD-9-CM should be directed to 
Patricia E. Brooks, Co-Chairperson, ICD-9-CM Coordination and 
Maintenance Committee, CMS, Center for Medicare Management, Hospital 
and Ambulatory Policy Group, Division of Acute Care, Mailstop C4-08-06, 
7500 Security Boulevard, Baltimore, Maryland 21244-1850. The Web site 
for the CD-ROM which contains the complete official version of the 
International Classification of Diseases, Ninth Revision, Clinical 
Modification is located at: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/CDROM.html.
    Further information concerning the official version of the ICD-9-CM 
can be found on the IPPS Web site at: http://cms.hhs.gov/medicare/coding/icd9providerdiagnosticcodes/addendum.html.
Transition to ICD-10-CM
    We note that, in accordance with the requirements of the final rule 
published in the Federal Register on September 5, 2012 (77 FR 54664), 
we will be discontinuing our current use of the International 
Classification of Diseases, 9th revision, Clinical Modification (ICD-9-
CM), effective with the compliance date for using the international 
Classification of Diseases, 10th revision, Clinical Modifications (ICD-
10-CM) of October 1, 2014. The ICD-10-CM coding guidelines are 
available through the CMS Web site at: www.cms.gov/Medicare/Coding/ICD10/downloads/pcs_2012_guidelines.pdf and http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10 or on the CDC's Web 
site at www.cdc.gov/nchs/data/icd10/10cmguidelines2012.pdf.
    The MS-IPF-DRG adjustment factors (as shown in Table 2) will 
continue to be paid for discharges occurring in FY 2014. In FY 2015, 
the MS-IPF-DRG adjustment factors will be updated effective with the 
compliance date for using the ICD-10-CM of October 1, 2014.

             Table 2--FY 2014 Current MS-IPF-DRGS Applicable for the Principal Diagnosis Adjustment
----------------------------------------------------------------------------------------------------------------
                                                                                                      Adjustment
                   MS-DRG                                      MS-DRG descriptions                      factor
----------------------------------------------------------------------------------------------------------------
056........................................  Degenerative nervous system disorders w MCC...........         1.05
057........................................  Degenerative nervous system disorders w/o MCC.........         1.05
080........................................  Nontraumatic stupor & coma w MCC......................         1.07
081........................................  Nontraumatic stupor & coma w/o MCC....................         1.07
876........................................  O.R. procedure w principal diagnoses of mental illness         1.22
880........................................  Acute adjustment reaction & psychosocial dysfunction..         1.05
881........................................  Depressive neuroses...................................         0.99
882........................................  Neuroses except depressive............................         1.02
883........................................  Disorders of personality & impulse control............         1.02
884........................................  Organic disturbances & mental retardation.............         1.03
885........................................  Psychoses.............................................         1.00
886........................................  Behavioral & developmental disorders..................         0.99
887........................................  Other mental disorder diagnoses.......................         0.92
894........................................  Alcohol/drug abuse or dependence, left AMA............         0.97
895........................................  Alcohol/drug abuse or dependence w rehabilitation              1.02
                                              therapy.
896........................................  Alcohol/drug abuse or dependence w/o rehabilitation            0.88
                                              therapy w MCC.
897........................................  Alcohol/drug abuse or dependence w/o rehabilitation            0.88
                                              therapy w/o MCC.
----------------------------------------------------------------------------------------------------------------

2. Payment for Comorbid Conditions
    The intent of the comorbidity adjustments is to recognize the 
increased costs associated with comorbid conditions by providing 
additional payments for certain concurrent medical or psychiatric 
conditions that are expensive to treat. In the May 2011 IPF PPS final 
rule (76 FR 26451 through 26452), we explained that the IPF PPS 
includes 17 comorbidity categories and identified the new, revised, and 
deleted ICD-9-CM diagnosis codes that generate a comorbid condition 
payment adjustment under the IPF PPS for RY 2012 (76 FR 26451).
    Comorbidities are specific patient conditions that are secondary to 
the patient's principal diagnosis and that require treatment during the 
stay. Diagnoses that relate to an earlier episode of care and have no 
bearing on

[[Page 46742]]

the current hospital stay are excluded and must not be reported on IPF 
claims. Comorbid conditions must exist at the time of admission or 
develop subsequently, and affect the treatment received, length of stay 
(LOS), or both treatment and LOS.
    For each claim, an IPF may receive only one comorbidity adjustment 
within a comorbidity category, but it may receive an adjustment for 
more than one comorbidity category. Billing instructions require that 
IPFs must enter the full ICD-9-CM codes for up to 24 additional 
diagnoses if they co-exist at the time of admission or develop 
subsequently and impact the treatment provided.
    The comorbidity adjustments were determined based on the regression 
analysis using the diagnoses reported by IPFs in FY 2002. The principal 
diagnoses were used to establish the DRG adjustments and were not 
accounted for in establishing the comorbidity category adjustments, 
except where ICD-9-CM ``code first'' instructions apply. As we 
explained in the May 2011 IPF PPS final rule (76 FR 265451), the code 
first rule applies when a condition has both an underlying etiology and 
a manifestation due to the underlying etiology. For these conditions, 
ICD-9-CM has a coding convention that requires the underlying 
conditions to be sequenced first followed by the manifestation. 
Whenever a combination exists, there is a ``use additional code'' note 
at the etiology code and a code first note at the manifestation code.
    As discussed in the MS-DRG section, it is our policy to maintain 
the same diagnostic coding set for IPFs that is used under the IPPS for 
providing the same psychiatric care.
    For FY 2014, we are applying the 17 comorbidity categories for 
which we are providing an adjustment, their respective codes, and their 
respective adjustment factors in Table 3 below. In FY 2015, the 
diagnosis codes and adjustment factors for the comorbidity categories 
will be updated effective with the compliance date for using the ICD-
10-CM of October 1, 2014.

               Table 3--FY 2014 Diagnosis Codes and Adjustment Factors for Comorbidity Categories
----------------------------------------------------------------------------------------------------------------
                                                                                                      Adjustment
      Description of comorbidity                              Diagnoses codes                           factor
----------------------------------------------------------------------------------------------------------------
Developmental Disabilities............  317, 3180, 3181, 3182, and 319.............................         1.04
Coagulation Factor Deficits...........  2860 through 2864..........................................         1.13
Tracheostomy..........................  51900 through 51909 and V440...............................         1.06
Renal Failure, Acute..................  5845 through 5849, 63630, 63631, 63632, 63730, 63731,               1.11
                                         63732, 6383, 6393, 66932, 66934, 9585.
Renal Failure, Chronic................  40301, 40311, 40391, 40402, 40412, 40413, 40492, 40493,             1.11
                                         5853, 5854, 5855, 5856, 5859, 586, V4511, V4512, V560,
                                         V561, and V562.
Oncology Treatment....................  1400 through 2399 with a radiation therapy code 92.21-92.29         1.07
                                         or chemotherapy code 99.25.
Uncontrolled Diabetes-Mellitus with or  25002, 25003, 25012, 25013, 25022, 25023, 25032, 25033,             1.05
 without complications.                  25042, 25043, 25052, 25053, 25062, 25063, 25072, 25073,
                                         25082, 25083, 25092, and 25093.
Severe Protein Calorie Malnutrition...  260 through 262............................................         1.13
Eating and Conduct Disorders..........  3071, 30750, 31203, 31233, and 31234.......................         1.12
Infectious Disease....................  01000 through 04110, 042, 04500 through 05319, 05440                1.07
                                         through 05449, 0550 through 0770, 0782 through 07889, and
                                         07950 through 07959.
Drug and/or Alcohol Induced Mental      2910, 2920, 29212, 2922, 30300, and 30400..................         1.03
 Disorders.
Cardiac Conditions....................  3910, 3911, 3912, 40201, 40403, 4160, 4210, 4211, and 4219.         1.11
Gangrene..............................  44024 and 7854.............................................         1.10
Chronic Obstructive Pulmonary Disease.  49121, 4941, 5100, 51883, 51884, V4611, V4612, V4613 and            1.12
                                         V4614.
Artificial Openings--Digestive and      56960 through 56969, 9975, and V441 through V446...........         1.08
 Urinary.
Severe Musculoskeletal and Connective   6960, 7100, 73000 through 73009, 73010 through 73019, and           1.09
 Tissue Diseases.                        73020 through 73029.
Poisoning.............................  96500 through 96509, 9654, 9670 through 9699, 9770, 9800            1.11
                                         through 9809, 9830 through 9839, 986, 9890 through 9897.
----------------------------------------------------------------------------------------------------------------

3. Patient Age Adjustments
    As explained in the November 2004 IPF PPS final rule (69 FR 66922), 
we analyzed the impact of age on per diem cost by examining the age 
variable (that is, the range of ages) for payment adjustments.
    In general, we found that the cost per day increases with age. The 
older age groups are more costly than the under 45 age group, the 
differences in per diem cost increase for each successive age group, 
and the differences are statistically significant.
    We do not plan to update the regression analysis until we are able 
to analyze IPF PPS data. Therefore, for FY 2014, we are continuing to 
use the patient age adjustments currently in effect as shown in Table 4 
below.

              Table 4--Age Groupings and Adjustment Factors
------------------------------------------------------------------------
                                                              Adjustment
                            Age                                 factor
------------------------------------------------------------------------
Under 45...................................................         1.00
45 and under 50............................................         1.01
50 and under 55............................................         1.02
55 and under 60............................................         1.04
60 and under 65............................................         1.07
65 and under 70............................................         1.10
70 and under 75............................................         1.13
75 and under 80............................................         1.15
80 and over................................................         1.17
------------------------------------------------------------------------

4. Variable Per Diem Adjustments
    We explained in the November 2004 IPF PPS final rule (69 FR 66946) 
that the regression analysis indicated that per diem cost declines as 
the LOS increases. The variable per diem adjustments to the Federal per 
diem base rate account for ancillary and administrative costs that 
occur disproportionately in the first days after admission to an IPF.
    We used a regression analysis to estimate the average differences 
in per diem cost among stays of different lengths. As a result of this 
analysis, we established variable per diem adjustments that begin on 
day 1 and decline gradually until day 21 of a patient's stay. For day 
22 and thereafter, the variable per diem adjustment

[[Page 46743]]

remains the same each day for the remainder of the stay. However, the 
adjustment applied to day 1 depends upon whether the IPF has a 
qualifying ED. If an IPF has a qualifying ED, it receives a 1.31 
adjustment factor for day 1 of each stay. If an IPF does not have a 
qualifying ED, it receives a 1.19 adjustment factor for day 1 of the 
stay. The ED adjustment is explained in more detail in section VII.C.5 
of this notice.
    For FY 2014, we are continuing to use the variable per diem 
adjustment factors currently in effect as shown in Table 5 below. A 
complete discussion of the variable per diem adjustments appears in the 
November 2004 IPF PPS final rule (69 FR 66946).

                 Table 5--Variable per Diem Adjustments
------------------------------------------------------------------------
                                                              Adjustment
                        Day-of-stay                             factor
------------------------------------------------------------------------
Day 1--IPF Without a Qualifying ED.........................         1.19
Day 1--IPF With a Qualifying ED............................         1.31
Day 2......................................................         1.12
Day 3......................................................         1.08
Day 4......................................................         1.05
Day 5......................................................         1.04
Day 6......................................................         1.02
Day 7......................................................         1.01
Day 8......................................................         1.01
Day 9......................................................         1.00
Day 10.....................................................         1.00
Day 11.....................................................         0.99
Day 12.....................................................         0.99
Day 13.....................................................         0.99
Day 14.....................................................         0.99
Day 15.....................................................         0.98
Day 16.....................................................         0.97
Day 17.....................................................         0.97
Day 18.....................................................         0.96
Day 19.....................................................         0.95
Day 20.....................................................         0.95
Day 21.....................................................         0.95
After Day 21...............................................         0.92
------------------------------------------------------------------------

C. Facility-Level Adjustments

    The IPF PPS includes facility-level adjustments for the wage index, 
IPFs located in rural areas, teaching IPFs, cost of living adjustments 
for IPFs located in Alaska and Hawaii, and IPFs with a qualifying ED.
1. Wage Index Adjustment
a. Background
    As discussed in the May 2006 IPF PPS final rule (71 FR 27061) and 
in the May 2008 (73 FR 25719) and May 2009 IPF PPS notices (74 FR 
20373), in order to provide an adjustment for geographic wage levels, 
the labor-related portion of an IPF's payment is adjusted using an 
appropriate wage index. Currently, an IPF's geographic wage index value 
is determined based on the actual location of the IPF in an urban or 
rural area as defined in Sec.  412.64(b)(1)(ii)(A) and (C).
b. Wage Index for FY 2014
    Since the inception of the IPF PPS, we have used the pre-
reclassified, pre-floor hospital wage index in developing a wage index 
to be applied to IPFs because there is not an IPF-specific wage index 
available and we believe that IPFs generally compete in the same labor 
market as acute care hospitals so the pre-reclassified, pre-floor 
inpatient acute care hospital wage index should be reflective of labor 
costs of IPFs. As discussed in the May 2006 IPF PPS final rule for FY 
2007 (71 FR 27061 through 27067), under the IPF PPS, the wage index is 
calculated using the IPPS wage index for the labor market area in which 
the IPF is located, without taking into account geographic 
reclassifications, floors, and other adjustments made to the wage index 
under the IPPS. For a complete description of these IPPS wage index 
adjustments, please see the CY 2013 IPPS/IRF PPS final rule (77 FR 
53365 through 53374). We are continuing that practice for FY 2014.
    We apply the wage index adjustment to the labor-related portion of 
the Federal rate, which is 69.494 percent. This percentage reflects the 
labor-related relative importance of the FY 2008-based RPL market 
basket for FY 2014 (see section V.C. of this notice).
    Changes to the wage index are made in a budget neutral manner so 
that updates do not increase expenditures. For FY 2014, we are applying 
the most recent hospital wage index (that is, the FY 2013 pre-floor, 
pre-reclassified hospital wage index because this is the most 
appropriate index as it best reflects the variation in local labor 
costs of IPFs in the various geographic areas) using the most recent 
hospital wage data (that is, data from hospital cost reports for the 
cost reporting period beginning during FY 2009), and applying an 
adjustment in accordance with our budget neutrality policy. This policy 
requires us to estimate the total amount of IPF PPS payments for FY 
2013 using the labor-related share and the wage indices from FY 2013 
divided by the total estimated IPF PPS payments for FY 2014 using the 
labor-related share and wage indices from FY 2014. The estimated 
payments are based on FY 2012 IPF claims, inflated to the appropriate 
FY. This quotient is the wage index budget neutrality factor, and it is 
applied in the update of the Federal per diem base rate for FY 2014 in 
addition to the market basket described in section VI.B. of this 
notice. The wage index budget neutrality factor for FY 2014 is 1.0010. 
The wage index applicable for FY 2014 appears in Table 1 and Table 2 in 
Addendum B of this notice.
    In the May 2006 IPF PPS final rule for RY 2007 (71 FR 27061-27067), 
we adopted the changes discussed in the Office of Management and Budget 
(OMB) Bulletin No. 03-04 (June 6, 2003), which announced revised 
definitions for Metropolitan Statistical Areas (MSAs), and the creation 
of Micropolitan Statistical Areas and Combined Statistical Areas. In 
adopting the OMB Core-Based Statistical Area (CBSA) geographic 
designations, we did not provide a separate transition for the CBSA-
based wage index since the IPF PPS was already in a transition period 
from TEFRA payments to PPS payments.
    As was the case in FY 2013, for FY 2014, we will continue to use 
the CBSA geographic designations. The updated FY 2014 CBSA-based wage 
index values are presented in Tables 1 and 2 in Addendum B of this 
notice. A complete discussion of the CBSA labor market definitions 
appears in the May 2006 IPF PPS final rule (71 FR 27061 through 27067).
    In keeping with established IPF PPS wage index policy, we will use 
the FY 2013 pre-floor, pre-reclassified hospital wage index (which is 
based on data collected from hospital cost reports submitted by 
hospitals for cost reporting periods beginning during FY 2009) to 
adjust IPF PPS payments beginning October 1, 2013.
c. OMB Bulletins
    OMB publishes bulletins regarding CBSA changes, including changes 
to CBSA numbers and titles. In the May 2008 IPF PPS notice, we 
incorporated the CBSA nomenclature changes published in the most recent 
OMB bulletin that applies to the hospital wage index used to determine 
the current IPF PPS wage index and stated that we expect to continue to 
do the same for all the OMB CBSA nomenclature changes in future IPF PPS 
rules and notices, as necessary (73 FR 25721). The OMB bulletins may be 
accessed online at http://www.whitehouse.gov/omb/bullentins/index.html.
    In accordance with our established methodology, we have 
historically adopted any CBSA changes that are published in the OMB 
bulletin that corresponds with the hospital wage index used to 
determine the IPF PPS wage index. For FY 2014, we use the FY 2013 pre-
floor, pre-reclassified hospital wage index to adjust the IPF PPS 
payments. On February 28, 2013, OMB issued OMB Bulletin No. 13-01, 
which

[[Page 46744]]

establishes revised delineations of statistical areas based on OMB 
standards published in the Federal Register on June 28, 2010 and 2010 
Census Bureau data. Because the FY 2013 pre-floor, pre-reclassified 
hospital wage index was finalized prior to the issuance of this 
Bulletin, the FY 2013 pre-floor, pre-reclassified hospital wage index 
does not reflect OMB's new area delineations based on the 2010 Census 
and, thus, the FY 2014 IPF PPS wage index will not reflect the OMB 
changes. CMS intends to propose changes to the hospital wage index 
based on this OMB Bulletin in the FY 2015 IPPS/LTCH PPS proposed rule, 
as stated in the FY 2014 IPPS/LTCH PPS proposed rule (78 FR 27552 
through 27553). Therefore, we anticipate that the OMB Bulletin changes 
will be reflected in the FY 2015 hospital wage index. Because we base 
the IPF PPS wage index on the hospital wage index from the prior year, 
we anticipate that the OMB Bulletin changes would be reflected in the 
FY 2016 IPPS PPS wage index.
2. Adjustment for Rural Location
    In the November 2004 IPF PPS final rule, we provided a 17 percent 
payment adjustment for IPFs located in a rural area. This adjustment 
was based on the regression analysis, which indicated that the per diem 
cost of rural facilities was 17 percent higher than that of urban 
facilities after accounting for the influence of the other variables 
included in the regression. For FY 2014, we are applying a 17 percent 
payment adjustment for IPFs located in a rural area as defined at Sec.  
412.64(b)(1)(ii)(C). As stated in the November 2004 IPF PPS final rule, 
we do not intend to update the adjustment factors derived from the 
regression analysis until we are able to analyze IPF PPS data. A 
complete discussion of the adjustment for rural locations appears in 
the November 2004 IPF PPS final rule (69 FR 66954).
3. Teaching Adjustment
    In the November 2004 IPF PPS final rule, we implemented regulations 
at Sec.  412.424(d)(1)(iii) to establish a facility-level adjustment 
for IPFs that are, or are part of, teaching hospitals. The teaching 
adjustment accounts for the higher indirect operating costs experienced 
by hospitals that participate in graduate medical education (GME) 
programs. The payment adjustments are made based on the number of full-
time equivalent (FTE) interns and residents training in the IPF and the 
IPF's average daily census.
    Medicare makes direct GME payments (for direct costs such as 
resident and teaching physician salaries, and other direct teaching 
costs) to all teaching hospitals including those paid under a PPS, and 
those paid under the TEFRA rate-of-increase limits. These direct GME 
payments are made separately from payments for hospital operating costs 
and are not part of the IPF PPS. The direct GME payments do not address 
the estimated higher indirect operating costs teaching hospitals may 
face.
    For teaching hospitals paid under the TEFRA rate-of-increase 
limits, Medicare does not make separate payments for indirect medical 
education costs because payments to these hospitals are based on the 
hospitals' reasonable costs which already include these higher indirect 
costs that may be associated with teaching programs.
    The results of the regression analysis of FY 2002 IPF data 
established the basis for the payment adjustments included in the 
November 2004 IPF PPS final rule. The results showed that the indirect 
teaching cost variable is significant in explaining the higher costs of 
IPFs that have teaching programs. We calculated the teaching adjustment 
based on the IPF's ``teaching variable,'' which is one plus the ratio 
of the number of FTE residents training in the IPF (subject to 
limitations described below) to the IPF's average daily census (ADC).
    We established the teaching adjustment in a manner that limited the 
incentives for IPFs to add FTE residents for the purpose of increasing 
their teaching adjustment. We imposed a cap on the number of FTE 
residents that may be counted for purposes of calculating the teaching 
adjustment. The cap limits the number of FTE residents that teaching 
IPFs may count for the purpose of calculating the IPF PPS teaching 
adjustment, not the number of residents teaching institutions can hire 
or train. We calculated the number of FTE residents that trained in the 
IPF during a ``base year'' and used that FTE resident number as the 
cap. An IPF's FTE resident cap is ultimately determined based on the 
final settlement of the IPF's most recent cost report filed before 
November 15, 2004 (that is, the publication date of the IPF PPS final 
rule).
    In the regression analysis, the logarithm of the teaching variable 
had a coefficient value of 0.5150. We converted this cost effect to a 
teaching payment adjustment by treating the regression coefficient as 
an exponent and raising the teaching variable to a power equal to the 
coefficient value. We note that the coefficient value of 0.5150 was 
based on the regression analysis holding all other components of the 
payment system constant.
    As with other adjustment factors derived through the regression 
analysis, we do not plan to rerun the regression analysis until we 
analyze IPF PPS data. Therefore, in this notice, for FY 2014, we are 
retaining the coefficient value of 0.5150 for the teaching adjustment 
to the Federal per diem base rate.
    A complete discussion of how the teaching adjustment was calculated 
appears in the November 2004 IPF PPS final rule (69 FR 66954 through 
66957) and the May 2008 IPF PPS notice (73 FR 25721).
a. FTE Intern and Resident Cap Adjustment
    CMS had been asked to reconsider the original IPF teaching policy 
and permit a temporary increase in the FTE resident cap when an IPF 
increases the number of FTE residents it trains due to the acceptance 
of displaced residents (residents that are training in an IPF or a 
program before the IPF or program closed) when another IPF closes or 
closes its medical residency training program.
    To help us assess how many IPFs had been, or were expected to be 
adversely affected by their inability to adjust their caps under Sec.  
412.424(d)(1) and under these situations, we specifically requested 
public comment from IPFs in the May 1, 2009 IPF PPS notice (74 FR 20376 
through 20377). A summary of the comments and our responses can be 
reviewed in the April 30, 2010 IPF PPS notice (75 FR 23106 through 
23117). All of the commenters recommended that CMS modify the IPF PPS 
teaching adjustment policy, supporting a policy change that would 
permit the IPF PPS residency cap to be temporarily adjusted when that 
IPF trains displaced residents due to closure of an IPF or closure of 
an IPF's medical residency training program(s). The commenters 
recommended a temporary resident cap adjustment policy similar to the 
policies applied in similar contexts for acute care hospitals.
    We agreed with the commenters that, when a hospital temporarily 
takes on residents because another hospital closes or discontinues its 
program, a temporary adjustment to the cap would be appropriate for a 
rotation that occurs in an IPF setting (freestanding or units). In 
these situations, residents may have partially completed a medical 
residency training program at the hospital that has closed its training 
program and may be unable to complete their training at another 
hospital that is already training residents up to or in excess of its 
cap. We believe that it is appropriate to allow temporary adjustments 
to the FTE caps for an IPF that provides residency

[[Page 46745]]

training to medical residents who have partially completed a residency 
training program at an IPF that closes or at an IPF that discontinues 
training residents in a residency training program(s) (also referred to 
as a ``closed'' program throughout this preamble). For this reason, we 
adopted the following temporary resident cap adjustment policies, 
similar to the temporary adjustments to the FTE cap used for acute care 
hospitals. We proposed and finalized that the cap adjustment would be 
temporary because it is resident specific and would only apply to the 
displaced resident(s) until the resident(s) completes training in that 
specialty. As under the IPPS policy for displaced residents, the IPF 
PPS temporary cap adjustment would apply only to residents that were 
still training at the IPF at the time the IPF closed or at the time the 
IPF ceased training residents in the residency training program(s). 
Residents who leave the IPF, for whatever reason, before the closure of 
the IPF hospital or medical residency training program would not be 
considered displaced residents for purposes of the IPF temporary cap 
adjustment policy. Similarly, as under the IPPS policy, medical 
students who match to a program at an IPF but the IPF or medical 
residency training program closes before the individual begins training 
at that IPF are also not considered displaced residents for purposes of 
the IPF temporary cap adjustments. For detailed information on these 
acute care hospital GME/IME payment policies, we refer the reader to 
the August 1, 2001 final rule (66 FR 39899), July 30, 1999 final rule 
(64 FR 41522), and May 7, 1999 proposed rule (64 FR 24736). We note 
that although we adopted a policy under the IPF PPS that is consistent 
with the policy applicable under the IPPS, the actual caps under the 
two payment systems may not be commingled.
b. Temporary Adjustment to the FTE Cap To Reflect Residents Added Due 
to Hospital Closure
    In the May 6, 2011 IPF PPS final rule (76 FR 26455), we indicated 
that we would allow an IPF to receive a temporary adjustment to the FTE 
cap to reflect residents added because of another IPF's closure. This 
adjustment is intended to account for medical residents who would have 
partially completed a medical residency training program at the 
hospital that has closed and may be unable to complete their training 
at another hospital because that hospital is already training residents 
up to or in excess of its cap. We made this change because IPFs have 
indicated a reluctance to accept additional residents from a closed IPF 
without a temporary adjustment to their caps. For purposes of this 
policy on IPF closure, we adopted the IPPS definition of ``closure of a 
hospital'' in 42 CFR 413.79(h) to mean the IPF terminates its Medicare 
provider agreement as specified in 42 CFR 489.52. Therefore, we added a 
new Sec.  412.424(d)(1)(iii)(F)(1) to allow a temporary adjustment to 
an IPF's FTE cap to reflect residents added because of an IPF's closure 
on or after July 1, 2011, to be effective for cost reporting periods 
beginning on or after July 1, 2011. Under this policy, we allow an 
adjustment to an IPF's FTE cap if the IPF meets the following criteria: 
(1) The IPF is training displaced residents from an IPF that closed on 
or after July 1, 2011; and (2) the IPF that is training the displaced 
residents from the closed IPF submits a request for a temporary 
adjustment to its FTE cap to its Medicare contractor no later than 60 
days after the hospital first begins training the displaced residents, 
and documents that the IPF is eligible for this temporary adjustment to 
its FTE cap by identifying the residents who have come from the closed 
IPF and have caused the IPF to exceed its cap, (or the IPF may already 
be over its cap), and specifies the length of time that the adjustment 
is needed. After the displaced residents leave the IPF's training 
program or complete their residency program, the IPF's cap would revert 
to its original level. This means that the temporary adjustment to the 
FTE cap would be available to the IPF only for the period of time 
necessary for the displaced residents to complete their training. 
Further, as under the IPPS policy, we also indicated that the total 
amount of temporary cap adjustment that can be distributed to all 
receiving hospitals cannot exceed the cap amount of the IPF that 
closed.
c. Temporary Adjustment to FTE Cap To Reflect Residents Affected by 
Residency Program Closure
    In the May 6, 2011 final rule (76 FR 26455), we indicated that if 
an IPF that ceases training residents in a residency training 
program(s) agrees to temporarily reduce its FTE cap, we would allow 
another IPF to receive a temporary adjustment to its FTE cap to reflect 
residents added because of the closure of another IPF's residency 
training program. For purposes of this policy on closed residency 
programs, we adopted the IPPS definition of ``closure of a hospital 
residency training program'' to mean that the hospital ceases to offer 
training for residents in a particular approved medical residency 
training program as specified in Sec.  413.79(h). The methodology for 
adjusting the caps for the ``receiving IPF'' and the ``IPF that closed 
its program'' is described below.
i. Receiving IPF
    We proposed and finalized that an IPF(s) may receive a temporary 
adjustment to its FTE cap to reflect residents added because of the 
closure of another IPF's residency training program for cost reporting 
periods beginning on or after July 1, 2011 if--
     The IPF is training additional residents from the 
residency training program of an IPF that closed its program on or 
after July 1, 2011.
     No later than 60 days after the IPF begins to train the 
residents, the IPF submits to its Medicare Contractor a request for a 
temporary adjustment to its FTE cap, documents that the IPF is eligible 
for this temporary adjustment by identifying the residents who have 
come from another IPF's closed program and have caused the IPF to 
exceed its cap, (or the IPF may already be in excess of its cap), 
specifies the length of time the adjustment is needed, and, submits to 
its Medicare contractor a copy of the FTE cap reduction statement by 
the IPF closing the residency training program.
    In general, the temporary adjustment criteria established for 
closed medical residency training programs at IPFs is similar to the 
criteria established for closed IPFs. More than one IPF may be eligible 
to apply for the temporary adjustment because residents from one closed 
program may complete their training at one IPF, or at several IPFs. 
Also, an IPF would be eligible for the temporary adjustment only to the 
extent that the displaced residents would cause the IPF to exceed its 
FTE cap.
    Finally, we proposed and finalized that IPFs meeting the proposed 
criteria would be eligible to receive temporary adjustments to their 
FTE caps for cost reporting periods beginning on or after July 1, 2011.
ii. IPF That Closed Its Program
    We indicated that an IPF that agrees to train residents who have 
been displaced by the closure of another IPF's resident teaching 
program, may receive a temporary FTE cap adjustment only if the IPF 
that closed a program:
     Temporarily reduces its FTE cap by the number of FTE 
residents, in each program year, training in the program at the time of 
the program's closure. The yearly reduction would be determined by 
deducting the number of those residents who would have been training in 
the program during the year of the closure, had the program not closed.

[[Page 46746]]

     No later than 60 days after the residents who were in the 
closed program begin training at another IPF, submits to its Medicare 
contractor a statement signed and dated by its representative that 
specifies that it agrees to the temporary reduction in its FTE cap to 
allow the IPF training the displaced residents to obtain a temporary 
adjustment to its cap; identifies the residents who were training at 
the time of the program's closure; identifies the IPFs to which the 
residents are transferring once the program closes; and specifies the 
reduction for the applicable program years.
    We proposed and finalized that the cap reduction for the IPF with 
the closed program would be based on the number of FTE residents in 
each program year who were in the program at the IPF at the time of the 
program's closure, and who begin training at another IPF.
    A complete discussion on the temporary adjustment to the FTE cap to 
reflect residents added due to hospital closure and by residency 
program appears in the January 27, 2011 IPF PPS proposed rule (76 FR 
5018 through 5020) and the May 6, 2011 IPF PPS final rule (76 FR 26453 
through 26456).
4. Cost of Living Adjustment for IPFs Located in Alaska and Hawaii
    The IPF PPS includes a payment adjustment for IPFs located in 
Alaska and Hawaii based upon the county in which the IPF is located. As 
we explained in the November 2004 IPF PPS final rule, the FY 2002 data 
demonstrated that IPFs in Alaska and Hawaii had per diem costs that 
were disproportionately higher than other IPFs. Other Medicare PPSs 
(for example, the IPPS and LTCH PPS) have adopted a cost of living 
adjustment (COLA) to account for the cost differential of care 
furnished in Alaska and Hawaii.
    We analyzed the effect of applying a COLA to payments for IPFs 
located in Alaska and Hawaii. The results of our analysis demonstrated 
that a COLA for IPFs located in Alaska and Hawaii would improve payment 
equity for these facilities. As a result of this analysis, we provided 
a COLA in the November 2004 IPF PPS final rule.
    A COLA adjustment for IPFs located in Alaska and Hawaii is made by 
multiplying the nonlabor-related portion of the Federal per diem base 
rate by the applicable COLA factor based on the COLA area in which the 
IPF is located.
    The COLA factors are published on the Office of Personnel 
Management (OPM) Web site (http://www.opm.gov/oca/cola/rates.asp).
    We note that the COLA areas for Alaska are not defined by county as 
are the COLA areas for Hawaii. In 5 CFR 591.207, the OPM established 
the following COLA areas:
     City of Anchorage, and 80-kilometer (50-mile) radius by 
road, as measured from the Federal courthouse;
     City of Fairbanks, and 80-kilometer (50-mile) radius by 
road, as measured from the Federal courthouse;
     City of Juneau, and 80-kilometer (50-mile) radius by road, 
as measured from the Federal courthouse;
     Rest of the State of Alaska.
    As previously stated in the November 2004 IPF PPS final rule, we 
update the COLA factors according to updates established by the OPM. 
Sections 1911 through 1919 of the Nonforeign Area Retirement Equity 
Assurance Act, as contained in subtitle B of title XIX of the National 
Defense Authorization Act (NDAA) for Fiscal Year 2010 (Pub. L. 111-84, 
October 28, 2009), transitions the Alaska and Hawaii COLAs to locality 
pay. Under section 1914 of Public Law 111-84, locality pay is being 
phased in over a 3-year period beginning in January 2010, with COLA 
rates frozen as of the date of enactment, October 28, 2009, and then 
proportionately reduced to reflect the phase-in of locality pay.
    When we published the proposed COLA adjustment factors in the 
January 2011 IPF proposed rule (76 FR 4998), we inadvertently selected 
the FY 2010 COLA rates. The FY 2010 COLA rates were reduced rates to 
account for the phase-in of locality pay. We did not intend to propose 
reduced COLA rates, and we do not believe it is appropriate to finalize 
the reduced COLAs that we showed in our January 2011 proposed rule. The 
2009 COLA rates do not reflect the phase-in of locality pay. Therefore, 
we finalized the FY 2009 COLA rates, which are the same rates that were 
in effect for RY 2010 through RY 2012. We plan to address the COLA in 
the future refinement process in FY 2015. For FY 2014, IPFs located in 
Alaska and Hawaii will continue to receive the updated COLA factors 
based on the COLA area in which the IPF is located as shown in Table 6 
below.

            Table 6--COLA Factors for Alaska and Hawaii IPFs
------------------------------------------------------------------------
                                                         Cost of living
                         Area                              adjustment
                                                             factor
------------------------------------------------------------------------
Alaska:
    City of Anchorage and 80-kilometer (50-mile)                    1.23
     radius by road...................................
    City of Fairbanks and 80-kilometer (50-mile)                    1.23
     radius by road...................................
    City of Juneau and 80-kilometer (50-mile) radius                1.23
     by road..........................................
    Rest of Alaska....................................              1.25
Hawaii:
    City and County of Honolulu.......................              1.25
    County of Hawaii..................................              1.18
    County of Kauai...................................              1.25
    County of Maui and County of Kalawao..............              1.25
------------------------------------------------------------------------
(The above factors are based on data obtained from the U.S. Office of
  Personnel Management Web site at: http://www.opm.gov/oca/cola/rates.asp.)

5. Adjustment for IPFs With a Qualifying Emergency Department (ED)
    The IPF PPS includes a facility-level adjustment for IPFs with 
qualifying EDs. We provide an adjustment to the Federal per diem base 
rate to account for the costs associated with maintaining a full-
service ED. The adjustment is intended to account for ED costs incurred 
by a freestanding psychiatric hospital with a qualifying ED or a 
distinct part psychiatric unit of an acute hospital or a CAH for 
preadmission services otherwise payable under the Medicare Outpatient 
Prospective Payment System (OPPS) furnished to a beneficiary on the 
date of the beneficiary's admission to the

[[Page 46747]]

hospital and during the day immediately preceding the date of admission 
to the IPF (see Sec.  413.40(c)(2)) and the overhead cost of 
maintaining the ED. This payment is a facility-level adjustment that 
applies to all IPF admissions (with one exception described below), 
regardless of whether a particular patient receives preadmission 
services in the hospital's ED.
    The ED adjustment is incorporated into the variable per diem 
adjustment for the first day of each stay for IPFs with a qualifying 
ED. That is, IPFs with a qualifying ED receive an adjustment factor of 
1.31 as the variable per diem adjustment for day 1 of each stay. If an 
IPF does not have a qualifying ED, it receives an adjustment factor of 
1.19 as the variable per diem adjustment for day 1 of each patient 
stay.
    The ED adjustment is made on every qualifying claim except as 
described below. As specified in Sec.  412.424(d)(1)(v)(B), the ED 
adjustment is not made where a patient is discharged from an acute care 
hospital or CAH and admitted to the same hospital's or CAH's 
psychiatric unit. An ED adjustment is not made in this case because the 
costs associated with ED services are reflected in the DRG payment to 
the acute care hospital or through the reasonable cost payment made to 
the CAH. If we provided the ED adjustment in these cases, the hospital 
would be paid twice for the overhead costs of the ED, as stated in the 
November 2004 IPF PPS final rule (69 FR 66960).
    Therefore, when patients are discharged from an acute care hospital 
or CAH and admitted to the same hospital's or CAH's psychiatric unit, 
the IPF receives the 1.19 adjustment factor as the variable per diem 
adjustment for the first day of the patient's stay in the IPF.
    For FY 2014, we are retaining the 1.31 adjustment factor for IPFs 
with qualifying EDs. A complete discussion of the steps involved in the 
calculation of the ED adjustment factor appears in the November 2004 
IPF PPS final rule (69 FR 66959 through 66960) and the May 2006 IPF PPS 
final rule (71 FR 27070 through 27072).

D. Other Payment Adjustments and Policies

    For FY 2014, the IPF PPS includes an outlier adjustment to promote 
access to IPF care for those patients who require expensive care and to 
limit the financial risk of IPFs treating unusually costly patients. In 
this section, we also explain the reason for ending the stop-loss 
provision that was applicable during the transition period.
1. Outlier Payments
    In the November 2004 IPF PPS final rule, we implemented regulations 
at Sec.  412.424(d)(3)(i) to provide a per-case payment for IPF stays 
that are extraordinarily costly. Providing additional payments to IPFs 
for extremely costly cases strongly improves the accuracy of the IPF 
PPS in determining resource costs at the patient and facility level. 
These additional payments reduce the financial losses that would 
otherwise be incurred in treating patients who require more costly care 
and, therefore, reduce the incentives for IPFs to under-serve these 
patients.
    We make outlier payments for discharges in which an IPF's estimated 
total cost for a case exceeds a fixed dollar loss threshold amount 
(multiplied by the IPF's facility-level adjustments) plus the Federal 
per diem payment amount for the case.
    In instances when the case qualifies for an outlier payment, we pay 
80 percent of the difference between the estimated cost for the case 
and the adjusted threshold amount for days 1 through 9 of the stay 
(consistent with the median LOS for IPFs in FY 2002), and 60 percent of 
the difference for day 10 and thereafter. We established the 80 percent 
and 60 percent loss sharing ratios because we were concerned that a 
single ratio established at 80 percent (like other Medicare PPSs) might 
provide an incentive under the IPF per diem payment system to increase 
LOS in order to receive additional payments. After establishing the 
loss sharing ratios, we determined the current fixed dollar loss 
threshold amount of $11,600 through payment simulations designed to 
compute a dollar loss beyond which payments are estimated to meet the 2 
percent outlier spending target.
a. Update to the Outlier Fixed Dollar Loss Threshold Amount
    In accordance with the update methodology described in Sec.  
412.428(d), we are updating the fixed dollar loss threshold amount used 
under the IPF PPS outlier policy. Based on the regression analysis and 
payment simulations used to develop the IPF PPS, we established a 2 
percent outlier policy which strikes an appropriate balance between 
protecting IPFs from extraordinarily costly cases while ensuring the 
adequacy of the Federal per diem base rate for all other cases that are 
not outlier cases.
    We believe it is necessary to update the fixed dollar loss 
threshold amount because an analysis of the latest available data (that 
is, FY 2012 IPF claims) and rate increases indicate that adjusting the 
fixed dollar loss amount is necessary in order to maintain an outlier 
percentage that equals 2 percent of total estimated IPF PPS payments.
    In the May 2006 IPF PPS final rule (71 FR 27072), we describe the 
process by which we calculate the outlier fixed dollar loss threshold 
amount. We will continue to use this process for FY 2014. We begin by 
simulating aggregate payments with and without an outlier policy, and 
applying an iterative process to determine an outlier fixed dollar loss 
threshold amount that will result in estimated outlier payments being 
equal to 2 percent of total estimated payments under the simulation. 
Based on this process, using the FY 2012 claims data, we estimate that 
IPF outlier payments as a percentage of total estimated payments are 
approximately 1.7 percent in FY 2013. Thus, for this notice, we are 
updating the FY 2014 IPF outlier threshold amount to ensure that 
estimated FY 2014 outlier payments are approximately 2 percent of total 
estimated IPF payments. The outlier fixed dollar loss threshold amount 
of $11,600 for FY 2013 will be changed to $10,245 for FY 2014 to 
increase estimated outlier payments and thereby maintain estimated 
outlier payments at 2 percent of total estimated aggregate IPF payments 
for FY 2014.
b. Update to IPF Cost-to-Charge Ratio Ceilings
    As previously stated, under the IPF PPS, an outlier payment is made 
if an IPF's cost for a stay exceeds a fixed dollar loss threshold 
amount. In order to establish an IPF's cost for a particular case, we 
multiply the IPF's reported charges on the discharge bill by its 
overall cost-to-charge ratio (CCR). This approach to determining an 
IPF's cost is consistent with the approach used under the IPPS and 
other PPSs. In the June 2003 IPPS final rule (68 FR 34494), we 
implemented changes to the IPPS policy used to determine CCRs for acute 
care hospitals because we became aware that payment vulnerabilities 
resulted in inappropriate outlier payments. Under the IPPS, we 
established a statistical measure of accuracy for CCRs in order to 
ensure that aberrant CCR data did not result in inappropriate outlier 
payments.
    As we indicated in the November 2004 IPF PPS final rule, because we 
believe that the IPF outlier policy is susceptible to the same payment 
vulnerabilities as the IPPS, we adopted a method to ensure the 
statistical accuracy of CCRs under the IPF PPS (69

[[Page 46748]]

FR 66961). Specifically, we adopted the following procedure in the 
November 2004 IPF PPS final rule: We calculated two national ceilings, 
one for IPFs located in rural areas and one for IPFs located in urban 
areas. We computed the ceilings by first calculating the national 
average and the standard deviation of the CCR for both urban and rural 
IPFs using the most recent CCRs entered in the CY 2013 Provider 
Specific File.
    To determine the rural and urban ceilings, we multiplied each of 
the standard deviations by 3 and added the result to the appropriate 
national CCR average (either rural or urban). The upper threshold CCR 
for IPFs in FY 2014 is 1.8644 for rural IPFs, and 1.7066 for urban 
IPFs, based on CBSA-based geographic designations. If an IPF's CCR is 
above the applicable ceiling, the ratio is considered statistically 
inaccurate and we assign the appropriate national (either rural or 
urban) median CCR to the IPF.
    We apply the national CCRs to the following situations:
    ++ New IPFs that have not yet submitted their first Medicare cost 
report.
    ++ IPFs whose overall CCR is in excess of 3 standard deviations 
above the corresponding national geometric mean (that is, above the 
ceiling).
    ++ Other IPFs for which the Medicare contractor obtains inaccurate 
or incomplete data with which to calculate a CCR.
    For new IPFs, we are using these national CCRs until the facility's 
actual CCR can be computed using the first tentatively or final settled 
cost report.
    We are not making any changes to the procedures for updating the 
CCR ceilings in FY 2014. However, we are updating the FY 2014 national 
median and ceiling CCRs for urban and rural IPFs based on the CCRs 
entered in the latest available IPF PPS Provider Specific File. 
Specifically, for FY 2014, and to be used in each of the three 
situations listed above, using the most recent CCRs entered in the CY 
2013 Provider Specific File we estimate the national median CCR of 
0.6220 for rural IPFs and the national median CCR of 0.4770 for urban 
IPFs. These calculations are based on the IPF's location (either urban 
or rural) using the CBSA-based geographic designations.
    A complete discussion regarding the national median CCRs appears in 
the November 2004 IPF PPS final rule (69 FR 66961 through 66964).
2. Expiration of the Stop-Loss Provision
    In the November 2004 IPF PPS final rule, we implemented a stop-loss 
policy that reduced financial risk to IPFs projected to experience 
substantial reductions in Medicare payments during the period of 
transition to the IPF PPS. This stop-loss policy guaranteed that each 
facility received total IPF PPS payments that were no less than 70 
percent of its TEFRA payments had the IPF PPS not been implemented. 
This policy was applied to the IPF PPS portion of Medicare payments 
during the 3-year transition.
    In the implementation year, the 70 percent of TEFRA payment stop-
loss policy required a reduction in the standardized Federal per diem 
and ECT base rates of 0.39 percent in order to make the stop-loss 
payments budget neutral. As described in the May 2008 IPF PPS notice 
for RY 2009, we increased the Federal per diem base rate and ECT rate 
by 0.39 percent because these rates were reduced by 0.39 percent in the 
implementation year to ensure stop-loss payments were budget neutral.
    The stop-loss provision ended during RY 2009 (that is for 
discharges occurring on or after July 1, 2008 through June 30, 2009). 
The stop-loss policy is no longer applicable under the IPF PPS.
3. Future Refinements
    As we have indicated throughout this notice, we have delayed making 
refinements to the IPF PPS until we have adequate IPF PPS data on which 
to base those refinements. Specifically, we explained that we will 
delay updating the adjustment factors derived from the regression 
analysis until we have IPF PPS data that include as much information as 
possible regarding the patient-level characteristics of the population 
that each IPF serves. Now that we are approximately 8 years into the 
system, we believe that we have enough data to begin that process. We 
have begun the necessary analysis to better understand IPF industry 
practices so that we may refine the IPF PPS as appropriate. Using more 
recent data, we plan to re-run the regression analyses and recalculate 
the Federal per diem base rate and the patient-and facility-level 
adjustments. While we are not making these refinements in this notice, 
we expect that in the rulemaking for FY 2015 we will be ready to 
present the results of our analysis.
    For RY 2012, we published several areas of concern for future 
refinement and we invited comments on these issues in our RY 2012 
proposed and final rules. For further discussion of these issues and to 
review public comments, we refer readers to the RY 2012 IPF PPS 
proposed rule (76 FR 4998) and final rule (76 FR 26432).

VIII. Secretary's Recommendations

    Section 1886(e)(4)(A) of the Act requires the Secretary, taking 
into consideration the recommendations of MedPAC, to recommend update 
factors for inpatient hospital services (including IPFs) for each FY 
that take into account the amounts necessary for the efficient and 
effective delivery of medically appropriate and necessary care of high 
quality. Section 1886(e)(5) of the Act requires the Secretary to 
publish the recommended and final update factors in the Federal 
Register.
    In the past, the Secretary's recommendations and a discussion about 
the MedPAC recommendations for the IPF PPS were included in the IPPS 
proposed and final rules. The market basket update for the IPF PPS was 
also included in the IPPS proposed and final rules, as well as in the 
IPF PPS annual update.
    Beginning FY 2013, however, we only publish the market basket 
update for the IPF PPS in the annual IPF PPS FY update and not in the 
IPPS proposed and final rules. Furthermore, for any years in which 
MedPAC makes recommendations for the IPF PPS, those recommendations 
will be noted and considered in the IPF PPS update.
    MedPAC did not make any recommendations for the IPF PPS for FY 
2014. For the update to the IPF PPS standard Federal rate for FY 2014, 
see section IV B. of this notice.

IX. Waiver of Notice and Comment

    We ordinarily publish a notice of proposed rulemaking in the 
Federal Register to provide a period for public comment before the 
provisions of a rule take effect. We can waive this procedure, however, 
if we find good cause that notice and comment procedures are 
impracticable, unnecessary, or contrary to the public interest and we 
incorporate a statement of finding and its reasons in the notice.
    We find it is unnecessary to undertake notice and comment 
rulemaking for this action because the updates in this notice do not 
reflect any substantive changes in policy, but merely reflect the 
application of previously established methodologies. Therefore, under 5 
U.S.C 553(b)(3)(B), for good cause, we waive notice and comment 
procedures.

X. Collection of Information Requirements

    This notice does not impose any new or revised information 
collection, recordkeeping, or third-party disclosure requirements. 
Consequently, it does not need additional Office of Management and 
Budget review under the authority

[[Page 46749]]

of the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.).

XI. Regulatory Impact Analysis

A. Statement of Need

    This notice will update the prospective payment rates for Medicare 
inpatient hospital services provided by IPF for discharges occurring 
during the FY beginning October 1, 2013 through September 30, 2014. We 
are applying the FY 2008-based RPL market basket increase of 2.6 
percent, less the 0.1 percentage point required by sections 
1886(s)(2)(A) (ii) and 1886(s)(3)(B) of the Act and less the 
productivity adjustment of 0.5 percentage point as required by 
1886(s)(2)(A)(i) of the Act.

B. Overall Impact

    We have examined the impact of this notice as required by Executive 
Order 12866 on Regulatory Planning and Review (September 30, 1993), 
Executive Order 13563 on Improving Regulation and Regulatory Review 
(January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19, 
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, 
section 202 of the Unfunded Mandates Reform Act of 1995 (March 22, 
1995; Pub. L. 104-4), Executive Order 13132 on Federalism (August 4, 
1999) and the Congressional Review Act (5 U.S.C. 804(2)).
    Executive Orders 12866 and 13563 direct 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 a major notice 
with economically significant effects ($100 million or more in any 1 
year). This notice is designated as economically ``significant'' under 
section 3(f)(1) of Executive Order 12866.
    We estimate that the total impact of these changes for FY 2014 
payments compared to FY 2013 payments will be a net increase of 
approximately $115 million. This reflects a $100 million increase from 
the update to the payment rates, as well as, a $15 million increase as 
a result of the update to the outlier threshold amount. Outlier 
payments are estimated to increase from 1.7 percent in FY 2013 to 2.0 
percent in FY 2014.
    The RFA requires agencies to analyze options for regulatory relief 
of small entities, if a rule has a significant impact on a substantial 
number of small entities. For purposes of the RFA, small entities 
include small businesses, nonprofit organizations, and small 
governmental jurisdictions. Most IPFs and most other providers and 
suppliers are small entities, either by nonprofit status or having 
revenues of $7 million to $34.5 million or less in any 1 year depending 
on industry classification (for details, refer to the SBA Small 
Business Size Standards found at http://www.sba.gov/sites/default/files/files/Size_Standards_Table.pdf), or being nonprofit 
organizations that are not dominant in their markets.''
    Because we lack data on individual hospital receipts, we cannot 
determine the number of small proprietary IPFs or the proportion of 
IPFs' revenue that is derived from Medicare payments. Therefore, we 
assume that all IPFs are considered small entities. The Department of 
Health and Human Services generally uses a revenue impact of 3 to 5 
percent as a significance threshold under the RFA.
    As shown in Table 7, we estimate that the overall revenue impact of 
this notice on all IPFs is to increase Medicare payments by 
approximately 2.3 percent. As a result, since the estimated impact of 
this notice is a net increase in revenue across all categories of IPFs, 
the Secretary has determined that this notice will have a positive 
revenue impact on a substantial number of small entities. Medicare 
fiscal intermediaries, Medicare Administrative Contractors, and 
Carriers are not considered to be small entities. Individuals and 
States are not included in the definition of a small entity.
    In addition, section 1102(b) of the Social Security Act requires us 
to prepare a regulatory impact analysis if a rule may have a 
significant impact on the operations of a substantial number of small 
rural hospitals. This analysis must conform to the provisions of 
section 604 of the RFA. For purposes of section 1102(b) of the Act, we 
define a small rural hospital as a hospital that is located outside of 
a metropolitan statistical area and has fewer than 100 beds. As 
discussed in detail below, the rates and policies set forth in this 
notice will not have an adverse impact on the rural hospitals based on 
the data of the 309 rural units and 73 rural hospitals in our database 
of 1,624 IPFs for which data were available. Therefore, the Secretary 
has determined that this notice will not have a significant impact on 
the operations of a substantial number of small rural hospitals.
    Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending in any 1 year of $100 
million in 1995 dollars, updated annually for inflation. In 2014, that 
threshold is approximately $141 million. This notice will not impose 
spending costs on state, local, or tribal governments in the aggregate, 
or by the private sector, of $141 million.
    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. As stated above, this notice would not have a substantial 
effect on state and local governments.

C. Anticipated Effects

    We discuss the historical background of the IPF PPS and the impact 
of this notice on the Federal Medicare budget and on IPFs.
1. Budgetary Impact
    As discussed in the November 2004 and May 2006 IPF PPS final rules, 
we applied a budget neutrality factor to the Federal per diem and ECT 
base rates to ensure that total estimated payments under the IPF PPS in 
the implementation period would equal the amount that would have been 
paid if the IPF PPS had not been implemented. The budget neutrality 
factor includes the following components: outlier adjustment, stop-loss 
adjustment, and the behavioral offset. As discussed in the May 2008 IPF 
PPS notice (73 FR 25711), the stop-loss adjustment is no longer 
applicable under the IPF PPS.
    In accordance with Sec.  412.424(c)(3)(ii), we indicated that we 
will evaluate the accuracy of the budget neutrality adjustment within 
the first 5 years after implementation of the payment system. We may 
make a one-time prospective adjustment to the Federal per diem and ECT 
base rates to account for differences between the historical data on 
cost-based TEFRA payments (the basis of the budget neutrality 
adjustment) and estimates of TEFRA payments based on actual data from 
the first year of the IPF PPS. As part of that process, we will 
reassess the accuracy of all of the factors impacting budget 
neutrality. In addition, as discussed in section VII.C.1 of this 
notice, we are using the wage index and labor-related share in a budget 
neutral manner by applying a wage index budget neutrality factor to the 
Federal per diem and ECT base rates. Therefore, the budgetary impact to 
the Medicare program of this notice will be due to the market basket 
update for FY 2014 of 2.6 percent (see section V.B. of this notice) 
less the ``other

[[Page 46750]]

adjustment'' of 0.1 percentage point according to sections 
1886(s)(2)(A)(ii) and 1886 (s)(3)(B) of the Act, less the productivity 
adjustment of 0.5 percentage point required by section 1886 
(s)(2)(A)(i) of the Act, and the update to the outlier fixed dollar 
loss threshold amount.
    We estimate that the FY 2014 impact will be a net increase of $115 
million in payments to IPF providers. This reflects an estimated $100 
million increase from the update to the payment rates and a $15 million 
increase due to the update to the outlier threshold amount to increase 
outlier payments from approximately 1.7 percent in FY 2013 to 2.0 
percent in FY 2014.
2. Impact on Providers
    To understand the impact of the changes to the IPF PPS on 
providers, discussed in this notice, it is necessary to compare 
estimated payments under the IPF PPS rates and factors for FY 2014 
versus those under FY 2013. The estimated payments for FY 2013 and FY 
2014 will be 100 percent of the IPF PPS payment, since the transition 
period has ended and stop-loss payments are no longer paid. We 
determined the percent change of estimated FY 2014 IPF PPS payments to 
FY 2013 IPF PPS payments for each category of IPFs. In addition, for 
each category of IPFs, we have included the estimated percent change in 
payments resulting from the update to the outlier fixed dollar loss 
threshold amount, the labor-related share and wage index changes for 
the FY 2014 IPF PPS, and the market basket update for FY 2014, as 
adjusted by the ``other adjustment'' according to sections 
1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the Act and the productivity 
adjustment according to section 1886(s)(2)(A)(i).
    To illustrate the impacts of the FY 2014 changes in this notice, 
our analysis begins with a FY 2013 baseline simulation model based on 
FY 2012 IPF payments inflated to the midpoint of FY 2013 using IHS 
Global Insight Inc.'s most recent forecast of the market basket update 
(see section V.B. of this notice); the estimated outlier payments in FY 
2013; the CBSA designations for IPFs based on OMB's MSA definitions 
after June 2003; the FY 2012 pre-floor, pre-reclassified hospital wage 
index; the FY 2013 labor-related share; and the FY 2013 percentage 
amount of the rural adjustment. During the simulation, the total 
estimated outlier payments are maintained at 2 percent of total IPF PPS 
payments.
    Each of the following changes is added incrementally to this 
baseline model in order for us to isolate the effects of each change:
     The update to the outlier fixed dollar loss threshold 
amount.
     The FY 2013 pre-floor, pre-reclassified hospital wage 
index and FY 2014 labor-related share.
     The market basket update for FY 2014 of 2.6 percent less 
the ``other adjustment'' of 0.1 percentage point in accordance with 
sections 1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the Act and less the 
productivity adjustment of 0.5 percentage point reduction in accordance 
with section 1886(s)(2)(A)(i) of the Act.
    Our final comparison illustrates the percent change in payments 
from FY 2013 (that is, October 1, 2012 to September 30, 2013) to FY 
2014 (that is, October 1, 2013 to September 30, 2014) including all the 
changes in this notice.

                                      Table 7--IPF Impact Table for FY 2014
----------------------------------------------------------------------------------------------------------------
                                   Projected Impacts (% Change In Columns 3-6)
-----------------------------------------------------------------------------------------------------------------
                                                                     CBSA wage       Adjusted
        Facility by type             Number of        Outlier     index &  labor   market basket   Total percent
                                    facilities                         share        update \1\      change \2\
(1)                                          (2)             (3)             (4)             (5)             (6)
----------------------------------------------------------------------------------------------------------------
All Facilities..................           1,624             0.3             0.0             2.0             2.3
Total Urban.....................           1,242             0.3             0.0             2.0             2.3
Total Rural.....................             382             0.2            -0.1             2.0             2.1
Urban unit......................             834             0.4             0.0             2.0             2.5
Urban hospital..................             408             0.1             0.0             2.0             2.1
Rural unit......................             309             0.2            -0.1             2.0             2.2
Rural hospital..................              73             0.3            -0.2             2.0             2.0
By Type of Ownership:
Freestanding IPFs:
    Urban Psychiatric Hospitals:
        Government..............             130             0.3            -0.1             2.0             2.2
        Non-Profit..............              99             0.1             0.2             2.0             2.2
        For-Profit..............             177             0.1             0.0             2.0             2.0
    Rural Psychiatric Hospitals:
        Government..............              36             0.5            -0.4             2.0             2.1
        Non-Profit..............              13             0.1             0.0             2.0             2.1
        For-Profit..............              23             0.1            -0.1             2.0             2.0
IPF Units:
    Urban:
        Government..............             131             0.8             0.1             2.0             2.9
        Non-Profit..............             548             0.4             0.1             2.0             2.5
        For-Profit..............             155             0.3            -0.2             2.0             2.0
    Rural:
        Government..............              80             0.2            -0.1             2.0             2.1
        Non-Profit..............             163             0.3             0.0             2.0             2.2
        For-Profit..............              66             0.3            -0.1             2.0             2.2
Unknown Ownership Type..........               3             0.0             0.2             2.0             2.2
By Teaching Status:
    Non-teaching................           1,419             0.2             0.0             2.0             2.2
    Less than 10% interns and                109             0.5             0.0             2.0             2.5
     residents to beds..........
    10% to 30% interns and                    70             0.5             0.1             2.0             2.6
     residents to beds..........
    More than 30% interns and                 26             0.9             0.5             2.0             3.5
     residents to beds..........
By Region:

[[Page 46751]]

 
    New England.................             111             0.4             0.5             2.0             3.0
    Mid-Atlantic................             256             0.4            -0.1             2.0             2.3
    South Atlantic..............             233             0.2            -0.3             2.0             1.9
    East North Central..........             258             0.3             0.1             2.0             2.4
    East South Central..........             171             0.2            -0.7             2.0             1.6
    West North Central..........             139             0.3             0.2             2.0             2.5
    West South Central..........             234             0.2            -0.2             2.0             1.9
    Mountain....................              99             0.3            -0.6             2.0             1.7
    Pacific.....................             123             0.5             0.9             2.0             3.5
By Bed Size:
Psychiatric Hospitals:
        Beds: 0-24..............              82             0.2            -0.3             2.0             1.9
        Beds: 25-49.............              75             0.1            -0.1             2.0             1.9
        Beds: 50-75.............              79             0.2             0.0             2.0             2.2
        Beds: 76 +..............             245             0.1             0.0             2.0             2.1
        Psychiatric Units:
        Beds: 0-24..............             684             0.4             0.0             2.0             2.4
        Beds: 25-49.............             306             0.4             0.2             2.0             2.5
        Beds: 50-75.............              94             0.4            -0.1             2.0             2.2
        Beds: 76 +..............              59             0.5             0.0             2.0             2.6
----------------------------------------------------------------------------------------------------------------
\1\ This column reflects the payment update impact of the RPL market basket update for FY 2014 of 2.6 percent, a
  0.1 percentage point reduction in accordance with sections 1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the Act, and
  a 0.5 percentage point reduction for the productivity adjustment as required by section 1886(s)(2)(A)(i) of
  the Act.
\2\ Percent changes in estimated payments from FY 2013 to FY 2014 include all of the changes presented in this
  notice. Note, the products of these impacts may be different from the percentage changes shown here due to
  rounding effects.

3. Results
    Table 7 above displays the results of our analysis. The table 
groups IPFs into the categories listed below based on characteristics 
provided in the Provider of Services (POS) file, the IPF provider 
specific file, and cost report data from HCRIS:

     Facility Type
     Location
     Teaching Status Adjustment
     Census Region
     Size

The top row of the table shows the overall impact on the 1,624 IPFs 
included in this analysis.
    In column 3, we present the effects of the update to the outlier 
fixed dollar loss threshold amount. We estimate that IPF outlier 
payments as a percentage of total IPF payments are 1.7 percent in FY 
2013. Thus, we are adjusting the outlier threshold amount in this 
notice to set total estimated outlier payments equal to 2 percent of 
total payments in FY 2014. The estimated change in total IPF payments 
for FY 2014, therefore, includes an approximate 0.3 percent increase in 
payments because the outlier portion of total payments is expected to 
increase from approximately 1.7 percent to 2 percent.
    The overall impact of this outlier adjustment update (as shown in 
column 3 of table 7), across all hospital groups, is to increase total 
estimated payments to IPFs by 0.3 percent. We do not estimate that any 
group of IPFs will experience a decrease in payments from this update. 
The largest increase in payments is estimated to reflect a 0.9 percent 
increase in payments for IPFs located in teaching hospitals with an 
intern and resident ADC ratio greater than 30 percent.
    In column 4, we present the effects of the budget-neutral update to 
the labor-related share and the wage index adjustment under the CBSA 
geographic area definitions announced by OMB in June 2003. This is a 
comparison of the simulated FY 2014 payments under the FY 2013 hospital 
wage index under CBSA classification and associated labor-related share 
to the simulated FY 2013 payments under the FY 2012 hospital wage index 
under CBSA classifications and associated labor-related share. We note 
that there is no projected change in aggregate payments to IPFs, as 
indicated in the first row of column 4. However, there will be small 
distributional effects among different categories of IPFs. For example, 
we estimate the largest increase in payments to be a 0.9 percent 
increase for IPFs in the Pacific region and the largest decrease in 
payments to be a 0.7 percent decrease for IPFs in the East South 
Central region.
    Column 5 shows the estimated effect of the update to the IPF PPS 
payment rates, which includes a 2.6 percent market basket update less 
the 0.1 percentage point in accordance with section 1886(s)(2)(A)(ii) 
and 1886(s)(3)(B) and less the productivity adjustment of 0.5 
percentage point in accordance with section 1886(s)(2)(A)(i).
    Column 6 compares our estimates of the total changes reflected in 
this notice for FY 2014, to our payments for FY 2013 (without these 
changes). This column reflects all FY 2014 changes relative to FY 2013. 
The average estimated increase for all IPFs is approximately 2.3 
percent. This estimated net increase includes the effects of the 2.6 
percent market basket update adjusted by the ``other adjustment'' of 
minus 0.1 percentage point, as required by sections 1886(s)(2)(A)(ii) 
and 1886(s)(3)(B) of the Act and the productivity adjustment of minus 
0.5 percentage point, as required by section 1886(s)(2)(A)(i) of the 
Act. It also includes the overall estimated 0.3 percent increase in 
estimated IPF outlier payments from the update to the outlier fixed 
dollar loss threshold amount. Since we are making the updates to the 
IPF labor-related share and wage index in a budget-neutral manner, they 
will not affect total estimated IPF payments in the aggregate. However, 
they will

[[Page 46752]]

affect the estimated distribution of payments among providers.
    Overall, no IPFs are estimated to experience a net decrease in 
payments as a result of the updates in this notice. IPFs in urban areas 
will experience a 2.3 percent increase and IPFs in rural areas will 
experience a 2.1 percent increase. The largest payment increase is 
estimated at 3.5 percent for IPFs located in teaching hospitals with an 
intern and resident ADC ratio greater than 30 percent and IPFs in the 
Pacific region. This is due to the larger than average positive effect 
of the CBSA wage index and labor-related share updates and the higher 
volume of outlier payments for IPFs in these categories.
4. Effect on the Medicare Program
    Based on actuarial projections resulting from our experience with 
other PPSs, we estimate that Medicare spending (total Medicare program 
payments) for IPF services over the next 5 years would be as shown in 
Table 8 below.

        Table 8--Estimated Payments Shown in Current Year Dollars
------------------------------------------------------------------------
                                                              Dollars in
                        Fiscal year                            millions
------------------------------------------------------------------------
2014.......................................................        5,420
2015.......................................................        5,910
2016.......................................................        6,500
2017.......................................................        7,090
2018.......................................................        7,570
------------------------------------------------------------------------

    These estimates are based on the current forecast of the increases 
in the RPL market basket, including an adjustment for productivity, for 
the FY beginning in 2014 and each subsequent RY, as required by section 
1886(s)(2)(A)(i) of the Act, as follows:
     2.1 percent for FY 2014.
     2.3 percent for FY 2015.
     2.6 percent for FY 2016.
     2.6 percent for FY 2017.
     2.5 percent for FY 2018.
    The estimates in Table 8 also include the application of the 
``other adjustment,'' as required by sections 1886(s)(2)(A)(ii) and 
1886(s)(3)(B) of the Act, as follows:
     -0.3 percentage point for rate years beginning in 2014.
     -0.2 percentage point for rate years beginning in 2015.
     -0.2 percentage point for rate years beginning in 2016.
     -0.75 percentage point for rate years beginning in 2017.
     -0.75 percentage point for rate years beginning in 2018.
    We estimate that there would be a change in fee-for-service 
Medicare beneficiary enrollment as follows:
     2.2 percent in FY 2014.
     4.1 percent in FY 2015.
     5.0 percent in FY 2016.
     5.5 percent in FY 2017.
     4.4 percent in FY 2018.
5. Effect on Beneficiaries
    Under the IPF PPS, IPFs will receive payment based on the average 
resources consumed by patients for each day. We do not expect changes 
in the quality of care or access to services for Medicare beneficiaries 
under the FY 2014 IPF PPS but we continue to expect that paying 
prospectively for IPF services would enhance the efficiency of the 
Medicare program.

D. Alternatives Considered

    The statute does not specify an update strategy for the IPF PPS and 
is broadly written to give the Secretary discretion in establishing an 
update methodology. Therefore, we are updating the IPF PPS using the 
methodology published in the November 2004 IPF PPS final rule. Lastly, 
no alternative policy options were considered in this notice, since 
this notice does not initiate policy changes with regard to the IPF 
PPS. This notice simply provides an update to the rates for FY 2014.

E. Accounting Statement

    As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars_a004_a-4), in Table 9 below, we have 
prepared an accounting statement showing the classification of the 
expenditures associated with the provisions of this notice. This table 
provides our best estimate of the increase in Medicare payments under 
the IPF PPS as a result of the changes presented in this notice and 
based on the data for 1,624 IPFs in our database. All expenditures are 
classified as Federal transfers to IPF Medicare providers.

  Table 9--Accounting Statement: Classification of Estimated Expenditures, From the 2013 IPF PPS FY to the 2014
                                                   IPF PPS FY
                                                  [In millions]
----------------------------------------------------------------------------------------------------------------
               Category                                                 Transfers
----------------------------------------------------------------------------------------------------------------
Annualized Monetized Transfers........  $115.
From Whom To Whom?....................  Federal Government to IPF Medicare Providers.
----------------------------------------------------------------------------------------------------------------

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

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

    Dated: May 29, 2013.
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.
    Approved: June 28, 2013.
Kathleen Sebelius,
Secretary.

Addendum A--Rate and Adjustment Factors

Per Diem Rate:
    Federal Per Diem Base Rate--$713.19
    Labor Share--(0.69494)--$495.62
    Non-Labor Share (0.30506)--$217.57
Per Diem Rate Applying the 2 Percentage Point Reduction:
    Federal Per Diem Base Rate--$699.21
    Labor Share (0.69494)--$485.91
    Non-Labor Share (0.30506)--$213.30
Fixed Dollar Loss Threshold Amount: $10,245
Wage Index Budget Neutrality Factor: 1.0010
Facility Adjustments:
    Rural Adjustment Factor--1.17
    Teaching Adjustment Factor--0.5150
    Wage Index--Pre-reclass Hospital Wage Index (FY2013)

[[Page 46753]]

                   Cost of Living Adjustments (COLAs)
------------------------------------------------------------------------
                                                        Cost of living
                        Area                           adjustment factor
------------------------------------------------------------------------
Alaska:
    City of Anchorage and 80-kilometer (50-mile)                    1.23
     radius by road.................................
    City of Fairbanks and 80-kilometer (50-mile)                    1.23
     radius by road.................................
    City of Juneau and 80-kilometer (50-mile) radius                1.23
     by road........................................
    Rest of Alaska..................................                1.25
Hawaii:
    City and County of Honolulu.....................                1.25
    County of Hawaii................................                1.18
    County of Kauai.................................                1.25
    County of Maui and County of Kalawao............                1.25
------------------------------------------------------------------------

Patient Adjustments:
    ECT--Per Treatment--$307.04
    ECT--Per Treatment Applying the 2 Percentage Point Reduction--
$301.02

                      Variable Per Diem Adjustments
------------------------------------------------------------------------
                                                              Adjustment
                                                                factor
------------------------------------------------------------------------
Day 1--Facility Without a Qualifying Emergency Department..         1.19
Day 1--Facility With a Qualifying Emergency Department.....         1.31
Day 2......................................................         1.12
Day 3......................................................         1.08
Day 4......................................................         1.05
Day 5......................................................         1.04
Day 6......................................................         1.02
Day 7......................................................         1.01
Day 8......................................................         1.01
Day 9......................................................         1.00
Day 10.....................................................         1.00
Day 11.....................................................         0.99
Day 12.....................................................         0.99
Day 13.....................................................         0.99
Day 14.....................................................         0.99
Day 15.....................................................         0.98
Day 16.....................................................         0.97
Day 17.....................................................         0.97
Day 18.....................................................         0.96
Day 19.....................................................         0.95
Day 20.....................................................         0.95
Day 21.....................................................         0.95
After Day 21...............................................         0.92
------------------------------------------------------------------------

                             Age Adjustments
------------------------------------------------------------------------
                                                              Adjustment
                      Age  (in years)                           factor
------------------------------------------------------------------------
Under 45...................................................         1.00
45 and under 50............................................         1.01
50 and under 55............................................         1.02
55 and under 60............................................         1.04
60 and under 65............................................         1.07
65 and under 70............................................         1.10
70 and under 75............................................         1.13
75 and under 80............................................         1.15
80 and over................................................         1.17
------------------------------------------------------------------------

                                                 DRG Adjustments
----------------------------------------------------------------------------------------------------------------
                                                                                                      Adjustment
                MS-DRG                                      MS-DRG descriptions                         factor
----------------------------------------------------------------------------------------------------------------
056...................................  Degenerative nervous system disorders w MCC................         1.05
057...................................  Degenerative nervous system disorders w/o MCC..............  ...........
080...................................  Nontraumatic stupor & coma w MCC...........................         1.07

[[Page 46754]]

 
081...................................  Nontraumatic stupor & coma w/o MCC.........................  ...........
876...................................  O.R. procedure w principal diagnoses of mental illness.....         1.22
880...................................  Acute adjustment reaction & psychosocial dysfunction.......         1.05
881...................................  Depressive neuroses........................................         0.99
882...................................  Neuroses except depressive.................................         1.02
883...................................  Disorders of personality & impulse control.................         1.02
884...................................  Organic disturbances & mental retardation..................         1.03
885...................................  Psychoses..................................................         1.00
886...................................  Behavioral & developmental disorders.......................         0.99
887...................................  Other mental disorder diagnoses............................         0.92
894...................................  Alcohol/drug abuse or dependence, left AMA.................         0.97
895...................................  Alcohol/drug abuse or dependence w rehabilitation therapy..         1.02
896...................................  Alcohol/drug abuse or dependence w/o rehabilitation therapy         0.88
                                         w MCC.
897...................................  Alcohol/drug abuse or dependence w/o rehabilitation therapy  ...........
                                         w/o MCC.
----------------------------------------------------------------------------------------------------------------

                         Comorbidity Adjustments
------------------------------------------------------------------------
                                                              Adjustment
                        Comorbidity                             factor
------------------------------------------------------------------------
Developmental Disabilities.................................         1.04
Coagulation Factor Deficit.................................         1.13
Tracheostomy...............................................         1.06
Eating and Conduct Disorders...............................         1.12
Infectious Diseases........................................         1.07
Renal Failure, Acute.......................................         1.11
Renal Failure, Chronic.....................................         1.11
Oncology Treatment.........................................         1.07
Uncontrolled Diabetes Mellitus.............................         1.05
Severe Protein Malnutrition................................         1.13
Drug/Alcohol Induced Mental Disorders......................         1.03
Cardiac Conditions.........................................         1.11
Gangrene...................................................         1.10
Chronic Obstructive Pulmonary Disease......................         1.12
Artificial Openings--Digestive & Urinary...................         1.08
Severe Musculoskeletal & Connective Tissue Diseases........         1.09
Poisoning..................................................         1.11
------------------------------------------------------------------------

Addendum B--FY 2014 CBSA Wage Index Tables

    In this addendum, we provide the wage index tables referred to in 
the preamble to this notice. The tables presented below are as follows:
    Table1--FY 2014 Wage Index For Urban Areas Based on CBSA Labor 
Market Areas.
    Table 2--FY 2014 Wage Index Based On CBSA Labor Market Areas For 
Rural Areas.

 Table 1--FY 2014 Wage Index for Urban Areas Based on CBSA Labor Market
                                  Areas
------------------------------------------------------------------------
                                Urban area (constituent
          CBSA code                    counties)            Wage index
------------------------------------------------------------------------
10180........................  Abilene, TX..............          0.8324
                               Callahan County, TX......
                               Jones County, TX.........
                               Taylor County, TX........
10380........................  Aguadilla-Isabela-San              0.3532
                                Sebasti[aacute]n, PR.
                               Aguada Municipio, PR.....
                               Aguadilla Municipio, PR..
                               A[ntilde]asco Municipio,
                                PR.
                               Isabela Municipio, PR....
                               Lares Municipio, PR......
                               Moca Municipio, PR.......
                               Rinc[oacute]n Municipio,
                                PR.
                               San Sebasti[aacute]n
                                Municipio, PR.
10420........................  Akron, OH................          0.8729
                               Portage County, OH.......
                               Summit County, OH........
10500........................  Albany, GA...............          0.8435
                               Baker County, GA.........
                               Dougherty County, GA.....

[[Page 46755]]

 
                               Lee County, GA...........
                               Terrell County, GA.......
                               Worth County, GA.........
10580........................  Albany-Schenectady-Troy,           0.8647
                                NY.
                               Albany County, NY........
                               Rensselaer County, NY....
                               Saratoga County, NY......
                               Schenectady County, NY...
                               Schoharie County, NY.....
10740........................  Albuquerque, NM..........          0.9542
                               Bernalillo County, NM....
                               Sandoval County, NM......
                               Torrance County, NM......
                               Valencia County, NM......
10780........................  Alexandria, LA...........          0.7857
                               Grant Parish, LA.........
                               Rapides Parish, LA.......
10900........................  Allentown-Bethlehem-               0.9084
                                Easton, PA-NJ.
                               Warren County, NJ........
                               Carbon County, PA........
                               Lehigh County, PA........
                               Northampton County, PA...
11020........................  Altoona, PA..............          0.8898
                               Blair County, PA.........
11100........................  Amarillo, TX.............          0.8506
                               Armstrong County, TX.....
                               Carson County, TX........
                               Potter County, TX........
                               Randall County, TX.......
11180........................  Ames, IA.................          0.9595
                               Story County, IA.........
11260........................  Anchorage, AK............          1.2147
                               Anchorage Municipality,
                                AK.
                               Matanuska-Susitna
                                Borough, AK.
11300........................  Anderson, IN.............          0.9547
                               Madison County, IN.......
11340........................  Anderson, SC.............          0.8929
                               Anderson County, SC......
11460........................  Ann Arbor, MI............          1.0115
                               Washtenaw County, MI.....
11500........................  Anniston-Oxford, AL......          0.7539
                               Calhoun County, AL.......
11540........................  Appleton, WI.............          0.9268
                               Calumet County, WI.......
                               Outagamie County, WI.....
11700........................  Asheville, NC............          0.8555
                               Buncombe County, NC......
                               Haywood County, NC.......
                               Henderson County, NC.....
                               Madison County, NC.......
12020........................  Athens-Clarke County, GA.          0.9488
                               Clarke County, GA........
                               Madison County, GA.......
                               Oconee County, GA........
                               Oglethorpe County, GA....
12060........................  Atlanta-Sandy Springs-             0.9517
                                Marietta, GA.
                               Barrow County, GA........
                               Bartow County, GA........
                               Butts County, GA.........
                               Carroll County, GA.......
                               Cherokee County, GA......
                               Clayton County, GA.......
                               Cobb County, GA..........
                               Coweta County, GA........
                               Dawson County, GA........
                               DeKalb County, GA........
                               Douglas County, GA.......
                               Fayette County, GA.......
                               Forsyth County, GA.......
                               Fulton County, GA........
                               Gwinnett County, GA......

[[Page 46756]]

 
                               Haralson County, GA......
                               Heard County, GA.........
                               Henry County, GA.........
                               Jasper County, GA........
                               Lamar County, GA.........
                               Meriwether County, GA....
                               Newton County, GA........
                               Paulding County, GA......
                               Pickens County, GA.......
                               Pike County, GA..........
                               Rockdale County, GA......
                               Spalding County, GA......
                               Walton County, GA........
12100........................  Atlantic City-Hammonton,           1.1977
                                NJ.
                               Atlantic County, NJ......
12220........................  Auburn-Opelika, AL.......          0.7437
                               Lee County, AL...........
12260........................  Augusta-Richmond County,           0.9373
                                GA-SC.
                               Burke County, GA.........
                               Columbia County, GA......
                               McDuffie County, GA......
                               Richmond County, GA......
                               Aiken County, SC.........
                               Edgefield County, SC.....
12420........................  Austin-Round Rock, TX....          0.9746
                               Bastrop County, TX.......
                               Caldwell County, TX......
                               Hays County, TX..........
                               Travis County, TX........
                               Williamson County, TX....
12540........................  Bakersfield, CA..........          1.1611
                               Kern County, CA..........
12580........................  Baltimore-Towson, MD.....          1.0147
                               Anne Arundel County, MD..
                               Baltimore County, MD.....
                               Carroll County, MD.......
                               Harford County, MD.......
                               Howard County, MD........
                               Queen Anne's County, MD..
                               Baltimore City, MD.......
12620........................  Bangor, ME...............          1.0184
                               Penobscot County, ME.....
12700........................  Barnstable Town, MA......          1.2843
                               Barnstable County, MA....
12940........................  Baton Rouge, LA..........          0.8147
                               Ascension Parish, LA.....
                               East Baton Rouge Parish,
                                LA.
                               East Feliciana Parish, LA
                               Iberville Parish, LA.....
                               Livingston Parish, LA....
                               Pointe Coupee Parish, LA.
                               St. Helena Parish, LA....
                               West Baton Rouge Parish,
                                LA.
                               West Feliciana Parish, LA
12980........................  Battle Creek, MI.........          0.9912
                               Calhoun County, MI.......
13020........................  Bay City, MI.............          0.9181
                               Bay County, MI...........
13140........................  Beaumont-Port Arthur, TX.          0.8533
                               Hardin County, TX........
                               Jefferson County, TX.....
                               Orange County, TX........
13380........................  Bellingham, WA...........          1.1415
                               Whatcom County, WA.......
13460........................  Bend, OR.................          1.1119
                               Deschutes County, OR.....
13644........................  Bethesda-Frederick-                1.0374
                                Gaithersburg, MD.
                               Frederick County, MD.....
                               Montgomery County, MD....
13740........................  Billings, MT.............          0.8737
                               Carbon County, MT........

[[Page 46757]]

 
                               Yellowstone County, MT...
13780........................  Binghamton, NY...........          0.8707
                               Broome County, NY........
                               Tioga County, NY.........
13820........................  Birmingham-Hoover, AL....          0.8516
                               Bibb County, AL..........
                               Blount County, AL........
                               Chilton County, AL.......
                               Jefferson County, AL.....
                               St. Clair County, AL.....
                               Shelby County, AL........
                               Walker County, AL........
13900........................  Bismarck, ND.............          0.7261
                               Burleigh County, ND......
                               Morton County, ND........
13980........................  Blacksburg-Christiansburg-         0.8348
                                Radford, VA.
                               Giles County, VA.........
                               Montgomery County, VA....
                               Pulaski County, VA.......
                               Radford City, VA.........
14020........................  Bloomington, IN..........          0.8752
                               Greene County, IN........
                               Monroe County, IN........
                               Owen County, IN..........
14060........................  Bloomington-Normal, IL...          0.9502
                               McLean County, IL........
14260........................  Boise City-Nampa, ID.....          0.8897
                               Ada County, ID...........
                               Boise County, ID.........
                               Canyon County, ID........
                               Gem County, ID...........
                               Owyhee County, ID........
14484........................  Boston-Quincy, MA........          1.2378
                               Norfolk County, MA.......
                               Plymouth County, MA......
                               Suffolk County, MA.......
14500........................  Boulder, CO..............          1.0574
                               Boulder County, CO.......
14540........................  Bowling Green, KY........          0.8665
                               Edmonson County, KY......
                               Warren County, KY........
14740........................  Bremerton-Silverdale, WA.          1.0829
                               Kitsap County, WA........
14860........................  Bridgeport-Stamford-               1.3170
                                Norwalk, CT.
                               Fairfield County, CT.....
15180........................  Brownsville-Harlingen, TX          0.8612
                               Cameron County, TX.......
15260........................  Brunswick, GA............          0.8792
                               Brantley County, GA......
                               Glynn County, GA.........
                               McIntosh County, GA......
15380........................  Buffalo-Niagara Falls, NY          0.9999
                               Erie County, NY..........
                               Niagara County, NY.......
15500........................  Burlington, NC...........          0.8485
                               Alamance County, NC......
15540........................  Burlington-South                   0.9997
                                Burlington, VT.
                               Chittenden County, VT....
                               Franklin County, VT......
                               Grand Isle County, VT....
15764........................  Cambridge-Newton-                  1.1262
                                Framingham, MA.
                               Middlesex County, MA.....
15804........................  Camden, NJ...............          1.0474
                               Burlington County, NJ....
                               Camden County, NJ........
                               Gloucester County, NJ....
15940........................  Canton-Massillon, OH.....          0.8834
                               Carroll County, OH.......
                               Stark County, OH.........
15980........................  Cape Coral-Fort Myers, FL          0.9153
                               Lee County, FL...........

[[Page 46758]]

 
16020........................  Cape Girardeau-Jackson,            0.8860
                                MO-IL.
                               Alexander County, IL.....
                               Bollinger County, MO.....
                               Cape Girardeau County, MO
16180........................  Carson City, NV..........          1.0559
                               Carson City, NV..........
16220........................  Casper, WY...............          1.0143
                               Natrona County, WY.......
16300........................  Cedar Rapids, IA.........          0.8944
                               Benton County, IA........
                               Jones County, IA.........
                               Linn County, IA..........
16580........................  Champaign-Urbana, IL.....          0.9907
                               Champaign County, IL.....
                               Ford County, IL..........
                               Piatt County, IL.........
16620........................  Charleston, WV...........          0.8050
                               Boone County, WV.........
                               Clay County, WV..........
                               Kanawha County, WV.......
                               Lincoln County, WV.......
                               Putnam County, WV........
16700........................  Charleston-North                   0.8820
                                Charleston-Summerville,
                                SC.
                               Berkeley County, SC......
                               Charleston County, SC....
                               Dorchester County, SC....
16740........................  Charlotte-Gastonia-                0.9215
                                Concord, NC[dash]SC.
                               Anson County, NC.........
                               Cabarrus County, NC......
                               Gaston County, NC........
                               Mecklenburg County, NC...
                               Union County, NC.........
                               York County, SC..........
16820........................  Charlottesville, VA......          0.9195
                               Albemarle County, VA.....
                               Fluvanna County, VA......
                               Greene County, VA........
                               Nelson County, VA........
                               Charlottesville City, VA.
16860........................  Chattanooga, TN-GA.......          0.8678
                               Catoosa County, GA.......
                               Dade County, GA..........
                               Walker County, GA........
                               Hamilton County, TN......
                               Marion County, TN........
                               Sequatchie County, TN....
16940........................  Cheyenne, WY.............          0.9730
                               Laramie County, WY.......
16974........................  Chicago-Naperville-                1.0600
                                Joliet, IL.
                               Cook County, IL..........
                               DeKalb County, IL........
                               DuPage County, IL........
                               Grundy County, IL........
                               Kane County, IL..........
                               Kendall County, IL.......
                               McHenry County, IL.......
                               Will County, IL..........
17020........................  Chico, CA................          1.1197
                               Butte County, CA.........
17140........................  Cincinnati-Middletown, OH-         0.9508
                                KY-IN.
                               Dearborn County, IN......
                               Franklin County, IN......
                               Ohio County, IN..........
                               Boone County, KY.........
                               Bracken County, KY.......
                               Campbell County, KY......
                               Gallatin County, KY......
                               Grant County, KY.........
                               Kenton County, KY........
                               Pendleton County, KY.....
                               Brown County, OH.........

[[Page 46759]]

 
                               Butler County, OH........
                               Clermont County, OH......
                               Hamilton County, OH......
                               Warren County, OH........
17300........................  Clarksville, TN-KY.......          0.8082
                               Christian County, KY.....
                               Trigg County, KY.........
                               Montgomery County, TN....
                               Stewart County, TN.......
17420........................  Cleveland, TN............          0.7592
                               Bradley County, TN.......
                               Polk County, TN..........
17460........................  Cleveland-Elyria-Mentor,           0.9082
                                OH.
                               Cuyahoga County, OH......
                               Geauga County, OH........
                               Lake County, OH..........
                               Lorain County, OH........
                               Medina County, OH........
17660........................  Coeur d'Alene, ID........          0.9218
                               Kootenai County, ID......
17780........................  College Station-Bryan, TX          0.9584
                               Brazos County, TX........
                               Burleson County, TX......
                               Robertson County, TX.....
17820........................  Colorado Springs, CO.....          0.9364
                               El Paso County, CO.......
                               Teller County, CO........
17860........................  Columbia, MO.............          0.8339
                               Boone County, MO.........
                               Howard County, MO........
17900........................  Columbia, SC.............          0.8560
                               Calhoun County, SC.......
                               Fairfield County, SC.....
                               Kershaw County, SC.......
                               Lexington County, SC.....
                               Richland County, SC......
                               Saluda County, SC........
17980........................  Columbus, GA-AL..........          0.8857
                               Russell County, AL.......
                               Chattahoochee County, GA.
                               Harris County, GA........
                               Marion County, GA........
                               Muscogee County, GA......
18020........................  Columbus, IN.............          0.9564
                               Bartholomew County, IN...
18140........................  Columbus, OH.............          0.9763
                               Delaware County, OH......
                               Fairfield County, OH.....
                               Franklin County, OH......
                               Licking County, OH.......
                               Madison County, OH.......
                               Morrow County, OH........
                               Pickaway County, OH......
                               Union County, OH.........
18580........................  Corpus Christi, TX.......          0.8591
                               Aransas County, TX.......
                               Nueces County, TX........
                               San Patricio County, TX..
18700........................  Corvallis, OR............          1.0715
                               Benton County, OR........
18880........................  Crestview-Fort Walton              0.8916
                                Beach-Destin, FL.
                               Okaloosa County, FL......
19060........................  Cumberland, MD-WV........          0.8836
                               Allegany County, MD......
                               Mineral County, WV.......
19124........................  Dallas-Plano-Irving, TX..          0.9835
                               Collin County, TX........
                               Dallas County, TX........
                               Delta County, TX.........
                               Denton County, TX........
                               Ellis County, TX.........

[[Page 46760]]

 
                               Hunt County, TX..........
                               Kaufman County, TX.......
                               Rockwall County, TX......
19140........................  Dalton, GA...............          0.8828
                               Murray County, GA........
                               Whitfield County, GA.....
19180........................  Danville, IL.............          0.9977
                               Vermilion County, IL.....
19260........................  Danville, VA.............          0.8218
                               Pittsylvania County, VA..
                               Danville City, VA........
19340........................  Davenport-Moline-Rock              0.9145
                                Island, IA-IL.
                               Henry County, IL.........
                               Mercer County, IL........
                               Rock Island County, IL...
                               Scott County, IA.........
19380........................  Dayton, OH...............          0.9136
                               Greene County, OH........
                               Miami County, OH.........
                               Montgomery County, OH....
                               Preble County, OH........
19460........................  Decatur, AL..............          0.7261
                               Lawrence County, AL......
                               Morgan County, AL........
19500........................  Decatur, IL..............          0.7993
                               Macon County, IL.........
19660........................  Deltona-Daytona Beach-             0.8716
                                Ormond Beach, FL.
                               Volusia County, FL.......
19740........................  Denver-Aurora-Broomfield,          1.0469
                                CO.
                               Adams County, CO.........
                               Arapahoe County, CO......
                               Broomfield County, CO....
                               Clear Creek County, CO...
                               Denver County, CO........
                               Douglas County, CO.......
                               Elbert County, CO........
                               Gilpin County, CO........
                               Jefferson County, CO.....
                               Park County, CO..........
19780........................  Des Moines-West Des                0.9616
                                Moines, IA.
                               Dallas County, IA........
                               Guthrie County, IA.......
                               Madison County, IA.......
                               Polk County, IA..........
                               Warren County, IA........
19804........................  Detroit-Livonia-Dearborn,          0.9361
                                MI.
                               Wayne County, MI.........
20020........................  Dothan, AL...............          0.7398
                               Geneva County, AL........
                               Henry County, AL.........
                               Houston County, AL.......
20100........................  Dover, DE................          0.9893
                               Kent County, DE..........
20220........................  Dubuque, IA..............          0.8662
                               Dubuque County, IA.......
20260........................  Duluth, MN-WI............          1.0741
                               Carlton County, MN.......
                               St. Louis County, MN.....
                               Douglas County, WI.......
20500........................  Durham-Chapel Hill, NC...          0.9525
                               Chatham County, NC.......
                               Durham County, NC........
                               Orange County, NC........
                               Person County, NC........
20740........................  Eau Claire, WI...........          0.9705
                               Chippewa County, WI......
                               Eau Claire County, WI....
20764........................  Edison-New Brunswick, NJ.          1.0806
                               Middlesex County, NJ.....
                               Monmouth County, NJ......
                               Ocean County, NJ.........

[[Page 46761]]

 
                               Somerset County, NJ......
20940........................  El Centro, CA............          0.8602
                               Imperial County, CA......
21060........................  Elizabethtown, KY........          0.8294
                               Hardin County, KY........
                               Larue County, KY.........
21140........................  Elkhart-Goshen, IN.......          0.9097
                               Elkhart County, IN.......
21300........................  Elmira, NY...............          0.8205
                               Chemung County, NY.......
21340........................  El Paso, TX..............          0.8426
                               El Paso County, TX.......
21500........................  Erie, PA.................          0.7823
                               Erie County, PA..........
21660........................  Eugene-Springfield, OR...          1.1454
                               Lane County, OR..........
21780........................  Evansville, IN-KY........          0.8401
                               Gibson County, IN........
                               Posey County, IN.........
                               Vanderburgh County, IN...
                               Warrick County, IN.......
                               Henderson County, KY.....
                               Webster County, KY.......
21820........................  Fairbanks, AK............          1.0816
                               Fairbanks North Star
                                Borough, AK.
21940........................  Fajardo, PR..............          0.3663
                               Ceiba Municipio, PR......
                               Fajardo Municipio, PR....
                               Luquillo Municipio, PR...
22020........................  Fargo, ND-MN.............          0.8108
                               Cass County, ND..........
                               Clay County, MN..........
22140........................  Farmington, NM...........          0.9323
                               San Juan County, NM......
22180........................  Fayetteville, NC.........          0.8971
                               Cumberland County, NC....
                               Hoke County, NC..........
22220........................  Fayetteville-Springdale-           0.9288
                                Rogers, AR-MO.
                               Benton County, AR........
                               Madison County, AR.......
                               Washington County, AR....
                               McDonald County, MO......
22380........................  Flagstaff, AZ............          1.2369
                               Coconino County, AZ......
22420........................  Flint, MI................          1.1257
                               Genesee County, MI.......
22500........................  Florence, SC.............          0.8087
                               Darlington County, SC....
                               Florence County, SC......
22520........................  Florence-Muscle Shoals,            0.7679
                                AL.
                               Colbert County, AL.......
                               Lauderdale County, AL....
22540........................  Fond du Lac, WI..........          0.9158
                               Fond du Lac County, WI...
22660........................  Fort Collins-Loveland, CO          0.9833
                               Larimer County, CO.......
22744........................  Fort Lauderdale-Pompano            1.0363
                                Beach-Deerfield Beach,
                                FL.
                               Broward County, FL.......
22900........................  Fort Smith, AR-OK........          0.7848
                               Crawford County, AR......
                               Franklin County, AR......
                               Sebastian County, AR.....
                               Le Flore County, OK......
                               Sequoyah County, OK......
23060........................  Fort Wayne, IN...........          0.9633
                               Allen County, IN.........
                               Wells County, IN.........
                               Whitley County, IN.......
23104........................  Fort Worth-Arlington, TX.          0.9516
                               Johnson County, TX.......
                               Parker County, TX........

[[Page 46762]]

 
                               Tarrant County, TX.......
                               Wise County, TX..........
23420........................  Fresno, CA...............          1.1593
                               Fresno County, CA........
23460........................  Gadsden, AL..............          0.7697
                               Etowah County, AL........
23540........................  Gainesville, FL..........          0.9631
                               Alachua County, FL.......
                               Gilchrist County, FL.....
23580........................  Gainesville, GA..........          0.9327
                               Hall County, GA..........
23844........................  Gary, IN.................          0.9259
                               Jasper County, IN........
                               Lake County, IN..........
                               Newton County, IN........
                               Porter County, IN........
24020........................  Glens Falls, NY..........          0.8340
                               Warren County, NY........
                               Washington County, NY....
24140........................  Goldsboro, NC............          0.8560
                               Wayne County, NC.........
24220........................  Grand Forks, ND-MN.......          0.7250
                               Polk County, MN..........
                               Grand Forks County, ND...
24300........................  Grand Junction, CO.......          0.9415
                               Mesa County, CO..........
24340........................  Grand Rapids-Wyoming, MI.          0.9125
                               Barry County, MI.........
                               Ionia County, MI.........
                               Kent County, MI..........
                               Newaygo County, MI.......
24500........................  Great Falls, MT..........          0.7927
                               Cascade County, MT.......
24540........................  Greeley, CO..............          0.9593
                               Weld County, CO..........
24580........................  Green Bay, WI............          0.9793
                               Brown County, WI.........
                               Kewaunee County, WI......
                               Oconto County, WI........
24660........................  Greensboro-High Point, NC          0.8638
                               Guilford County, NC......
                               Randolph County, NC......
                               Rockingham County, NC....
24780........................  Greenville, NC...........          0.9694
                               Greene County, NC........
                               Pitt County, NC..........
24860........................  Greenville-Mauldin-                0.9737
                                Easley, SC.
                               Greenville County, SC....
                               Laurens County, SC.......
                               Pickens County, SC.......
25020........................  Guayama, PR..............          0.3696
                               Arroyo Municipio, PR.....
                               Guayama Municipio, PR....
                               Patillas Municipio, PR...
25060........................  Gulfport-Biloxi, MS......          0.8544
                               Hancock County, MS.......
                               Harrison County, MS......
                               Stone County, MS.........
25180........................  Hagerstown-Martinsburg,            0.9422
                                MD-WV.
                               Washington County, MD....
                               Berkeley County, WV......
                               Morgan County, WV........
25260........................  Hanford-Corcoran, CA.....          1.0992
                               Kings County, CA.........
25420........................  Harrisburg-Carlisle, PA..          0.9525
                               Cumberland County, PA....
                               Dauphin County, PA.......
                               Perry County, PA.........
25500........................  Harrisonburg, VA.........          0.9087
                               Rockingham County, VA....
                               Harrisonburg City, VA....

[[Page 46763]]

 
25540........................  Hartford-West Hartford-            1.0869
                                East Hartford, CT.
                               Hartford County, CT......
                               Middlesex County, CT.....
                               Tolland County, CT.......
25620........................  Hattiesburg, MS..........          0.8035
                               Forrest County, MS.......
                               Lamar County, MS.........
                               Perry County, MS.........
25860........................  Hickory-Lenoir-Morganton,          0.8677
                                NC.
                               Alexander County, NC.....
                               Burke County, NC.........
                               Caldwell County, NC......
                               Catawba County, NC.......
25980........................  Hinesville-Fort Stewart,           0.8843
                                GA \1\.
                               Liberty County, GA.......
                               Long County, GA..........
26100........................  Holland-Grand Haven, MI..          0.8024
                               Ottawa County, MI........
26180........................  Honolulu, HI.............          1.2156
                               Honolulu County, HI......
26300........................  Hot Springs, AR..........          0.8944
                               Garland County, AR.......
26380........................  Houma-Bayou Cane-                  0.7928
                                Thibodaux, LA.
                               Lafourche Parish, LA.....
                               Terrebonne Parish, LA....
26420........................  Houston-Sugar Land-                0.9933
                                Baytown, TX.
                               Austin County, TX........
                               Brazoria County, TX......
                               Chambers County, TX......
                               Fort Bend County, TX.....
                               Galveston County, TX.....
                               Harris County, TX........
                               Liberty County, TX.......
                               Montgomery County, TX....
                               San Jacinto County, TX...
                               Waller County, TX........
26580........................  Huntington-Ashland, WV-KY-         0.8635
                                OH.
                               Boyd County, KY..........
                               Greenup County, KY.......
                               Lawrence County, OH......
                               Cabell County, WV........
                               Wayne County, WV.........
26620........................  Huntsville, AL...........          0.8667
                               Limestone County, AL.....
                               Madison County, AL.......
26820........................  Idaho Falls, ID..........          0.9114
                               Bonneville County, ID....
                               Jefferson County, ID.....
26900........................  Indianapolis-Carmel, IN..          0.9870
                               Boone County, IN.........
                               Brown County, IN.........
                               Hamilton County, IN......
                               Hancock County, IN.......
                               Hendricks County, IN.....
                               Johnson County, IN.......
                               Marion County, IN........
                               Morgan County, IN........
                               Putnam County, IN........
                               Shelby County, IN........
26980........................  Iowa City, IA............          1.0120
                               Johnson County, IA.......
                               Washington County, IA....
27060........................  Ithaca, NY...............          0.9249
                               Tompkins County, NY......
27100........................  Jackson, MI..............          0.8511
                               Jackson County, MI.......
27140........................  Jackson, MS..............          0.8177
                               Copiah County, MS........
                               Hinds County, MS.........
                               Madison County, MS.......
                               Rankin County, MS........

[[Page 46764]]

 
                               Simpson County, MS.......
27180........................  Jackson, TN..............          0.7672
                               Chester County, TN.......
                               Madison County, TN.......
27260........................  Jacksonville, FL.........          0.8883
                               Baker County, FL.........
                               Clay County, FL..........
                               Duval County, FL.........
                               Nassau County, FL........
                               St. Johns County, FL.....
27340........................  Jacksonville, NC.........          0.7957
                               Onslow County, NC........
27500........................  Janesville, WI...........          0.9458
                               Rock County, WI..........
27620........................  Jefferson City, MO.......          0.8263
                               Callaway County, MO......
                               Cole County, MO..........
                               Moniteau County, MO......
                               Osage County, MO.........
27740........................  Johnson City, TN.........          0.7359
                               Carter County, TN........
                               Unicoi County, TN........
                               Washington County, TN....
27780........................  Johnstown, PA............          0.8116
                               Cambria County, PA.......
27860........................  Jonesboro, AR............          0.8084
                               Craighead County, AR.....
                               Poinsett County, AR......
27900........................  Joplin, MO...............          0.7828
                               Jasper County, MO........
                               Newton County, MO........
28020........................  Kalamazoo-Portage, MI....          0.9834
                               Kalamazoo County, MI.....
                               Van Buren County, MI.....
28100........................  Kankakee-Bradley, IL.....          1.0127
                               Kankakee County, IL......
28140........................  Kansas City, MO-KS.......          0.9614
                               Franklin County, KS......
                               Johnson County, KS.......
                               Leavenworth County, KS...
                               Linn County, KS..........
                               Miami County, KS.........
                               Wyandotte County, KS.....
                               Bates County, MO.........
                               Caldwell County, MO......
                               Cass County, MO..........
                               Clay County, MO..........
                               Clinton County, MO.......
                               Jackson County, MO.......
                               Lafayette County, MO.....
                               Platte County, MO........
                               Ray County, MO...........
28420........................  Kennewick-Pasco-Richland,          0.9708
                                WA.
                               Benton County, WA........
                               Franklin County, WA......
28660........................  Killeen-Temple-Fort Hood,          0.9102
                                TX.
                               Bell County, TX..........
                               Coryell County, TX.......
                               Lampasas County, TX......
28700........................  Kingsport-Bristol-                 0.7325
                                Bristol, TN-VA.
                               Hawkins County, TN.......
                               Sullivan County, TN......
                               Bristol City, VA.........
                               Scott County, VA.........
                               Washington County, VA....
28740........................  Kingston, NY.............          0.8953
                               Ulster County, NY........
28940........................  Knoxville, TN............          0.7575
                               Anderson County, TN......
                               Blount County, TN........
                               Knox County, TN..........

[[Page 46765]]

 
                               Loudon County, TN........
                               Union County, TN.........
29020........................  Kokomo, IN...............          0.8756
                               Howard County, IN........
                               Tipton County, IN........
29100........................  La Crosse, WI-MN.........          1.0070
                               Houston County, MN.......
                               La Crosse County, WI.....
29140........................  Lafayette, IN............          0.9316
                               Benton County, IN........
                               Carroll County, IN.......
                               Tippecanoe County, IN....
29180........................  Lafayette, LA............          0.8565
                               Lafayette Parish, LA.....
                               St. Martin Parish, LA....
29340........................  Lake Charles, LA.........          0.7813
                               Calcasieu Parish, LA.....
                               Cameron Parish, LA.......
29404........................  Lake County-Kenosha                1.0558
                                County, IL-WI.
                               Lake County, IL..........
                               Kenosha County, WI.......
29420........................  Lake Havasu City-Kingman,          0.9760
                                AZ.
                               Mohave County, AZ........
29460........................  Lakeland-Winter Haven, FL          0.8262
                               Polk County, FL..........
29540........................  Lancaster, PA............          0.9452
                               Lancaster County, PA.....
29620........................  Lansing-East Lansing, MI.          1.0065
                               Clinton County, MI.......
                               Eaton County, MI.........
                               Ingham County, MI........
29700........................  Laredo, TX...............          0.7486
                               Webb County, TX..........
29740........................  Las Cruces, NM...........          0.9044
                               Dona Ana County, NM......
29820........................  Las Vegas-Paradise, NV...          1.2076
                               Clark County, NV.........
29940........................  Lawrence, KS.............          0.8676
                               Douglas County, KS.......
30020........................  Lawton, OK...............          0.8351
                               Comanche County, OK......
30140........................  Lebanon, PA..............          0.7994
                               Lebanon County, PA.......
30300........................  Lewiston, ID-WA..........          0.9326
                               Nez Perce County, ID.....
                               Asotin County, WA........
30340........................  Lewiston-Auburn, ME......          0.9178
                               Androscoggin County, ME..
30460........................  Lexington-Fayette, KY....          0.9023
                               Bourbon County, KY.......
                               Clark County, KY.........
                               Fayette County, KY.......
                               Jessamine County, KY.....
                               Scott County, KY.........
                               Woodford County, KY......
30620........................  Lima, OH.................          0.9226
                               Allen County, OH.........
30700........................  Lincoln, NE..............          0.9726
                               Lancaster County, NE.....
                               Seward County, NE........
30780........................  Little Rock-North Little           0.8595
                                Rock-Conway, AR.
                               Faulkner County, AR......
                               Grant County, AR.........
                               Lonoke County, AR........
                               Perry County, AR.........
                               Pulaski County, AR.......
                               Saline County, AR........
30860........................  Logan, UT-ID.............          0.8456
                               Franklin County, ID......
                               Cache County, UT.........
30980........................  Longview, TX.............          0.8550

[[Page 46766]]

 
                               Gregg County, TX.........
                               Rusk County, TX..........
                               Upshur County, TX........
31020........................  Longview, WA.............          1.0081
                               Cowlitz County, WA.......
31084........................  Los Angeles-Long Beach-            1.2293
                                Glendale, CA.
                               Los Angeles County, CA...
31140........................  Louisville-Jefferson               0.8862
                                County, KY-IN.
                               Clark County, IN.........
                               Floyd County, IN.........
                               Harrison County, IN......
                               Washington County, IN....
                               Bullitt County, KY.......
                               Henry County, KY.........
                               Meade County, KY.........
                               Nelson County, KY........
                               Oldham County, KY........
                               Shelby County, KY........
                               Spencer County, KY.......
                               Trimble County, KY.......
31180........................  Lubbock, TX..............          0.8870
                               Crosby County, TX........
                               Lubbock County, TX.......
31340........................  Lynchburg, VA............          0.8615
                               Amherst County, VA.......
                               Appomattox County, VA....
                               Bedford County, VA.......
                               Campbell County, VA......
                               Bedford City, VA.........
                               Lynchburg City, VA.......
31420........................  Macon, GA................          0.8584
                               Bibb County, GA..........
                               Crawford County, GA......
                               Jones County, GA.........
                               Monroe County, GA........
                               Twiggs County, GA........
31460........................  Madera-Chowchilla, CA....          0.8050
                               Madera County, CA........
31540........................  Madison, WI..............          1.1264
                               Columbia County, WI......
                               Dane County, WI..........
                               Iowa County, WI..........
31700........................  Manchester-Nashua, NH....          1.0042
                               Hillsborough County, NH..
31740........................  Manhattan, KS............          0.7839
                               Geary County, KS.........
                               Pottawatomie County, KS..
                               Riley County, KS.........
31860........................  Mankato-North Mankato, MN          0.9413
                               Blue Earth County, MN....
                               Nicollet County, MN......
31900........................  Mansfield, OH............          0.8993
                               Richland County, OH......
32420........................  Mayag[uuml]ez, PR........          0.3586
                               Hormigueros Municipio, PR
                               Mayag[uuml]ez Municipio,
                                PR.
32580........................  McAllen-Edinburg-Mission,          0.8603
                                TX.
                               Hidalgo County, TX.......
32780........................  Medford, OR..............          1.0400
                               Jackson County, OR.......
32820........................  Memphis, TN-MS-AR........          0.9049
                               Crittenden County, AR....
                               DeSoto County, MS........
                               Marshall County, MS......
                               Tate County, MS..........
                               Tunica County, MS........
                               Fayette County, TN.......
                               Shelby County, TN........
                               Tipton County, TN........
32900........................  Merced, CA...............          1.2996
                               Merced County, CA........

[[Page 46767]]

 
33124........................  Miami-Miami Beach-                 1.0130
                                Kendall, FL.
                               Miami-Dade County, FL....
33140........................  Michigan City-La Porte,            0.9694
                                IN.
                               LaPorte County, IN.......
33260........................  Midland, TX..............          1.0640
                               Midland County, TX.......
33340........................  Milwaukee-Waukesha-West            0.9931
                                Allis, WI.
                               Milwaukee County, WI.....
                               Ozaukee County, WI.......
                               Washington County, WI....
                               Waukesha County, WI......
33460........................  Minneapolis-St. Paul-              1.1336
                                Bloomington, MN-WI.
                               Anoka County, MN.........
                               Carver County, MN........
                               Chisago County, MN.......
                               Dakota County, MN........
                               Hennepin County, MN......
                               Isanti County, MN........
                               Ramsey County, MN........
                               Scott County, MN.........
                               Sherburne County, MN.....
                               Washington County, MN....
                               Wright County, MN........
                               Pierce County, WI........
                               St. Croix County, WI.....
33540........................  Missoula, MT.............          0.9001
                               Missoula County, MT......
33660........................  Mobile, AL...............          0.7467
                               Mobile County, AL........
33700........................  Modesto, CA..............          1.2841
                               Stanislaus County, CA....
33740........................  Monroe, LA...............          0.7717
                               Ouachita Parish, LA......
                               Union Parish, LA.........
33780........................  Monroe, MI...............          0.8472
                               Monroe County, MI........
33860........................  Montgomery, AL...........          0.7858
                               Autauga County, AL.......
                               Elmore County, AL........
                               Lowndes County, AL.......
                               Montgomery County, AL....
34060........................  Morgantown, WV...........          0.8284
                               Monongalia County, WV....
                               Preston County, WV.......
34100........................  Morristown, TN...........          0.6768
                               Grainger County, TN......
                               Hamblen County, TN.......
                               Jefferson County, TN.....
34580........................  Mount Vernon-Anacortes,            1.0340
                                WA.
                               Skagit County, WA........
34620........................  Muncie, IN...............          0.8734
                               Delaware County, IN......
34740........................  Muskegon-Norton Shores,            1.1007
                                MI.
                               Muskegon County, MI......
34820........................  Myrtle Beach-North Myrtle          0.8717
                                Beach-Conway, SC.
                               Horry County, SC.........
34900........................  Napa, CA.................          1.6045
                               Napa County, CA..........
34940........................  Naples-Marco Island, FL..          0.9265
                               Collier County, FL.......
34980........................  Nashville-Davidson-                0.9061
                                Murfreesboro-Franklin,
                                TN.
                               Cannon County, TN........
                               Cheatham County, TN......
                               Davidson County, TN......
                               Dickson County, TN.......
                               Hickman County, TN.......
                               Macon County, TN.........
                               Robertson County, TN.....
                               Rutherford County, TN....
                               Smith County, TN.........
                               Sumner County, TN........

[[Page 46768]]

 
                               Trousdale County, TN.....
                               Williamson County, TN....
                               Wilson County, TN........
35004........................  Nassau-Suffolk, NY.......          1.2698
                               Nassau County, NY........
                               Suffolk County, NY.......
35084........................  Newark-Union, NJ-PA......          1.1223
                               Essex County, NJ.........
                               Hunterdon County, NJ.....
                               Morris County, NJ........
                               Sussex County, NJ........
                               Union County, NJ.........
                               Pike County, PA..........
35300........................  New Haven-Milford, CT....          1.2061
                               New Haven County, CT.....
35380........................  New Orleans-Metairie-              0.8932
                                Kenner, LA.
                               Jefferson Parish, LA.....
                               Orleans Parish, LA.......
                               Plaquemines Parish, LA...
                               St. Bernard Parish, LA...
                               St. Charles Parish, LA...
                               St. John the Baptist
                                Parish, LA.
                               St. Tammany Parish, LA...
35644........................  New York-White Plains-             1.2914
                                Wayne, NY-NJ.
                               Bergen County, NJ........
                               Hudson County, NJ........
                               Passaic County, NJ.......
                               Bronx County, NY.........
                               Kings County, NY.........
                               New York County, NY......
                               Putnam County, NY........
                               Queens County, NY........
                               Richmond County, NY......
                               Rockland County, NY......
                               Westchester County, NY...
35660........................  Niles-Benton Harbor, MI..          0.8237
                               Berrien County, MI.......
35840........................  North Port-Bradenton-              0.9375
                                Sarasota-Venice, FL.
                               Manatee County, FL.......
                               Sarasota County, FL......
35980........................  Norwich-New London, CT...          1.1376
                               New London County, CT....
36084........................  Oakland-Fremont-Hayward,           1.6654
                                CA.
                               Alameda County, CA.......
                               Contra Costa County, CA..
36100........................  Ocala, FL................          0.8455
                               Marion County, FL........
36140........................  Ocean City, NJ...........          1.0307
                               Cape May County, NJ......
36220........................  Odessa, TX...............          0.9741
                               Ector County, TX.........
36260........................  Ogden-Clearfield, UT.....          0.9031
                               Davis County, UT.........
                               Morgan County, UT........
                               Weber County, UT.........
36420........................  Oklahoma City, OK........          0.8810
                               Canadian County, OK......
                               Cleveland County, OK.....
                               Grady County, OK.........
                               Lincoln County, OK.......
                               Logan County, OK.........
                               McClain County, OK.......
                               Oklahoma County, OK......
36500........................  Olympia, WA..............          1.1397
                               Thurston County, WA......
36540........................  Omaha-Council Bluffs, NE-          1.0037
                                IA.
                               Harrison County, IA......
                               Mills County, IA.........
                               Pottawattamie County, IA.
                               Cass County, NE..........
                               Douglas County, NE.......

[[Page 46769]]

 
                               Sarpy County, NE.........
                               Saunders County, NE......
                               Washington County, NE....
36740........................  Orlando-Kissimmee, FL....          0.9082
                               Lake County, FL..........
                               Orange County, FL........
                               Osceola County, FL.......
                               Seminole County, FL......
36780........................  Oshkosh-Neenah, WI.......          0.9433
                               Winnebago County, WI.....
36980........................  Owensboro, KY............          0.8117
                               Daviess County, KY.......
                               Hancock County, KY.......
                               McLean County, KY........
37100........................  Oxnard-Thousand Oaks-              1.3079
                                Ventura, CA.
                               Ventura County, CA.......
37340........................  Palm Bay-Melbourne-                0.8838
                                Titusville, FL.
                               Brevard County, FL.......
37380........................  Palm Coast, FL...........          0.9880
                               Flagler County, FL.......
37460........................  Panama City-Lynn Haven-            0.7976
                                Panama City Beach, FL.
                               Bay County, FL...........
37620........................  Parkersburg-Marietta-              0.7487
                                Vienna, WV-OH.
                               Washington County, OH....
                               Pleasants County, WV.....
                               Wirt County, WV..........
                               Wood County, WV..........
37700........................  Pascagoula, MS...........          0.7662
                               George County, MS........
                               Jackson County, MS.......
37764........................  Peabody, MA..............          1.0551
                               Essex County, MA.........
37860........................  Pensacola-Ferry Pass-              0.7819
                                Brent, FL.
                               Escambia County, FL......
                               Santa Rosa County, FL....
37900........................  Peoria, IL...............          0.8882
                               Marshall County, IL......
                               Peoria County, IL........
                               Stark County, IL.........
                               Tazewell County, IL......
                               Woodford County, IL......
37964........................  Philadelphia, PA.........          1.0806
                               Bucks County, PA.........
                               Chester County, PA.......
                               Delaware County, PA......
                               Montgomery County, PA....
                               Philadelphia County, PA..
38060........................  Phoenix-Mesa-Scottsdale,           1.0477
                                AZ.
                               Maricopa County, AZ......
                               Pinal County, AZ.........
38220........................  Pine Bluff, AR...........          0.7847
                               Cleveland County, AR.....
                               Jefferson County, AR.....
                               Lincoln County, AR.......
38300........................  Pittsburgh, PA...........          0.8585
                               Allegheny County, PA.....
                               Armstrong County, PA.....
                               Beaver County, PA........
                               Butler County, PA........
                               Fayette County, PA.......
                               Washington County, PA....
                               Westmoreland County, PA..
38340........................  Pittsfield, MA...........          1.0721
                               Berkshire County, MA.....
38540........................  Pocatello, ID............          0.9555
                               Bannock County, ID.......
                               Power County, ID.........
38660........................  Ponce, PR................          0.4314
                               Juana D[iacute]az
                                Municipio, PR.
                               Ponce Municipio, PR......
                               Villalba Municipio, PR...

[[Page 46770]]

 
38860........................  Portland-South Portland-           0.9975
                                Biddeford, ME.
                               Cumberland County, ME....
                               Sagadahoc County, ME.....
                               York County, ME..........
38900........................  Portland-Vancouver-                1.1673
                                Beaverton, OR-WA.
                               Clackamas County, OR.....
                               Columbia County, OR......
                               Multnomah County, OR.....
                               Washington County, OR....
                               Yamhill County, OR.......
                               Clark County, WA.........
                               Skamania County, WA......
38940........................  Port St. Lucie, FL.......          0.9577
                               Martin County, FL........
                               St. Lucie County, FL.....
39100........................  Poughkeepsie-Newburgh-             1.1325
                                Middletown, NY.
                               Dutchess County, NY......
                               Orange County, NY........
39140........................  Prescott, AZ.............          1.2009
                               Yavapai County, AZ.......
39300........................  Providence-New Bedford-            1.0699
                                Fall River, RI-MA.
                               Bristol County, MA.......
                               Bristol County, RI.......
                               Kent County, RI..........
                               Newport County, RI.......
                               Providence County, RI....
                               Washington County, RI....
39340........................  Provo-Orem, UT...........          0.9133
                               Juab County, UT..........
                               Utah County, UT..........
39380........................  Pueblo, CO...............          0.8518
                               Pueblo County, CO........
39460........................  Punta Gorda, FL..........          0.8590
                               Charlotte County, FL.....
39540........................  Racine, WI...............          0.9158
                               Racine County, WI........
39580........................  Raleigh-Cary, NC.........          0.9488
                               Franklin County, NC......
                               Johnston County, NC......
                               Wake County, NC..........
39660........................  Rapid City, SD...........          0.9823
                               Meade County, SD.........
                               Pennington County, SD....
39740........................  Reading, PA..............          0.9072
                               Berks County, PA.........
39820........................  Redding, CA..............          1.4555
                               Shasta County, CA........
39900........................  Reno-Sparks, NV..........          1.0328
                               Storey County, NV........
                               Washoe County, NV........
40060........................  Richmond, VA.............          0.9695
                               Amelia County, VA........
                               Caroline County, VA......
                               Charles City County, VA..
                               Chesterfield County, VA..
                               Cumberland County, VA....
                               Dinwiddie County, VA.....
                               Goochland County, VA.....
                               Hanover County, VA.......
                               Henrico County, VA.......
                               King and Queen County, VA
                               King William County, VA..
                               Louisa County, VA........
                               New Kent County, VA......
                               Powhatan County, VA......
                               Prince George County, VA.
                               Sussex County, VA........
                               Colonial Heights City, VA
                               Hopewell City, VA........
                               Petersburg City, VA......
                               Richmond City, VA........

[[Page 46771]]

 
40140........................  Riverside-San Bernardino-          1.1396
                                Ontario, CA.
                               Riverside County, CA.....
                               San Bernardino County, CA
40220........................  Roanoke, VA..............          0.9088
                               Botetourt County, VA.....
                               Craig County, VA.........
                               Franklin County, VA......
                               Roanoke County, VA.......
                               Roanoke City, VA.........
                               Salem City, VA...........
40340........................  Rochester, MN............          1.0708
                               Dodge County, MN.........
                               Olmsted County, MN.......
                               Wabasha County, MN.......
40380........................  Rochester, NY............          0.8704
                               Livingston County, NY....
                               Monroe County, NY........
                               Ontario County, NY.......
                               Orleans County, NY.......
                               Wayne County, NY.........
40420........................  Rockford, IL.............          0.9935
                               Boone County, IL.........
                               Winnebago County, IL.....
40484........................  Rockingham County-                 1.0234
                                Strafford County, NH.
                               Rockingham County, NH....
                               Strafford County, NH.....
40580........................  Rocky Mount, NC..........          0.8898
                               Edgecombe County, NC.....
                               Nash County, NC..........
40660........................  Rome, GA.................          0.8844
                               Floyd County, GA.........
40900........................  Sacramento-Arden-Arcade-           1.4752
                                Roseville, CA.
                               El Dorado County, CA.....
                               Placer County, CA........
                               Sacramento County, CA....
                               Yolo County, CA..........
40980........................  Saginaw-Saginaw Township           0.8820
                                North, MI.
                               Saginaw County, MI.......
41060........................  St. Cloud, MN............          1.1010
                               Benton County, MN........
                               Stearns County, MN.......
41100........................  St. George, UT...........          0.8870
                               Washington County, UT....
41140........................  St. Joseph, MO-KS........          0.9856
                               Doniphan County, KS......
                               Andrew County, MO........
                               Buchanan County, MO......
                               DeKalb County, MO........
41180........................  St. Louis, MO-IL.........          0.9420
                               Bond County, IL..........
                               Calhoun County, IL.......
                               Clinton County, IL.......
                               Jersey County, IL........
                               Macoupin County, IL......
                               Madison County, IL.......
                               Monroe County, IL........
                               St. Clair County, IL.....
                               Crawford County, MO......
                               Franklin County, MO......
                               Jefferson County, MO.....
                               Lincoln County, MO.......
                               St. Charles County, MO...
                               St. Louis County, MO.....
                               Warren County, MO........
                               Washington County, MO....
                               St. Louis City, MO.......
41420........................  Salem, OR................          1.1069
                               Marion County, OR........
                               Polk County, OR..........
41500........................  Salinas, CA..............          1.6074
                               Monterey County, CA......

[[Page 46772]]

 
41540........................  Salisbury, MD............          0.9260
                               Somerset County, MD......
                               Wicomico County, MD......
41620........................  Salt Lake City, UT.......          0.9063
                               Salt Lake County, UT.....
                               Summit County, UT........
                               Tooele County, UT........
41660........................  San Angelo, TX...........          0.8221
                               Irion County, TX.........
                               Tom Green County, TX.....
41700........................  San Antonio, TX..........          0.8936
                               Atascosa County, TX......
                               Bandera County, TX.......
                               Bexar County, TX.........
                               Comal County, TX.........
                               Guadalupe County, TX.....
                               Kendall County, TX.......
                               Medina County, TX........
                               Wilson County, TX........
41740........................  San Diego-Carlsbad-San             1.1922
                                Marcos, CA.
                               San Diego County, CA.....
41780........................  Sandusky, OH.............          0.8347
                               Erie County, OH..........
41884........................  San Francisco-San Mateo-           1.6327
                                Redwood City, CA.
                               Marin County, CA.........
                               San Francisco County, CA.
                               San Mateo County, CA.....
41900........................  San Germ[aacute]n-Cabo             0.4804
                                Rojo, PR.
                               Cabo Rojo Municipio, PR..
                               Lajas Municipio, PR......
                               Sabana Grande Municipio,
                                PR.
                               San Germ[aacute]n
                                Municipio, PR.
41940........................  San Jose-Sunnyvale-Santa           1.7396
                                Clara, CA.
                               San Benito County, CA....
                               Santa Clara County, CA...
41980........................  San Juan-Caguas-Guaynabo,          0.4318
                                PR.
                               Aguas Buenas Municipio,
                                PR.
                               Aibonito Municipio, PR...
                               Arecibo Municipio, PR....
                               Barceloneta Municipio, PR
                               Barranquitas Municipio,
                                PR.
                               Bayam[oacute]n Municipio,
                                PR.
                               Caguas Municipio, PR.....
                               Camuy Municipio, PR......
                               Can[oacute]vanas
                                Municipio, PR.
                               Carolina Municipio, PR...
                               Cata[ntilde]o Municipio,
                                PR.
                               Cayey Municipio, PR......
                               Ciales Municipio, PR.....
                               Cidra Municipio, PR......
                               Comer[iacute]o Municipio,
                                PR.
                               Corozal Municipio, PR....
                               Dorado Municipio, PR.....
                               Florida Municipio, PR....
                               Guaynabo Municipio, PR...
                               Gurabo Municipio, PR.....
                               Hatillo Municipio, PR....
                               Humacao Municipio, PR....
                               Juncos Municipio, PR.....
                               Las Piedras Municipio, PR
                               Lo[iacute]za Municipio,
                                PR.
                               Manat[iacute] Municipio,
                                PR.
                               Maunabo Municipio, PR....
                               Morovis Municipio, PR....
                               Naguabo Municipio, PR....
                               Naranjito Municipio, PR..
                               Orocovis Municipio, PR...
                               Quebradillas Municipio,
                                PR.
                               R[iacute]o Grande
                                Municipio, PR.
                               San Juan Municipio, PR...
                               San Lorenzo Municipio, PR

[[Page 46773]]

 
                               Toa Alta Municipio, PR...
                               Toa Baja Municipio, PR...
                               Trujillo Alto Municipio,
                                PR.
                               Vega Alta Municipio, PR..
                               Vega Baja Municipio, PR..
                               Yabucoa Municipio, PR....
42020........................  San Luis Obispo-Paso               1.3081
                                Robles, CA.
                               San Luis Obispo County,
                                CA.
42044........................  Santa Ana-Anaheim-Irvine,          1.2038
                                CA.
                               Orange County, CA........
42060........................  Santa Barbara-Santa Maria-         1.2670
                                Goleta, CA.
                               Santa Barbara County, CA.
42100........................  Santa Cruz-Watsonville,            1.8062
                                CA.
                               Santa Cruz County, CA....
42140........................  Santa Fe, NM.............          1.0400
                               Santa Fe County, NM......
42220........................  Santa Rosa-Petaluma, CA..          1.6440
                               Sonoma County, CA........
42340........................  Savannah, GA.............          0.8968
                               Bryan County, GA.........
                               Chatham County, GA.......
                               Effingham County, GA.....
42540........................  Scranton-Wilkes-Barre, PA          0.8260
                               Lackawanna County, PA....
                               Luzerne County, PA.......
                               Wyoming County, PA.......
42644........................  Seattle-Bellevue-Everett,          1.1771
                                WA.
                               King County, WA..........
                               Snohomish County, WA.....
42680........................  Sebastian-Vero Beach, FL.          0.8850
                               Indian River County, FL..
43100........................  Sheboygan, WI............          0.9515
                               Sheboygan County, WI.....
43300........................  Sherman-Denison, TX......          0.8544
                               Grayson County, TX.......
43340........................  Shreveport-Bossier City,           0.8412
                                LA.
                               Bossier Parish, LA.......
                               Caddo Parish, LA.........
                               De Soto Parish, LA.......
43580........................  Sioux City, IA-NE-SD.....          0.9010
                               Woodbury County, IA......
                               Dakota County, NE........
                               Dixon County, NE.........
                               Union County, SD.........
43620........................  Sioux Falls, SD..........          0.8338
                               Lincoln County, SD.......
                               McCook County, SD........
                               Minnehaha County, SD.....
                               Turner County, SD........
43780........................  South Bend-Mishawaka, IN-          0.9531
                                MI.
                               St. Joseph County, IN....
                               Cass County, MI..........
43900........................  Spartanburg, SC..........          0.9186
                               Spartanburg County, SC...
44060........................  Spokane, WA..............          1.0824
                               Spokane County, WA.......
44100........................  Springfield, IL..........          0.9179
                               Menard County, IL........
                               Sangamon County, IL......
44140........................  Springfield, MA..........          1.0377
                               Franklin County, MA......
                               Hampden County, MA.......
                               Hampshire County, MA.....
44180........................  Springfield, MO..........          0.8581
                               Christian County, MO.....
                               Dallas County, MO........
                               Greene County, MO........
                               Polk County, MO..........
                               Webster County, MO.......
44220........................  Springfield, OH..........          0.9236
                               Clark County, OH.........

[[Page 46774]]

 
44300........................  State College, PA........          0.9510
                               Centre County, PA........
44600........................  Steubenville-Weirton, OH-          0.7640
                                WV.
                               Jefferson County, OH.....
                               Brooke County, WV........
                               Hancock County, WV.......
44700........................  Stockton, CA.............          1.3356
                               San Joaquin County, CA...
44940........................  Sumter, SC...............          0.7454
                               Sumter County, SC........
45060........................  Syracuse, NY.............          0.9829
                               Madison County, NY.......
                               Onondaga County, NY......
                               Oswego County, NY........
45104........................  Tacoma, WA...............          1.1741
                               Pierce County, WA........
45220........................  Tallahassee, FL..........          0.8521
                               Gadsden County, FL.......
                               Jefferson County, FL.....
                               Leon County, FL..........
                               Wakulla County, FL.......
45300........................  Tampa-St. Petersburg-              0.9032
                                Clearwater, FL.
                               Hernando County, FL......
                               Hillsborough County, FL..
                               Pasco County, FL.........
                               Pinellas County, FL......
45460........................  Terre Haute, IN..........          0.9113
                               Clay County, IN..........
                               Sullivan County, IN......
                               Vermillion County, IN....
                               Vigo County, IN..........
45500........................  Texarkana, TX-Texarkana,           0.7967
                                AR.
                               Miller County, AR........
                               Bowie County, TX.........
45780........................  Toledo, OH...............          0.9034
                               Fulton County, OH........
                               Lucas County, OH.........
                               Ottawa County, OH........
                               Wood County, OH..........
45820........................  Topeka, KS...............          0.8969
                               Jackson County, KS.......
                               Jefferson County, KS.....
                               Osage County, KS.........
                               Shawnee County, KS.......
                               Wabaunsee County, KS.....
45940........................  Trenton-Ewing, NJ........          1.0360
                               Mercer County, NJ........
46060........................  Tucson, AZ...............          0.9065
                               Pima County, AZ..........
46140........................  Tulsa, OK................          0.8139
                               Creek County, OK.........
                               Okmulgee County, OK......
                               Osage County, OK.........
                               Pawnee County, OK........
                               Rogers County, OK........
                               Tulsa County, OK.........
                               Wagoner County, OK.......
46220........................  Tuscaloosa, AL...........          0.8533
                               Greene County, AL........
                               Hale County, AL..........
                               Tuscaloosa County, AL....
46340........................  Tyler, TX................          0.8361
                               Smith County, TX.........
46540........................  Utica-Rome, NY...........          0.8653
                               Herkimer County, NY......
                               Oneida County, NY........
46660........................  Valdosta, GA.............          0.7918
                               Brooks County, GA........
                               Echols County, GA........
                               Lanier County, GA........
                               Lowndes County, GA.......

[[Page 46775]]

 
46700........................  Vallejo-Fairfield, CA....          1.5844
                               Solano County, CA........
47020........................  Victoria, TX.............          0.8992
                               Calhoun County, TX.......
                               Goliad County, TX........
                               Victoria County, TX......
47220........................  Vineland-Millville-                1.0596
                                Bridgeton, NJ.
                               Cumberland County, NJ....
47260........................  Virginia Beach-Norfolk-            0.9208
                                Newport News, VA-NC.
                               Currituck County, NC.....
                               Gloucester County, VA....
                               Isle of Wight County, VA.
                               James City County, VA....
                               Mathews County, VA.......
                               Surry County, VA.........
                               York County, VA..........
                               Chesapeake City, VA......
                               Hampton City, VA.........
                               Newport News City, VA....
                               Norfolk City, VA.........
                               Poquoson City, VA........
                               Portsmouth City, VA......
                               Suffolk City, VA.........
                               Virginia Beach City, VA..
                               Williamsburg City, VA....
47300........................  Visalia-Porterville, CA..          1.0349
                               Tulare County, CA........
47380........................  Waco, TX.................          0.8458
                               McLennan County, TX......
47580........................  Warner Robins, GA........          0.8197
                               Houston County, GA.......
47644........................  Warren-Troy-Farmington             0.9543
                                Hills, MI.
                               Lapeer County, MI........
                               Livingston County, MI....
                               Macomb County, MI........
                               Oakland County, MI.......
                               St. Clair County, MI.....
47894........................  Washington-Arlington-              1.0659
                                Alexandria, DC-VA-MD-WV.
                               District of Columbia, DC.
                               Calvert County, MD.......
                               Charles County, MD.......
                               Prince George's County,
                                MD.
                               Arlington County, VA.....
                               Clarke County, VA........
                               Fairfax County, VA.......
                               Fauquier County, VA......
                               Loudoun County, VA.......
                               Prince William County, VA
                               Spotsylvania County, VA..
                               Stafford County, VA......
                               Warren County, VA........
                               Alexandria City, VA......
                               Fairfax City, VA.........
                               Falls Church City, VA....
                               Fredericksburg City, VA..
                               Manassas City, VA........
                               Manassas Park City, VA...
                               Jefferson County, WV.....
47940........................  Waterloo-Cedar Falls, IA.          0.8422
                               Black Hawk County, IA....
                               Bremer County, IA........
                               Grundy County, IA........
48140........................  Wausau, WI...............          0.8921
                               Marathon County, WI......
48300........................  Wenatchee-East Wenatchee,          1.0037
                                WA.
                               Chelan County, WA........
                               Douglas County, WA.......
48424........................  West Palm Beach-Boca               0.9661
                                Raton-Boynton Beach, FL.
                               Palm Beach County, FL....
48540........................  Wheeling, WV-OH..........          0.6863
                               Belmont County, OH.......

[[Page 46776]]

 
                               Marshall County, WV......
                               Ohio County, WV..........
48620........................  Wichita, KS..............          0.8681
                               Butler County, KS........
                               Harvey County, KS........
                               Sedgwick County, KS......
                               Sumner County, KS........
48660........................  Wichita Falls, TX........          0.9048
                               Archer County, TX........
                               Clay County, TX..........
                               Wichita County, TX.......
48700........................  Williamsport, PA.........          0.8230
                               Lycoming County, PA......
48864........................  Wilmington, DE-MD-NJ.....          1.0687
                               New Castle County, DE....
                               Cecil County, MD.........
                               Salem County, NJ.........
48900........................  Wilmington, NC...........          0.9155
                               Brunswick County, NC.....
                               New Hanover County, NC...
                               Pender County, NC........
49020........................  Winchester, VA-WV........          0.9249
                               Frederick County, VA.....
                               Winchester City, VA......
                               Hampshire County, WV.....
49180........................  Winston-Salem, NC........          0.8660
                               Davie County, NC.........
                               Forsyth County, NC.......
                               Stokes County, NC........
                               Yadkin County, NC........
49340........................  Worcester, MA............          1.1205
                               Worcester County, MA.....
49420........................  Yakima, WA...............          1.0097
                               Yakima County, WA........
49500........................  Yauco, PR................          0.4059
                               Gu[aacute]nica Municipio,
                                PR.
                               Guayanilla Municipio, PR.
                               Pe[ntilde]uelas
                                Municipio, PR.
                               Yauco Municipio, PR......
49620........................  York-Hanover, PA.........          0.9557
                               York County, PA..........
49660........................  Youngstown-Warren-                 0.8283
                                Boardman, OH-PA.
                               Mahoning County, OH......
                               Trumbull County, OH......
                               Mercer County, PA........
49700........................  Yuba City, CA \1\........          1.2004
                               Sutter County, CA........
                               Yuba County, CA..........
49740........................  Yuma, AZ.................          0.9517
                               Yuma County, AZ..........
------------------------------------------------------------------------
\1\ At this time, there are no hospitals located in this urban area on
  which to base a wage index.

 Table 2--FY 2014 Wage Index Based on CBSA Labor Market Areas for Rural
                                  Areas
------------------------------------------------------------------------
                                                                  Wage
             State code                    Nonurban area         index
------------------------------------------------------------------------
1...................................  Alabama................     0.7121
2...................................  Alaska.................     1.2807
3...................................  Arizona................     0.9182
4...................................  Arkansas...............     0.7350
5...................................  California.............     1.2567
6...................................  Colorado...............     1.0208
7...................................  Connecticut............     1.1128
8...................................  Delaware...............     1.0171
10..................................  Florida................     0.8062
11..................................  Georgia................     0.7421
12..................................  Hawaii.................     1.0728
13..................................  Idaho..................     0.7583
14..................................  Illinois...............     0.8438
15..................................  Indiana................     0.8472
16..................................  Iowa...................     0.8351
17..................................  Kansas.................     0.7997
18..................................  Kentucky...............     0.7877
19..................................  Louisiana..............     0.7718
20..................................  Maine..................     0.8300
21..................................  Maryland...............     0.8797
22..................................  Massachusetts..........     1.3540
23..................................  Michigan...............     0.8387
24..................................  Minnesota..............     0.9053
25..................................  Mississippi............     0.7537
26..................................  Missouri...............     0.7622
27..................................  Montana................     0.8600
28..................................  Nebraska...............     0.8733
29..................................  Nevada.................     0.9739

[[Page 46777]]

 
30..................................  New Hampshire..........     1.0372
31..................................  New Jersey \1\.........
32..................................  New Mexico.............     0.8879
33..................................  New York...............     0.8199
34..................................  North Carolina.........     0.8271
35..................................  North Dakota...........     0.6891
36..................................  Ohio...................     0.8470
37..................................  Oklahoma...............     0.7783
38..................................  Oregon.................     0.9500
39..................................  Pennsylvania...........     0.8380
40..................................  Puerto Rico \1\........     0.4047
41..................................  Rhode Island \1\.......
42..................................  South Carolina.........     0.8338
43..................................  South Dakota...........     0.8124
44..................................  Tennessee..............     0.7559
45..................................  Texas..................     0.7978
46..................................  Utah...................     0.8516
47..................................  Vermont................     0.9725
48..................................  Virgin Islands.........     0.7185
49..................................  Virginia...............     0.7728
50..................................  Washington.............     1.0092
51..................................  West Virginia..........     0.7333
52..................................  Wisconsin..............     0.9142
53..................................  Wyoming................     0.9238
65..................................  Guam...................     0.9611
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban, with the
  exception of Puerto Rico. Puerto Rico has areas designated as rural;
  however, no short-term, acute care hospitals are located in the
  area(s) for FY 2013. The Puerto Rico wage index is the same as FY
  2012.

[FR Doc. 2013-18445 Filed 7-29-13; 4:15 pm]
BILLING CODE P
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