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 Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Parts 414 and 484
[CMS-1304-F]
RIN 0938-AN76
 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
 ACTION: Final rule.
 SUMMARY: This final rule sets forth an update to the 60-day national episode rates and the national per-visit amounts under the Medicare prospective payment system for home health services. In addition, this final rule sets forth policy changes related to Medicare payment for certain durable medical equipment for the purpose of implementing sections 1834(a)(5) and 1834(a)(7) of the Social Security Act, as amended by section 5101 of the Deficit Reduction Act of 2005. This final rule also responds to public comments on the August 3, 2006, proposed rule that pertain to a number of issues including the requirement that home health payments are based on the reporting of specific quality data by home health agencies.
 DATES: *Effective Date:*
                             These regulations are effective on January 1, 2007.
 FOR FURTHER INFORMATION CONTACT: Randy Throndset, (410) 786-0131, or Sharon Ventura, (410) 786-1985 (for issues related to the home health prospective payment system).  Doug Brown, (410) 786-0028 (for issues related to reporting home health quality data).  Alexis Meholic, (410) 786-2300 (for issues related to payments for oxygen equipment and capped rental durable medical equipment).


SUPPLEMENTARY INFORMATION:  I. Background A. Statutory Background The Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33), enacted on August 5, 1997, significantly changed the way Medicare pays for Medicare home health services. Until the implementation of a home health prospective payment system (HH PPS) on October 1, 2000, home health agencies (HHAs) received payment under a cost-based reimbursement system. Section 4603 of the BBA governed the development of the HH PPS. Section 4603(a) of the BBA provides the authority for the development of a PPS for all Medicare-covered home health services provided under a plan of care that were paid on a reasonable cost basis by adding section 1895, entitled “Prospective Payment For Home Health Services,” to the Social Security Act (the Act). Section 1895(b)(1) of the Act requires the Secretary to establish a PPS for all costs of home health services paid under Medicare. Section 1895(b)(3)(A) of the Act requires that (1) the computation of a standard prospective payment amount include all costs of home health services covered and paid for on a reasonable cost basis and be initially based on the most recent audited cost report data available to the Secretary, and (2) the prospective payment amounts be standardized to eliminate the effects of case-mix and wage levels among HHAs. Section 1895(b)(3)(B) of the Act addresses the annual update to the standard prospective payment amounts by the home health applicable increase percentage as specified in the statute. Section 1895(b)(4) of the Act governs the payment computation. Sections 1895(b)(4)(A)(i) and (b)(4)(A)(ii) of the Act require the standard prospective payment amount to be adjusted for case-mix and geographic differences in wage levels. Section 1895(b)(4)(B) of the Act requires the establishment of an appropriate case-mix adjustment factor that explains a significant amount of the variation in cost among different units of services. Similarly, section 1895(b)(4)(C) of the Act requires the establishment of wage-adjustment factors that reflect the relative level of wages and wage-related costs applicable to the furnishing of home health services in a geographic area compared to the national average applicable level. These wage-adjustment factors may be the factors used by the Secretary for the different area wage levels for purposes of section 1886(d)(3)(E) of the Act. Section 1895(b)(5) of the Act gives the Secretary the option to grant additions or adjustments to the payment amount otherwise made in the case of outliers because of unusual variations in the type or amount of medically necessary care. Total outlier payments in a given fiscal year cannot exceed 5 percent of total payments projected or estimated. On February 8, 2006, the Congress enacted the Deficit Reduction Act (DRA) of 2005 (Pub. L. 109-171). This legislation made additional changes to the HH PPS. Section 5201 of the DRA changed the CY 2006 update from the applicable home health market basket percentage increase minus 0.8 percentage points to a 0 percent update. Section 5201 of the DRA amended section 421(a) of the MMA. The amended section 421(a) of the MMA requires, for home health services furnished in a rural area (as defined in section 1886(d)(2)(D) of the Act) with respect to episodes and visits beginning on or after January 1, 2006 and before January 1, 2007, that the Secretary increase by 5 percent the payment amount otherwise made under section 1895 of the Act. The statute waives budget neutrality for purposes of this increase as it specifically requires that the Secretary not reduce the standard prospective payment amount (or amounts) under section 1895 of the Act applicable to home health services furnished during a period to offset the increase in payments resulting in the application of this section of the statute. The 0 percent update to the payment rates and the rural add-on provisions of the DRA were implemented through Pub. 100-20, One Time Notification, Transmittal 211 issued February 10, 2006. In addition, section 5201(c) of the DRA amends the statute to add section 1895(b)(3)(B)(v) to the Act, requiring HHAs to submit data for purposes of measuring health care quality. This requirement is applicable for 2007 and each subsequent year. For 2007 and each subsequent year, in the case of a HHA that does not submit quality data, the home health market basket percentage increase would be reduced by 2 percentage points. B. Updates 1. 2000 Final Rule On July 3, 2000, we published a final rule (65 FR 41128) in the 
                        **Federal Register**
                         to implement the HH PPS legislation. That final rule established requirements for a new PPS for HHAs as required by section 4603 of the BBA, and as subsequently amended by section 5101 of the Omnibus Consolidated and Emergency Supplemental Appropriations Act (OCESAA) for Fiscal Year 1999 (Pub. L. 105-277), enacted on October 21, 1998; and by sections 302, 305, and 306 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act (BBRA) of 1999 (Pub. L. 106-113), enacted on November 29, 1999. The requirements include the implementation of a PPS for home 
                        ( print page 65885)
                        health services, consolidated billing requirements, and a number of other related changes. The PPS described in that rule replaced the retrospective reasonable-cost-based system that was used by Medicare for the payment of home health services under Part A and Part B. 2. 2005 Final Rule On November 9, 2005, we published a final rule (70 FR 68132), which set forth an update to the 60-day national episode rates and the national per-visit amounts under the Medicare prospective payment system for home health services for CY 2006. As part of that final rule, we adopted revised area labor market Metropolitan Statistical Area designations for CY 2006. In implementing the new area labor market designations, we allowed for a 1-year transition period. This transition consists of a blend of 50 percent of the new area labor market designations' wage index and 50 percent of the previous area labor market designations' wage index. In addition, we revised the fixed dollar loss ratio, which is used in the calculation of outlier payments. C. System for Payment of Home Health Services Generally, Medicare makes payment under the HH PPS on the basis of a national standardized 60-day episode payment, adjusted for case mix and wage index. For episodes with four or fewer visits, Medicare pays on the basis of a national per-visit amount by discipline, referred to as a low utilization payment adjustment (LUPA). Medicare also adjusts the 60-day episode payment for certain intervening events that give rise to a partial episode payment adjustment (PEP adjustment) or a significant change in condition adjustment (SCIC). For certain cases that exceed a specific cost threshold, an outlier adjustment may also be available. For a complete and full description of the HH PPS as required by the BBA and as amended by OCESAA and BBRA, see the July 3, 2000 HH PPS final rule (65 FR 41128). D. Changes in Payment for Oxygen and Oxygen Equipment and Other Durable Medical Equipment (Capped Rental Items) The Medicare payment rules for durable medical equipment (DME) are set forth in section 1834(a) of the Act and 42 CFR part 414, subpart D of our regulations. General payment rules for DME are set forth in section 1834(a)(1) of the Act and § 414.210 of our regulations, and § 414.210 also contains paragraphs relating to maintenance and servicing of items and replacement of items. Specific rules for oxygen and oxygen equipment are set forth in section 1834(a)(5) of the Act and § 414.226 of our regulations, and specific rules for capped rental items are set forth in section 1834(a)(7) of the Act and § 414.229 of our regulations. Rules for determining a period of continuous use for the rental of DME are set forth in § 414.230 of our regulations. The Medicare payment basis for DME is equal to 80 percent of either the lower of the actual charge or the fee schedule amount for the item. The beneficiary coinsurance is equal to 20 percent of either the lower of the actual charge or the fee schedule amount for the item. In accordance with the rules set forth in section 1834(a)(5) of the Act and § 414.226 of our regulations, since 1989, suppliers have been paid monthly for furnishing oxygen and oxygen equipment to Medicare beneficiaries. Suppliers have also been paid an add-on fee for furnishing portable oxygen equipment to patients when medically necessary. Before the enactment of the DRA, these monthly payments continued for the duration of use of the equipment, provided that Medicare Part B coverage and eligibility criteria were met. Medicare covers three types of oxygen delivery systems: (1) Stationary or portable oxygen concentrators, which concentrate oxygen in room air; (2) stationary or portable liquid oxygen systems, which use oxygen stored as a very cold liquid in cylinders and tanks; and (3) stationary or portable gaseous oxygen systems, which administer compressed oxygen directly from cylinders. Both liquid and gaseous oxygen systems require delivery of oxygen contents. Medicare payment for furnishing oxygen and oxygen equipment is made on a monthly basis and the fee schedule amounts vary by State. Payment for oxygen contents for both stationary and portable equipment is included in the fee schedule allowances for stationary equipment. Medicare fee schedules for home oxygen equipment are modality neutral; meaning that in a given State, there is one fee schedule amount that applies to all stationary systems and one fee schedule amount that applies to all portable systems. Effective January 1, 2006, section 5101(b) of the DRA amended the Act at section 1834(a)(5) of the Act, limiting to 36 months the total number of continuous months for which Medicare will pay for oxygen equipment on a rental basis. At the end of the 36-month period, this section mandates that the supplier transfer title to the stationary and portable oxygen equipment to the beneficiary. Section 5101(b) of the DRA does not, however, limit the number of months for which Medicare will pay for oxygen contents for beneficiary-owned stationary or portable gaseous or liquid systems, and payment will continue to be made as long as the oxygen remains medically necessary. Section 5101(b) of the DRA also provides that payment for reasonable and necessary maintenance and servicing of beneficiary-owned oxygen equipment will be made for parts and labor not covered by a supplier's or manufacturer's warranty. In the case of beneficiaries using oxygen equipment on December 31, 2005, the 36-month rental period prescribed by the DRA begins on January 1, 2006. In accordance with the rules set forth in section 1834(a)(7) of the Act and § 414.229 of our regulations, before the enactment of the DRA, suppliers of capped rental items (that is, other DME not described in paragraphs (2) through (6) of section 1834(a) of the Act) were paid on a rental or purchase option basis. Payment for most items in the capped rental category was made on a monthly rental basis, with rental payments being capped at 15 months or 13 months, depending on whether the beneficiary chose to continue renting the item or to take over ownership of the item through the “purchase option.” For all capped rental items, the supplier was required to inform the beneficiary of his or her purchase option, during the 10th rental month, to enter into a purchase agreement under which the supplier would transfer title to the item to the beneficiary on the first day after the 13th continuous month during which payment was made for the rental of the item. Therefore, if the beneficiary chose the purchase option, rental payments to the supplier would continue through the 13th month of continuous use of the equipment, after which time title to the equipment would transfer from the supplier to the beneficiary. Medicare would also make payment for any reasonable and necessary repair or maintenance and servicing of the equipment following the transfer of title. If the beneficiary did not choose the purchase option, rental payments would continue through the 15th month of continuous use. In these cases, suppliers would maintain title to the equipment but would have to continue furnishing the item to the beneficiary as long as medical necessity continued. Beginning 6 months after the 15th month of continuous use in which payment was made, Medicare would also make semi-annual maintenance and servicing payments to suppliers. These payments were approximately equal to 10 percent 
                        ( print page 65886)
                        of the purchase price for the equipment as determined by the statute. Total Medicare payments made through the 13th and 15th months of rental equal 105 and 120 percent, respectively, of the purchase price for the equipment. In the case of power-driven wheelchairs, since 1989 payment has also been made on a lump-sum purchase basis at the time that the item is initially furnished to the beneficiary if the beneficiary chooses to obtain the item in this manner. Most beneficiaries choose to obtain power-driven wheelchairs via this lump-sum purchase option. Effective for items for which the first rental month occurs on or after January 1, 2006, section 5101(a) of the DRA of 2005 amended section 1834(a)(7) of the Act, limiting to 13 months the total number of continuous months for which Medicare will pay for DME in this category. After a 13-month period of continuous use during which rental payments are made, the statute requires that the supplier transfer title to the equipment to the beneficiary. Beneficiaries may still elect to obtain power-driven wheelchairs on a lump-sum purchase agreement basis. In all cases, payment for reasonable and necessary maintenance and servicing of beneficiary-owned equipment will be made for parts and labor not covered by the supplier's or manufacturer's warranty. E. Requirements for Issuance of Regulations Section 902 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) amended section 1871(a) of the Act and requires the Secretary, in consultation with the Director of the Office of Management and Budget, to establish and publish timelines for the publication of Medicare final regulations based on the previous publication of a Medicare proposed or interim final regulation. Section 902 of the MMA also states that the timelines for these regulations may vary but shall not exceed 3 years after publication of the preceding proposed or interim final regulation except under exceptional circumstances. This final rule finalizes provisions set forth in the August 3, 2006 proposed rule. In addition, this final rule has been published within the 3-year time limit imposed by section 902 of the MMA. Therefore, we believe that the final rule is in accordance with the Congress' intent to ensure timely publication of final regulations. II. Provisions of the Proposed Regulations We published a proposed rule in the 
                        **Federal Register**
                         on August 3, 2006 (71 FR 44081) that set forth a proposed update to the 60-day national episode rates and the national per-visit amounts under the Medicare prospective payment system for home health services. In addition, that proposed rule set forth proposed policy changes related to Medicare payment for certain durable medical equipment for the purpose of implementing sections 1834(a)(5) and 1834(a)(7) of the Social Security Act, as amended by section 5101 of the Deficit Reduction Act of 2005. That proposed rule also invited comments on a number of issues including payments based on reporting quality data, the adoption of health information technology, as well as how to improve data transparency for consumers. A. National Standardized 60-Day Episode Rate The Medicare HH PPS has been effective since October 1, 2000. As set forth in the final rule published July 3, 2000 in the 
                        **Federal Register**
                         (65 FR 41128), the unit of payment under the Medicare HH PPS is a national standardized 60-day episode rate. As set forth in § 484.220, we adjust the national standardized 60-day episode rate by a case mix grouping and a wage index value based on the site of service for the beneficiary. The proposed CY 2007 HH PPS rates used the same case-mix methodology and application of the wage index adjustment to the labor portion of the HH PPS rates as set forth in the July 3, 2000 final rule. In the October 22, 2004 final rule, we rebased and revised the home health market basket, resulting in a labor-related share of 76.775 percent and a non-labor portion of 23.225 percent (69 FR 62126). We multiply the national 60-day episode rate by the patient's applicable case-mix weight. We divide the case-mix adjusted amount into a labor and non-labor portion. We multiply the labor portion by the applicable wage index based on the site of service of the beneficiary. As required by section 1895(b)(3)(B) of the Act, we have updated the HH PPS rates annually in a separate 
                        **Federal Register**
                         document. Section 484.225 sets forth the specific annual percentage update. To reflect section 1895(b)(3)(B)(v) of the Act, as added by section 5201 of the DRA, we proposed to revise § 484.225, paragraph (g) as follows: (g) For 2007 and subsequent calendar years, the unadjusted national rate is equal to the rate for the previous calendar year increased by the applicable home health market basket index amount unless the HHA has not submitted quality data in which case the unadjusted national rate is equal to the rate for the previous calendar year increased by the applicable home health market basket index amount minus 2 percentage points. For CY 2007, we proposed to use again the design and case-mix methodology described in section III.G of the HH PPS July 3, 2000 final rule (65 FR 41192 through 41203). For CY 2007, we will base the wage index adjustment to the labor portion of the PPS rates on the most recent pre-floor and pre-reclassified hospital wage index as discussed in section II.F of the August 3, 2006 proposed rule (not including any reclassifications under section 1886(d)(8)(B) of the Act). As discussed in the July 3, 2000 HH PPS final rule, for episodes with four or fewer visits, Medicare pays the national per-visit amount by discipline, referred to as a LUPA. We update the national per-visit amounts by discipline annually by the applicable home health market basket percentage. We adjust the national per-visit amount by the appropriate wage index based on the site of service for the beneficiary as set forth in § 484.230. We will adjust the labor portion of the updated national per-visit amounts by discipline used to calculate the LUPA by the most recent pre-floor and pre-reclassified hospital wage index, as discussed in section II.F of the August 3, 2006 proposed rule. Medicare pays the 60-day case-mix and wage-adjusted episode payment on a split percentage payment approach. The split percentage payment approach includes an initial percentage payment and a final percentage payment as set forth in § 484.205(b)(1) and § 484.205(b)(2). We may base the initial percentage payment on the submission of a request for anticipated payment (RAP) and the final percentage payment on the submission of the claim for the episode, as discussed in § 409.43. The claim for the episode that the HHA submits for the final percentage payment determines the total payment amount for the episode and whether we make an applicable adjustment to the 60-day case-mix and wage-adjusted episode payment. The end date of the 60-day episode as reported on the claim determines which calendar year rates Medicare would use to pay the claim. We may also adjust the 60-day case-mix and wage-adjusted episode payment based on the information submitted on the claim to reflect the following: 
                        ( print page 65887) A low utilization payment provided on a per-visit basis as set forth in § 484.205(c) and § 484.230.
                    A partial episode payment adjustment as set forth in § 484.205(d) and § 484.235.
                    A significant change in condition adjustment as set forth in § 484.205(e) and § 484.237.
                    An outlier payment as set forth in § 484.205(f) and § 484.240. B. CY 2007 Update to the Home Health Market Basket Index Section 1895(b)(3)(B) of the Act, as amended by section 5201 of the DRA, requires for CY 2007 that the standard prospective payment amounts be increased by a factor equal to the applicable home health market basket update. The proposed rule contained a home health market basket update of 3.1 percent. Since publication of the proposed rule, we have estimated a new home health market basket update of 3.3 percent for CY 2007. CY 2007 Adjustments In calculating the annual update for the CY 2007 60-day episode rates, we first look at the CY 2006 rates as a starting point. The CY 2006 national 60-day episode rate, as modified by section 5201(a)(4) of the DRA (and implemented through Pub. 100-20, One Time Notification, Transmittal 211 issued February 10, 2006) is $2,264.28. In order to calculate the CY 2007 national 60-day episode rate, we multiply the CY 2006 national 60-day episode rate ($2,264.28) by the estimated home health market basket update of 3.3 percent for CY 2007. The estimated home health market basket percentage increase reflects changes over time in the prices of an appropriate mix of goods and services included in covered home health services. The estimated home health market basket percentage increase is generally used to update the HH PPS rates on an annual basis. We increase the CY 2006 60-day episode payment rate by the estimated home health market basket update (3.3 percent) ($2,264.28 × 1.033) to yield the updated CY 2007 national 60-day episode rate ($2,339.00) (see Table 1 below). The CY 2007 HH PPS rates apply to episodes ending on or after January 1, 2007, and before January 1, 2008. Table 1.—National 60-Day Episode Amounts Updated by the Estimated Home Health Market Basket Update for CY 2007, Before Case-Mix Adjustment
Total CY 2006 Prospective Payment Amount Per 60-day Episode
Multiply by the Estimated Home Health Market Basket Update (3.3 Percent)1
CY 2007 Updated National 60-Day Episode Rate$2,264.28
× 1.033
$2,339.001
                             The estimated home health market basket update of 3.3 percent for CY 2007 is based on Global Insight, Inc, 3rd Qtr, 2006 forecast with historical data through 2nd Qtr, 2006.
 National Per-Visit Amounts Used To Pay LUPAs and Compute Imputed Costs Used in Outlier Calculations As discussed previously in the August 3, 2006 proposed rule, the policies governing the LUPAs and outlier calculations set forth in the July 3, 2000 HH PPS final rule will continue during CY 2007. In calculating the annual update for the CY 2007 national per-visit amounts we use to pay LUPAs and to compute the imputed costs in outlier calculations, we look again at the CY 2006 rates as a starting point. We then multiply those amounts by the estimated home health market basket update for CY 2007 (3.3 percent) to yield the updated per-visit amounts for each home health discipline for CY 2007 (episodes ending on or after January 1, 2007, and before January 1, 2008) (see Table 2 below). Table 2.—National Per-Visit Amounts for LUPAs and Outlier Calculations Updated by the Estimated Home Health Market Basket Update for CY 2007
Home health discipline type
Final CY 2006 per-visit amounts per 60-day episode for LUPAs
Multiply by the estimated home health market basket (3.3 percent) 1
CY 2007 per-visit payment amount per discipline for LUPAsHome Health Aide
$44.76
× 1.033
$46.24Medical Social Services
158.45
× 1.033
163.68Occupational Therapy
108.81
× 1.033
112.40Physical Therapy
108.08
× 1.033
111.65Skilled Nursing
98.85
× 1.033
102.11Speech-Language Pathology
117.44
× 1.033
121.321
                             The estimated home health market basket update of 3.3 percent for CY 2007 is based on Global Insight, Inc, 3rd Qtr, 2006 forecast with historical data through 2nd Qtr, 2006.
 C. Rural Add-On As stated above, section 5201(b) of the DRA requires, for home health services furnished in a rural area (as defined in section 1886(d)(2)(D) of the Act) with respect to episodes and visits beginning on or after January 1, 2006 and before January 1, 2007, that the Secretary increase by 5 percent the payment amount otherwise made under section 1895 of the Act. The statute waives budget neutrality related to this provision as it specifically states that the Secretary shall not reduce the standard prospective payment amount (or amounts) under section 1895 of the Act applicable to home health services furnished during a period to offset the increase in payments resulting in the application of this section of the statute. While the rural add-on primarily affects those episodes paid based on CY 2006 rates, it also affects a number of CY 2007 episodes. For example, an episode that begins on December 20, 2006 and ends on February 17, 2007 for services furnished in a rural area, will be paid based on CY 2007 rates because the episode ends on or after January 1, 2007 and before January 1, 2008; and the 
                        ( print page 65888)
                        episode will also receive the rural add-on because the episode begins on or after January 1, 2006 and before January 1, 2007. The applicable case-mix and wage index adjustment is subsequently applied to the 60-day episode amount for the provision of home health services where the site of service for the beneficiary is a non-Metropolitan Statistical Area (MSA). Similarly, the applicable wage index adjustment is subsequently applied to the LUPA per-visit amounts adjusted for the provision of home health services where the site of service for the beneficiary is a non-MSA area. We implemented this provision for CY 2006 on February 13, 2006 through Pub. 100-20, One Time Notification, Transmittal 211 issued February 10, 2006. The 5 percent rural add-on is noted in tables 3 and 4 below. Table 3.—Payment Amounts for 60-Day Episodes Beginning in CY 2006 and Ending in CY 2007 Updated by the Estimated Home Health Market Basket Update for CY 2007 with Rural Add-on, Before Case-Mix Adjustment
CY 2007 Total prospective payment amount per 60-day episode
5 Percent rural add-on
CY 2007 Payment amount per 60-day episode beginning in CY 2006 and before January 1, 2007 and ending in CY 2007 for a beneficiary who resides in a non-MSA area$2,339
× 1.05
$2,455.95
 Table 4.—Per-Visit Amounts for Episodes Beginning in CY 2006 and Ending in CY 2007 Updated by the Estimated Home Health Market Basket Update for CY 2007 with Rural Add-on
Home health discipline type
CY 2007 Per-visit amounts
Multiply by the 5 percent rural add-on
CY 2007 per-visit payment amount per discipline for 60-day episodes beginning on or after January 1, in CY 2006 and ending in CY 2007 for a beneficiary who resides in a non-MSA areaHome Health Aide
$46.24
× 1.05
$48.55Medical Social Services
163.68
× 1.05
171.86Occupational Therapy
112.40
× 1.05
118.02Physical Therapy
111.65
× 1.05
117.23Skilled Nursing
102.11
× 1.05
107.22Speech-Language Pathology
121.32
× 1.05
127.39
 D. Home Health Care Quality Improvement Section 5201(c)(2) of the DRA added section 1895(b)(3)(B)(v)(II) to the Act, requiring that “each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality. Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this clause.” In addition, section 1895(b)(3)(B)(v)(I) of the Act, as also added by section 5201(c)(2) of the DRA, dictates that “for 2007 and each subsequent year, in the case of a home health agency that does not submit data to the Secretary in accordance with subclause (II) with respect to such a year, the home health market basket percentage increase applicable under such clause for such year shall be reduced by 2 percentage points.” The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) required the use of a standardized assessment instrument for quality oversight of HHAs. A standardized assessment instrument provides an HHA with a uniform mechanism to assess the needs of their patients and provide CMS with a uniform mechanism to assess the HHA's ability to adequately address those needs. To fulfill the OBRA 87 mandate, CMS required that, as part of their comprehensive assessment process, HHAs collect and report Outcome and Assessment Information Set (OASIS) data and later mandated the submission of this data as a Medicare Condition of Participation for home health agencies at 42 CFR 484.20 and 484.55. The OASIS data provide consumers and HHAs with ten publicly-reported home health quality measures which have been endorsed by the National Quality Forum (NQF). Reporting this quality data has also required the development of several supporting mechanisms such as the HAVEN software used to encode and transmit data using a CMS standard electronic record layout, edit specifications, and data dictionary. Use of the HAVEN software, which includes the OASIS, has become a standard practice within HHA operations. These early investments in data infrastructure and supporting software that CMS and HHAs have made over the past several years in order to create this quality reporting structure, have made quality reporting and measurement an important component of the HHA industry. The 10 measures are: (1) Improvement in ambulation/locomotion (2) Improvement in bathing (3) Improvement in transferring (4) Improvement in management of oral medications (5) Improvement in pain interfering with activity (6) Acute care hospitalization (7) Emergent care (8) Improvement in dyspnea (9) Improvement in urinary incontinence (10) Discharge to community We proposed to use OASIS data and the 10 quality measures based on those data as the appropriate measure of home health quality for CY 2007. Continuing to use the OASIS instrument minimizes 
                        ( print page 65889)
                        the burden to providers and ensures that costs associated with the development and testing of a new reporting mechanism are not incurred. We believe that the noted 10 quality measures are the most appropriate measure of home health quality. Accordingly, for CY 2007, we proposed to require that the OASIS data, specifically the 10 quality measures, be submitted by HHAs, to meet the requirement that each HHA submit data appropriate for the measurement of health care quality, as determined by the Secretary. Additionally, section 1895(b)(3)(B)(v)(II) of the Act provides the Secretary with the discretion to require the submission of the required data in a form, manner, and time specified by him. For CY 2007, we proposed to consider OASIS data submitted by HHAs to CMS for episodes beginning on or after July 1, 2005 and before July 1, 2006 as meeting the reporting requirement. This proposed reporting time period would allow a full 12 months of data and provides CMS the time necessary to analyze and make any necessary payment adjustments to the CY 2007 payment rates for HHAs that fail to meet the reporting requirement. HHAs that met the reporting requirement would be eligible for the full home health market basket percentage increase. Using historical data to determine a prospective update is also used for hospital pay for reporting. As discussed in the August 3, 2006 proposed rule, during the next few years, we noted that we would be pursuing the development of patient level process measures for home health agencies. We also proposed to continue to refine the current OASIS tool in response to recommendations from a Technical Expert Panel conducted to review the data elements that make up the OASIS tool. These process measures would refer to specific care practices that are, or are not, followed by the home health agency for each patient. An example of this type of measure may be: the percentage of patients at risk of falls for whom prevention of falls was addressed in the care plan. We expect to introduce these additional measures over CY 2008 and CY 2009 so as to complement the existing OASIS outcome measures. During the years leading to CY 2010 payments, we will test and refine these measures to determine if they can more accurately reflect the level of quality care being provided at HHAs without being overly burdensome with the data collection instrument. Some process measures are in the very early stages of development. To the extent that evidence-based data are available on which to determine the appropriate measure specifications, and adequate risk-adjustments are made, we anticipate collecting and reporting these measures as part of each agency's home health quality plan. We believe that future modifications to the current OASIS tool including reducing the number of questions on the tool, refining possible responses, as well as adding new process measures will be made. In all cases, we anticipate that any future quality measures should be evidence-based, clearly linked to improved outcomes, and able to be reliably captured with the least burden to the provider. We are also beginning work in order to measure patient experience of care (in the form of a patient satisfaction survey) in the home health setting. We recognize, however, that the conditions of participation (42 CFR part 484) that require OASIS submission also provide for exclusions from this requirement. Generally, agencies are not subject to the OASIS submission requirement, and thus do not receive Medicare payments, for patients that are not Medicare beneficiaries or for patients that are not receiving Medicare-covered home health services. Under the conditions of participation, agencies are excluded from the OASIS reporting requirement on individual patients if: Those patients are receiving only non-skilled services,
                    Neither Medicare nor Medicaid is paying for home health care (patients receiving care under a Medicare or Medicaid Managed Care Plan are not excluded from the OASIS reporting requirement),
                    Those patients are receiving pre- or post-partum services,
                    Those patients are under 18 years of age. We believe that the rationale behind our proposal to exclude these agencies from submitting OASIS data on patients excluded from OASIS submission as a condition of participation is equally applicable to HHAs for purposes of meeting the DRA quality data reporting requirement. If an agency is not submitting OASIS for patients excluded from OASIS submission as a condition of participation, we believe that the submission of OASIS data for quality measures for Medicare payment purposes is also not necessary. Accordingly, we proposed that HHAs would not need to submit quality measures for DRA reporting purposes for those patients who are excluded from OASIS submission as a condition of participation. Additionally, we proposed that agencies that are newly certified (on or after May 31, 2006 for payments to be made in CY 2007) would be excluded from the DRA reporting requirement as data submission and analysis would not be possible for an agency certified this late in the reporting time period. In future years, agencies that certify on or after May 31 of the preceding year involved would be excluded from any payment penalty under the DRA for the following calendar year. For example, for purposes of determining compliance with the quality data reporting requirement for CY 2007, if HHA “X” were to enroll in the Medicare Program on or before May 30, 2006, CMS would expect HHA “X” to submit the required quality data (unless covered by another exclusion protocol) on or before June 30, 2006 (the end of the reporting period for payments effectuated in CY 2007). However, if HHA “Y” was to enroll in the Medicare Program on or after May 31, 2006, CMS would automatically exclude HHA “Y” from the DRA quality data reporting requirements and the agency would be entitled to the full market basket increase for CY 2007. We note that these proposed exclusions would only affect reporting requirements under the DRA and would not otherwise affect the agency's OASIS reporting responsibilities under the conditions of participation. We proposed to require that all HHAs, unless covered by these specific exclusions, meet the reporting requirement, or be subject to a 2 percent reduction in the home health market basket percentage increase in accordance with section 1895(b)(3)(B)(v)(I) of the Act. The 2 percent reduction would apply to all episodes ending on or before December 31, 2007. We provide the reduced payment rates in tables 5, 6, 7, and 8 below. 
                        ( print page 65890) Table 5.—For HHAs That Do Not Submit the Required Quality Data— National 60-Day Episode Amount Updated by the Estimated Home Health Market Basket Update for CY 2007, Minus 2 Percentage Points, Before Case-Mix Adjustment
Total CY 2006 prospective payment amount per 60-day episode
Multiply by the estimated home health market basket update (3.3 Percent 1
                                 minus 2 percent)
CY 2007 updated national 60-day episode rate for HHAs that do not submit required quality data$2,264.28
× 1.013
$2,293.721
                            The estimated home health market basket update of 3.3 percent for CY 2007 is based on Global Insight, Inc, 3rd Qtr, 2006 forecast with historical data through 2nd Qtr, 2006.
 Table 6—For HHAs That Do Not Submit the Required Quality Data—National Per-Visit Amounts Updated by the Estimated Home Health Market Basket Update for CY 2007, Minus 2 Percentage Points
Home health discipline type
Final CY 2006 per-visit amounts per 60-day episode
Multiply by the estimated home health market basket update (3.3 percent 1
                                 minus 2 percent)
CY 2007 per-visit payment amount per discipline for HHAs that do not submit required quality dataHome Health Aide
$44.76
× 1.013
$45.34Medical Social Services
158.45
× 1.013
160.51Occupational Therapy
108.81
× 1.013
110.22Physical Therapy
108.08
× 1.013
109.49Skilled Nursing
98.85
× 1.013
100.14Speech-Language Pathology
117.44
× 1.013
118.971
                            The estimated home health market basket update of 3.3 percent for CY 2007 is based on Global Insight, Inc, 3rd Qtr, 2006 forecast with historical data through 2nd Qtr, 2006.
 Table 7.—For HHAs That Do Not Submit the Required Quality Data— Payment Amount for 60-Day Episodes Beginning in CY 2006 and Ending in CY 2007 Updated by the Estimated Home Health Market Basket for CY 2007, Minus 2 Percentage Points, with Rural Add-on, Before Case-Mix Adjustment
CY 2007 Updated national 60-day episode rate for HHAs that do not submit required quality data
5 Percent rural add-on
CY 2007 Payment amount per 60-day episode beginning in CY 2006 and ending in CY 2007 for a beneficiary who resides in a non-MSA area for HHAs that do not submit required quality data$2,293.72
× 1.05
$2,408.41
 Table 8—For HHAs That Do Not Submit the Required Quality Data— Per-Visit Payment Amounts for Episodes Beginning in CY 2006 and Ending in CY 2007 Updated by the Estimated Home Health Market Basket for CY 2007, Minus 2 Percentage Points, with Rural Add-on
Home health discipline type
CY 2007 Per-visit amounts for HHAs that do not submit required quality data
5 Percent rural add-on
CY 2007 Per-visit payment amounts for episodes beginning in CY 2006 and ending in CY 2007 for a beneficiary who resides in a non-MSA area for HHAs that do not submit required quality dataHome Health Aide
$45.34
× 1.05
$47.61Medical Social Services
160.51
× 1.05
168.54Occupational Therapy
110.22
× 1.05
115.73Physical Therapy
109.49
× 1.05
114.96Skilled Nursing
100.14
× 1.05
105.55Speech-Language Pathology
118.97
× 1.05
124.92
 Section 1895(b)(3)(B)(v)(III) of the Act further requires that the “Secretary shall establish procedures for making data submitted under subclause (II) available to the public.” Additionally, the statute requires that “such procedures shall ensure that a home health agency has the opportunity to review the data that is to be made public with respect to the agency prior to such data being made public.” To meet the requirement for making such data public, we proposed 
                        ( print page 65891)
                        to continue to use the CMS 
                        *Home Health Compare*
                         Web site whereby HHAs are listed geographically. Currently the 10 proposed quality measures are posted on the CMS 
                        *Home Health Compare*
                         Web site. Consumers can search for all Medicare-approved home health providers that serve their city or zip code and then find the agencies offering the types of services they need as well as the required quality measures. See 
                        *http://www.medicare.gov/​HHCompare*. HHAs would continue to have access (through the 
                        *Home Health Compare*
                         contractor) to its own quality data (updated periodically) and we would establish a process by which agencies would receive a report before reporting the data publicly. Currently, the CMS 
                        *Home Health Compare*
                         Web site does not publicly report data when agencies have fewer than 20 episodes of care within a reporting period. In light of the DRA requirements, we recognize the need to provide the required data to the public and would make these statistics available through expansion of the CMS 
                        *Home Health Compare*
                         Web site. In the July 27, 2005 Medicare Payment Advisory Commission (MedPAC) testimony before the U.S. Senate Committee on Finance, MedPAC expressed support for the concept of differential payments for Medicare providers, which could create incentives to improve quality. To support this initiative, MedPAC stated that “outcome measures from CMS' Outcome-based Quality Indicators” (currently collected through the OASIS instrument) “could form the starter set.” MedPAC further states “* * * the Agency for Healthcare Research and Quality concur(s) that a set of these measures is reliable and adequately risk adjusted.” The MedPAC testimony recognizes that while the goal of care for many home health patients is improving health and functioning, for some patients the goal of the HHA is to simply stabilize their conditions and prevent further decline. Additionally, the MedPAC testimony reflects that measures of structure and process could also be considered. Various home health outcome measures are now in common use and have been studied for some time. A number of these measures have been endorsed by the National Quality Forum (NQF) and are evidence-based, well accepted, and not unduly burdensome. When determining outcome measures that will be most appropriate, it is important to measure aspects of care that providers can control and are adequately risk-adjusted. Home-based care presents particular difficulties for provider control because patient conditions are compounded by a variety of home environment and support system issues. We are currently pursuing the development of patient-level process measures for HHAs, as well as refining the current OASIS tool in response to recommendations from a Technical Expert Panel conducted to review the data elements that make up the OASIS tool. These additional measures would complement the existing OASIS outcome measures and would assist us in identifying processes of care that lead to improvements for certain populations of patients. These process measures are currently in the very early stages of development. As we stated previously, to the extent that evidence-based data are available on which to determine the appropriate measure specifications, and adequate risk-adjustments are made, we anticipate collecting and reporting these measures as part of our home health quality plan. Possible modifications to the current OASIS tool include reducing the number of questions on the tool, refining possible responses, as well as adding new process measures. We solicited comments on how to make the outcome measures more useful. We also solicited comments on measures of home health care processes for which there is evidence of improved care to beneficiaries. In all cases, we noted that measures should be evidence-based, clearly linked to improved outcomes, and able to be reliably captured with the least burden to the provider. We also considered measures of patient experience of care in the home health setting, as well as efficiency measures, and solicited comment on the use of these measures and their importance in the home health setting. In the proposed rule, we noted that we would address any changes to the HH PPS quality data submission requirement in future rulemaking. We also stated our intent to provide guidance on the specifications, definitions, and reporting requirements of any additional measures through the standard protocol for measure development. We proposed to revise the regulations at § 484.225 to reflect these proposed payment requirements which would require submission of quality data. For CY 2007, we will finalize the requirement to use the 10 OASIS measures as meeting the DRA quality data reporting requirement as discussed in section II.D. of the August 3, 2006 proposed rule and the regulations at § 484.225. E. Outliers and Fixed Dollar Loss Ratio Outlier payments are payments made in addition to regular 60-day case-mix and wage-adjusted episode payments for episodes that incur unusually large costs due to patient home health care needs. Outlier payments are made for episodes for which the estimated cost exceeds a threshold amount. The episode's estimated cost is the sum of the national wage-adjusted per-visit payment amounts for all visits delivered during the episode. The outlier threshold for each case-mix group, PEP adjustment, or total SCIC adjustment is defined as the 60-day episode payment amount, PEP adjustment, or total SCIC adjustment for that group plus a fixed dollar loss amount. Both components of the outlier threshold are wage-adjusted. The wage-adjusted fixed dollar loss (FDL) amount represents the amount of loss that an agency must bear before an episode becomes eligible for outlier payments. The FDL is computed by multiplying the wage-adjusted 60-day episode payment amount by the FDL ratio, which is a proportion expressed in terms of the national standardized episode payment amount. The outlier payment is defined to be a proportion of the wage-adjusted estimated costs beyond the wage-adjusted threshold. The proportion of additional costs paid as outlier payments is referred to as the loss-sharing ratio. Section 1895(b)(5) of the Act requires that estimated total outlier payments are no more than 5 percent of total estimated HH PPS payments. In response to the concerns about potential financial losses that might result from unusually expensive cases expressed in comments to the October 28, 1999 proposed rule (64 FR 58133), the July 2000 final rule set the target for estimated outlier payments at the 5 percent level. The FDL ratio and the loss-sharing ratio were then selected so that estimated total outlier payments would meet the 5 percent target. For a given level of outlier payments, there is a trade-off between the values selected for the FDL ratio and the loss-sharing ratio. A high FDL ratio reduces the number of episodes that can receive outlier payments, but makes it possible to select a higher loss-sharing ratio and, therefore, increase outlier payments for outlier episodes. Alternatively, a lower FDL ratio means that more episodes can qualify for outlier payments, but outlier payments per episode must be lower. As a result of public comments on the October 28, 1999 proposed rule, in our July 2000 final rule, we made the decision to attempt to do the former. 
                        ( print page 65892) In the July 2000 final rule, we chose a value of 0.80 for the loss-sharing ratio, which preserves incentives for agencies to attempt to provide care efficiently for outlier cases. A loss-sharing ratio of 0.80 was also consistent with the loss-sharing ratios used in other Medicare PPS outlier policies. Furthermore, we estimated the value of the FDL ratio that would yield estimated total outlier payments that were 5 percent of total home health PPS payments. The resulting value for the FDL ratio for the July 2000 final rule was 1.13. Our CY 2005 update to the HH PPS rates (69 FR 62124) changed the FDL ratio from the original 1.13 to 0.70 to allow more home health episodes to qualify for outlier payments and to better meet the 5 percent target of outlier payments to total HH PPS payments. We stated in that CY 2005 update that we planned to continue to monitor the outlier expenditures on a yearly basis and to make adjustments as necessary (69 FR 62129). To do so, we planned on using the best Medicare data available at the time of publication. For the CY 2005 update, we used CY 2003 home health claims data. Our CY 2006 update to the HH PPS rates (70 FR 68132) changed the FDL ratio from 0.70 to 0.65 to allow even more home health episodes to qualify for outlier payments and to better meet the 5 percent target of outlier payments to total HH PPS payments. For the CY 2006 update, we used CY 2004 home health claims data. At the time of publication of the August 3, 2006 proposed rule, we did not have more recent data, but we noted that we may update the FDL ratio for CY 2007 depending on the availability of more recent data. We further noted that if we updated the FDL ratio for the CY 2007 update, we would use the same methodology performed in updating the current FDL ratio described in the October 22, 2004 final rule. Subsequent to the publication of the August 3, 2006 proposed rule, we have now obtained more recent data, that is, CY 2005 home health claims data. Accordingly for this final rule, we have used the same methodology and performed an analysis on the CY 2005 HH PPS analytic data to update the FDL ratio for CY 2007. The results of this analysis indicate that an FDL ratio of 0.67 is consistent with the existing loss-sharing ratio of 0.80 and a projected target percentage of estimated outlier payments of 5 percent. Therefore, we are updating the FDL ratio from the current 0.65 to 0.67 for CY 2007. Expressed in terms of a fixed dollar loss amount, an FDL ratio of 0.67 indicates that providers would absorb approximately $1,567 of their costs (before wage adjustment), in addition to their loss-sharing portion of the estimated cost in excess of the outlier threshold. This fixed dollar loss amount of approximately $1,567 is computed by multiplying the standard 60-day episode payment amount (2,339.00) by the FDL ratio (0.67). In contrast, using the current FDL ratio (0.65), the fixed dollar loss amount would be approximately $1,520 ($2,339.00 × 0.65) F. Hospital Wage Index—Revised OMB Definitions for Geographical Statistical Areas Sections 1895(b)(4)(A)(ii) and (b)(4)(C) of the Act require the Secretary to establish area wage adjustment factors that reflect the relative level of wages and wage-related costs applicable to the furnishing of home health services and to provide appropriate adjustments to the episode payment amounts under the HH PPS to account for area wage differences. We apply the appropriate wage index value to the labor portion (76.775 percent; see 60 FR 62126) of the HH PPS rates based on the geographic area in which the beneficiary received home health services as discussed in section II.A of the August 3, 2006 proposed rule. Generally, we determine each HHA's labor market area based on definitions of Metropolitan Statistical Areas (MSAs) issued by the Office of Management and Budget (OMB). We acknowledged in our October 22, 2004 final rule that on June 6, 2003, the OMB issued an OMB Bulletin (No. 03-04) announcing revised definitions for MSAs, new definitions for Micropolitan Statistical Areas and Combined Statistical Areas, and guidance on using the statistical definitions. A copy of the Bulletin may be obtained at the following Internet address: 
                        *http://www.whitehouse.gov/​omb/​bulletins/​b03-04.html.*
                         At that time, we did not propose to apply these new definitions known as Core-Based Statistical Areas (CBSAs). In the November 9, 2005 final rule, we adopted the OMB-revised definitions and implemented a one-year transition policy consisting of a 50/50 blend of the MSA-based and the new CBSA-based wage indexes. As discussed previously and set forth in the July 3, 2000 final rule, the statute provides that the wage adjustment factors may be the factors used by the Secretary for purposes of section 1886(d)(3)(E) of the Act for hospital wage adjustment factors. Again, as discussed in the July 3, 2000 final rule, we proposed to use the pre-floor and pre-reclassified hospital wage index data to adjust the labor portion of the HH PPS rates based on the geographic area in which the beneficiary receives the home health services. We believe the use of the pre-floor and pre-reclassified hospital wage index data results in the appropriate adjustment to the labor portion of the costs as required by statute. For the CY 2007 update to the home health payment rates, we proposed to continue using the most recent pre-floor and pre-reclassified hospital wage index available at the time of publication. See Addenda A and B of this final rule, respectively, for the rural and urban hospital wage indexes using the CBSA designations. For the HH PPS rates addressed in the August 3, 2006 proposed rule, we used preliminary 2007 pre-floor and pre-reclassified hospital wage index data. We incorporated updated hospital wage index data for the 2007 pre-floor and pre-reclassified hospital wage index to be used in this final rule (not including any reclassifications under section 1886(d)(8)(B) of the Act). As implemented under the HH PPS in the July 3, 2000 HH PPS final rule, each HHA's labor market is determined based on definitions of MSAs issued by OMB. In general, an urban area is defined as an MSA or New England County Metropolitan Area (NECMA) as defined by OMB. Under § 412.62(f)(1)(iii), a rural area is defined as any area outside of an urban area. The urban and rural area geographic classifications are defined in § 412.62(f)(1)(ii) and § 412.62(f)(1)(iii), respectively, and have been used under the HH PPS since it was implemented. Under the HH PPS, the wage index value is based upon the site of service for the beneficiary (defined by section 1861(m) of the Act as the beneficiary's place of residence). As has been our longstanding practice, any area not included in an MSA (urban area) is considered to be nonurban (§ 412.64(b)(1)(ii)(C)) and receives the statewide rural wage index value (see, for example, 65 FR 41173). For CY 2007, we proposed using 100 percent of the CBSA-based wage area designations for purposes of determining the HH PPS wage index adjustment. In adopting the CBSA designations, we identified some geographic areas where there were no hospitals, and thus no hospital wage data on which to base the calculation of the CY 2007 home health wage index. For CY 2006, we adopted a policy in the HH PPS final rule (70 FR 68132) of using the CY 2005 pre-floor, pre-reclassified hospital wage index value for rural areas when no rural hospital wage data are available. We also adopted a policy that for urban labor markets without an urban hospital 
                        ( print page 65893)
                        from which a hospital wage index can be derived, all of the CBSAs within the State would be used to calculate a statewide urban average wage index to use as a reasonable proxy for these areas. We have not received any concerns from the industry regarding our policy to calculate an urban wage index, using an average of all of the urban CBSAs wage index values within the State, for urban labor markets without an urban hospital from which a hospital wage index can be derived. Consequently, in the August 3, 2006 proposed rule, we proposed to continue to apply the average wage index from all urban areas in the state to any urban areas lacking hospital wage data in that state. Currently, the only CBSA that would be affected by this is CBSA 25980 Hinesville, Georgia. In the August 3, 2006 proposed rule, we again proposed to apply the CY 2005 pre-floor/pre-reclassified hospital wage index to rural areas where no hospital wage data is available. Currently, the only rural areas that would be affected by this are Massachusetts and Puerto Rico. Since publication of the CY 2006 HH PPS final rule, representatives of the home health industry have expressed concerns with this policy, specifically as it applies to Massachusetts. In response to these concerns and in recognition that, in the future, there may be additional rural areas impacted by a lack of hospital wage data from which to derive a wage index, we considered alternative methodologies for imputing a rural wage index for areas where no hospital wage data are available. We specifically considered imputing a rural wage index by computing a simple average of all of the statewide (rural) wage indexes at the Census Division level. Census Divisions are defined by the U.S. Census Bureau and may be found at 
                        *www.census.gov/​geo/​www/​us_​regdiv.pdf.*
                         Massachusetts is located in Census Division I, along with Connecticut, Maine, New Hampshire, Vermont and Rhode Island. The Census Bureau states, “Puerto Rico and the Island Areas are not part of any census region or census division.” Therefore, we could not compute a rural wage index for Puerto Rico using this alternative methodology. In the August 3, 2006 proposed rule, we solicited comments on the current methodology and alternative methodologies for determining a wage index for areas without the necessary hospital wage data. Since publication of the August 3, 2006 proposed rule, we have received numerous comments regarding our policy for determining a wage index for rural areas without the necessary hospital wage data. In direct response to these comments, we have decided to revise the methodology for imputing a rural wage index. We discuss the change to the methodology for imputing a rural wage index in section III of this final rule. G. Payment for Oxygen, Oxygen Equipment and Capped Rental DME Items As discussed in the August 3, 2006 proposed rule, we would amend our regulations at § 414.226 by revising the payment rules for oxygen and oxygen equipment in paragraph (a), adding a new paragraph (f) that provides that the beneficiary assumes ownership of oxygen equipment on the first day that begins after the 36th continuous month in which rental payments are made, and adding a new paragraph (g) that contains new supplier requirements that we believe are necessary in light of the amendments made to section 1834(a)(5) of the Act by section 5101(b) of the DRA. As discussed in the August 3, 2006 proposed rule, we would amend our regulations at § 414.226 by adding a new paragraph (c) that establishes new classes and national payment amounts for oxygen and oxygen equipment based on our authority in section 1834(a)(9)(D) of the Act. We also proposed to revise paragraph (b) of this section to incorporate the special payment rules for oxygen equipment mandated by section 1834(a)(21) of the Act. The provisions of section 1834(a)(21), which we believe are self-implementing, resulted in adjustments to Medicare payment amounts for oxygen contents and stationary oxygen equipment as well as portable oxygen equipment in 2005, which were implemented through program instructions. We are now seeking to codify these changes to make our regulations consistent with the payment methodology for these items in 2005 and 2006, and because the payment reductions mandated by section 1834(a)(21) are incorporated into our proposal, as more fully discussed in section I of the August 3, 2006 proposed rule, to create new payment classes for oxygen and oxygen equipment. The August 3, 2006 proposed rule indicated that we would redesignate old paragraph (c) of this section as paragraph (d) and would amend this paragraph to indicate under what situations payments would be made for the items and services described in new paragraph (c). Finally, the August 3, 2006 proposed rule indicated that we would redesignate old paragraph (d) of this section as paragraph (e) and would make technical changes to this paragraph so that the cross-references are accurate in light of the other changes we proposed to make to § 414.226. The August 3, 2006 proposed rule would also amend our regulations at § 414.229 by revising the payment rules for capped rental durable medical equipment (DME) items (also called capped rental items) in paragraph (a), revising paragraph (f) to provide for new payment rules for capped rental items furnished beginning on or after January 1, 2006, revising paragraph (g) to provide for supplier requirements that we believe are necessary in light of the amendments made to section 1834(a)(7)(A) of the Act by section 5101(a) of the DRA, and adding a new paragraph (h) to address the lump-sum purchase option for power-driven wheelchairs furnished on or after January 1, 2006. The language in current paragraphs (f) and (g) of this section is obsolete, and therefore, we proposed to delete this language. The August 3, 2006 proposed rule indicated that we would amend our regulations at § 414.210 by revising the maintenance and servicing rules in paragraph (e) and the replacement of equipment rules in paragraph (f) to further implement the new supplier requirements that we proposed below. Finally, we proposed to revise § 414.230(b) to incorporate section 5101(b)(2)(B) of the DRA, which provides that for all beneficiaries receiving oxygen equipment paid for under section 1834(a) on December 31, 2005, the period of continuous use begins on January 1, 2006. We also proposed to revise § 414.230(f), which governs when a new period of continuous use begins if a beneficiary receives new equipment, to account for the fact that oxygen equipment is paid on a modality neutral basis. Section 5101(a) of the DRA changes the Medicare payment methodology for capped rental equipment to beneficiary ownership after 13 months of continuous use, for those beneficiaries who need the equipment for more than 13 months. This section also makes the transfer of title for the capped rental items a requirement rather than a beneficiary option after 13 months of continuous use. The changes made by this section of the DRA apply to capped rental items, including rented power-driven wheelchairs, for which the first rental month occurs on or after January 1, 2006. We proposed to update § 414.229 of our regulations to reflect these new statutory requirements. However, for capped rental items and rented power-driven wheelchairs for which the first rental month occurred before January 1, 2006, the existing rules in § 414.229 would continue to apply. In 
                        ( print page 65894)
                        addition, as was the case before enactment of the DRA, beneficiaries may elect to obtain power-driven wheelchairs furnished on or after January 1, 2006, on a lump-sum purchase basis. Section 5101(b) of the DRA changes the Medicare payment methodology for oxygen equipment from continuous rental to beneficiary ownership after 36 months of continuous use, for those beneficiaries who medically need the oxygen equipment for more than 36 months. For beneficiaries who were receiving oxygen equipment on December 31, 2005 for which payment was made under section 1834(a) of the Act, the 36-month rental period began on January 1, 2006. For beneficiaries who begin to rent oxygen equipment on or after January 1, 2006, the 36-month rental period commences at the time they begin to rent the equipment. We proposed to update § 414.226 of our regulations to incorporate these new requirements. In light of the changes made by sections 5101(a) and (b) of the DRA, we believe it was necessary to propose additional supplier requirements in order to maintain beneficiary protections and access to oxygen, oxygen equipment, and capped rental DME items under section 1834(a) of the Act. For both capped rental DME items and oxygen equipment, the DRA amendments make the transfer of title from the supplier to the beneficiary a requirement rather than an option after the statutorily-prescribed rental period ends for each category of items. Therefore, suppliers and beneficiaries should be aware that title to these items will automatically transfer to the beneficiary if the medical need for the equipment continues for a period of continuous use that is longer than 36 months for oxygen equipment and 13 months for capped rental items. We are concerned that there may be incentives for suppliers to avoid having to transfer title to equipment to beneficiaries as required by the DRA. For example, we are aware of cases where a supplier has informed beneficiaries that it would decline to accept assignment for capped rental items and would charge beneficiaries who elected the purchase option the full retail price for the item during the 13th rental month (which was right before the supplier would be required to transfer title under the purchase option). In these cases, the beneficiary would become financially liable for the total retail price for the equipment in the 13th month if they elected the purchase option. In our August 3, 2006 proposed rule, we made several proposals relating to the furnishing of oxygen equipment and capped rental items which we believe protect beneficiaries from these types of abusive practices and which we believe are reasonable for a supplier to comply with. Our authority to promulgate these requirements stems from our authority to administer the payment rules at section 1834(a)(5) of the Act for oxygen equipment and section 1834(a)(7) of the Act for capped rental items, as well as the general authority provided in section 1871 of the Act for prescribing regulations necessary for administering the Medicare program. Other than the length of the rental periods, which the DRA made effective beginning on January 1, 2006 for all oxygen equipment and for capped rental items for which the first rental period began on or after that date, we proposed that the requirements presented in this section of the regulations would be effective on January 1, 2007, and would apply to suppliers that furnish oxygen equipment or capped rental items on a rental basis. We believe that a supplier of an item that is subject to these new payment rules that furnishes the item in the first month for which a rental payment is made has an obligation to continue furnishing the item to the beneficiary for the entire period of medical need in which payments are made, up to and including the time when title to the equipment transfers to the beneficiary. We believe it is reasonable for the beneficiary to have an expectation that he or she will not be forced to change equipment or suppliers during the period of medical need unless he or she wants to. Therefore, we proposed that unless an exception applies, the supplier that furnishes oxygen equipment or a capped rental item for the first month of the statutorily prescribed rental period must continue to furnish the oxygen equipment or the capped rental item for as long as the equipment remains medically necessary, up to and including the last month for which a rental payment is made by Medicare. We believe that this proposal was necessary to ensure beneficiary access to equipment during a period of medical need, which we believe could be jeopardized if suppliers have the option to take back the rented equipment just before the rental period expires in order to retain title to that equipment. We proposed that this requirement would be subject to the following exceptions: (1) Cases where the item becomes subject to a competitive acquisition program implemented in accordance with section 1847(a) of the Act; (2) cases where a beneficiary relocates on either a temporary or permanent basis to an area that is outside the normal service area of the initial supplier; (3) cases where the beneficiary chooses to obtain equipment from a different supplier; and (4) other cases where CMS or the carrier determine that an exception is warranted. We have proposed rules in connection with the first exception in our Notice of Proposed Rulemaking for Competitive Acquisition for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Other Issues. These proposed rules are addressed beginning on page 25662 of the May 1, 2006 proposed rule (71 FR 25654). If the second exception applies, we proposed that the supplier or beneficiary would need to arrange for another supplier in the new area to furnish the item on either a temporary or permanent basis. This proposed exception is consistent with what currently happens when beneficiaries move outside a supplier's service area on either a temporary or permanent basis. The third exception is intended to protect a beneficiary's right to obtain the equipment from the supplier of his or her choice. Finally, we proposed to allow other exceptions to this proposed requirement on a case-by-case basis at the discretion of CMS or the Medicare contractor. CMS will be monitoring the case-by-case determinations made by the Medicare contractor. We are concerned that there might be potential incentives for a supplier to replace more valuable or newer equipment used by the beneficiary with less valuable or older equipment from its inventory at some point before the 36th rental month for oxygen equipment or 13th rental month for capped rental DME expires in order to avoid losing title to the more valuable equipment. In order to avoid such potential situations, we proposed that the supplier may not provide different equipment from that which was initially furnished to the beneficiary at any time during the 36-month period for oxygen equipment or 13th rental month for capped rental DME unless one of the following exceptions applies: (1) The equipment is lost, stolen, or irreparably damaged; (2) the equipment is being repaired while loaner equipment is in use; (3) there is a change in the beneficiary's medical condition such that the equipment initially furnished is no longer appropriate or medically necessary; or (4) the carrier determines that a change in equipment is warranted. However, we proposed that a change from one oxygen equipment modality to another 
                        ( print page 65895)
                        without physician documentation that such a change is medically necessary for the individual would not be considered a change in equipment that is warranted under the fourth exception stated above since there is no medical basis for the change. In those cases where the equipment is replaced, we proposed that the replacement item must be equipment that is, at minimum, in the same condition as the equipment being replaced. That proposal was intended to safeguard beneficiary access to quality oxygen equipment and capped rental items throughout the duration of the rental period. Under Medicare, suppliers who furnish items of DME can accept assignment on all claims for Medicare services or on a claim-by-claim basis. Assignment is an agreement between the supplier and the beneficiary under which the supplier agrees to request direct payment from Medicare for the item, to accept 80 percent of the Medicare allowed payment amount for the item from the carrier, and to charge the beneficiary not more than the remaining 20 percent of the Medicare approved payment amount, plus any unmet deductible. If a supplier elects not to accept assignment, Medicare pays the beneficiary 80 percent of the Medicare allowed payment amount, after subtracting any unmet deductible, and there is no limit under Title XVIII of the Act on the amount the supplier can charge the beneficiary for rental of the DME item. The beneficiary, in these situations, is financially responsible for the difference between 80 percent of the Medicare allowed payment amount and the amount the supplier charges for the rental of the DME item. Section 1842(h) allows suppliers to sign a participation agreement where the supplier agrees voluntarily, before a calendar year, to accept assignment for all Medicare items and services furnished to a beneficiary for the following calendar year. Current supplier participation agreements are renewable annually. However, the agreements do not apply for a full period of medical need for specific beneficiaries in cases where such need extends for more than a calendar year. Nor do current participation agreements apply to periods of medical need where such a period overlaps calendar years. In the latter case, while a supplier may renew its participation agreement annually, a beneficiary would not know before choosing a supplier whether the supplier would be willing to accept assignment of all claims during the 13-month or 36-month rental period. In order for the beneficiary to make an informed choice, we proposed that before furnishing the oxygen equipment or a capped rental item, the supplier must disclose to the beneficiary its intentions regarding whether it will accept assignment of all monthly rental claims for the equipment during the period of medical necessity, up to and including the 36th month of continuous use for oxygen equipment or the 13th rental month of continuous use for capped rental DME in which rental payments could potentially be made. We believe that it is reasonable for the supplier to disclose to each beneficiary its intentions regarding assignment of claims for all months during a rental period as this decision has a direct financial effect on the beneficiary. A supplier's intentions could be expressed in the form of a written agreement between the supplier and a beneficiary. This proposal would require suppliers to give beneficiaries advance notice of the possible extent of their financial liability during the period of medical need in which monthly rental payments are made for the equipment, so that they can use this information to help select a supplier. Additionally, to promote informed beneficiary choices, we plan to post information on a CMS and/or CMS contractor Web site(s) indicating supplier specific information on oxygen equipment and capped rental items such as (1) the percentage of beneficiaries for whom each supplier accepted assignment during a prior period of time (for example, a quarter), and/or (2) the percentage of cases in which the supplier accepted assignment during the beneficiary's entire rental period. We believe that those proposals create reasonable rules for suppliers that furnish oxygen equipment and capped rental items and ensure that beneficiaries have information necessary to make informed choices that could have significant financial consequences for them. H. Payment for Oxygen Contents for Beneficiary-Owned Oxygen Equipment Section 1834(a)(5) of the Act, as amended by section 5101(b)(1) of the DRA, requires that Medicare continue to make monthly payments for the delivery and refilling of oxygen contents for the period of medical need after beneficiaries own their own gaseous or liquid oxygen stationary or portable equipment. Before the enactment of the DRA, Medicare made monthly payments for the delivery and refilling of oxygen contents for beneficiaries who own their own stationary and/or portable equipment (equipment they obtained on a purchase basis before June 1, 1989, out-of-pocket, or before they enrolled in Medicare Part B). In accordance with the DRA, we proposed that after the supplier transfers title to the stationary and/or portable oxygen equipment to the beneficiary, Medicare would continue to make separate monthly payments for gaseous or liquid oxygen contents until medical necessity ends. We also proposed that if the beneficiary-owned equipment is replaced, and Medicare pays for the replacement in accordance with proposed revised § 414.210(f) (see section K of this final rule for a more complete discussion of our proposed oxygen equipment replacement policies), a new 36-month rental period start and the payment for oxygen contents would be included in the monthly rental payments. We proposed that all oxygen content payment amounts would be based on new rates developed in accordance with our proposal to establish new payment classes, as discussed in section I below. In transferring title to gaseous or liquid oxygen equipment used during the 36-month rental period, we proposed that suppliers must transfer title for all equipment that will meet the beneficiary's continued medical need, including those oxygen cylinders or vessels that are refilled at the supplier's place of business. Customary practice by suppliers for refilling oxygen contents is to deliver to the beneficiary cylinders filled with contents and take back the empty cylinders to the supplier's place of business to refill the oxygen contents. Under our proposal, title would transfer for both sets of cylinders, meaning the ones that are being used by the beneficiary for the month and the ones that the supplier refills in its business location and delivers for use during the next subsequent month. This policy would apply to both gaseous and liquid oxygen stationary equipment and portable systems. Similarly, in those cases where the beneficiary uses an oxygen equipment system which includes a compressor which fills portable gaseous cylinders in the beneficiary's home, we proposed that suppliers must transfer title for this equipment to the beneficiary. Concerns have been raised regarding beneficiary access to, and safety issues associated with, the delivery of oxygen contents for beneficiary-owned stationary and portable gaseous or liquid equipment. We believe that these concerns are based on the misconception that beneficiaries become responsible for filling their own cylinders. To the contrary, there are numerous State and Federal regulations governing the safe handling, filling, and transport of oxygen and those regulations are unaffected by the DRA oxygen provisions. We expect that 
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                        suppliers will continue to furnish replacement contents for beneficiary-owned gaseous and liquid systems in the same way that they have furnished replacement contents for beneficiary-owned equipment in the past. For example, suppliers that deliver a 1 month supply of gaseous cylinders to a beneficiary's home at the same time that they are picking up empty cylinders that the beneficiary used during the previous month could continue this practice under section 5101(b) of the DRA. I. Classes of Oxygen and Oxygen Equipment Based on information from paid Medicare claims with dates of service in calendar year 2004, distribution of usage among the four general categories of oxygen systems was: (a) 69 percent of beneficiaries used both a stationary concentrator (which does not require delivery of oxygen contents) and a portable system that requires delivery of gaseous or liquid oxygen, (b) 5 percent of beneficiaries used a stationary system that requires delivery of gaseous or liquid oxygen and a portable system that requires delivery of gaseous or liquid oxygen, (c) 24 percent of beneficiaries used a stationary concentrator system only, and (d) 2 percent of beneficiaries used only a stationary system that requires delivery of liquid or gaseous oxygen. The prevalent use of stationary concentrator systems is due, in part, to the fact that this system is the most cost-effective and dependable of the stationary oxygen modalities. The main reason that the concentrator system is the most cost-effective system is that the oxygen is concentrated from room air, and therefore, the high cost of delivering contents to the beneficiary's residence is removed when this system is used. Medicare's current payment structure results in two separate payments for beneficiaries using both stationary and portable systems, both of which are modality neutral, meaning that the payment amount does not differ depending on the type of oxygen delivery system (gaseous, liquid, or concentrator) that is furnished. One payment, hereinto referred to as the “stationary payment,” includes payment for the rental of stationary equipment, delivery of stationary oxygen contents (for gaseous or liquid systems), and delivery of portable oxygen contents (for gaseous or liquid systems). A separate add-on payment, hereinto referred to as the “portable add-on,” is also made in cases where the beneficiary is renting portable oxygen equipment. As a result of this payment methodology which has been in place since 1989, suppliers have a financial incentive to furnish low cost concentrator systems as opposed to more expensive gaseous or liquid systems because the monthly payment is the same regardless of which system is used. Finally, in implementing section 1834(a)(5) and (9) of the Act, monthly payment amounts were established through regulations at § 414.226 for (1) stationary and portable oxygen contents (for beneficiaries who use stationary and, if applicable, portable equipment), and (2) portable oxygen contents only (for beneficiaries who only use portable oxygen equipment). The current average statewide monthly payment amounts are: Equipment & Contents
Oxygen Contents OnlyStationary Pmt
$199
Stationary & Portable
$156Portable Add-on
32
Portable Only
21
 Based on our data, 36 percent of Medicare beneficiaries continue using oxygen equipment for more than 3 years, that is, beyond the 36th month after which title for the equipment would transfer to the beneficiary in accordance with the DRA. We have heard concerns about the appropriateness of the current payment structure for oxygen and oxygen equipment in light of changes in the technologies for oxygen delivery systems that have occurred since 1989, and these concerns have been amplified in light of the recent changes made by the DRA. The specific concerns pertain to beneficiary access to (1) portable oxygen contents after title to the equipment transfers to the beneficiary, (2) devices that allow a beneficiary to fill portable tanks at home (otherwise referred to in the oxygen equipment industry as transfilling systems), and (3) portable oxygen concentrators. As we implement the DRA provisions for oxygen equipment and promulgate additional supplier requirements, we want to ensure that the Medicare payment methodology results in payments for oxygen and oxygen equipment that are accurate, do not impede beneficiary access to innovations in technology, and do not create inappropriate incentives for suppliers. Some believe that Medicare's stationary payment for equipment and contents (average of $199) is “too high” and that Medicare's payment for portable oxygen contents only for beneficiary-owned portable equipment (average of $21) is “too low”. While some contend that the overall payment (stationary payment plus portable add-on) for oxygen and oxygen equipment is adequate as long as the beneficiary continues to rent the equipment, they are concerned about the adequacy of Medicare's $21 monthly payment for furnishing oxygen contents for beneficiary-owned portable equipment. Some believe that Medicare's current average monthly payment of $156 for oxygen contents, which includes payment for both stationary and portable systems, is high enough to create an incentive for suppliers to furnish stationary oxygen systems that require the ongoing delivery of oxygen contents, rather than stationary concentrator systems that do not require delivery of oxygen contents. Some technologies provide an attachment to a stationary oxygen concentrator that allows beneficiaries to fill their own portable tanks at home. Delivery of portable oxygen contents to the beneficiary's home is, therefore, not necessary since this equipment refills the beneficiary's rented or owned portable oxygen tanks. This transfilling technology eliminates the need for frequent and costly trips by a supplier to a beneficiary's home to refill portable oxygen tanks and would save the Medicare program and beneficiaries who use portable equipment the expense of paying for delivery of portable oxygen contents. We note that we are not aware that a similar “transfilling” technology has been developed that would be capable of filling stationary tanks in the beneficiary's home. Therefore, there remains a need for ongoing delivery of gaseous or liquid oxygen contents for stationary equipment. In accordance with the DRA, after 36 months of continuous use, title for the transfilling equipment and accompanying portable oxygen tanks would transfer to the beneficiary who would then own a portable equipment system that self-generates oxygen in their home. However, some are concerned that current Medicare payment rules that 
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                        allow payment for oxygen contents for stationary equipment creates an incentive for suppliers to furnish stationary oxygen equipment that require liquid or gaseous oxygen deliveries, rather than concentrators and transfilling equipment that self-generate oxygen in the beneficiary's home. In addition, portable oxygen concentrators are now available that meet both the beneficiary's stationary and portable oxygen needs. Some have raised concern about whether the combination of the Medicare stationary payment and portable add-on payment (approximately $231 per month), which is what is currently paid for portable oxygen concentrators, is sufficient to facilitate use of this new technology which, like a transfilling system, eliminates the need for delivery of oxygen contents, but is more expensive than a “standard” or “non-portable” concentrator. In light of these concerns, we proposed regulatory changes to address the Medicare payment rates for oxygen and oxygen equipment. We proposed to address these issues by using our authority under section 1834(a)(9)(D) of the Act to establish separate classes and monthly payment rates for items of oxygen and oxygen equipment. Specifically, there are two changes we proposed for oxygen and oxygen equipment: 1. We proposed to establish a new class and monthly payment amount for oxygen generating portable oxygen equipment (for example, portable concentrators and transfilling systems). 2. We proposed to establish separate classes and monthly payment amounts for gaseous and liquid oxygen contents that must be delivered for beneficiary-owned stationary and portable oxygen equipment. The first change involves creating a new separate class for portable oxygen systems that generate their own oxygen and therefore eliminate the need for delivery of oxygen contents (for example, portable concentrator systems or transfilling systems). A higher monthly payment amount would be allowed, as described below, for these systems to account for the increased, up-front costs to the supplier of furnishing these more expensive concentrator or transfilling systems, which would be partially offset by the reduced payments that the supplier would receive from the Medicare program and beneficiaries due to the fact that these systems do not require the delivery of oxygen contents. The second change involves creating two separate classes (stationary contents only and portable contents only) and monthly payment rates for furnishing oxygen contents for beneficiary-owned stationary and portable systems. Currently, the combined average monthly payment amount of $156 for furnishing oxygen contents for beneficiary-owned stationary and portable systems includes payment for both stationary contents and portable contents. The current fee schedule amounts for oxygen contents are based on calendar year data from 1986 for the combined average Medicare monthly payment for both stationary and portable contents divided by number of rental months for stationary liquid and gaseous oxygen equipment. As a result, the current combined stationary/portable contents payment results in Medicare payments for portable contents even in those cases where the beneficiary does not use portable oxygen equipment. Under our proposal to create one payment class for oxygen contents used for stationary equipment, and a separate class for oxygen contents used for portable equipment, new national monthly payment amounts for stationary contents delivery and portable contents delivery would be established by splitting the combined payment of $156 into two new payments as explained below. This change would increase the monthly payment for furnishing portable oxygen contents and would address the concerns that the monthly payment rate of $21 is too low for the delivery and filling of portable tanks after the beneficiary assumes ownership of the equipment in accordance with the DRA. In order to achieve budget neutrality for the new classes of oxygen and increase payment amounts for furnishing portable contents, we would need to reduce other Medicare oxygen payment rates. Budget neutrality would require that Medicare's total spending for all modalities of stationary and portable systems, including contents, be the same under the proposed change as they would be without the change. We proposed to achieve budget neutrality by reducing the current monthly payment amounts (the stationary payment) for stationary oxygen equipment and oxygen contents (for stationary or portable equipment) made during the rental period. This reduction in payment is necessary to offset increased payments for the changes identified above and to meet the requirement in section 1834(a)(9)(D)(ii) that the classes and payments be established in a budget neutral fashion. In most cases, suppliers furnish Medicare beneficiaries with stationary oxygen concentrators. These devices can be purchased for $1,000 or less and the current, average Medicare payment of $199 pays suppliers $1,990 over 10 months. We believe that these facts indicate that making a reduction (from $199 on average to $177) in Medicare payment for this relatively inexpensive oxygen equipment in order to pay oxygen suppliers adequately for furnishing portable oxygen contents and more expensive portable oxygen equipment technologies is warranted. With this approach, the proposed new classes, as well as proposed new national monthly payment rates, would be as follows: 1. Stationary Payment: $177. 2. Portable Add-On: $32. 3. Oxygen Generating Portable Equipment Add-On (portable concentrators or transfilling systems): $64. 4. Stationary Contents Delivery: $101. 5. Portable Contents Delivery: $55. We provide a detailed discussion of the payment rate calculations/adjustments in the paragraphs that follow. Under the proposed new oxygen and oxygen equipment class structure described above, in those cases where the beneficiary needs both stationary and portable oxygen, monthly payments of $241 or $209 (proposed revised stationary payment of $177 plus one of two proposed portable equipment payments, $32 or $64) would be made during rental months 1 through 36. The stationary payment (which includes payment for stationary equipment, as well as oxygen contents for stationary and portable systems) of $177 would be made during rental months 1 through 36 for beneficiaries who only need stationary oxygen and oxygen equipment. Monthly payments of $101 for stationary oxygen contents and/or $55 for portable oxygen contents would be made in cases where beneficiaries own their stationary and/or portable oxygen equipment. As explained in more detail in the paragraphs that follow, the $101 payment is for stationary oxygen contents only and is derived from the current payment of $156, which is made for both stationary and portable oxygen contents. The $55 payment for portable oxygen contents only is also derived from the current payment of $156 that is made for both stationary and portable oxygen contents and would replace the current statewide portable oxygen contents fees (average of $21), which was based on a relatively small number of claims and allowed services compared to the number of claims and allowed services that were used in computing the statewide fees (average of $156) for a combination of stationary and portable oxygen contents. 
                        ( print page 65898) As noted above, the proposed national payment rates for delivery of oxygen contents for beneficiary-owned gaseous/liquid equipment were derived from the current average payment for a combined oxygen contents delivery of $156. We proposed to establish $101, or 65 percent of $156, as the monthly payment rate for delivery of larger, heavier, beneficiary-owned stationary gaseous oxygen cylinders or liquid oxygen vessels and $55, or 35 percent of $156, as the monthly payment rate for delivery of smaller, lighter, beneficiary-owned portable gaseous oxygen cylinders or liquid oxygen vessels. The 65/35 split is based on our understanding that there are higher costs associated with delivering stationary tanks (cylinders of gaseous oxygen and vessels of liquid oxygen) which are approximately twice as large as the portable tanks. Such costs include supplier overhead costs, including the costs to purchase, maintain, and dispatch trucks, obtain insurance, and purchase fuel. The 65/35 split is intended to account for the difference in costs associated with the size of the tanks. Larger tanks take up more space on the trucks, take longer to fill, are harder to move, and result in increased fuel costs. We estimate that the increase from $21 to $55 in the monthly payment rate for delivery of oxygen contents for beneficiary-owned portable equipment will result in increased expenditures of approximately $22 million over a 24 month period, or $11 million annually. This figure is based on current data on utilization of portable oxygen by Medicare beneficiaries. The add-on payment amount of $64 for the oxygen generating portable equipment class was calculated based on data indicating long term savings generated from use of equipment that eliminated the need for payment of $55 per month for portable oxygen contents. The first step in calculating the proposed $64 payment for oxygen generating portable equipment involves the computation of a national, enhanced, modality neutral monthly payment amount of $241 for new technology systems (stationary concentrators and transfilling systems, as well as portable concentrators), which was derived from the sum of the current average stationary payment ($199), the current average portable add-on payment ($32), and an additional $10 to pay suppliers for furnishing more expensive equipment that eliminates the need for delivery of portable oxygen contents. Specifically, we calculated the modality neutral increased payment (that is, $10 above the current combination of the stationary payment and portable add-on payment) by estimating potential savings that the Medicare program would realize as a result of not having to pay for delivery of oxygen contents for beneficiary-owned portable oxygen systems in the fourth and fifth years of use. We calculated the increased payment to be equal to potential savings from not delivering oxygen contents. In calculating this increased payment, we were only factoring in savings from the fourth and fifth years of use since we assume that most beneficiaries will elect to obtain replacement equipment after the 5-year reasonable useful lifetime for their equipment has expired. Since our data indicate that 35.8 percent of beneficiaries will use oxygen equipment for more than 3 years, and that approximately 74 percent of these beneficiaries use portable equipment, the $10 amount is calculated based on the following formula, and is rounded to the nearest dollar:  We estimate that the additional $10 payment per month for oxygen generating portable equipment (transfilling units and portable concentrators) will result in increased expenditures of approximately $15 million over a 36 month period, or $5 million annually. This figure is based on current data on utilization of stationary and portable oxygen by Medicare beneficiaries over 36 months. The second step in calculating the proposed $64 add-on payment for the proposed new class of oxygen generating portable equipment involves subtracting the proposed new stationary payment. Therefore, the national monthly payment of $241 computed in the first step above would be reduced by $177, the proposed new adjusted stationary payment amount, to arrive at the proposed add-on payment of $64 for just the oxygen generating portable equipment. In addition, to offset the increased annual payments of approximately $16 million that will result from increased payments for portable oxygen contents ($11 million) and newer technology oxygen generating portable equipment ($5 million), we proposed to decrease the current stationary payment by $22 ($199-$177). We estimated that this offset would result in annual Medicare savings of approximately $16 million, and would therefore offset the increased payments for new technology oxygen generating portable equipment and delivery of oxygen contents for other beneficiary-owned portable equipment. We proposed that these fees be established on a nationwide basis due to the fact that the variation in the current statewide fee schedule amounts for oxygen and oxygen equipment, as well as the portable equipment add-on payment, are currently only 3 percent and 5 percent, respectively. We proposed that the $64 add-on payment would be made for oxygen generating portable equipment only if the equipment eliminates the need for delivery or portable oxygen contents. However, if transfilling equipment is used in connection with a stationary oxygen concentrator (whether as an integrated system component or as a separate part) to both deliver stationary oxygen and fill portable oxygen tanks, Medicare would make both a $177 stationary payment for the stationary oxygen concentrator and stationary oxygen contents, and a separate $64 oxygen generating portable equipment payment for the portable oxygen transfilling equipment. There are also portable oxygen transfilling products that are not part of or used in conjunction with a stationary oxygen concentrator. These products are only used to fill portable oxygen tanks in the beneficiary's home. If the beneficiary is using one of these products, Medicare would make a $64 oxygen generating portable equipment payment. If the patient is also renting any type of stationary oxygen equipment (gaseous, liquid, or concentrator), Medicare would make a separate, additional $177 stationary equipment payment for that equipment. If a portable oxygen concentrator is furnished, Medicare would make the $64 oxygen generating portable equipment add-on payment if the portable oxygen concentrator is used as both the beneficiary's stationary oxygen equipment and portable oxygen equipment. In this case, the portable oxygen concentrator equipment would fall under both the stationary oxygen equipment class and the oxygen generating portable equipment class. Therefore, the $177 stationary payment would also be made in this situation, since the equipment being furnished meets the beneficiary's needs for both stationary and portable oxygen equipment. In this case, it would be necessary for the supplier to use two HCPCS codes to bill for this device since it is being used as both the stationary and portable oxygen equipment for the beneficiary. If the beneficiary owns any type of stationary equipment (concentrator, liquid, or gaseous), and is also furnished with a portable oxygen concentrator, only the 
                        ( print page 65899)
                        oxygen generating payment of $64 would be made (that is, the supplier would not also receive the $177 payment) and the portable oxygen concentrator equipment would fall under the oxygen generating portable equipment class because it is only being used to meet the beneficiary's need for portable oxygen equipment. Finally, if, the beneficiary is renting any type of stationary equipment (concentrator, liquid, or gaseous), and is also furnished with a portable oxygen concentrator, the oxygen generating add-on payment of $64 would be paid for the portable oxygen concentrator and the stationary payment of $177 would be paid separately for the stationary oxygen equipment and contents. In summary, we proposed new payment classes for oxygen contents for beneficiary-owned stationary equipment, oxygen contents for beneficiary-owned portable equipment, and oxygen generating portable equipment. Payments for oxygen contents for beneficiary-owned portable equipment and oxygen generating portable equipment would exceed what is currently paid for these items to ensure access to portable oxygen regardless of the type of equipment used. These increased payments would be offset by a reduction in the stationary payment. The six broad categories of oxygen equipment used by beneficiaries are as follows: A. Concentrator and liquid or gaseous portable equipment. B. Concentrator and/or oxygen generating portable equipment. C. Liquid or gaseous stationary equipment and liquid or gaseous portable equipment. D. Liquid or gaseous stationary equipment and oxygen generating portable equipment. E. Concentrator only. F. Liquid or gaseous stationary equipment only. Based on our proposed new payment classes, Medicare payment under these six categories would be as follows: Category
Equipment rental 
                                 and contents
Contents for beneficiary-owned equipmentA
$209 ($177 + $32)
$55B
$241 ($177 + $64)
$0C
$209 ($177 + $32)
$156 ($101 + $55)D
$241 ($177 + $64)
$101E
$177
$0F
$177
$101
 We proposed to revise our regulations in order to implement these new payment classes and payment amounts, effective for claims with dates of service on or after January 1, 2007. J. Payment for Maintenance and Servicing of Oxygen and Oxygen Equipment and Capped Rental Items Immediately following passage of the DRA, concerns were raised regarding the ability of a beneficiary to obtain maintenance and servicing of his or her DME once he or she has taken title to it. We believe that these concerns are largely based on misconceptions that the beneficiary will “be on his or her own” in terms of maintenance and servicing of equipment and submission of claims for payment for these services. We believe that these concerns are unfounded because Medicare payment has traditionally been made for reasonable and necessary repair and maintenance of beneficiary-owned DME. In addition, section 1834(a)(5)(F)(ii)(II)(bb) of the Act, as amended by section 5101(b)(1)(B) of the DRA, and Section 1834(a)(7)(A)(iv) of the Act, as amended by Section 5101(A)(1) of the DRA, require that Medicare continue to pay for reasonable and necessary maintenance and servicing for parts and labor not covered under a manufacturer's or supplier's warranty in amounts determined to be appropriate by the Secretary. Medicare has also traditionally paid for loaner equipment used while the beneficiary's equipment is being repaired, or in some cases, when the beneficiary does not have access to the equipment (for example, in cases when a natural disaster such as a hurricane forces the beneficiary to be evacuated from his or her home). We proposed to continue Medicare payment for such loaner equipment. We are not aware of instances where beneficiaries have encountered problems in finding suppliers to provide maintenance and servicing of beneficiary-owned DME. Section 414.210(e) of our regulations currently provides that reasonable and necessary charges for maintenance and servicing of DME are those charges made for parts and labor not otherwise covered under a manufacturer's or supplier's warranty. This definition has been applied in paying claims for maintenance and servicing of beneficiary-owned DME for several years, and the wording of this regulatory definition is parallel to that used in amended sections 1834(a)(7)(A)(iv) and (a)(5)(F)(ii)(II)(bb) of the Act in describing the “maintenance and servicing” payments that are permitted for capped rental DME and oxygen equipment after title has transferred to the beneficiary. We proposed to continue use of this existing regulatory definition to define “maintenance and servicing” in section 5101 of the DRA. We, however, also proposed to apply our existing policy of not covering certain routine maintenance or periodic servicing of purchased equipment, such as testing, cleaning, regulating, changing filters, and general inspection of beneficiary-owned DME that can be done by the beneficiary or caregiver, to beneficiary-owned oxygen equipment and to continue that policy for beneficiary-owned capped rental equipment. As specified in current program instructions at section 110.2.B of chapter 15 of the Medicare Benefit Policy Manual (Pub 100-02), “the owner [of the equipment] is expected to perform such routine maintenance rather than a retailer or some other person who charges the beneficiary.” We expect that the supplier, when transferring title to the equipment to the beneficiary, would also provide to the beneficiary any operating manuals published by the manufacturer which describe the servicing an owner may perform to properly maintain the equipment. We also believe that these owner manuals are commonly available at the various manufacturer Web sites. In addition, the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) supplier standards at § 424.57(c)(12) require suppliers to provide the beneficiary with necessary information and instructions on how to use DME items safely and effectively. We believe that after receiving this information, and after becoming familiar with the equipment during the 13 or 36 month rental period, the beneficiary and/or caregiver should be very knowledgeable regarding the routine 
                        ( print page 65900)
                        maintenance required for the item. All non-routine maintenance of beneficiary-owned oxygen equipment and capped rental items which would need to be performed by authorized technicians would be covered as reasonable and necessary maintenance and servicing. Examples of the types of maintenance that would be covered are currently listed in program instructions at section 110.2.B of chapter 15 of the Medicare Benefit Policy Manual (Pub 100-02) and include “breaking down sealed components and performing tests which require specialized testing equipment not available to the beneficiary.” We proposed that maintenance and servicing of beneficiary-owned oxygen equipment and capped rental items would be reasonable and necessary if it is non-routine maintenance and servicing necessary to make the equipment serviceable. Payment is currently made under the Medicare program for parts and labor associated with repairing beneficiary-owned DME. Medicare allowed payment amounts for replacement parts are currently paid based on the carrier's individual consideration of the item. With regard to replacement parts for beneficiary-owned oxygen equipment or capped rental equipment, we proposed that the carrier pay for the parts in a lump sum amount based on its consideration of the cost of the item, as is consistent with what our carriers currently do when evaluating maintenance and servicing claims for other beneficiary-owned DME. Currently, payment for labor is based on 15-minute increments in amounts that are established by the carriers and updated on an annual basis by the same factor specified in section 1834(a)(14) of the Act, which is used to update fee schedule amounts for DME. We proposed that the carriers use the same fee for labor that is currently used in paying for labor associated with repairing, maintaining, and servicing other beneficiary-owned DME, as we are not aware of any past problems associated with access to these services paid at these rates. We believe that the current methods and fees used by carriers in paying for maintenance and servicing of beneficiary-owned DME are reasonable given that we are not aware of any past problems associated with access to these services paid at these rates. In most cases, neither the Medicare program nor the beneficiary actually pays the full amount for repairing or maintaining an item since manufacturer warranties that cover all or part of these costs are widespread. For example, some manufacturers of commonly used oxygen concentrators offer full warranties that cover all parts and labor for 5 years. Rules in § 414.210(f) regarding replacement of DME that has been in continuous use for the equipment's reasonable useful lifetime provide that the beneficiary can elect to obtain replacement equipment after the reasonable useful lifetime for the equipment has expired. Therefore, we believe that the beneficiary should incur little, if any, expense for repair or maintenance of necessary equipment in cases where manufacturer warranties exist that cover parts and labor necessary to repair a new item during a 5-year period. K. Payment for Replacement of Beneficiary-Owned Oxygen Equipment, Capped Rental Items, and Associated Supplies and Accessories Medicare has traditionally paid for replacement beneficiary-owned DME after the expiration of the equipment's useful lifetime (see § 414.210(f) and § 414.229(g) of our regulations), and for replacement supplies and accessories used in conjunction with beneficiary-owned DME when these supplies and accessories are necessary for the effective use of the DME (see § 110.3 of Chapter 15 of the Medicare Benefit Policy Manual (pub. 100-02)). Examples of supplies include drugs and administration sets used with infusion pumps. Examples of accessories include masks and tubing used with respiratory equipment. We proposed to apply these policies to beneficiary-owned oxygen equipment, as well as the supplies and accessories used in conjunction with this equipment, and to continue to apply these policies to beneficiary-owned capped rental items, as well as the supplies and accessories used in conjunction with these items. Specifically, we proposed to update § 414.210(f) and § 414.229(g) of our regulations to reflect that payment may be made for the replacement of beneficiary-owned oxygen equipment and capped rental DME in cases where the item is lost, stolen, or irreparably damaged, or in cases where the item has been in continuous use for its reasonable useful lifetime. We proposed that payment for the replacement be made on a rental basis in accordance with the payment rules in § 414.226 for oxygen equipment and § 414.229 for capped rental items. We also proposed to revise § 414.229 to reflect that these proposed changes to the replacement policy for beneficiary-owned capped rental items only apply to those items for which the first rental month occurs on or after January 1, 2007 since the DRA does not apply to capped rental items for which the first rental month occurs before January 1, 2006. The current rules will remain in place for capped rental items to which the DRA does not apply. We are aware that some manufacturer warranties may cover replacement of oxygen or capped rental equipment within a certain time period after the item is furnished. As was our policy before the enactment of DRA (see § 110.2.C of Chapter 15 of the Medicare Benefit Policy Manual (pub. 100-02)), we proposed that Medicare not pay for the replacement of beneficiary-owned oxygen equipment or capped rental items covered by a manufacturer's or supplier's warranty. In cases where equipment replacement is not covered by a manufacturer's or supplier's warranty, we proposed that the supplier must still replace beneficiary-owned oxygen equipment or beneficiary-owned capped rental items at no cost to the beneficiary or to the Medicare program if: (1) The total accumulated costs, as illustrated in the example below, to repair the item after transfer of title to the beneficiary exceed 60 percent of the replacement cost; and (2) the item has been in continuous use for less than its reasonable useful lifetime, as established in accordance with the procedures set forth in proposed revised § 414.210(f). For example, a capped rental item that can be replaced for $1,000 (total of fee schedule payments after 13 rental months) and for which title has transferred to the beneficiary in accordance with section 1834(a)(7)(A)(ii) of the Act can be used to illustrate what we mean when we use the term “accumulated costs” above. In this example, if Medicare has paid a total of $500 for 3 repairs necessary to make the item functional, and a fourth repair costing $200 is needed in order to make the item functional, the accumulated costs for repair in this case will equal $700, which exceeds $600 or 60 percent of the $1,000 cost to replace the item. In this case, the supplier would be required to furnish a replacement item. The greater than 60 percent of cost threshold for replacement is consistent with the threshold repair costs that can result in the replacement of prosthetics (artificial limbs) in accordance with section 1834(h)(1)(G) of the Act. We believe this threshold should apply to oxygen equipment and capped rental items as well, because artificial limbs, like these items, are built to withstand repeated use. We proposed that the supplier be responsible for the cost of the replacement equipment because we believe that the item in this case did not last for the entire reasonable useful 
                        ( print page 65901)
                        lifetime. After the beneficiary acquires title to the item, the supplier that transferred title would be responsible for furnishing the replacement item. We proposed this provision to safeguard the beneficiary from receiving, and the Medicare program from paying for, substandard equipment, and to avoid creating an incentive for suppliers to increase the number of claims submitted for repairs in an effort to recover revenue lost as a result of DRA section 5101. We believe that this requirement is not unreasonable since suppliers should be furnishing items in good working order and are otherwise bound by regulations at § 424.57(c)(15) to accept returns from beneficiaries of substandard items. Exceptions to this rule may be granted by CMS or the carrier as appropriate (for example, the supplier would not be responsible for replacing an item in need of repair due to beneficiary neglect or abuse). L. Periods of Continuous Use Rules that apply in determining a period of continuous use for rental of DME are found at § 414.230 of our regulations. We proposed that these rules would continue to apply in implementing section 5101 of the DRA, with one exception. The rules in § 414.230(f) provide that a new period of continuous use begins for new or additional equipment prescribed by a physician and found to be medically necessary, even if the new or additional equipment is similar to the old equipment. Medicare payments for stationary and portable oxygen and oxygen equipment are currently modality neutral, which means that the same payment amounts apply to the different types of oxygen equipment furnished to Medicare beneficiaries. Since there is no distinction made between oxygen equipment modalities for payment purposes under the Medicare program, we do not believe that it is necessary or appropriate to begin a new period of continuous use when the beneficiary changes from one oxygen equipment modality to another. We proposed to revise § 414.230(f) of our regulations to designate the existing language in this section as paragraph (f)(1) and to add a new paragraph (f)(2) to reflect this exception, effective for oxygen equipment furnished on or after January 1, 2007. We also proposed to revise § 414.230(b) to incorporate section 5101(b)(2)(B) of the DRA, which provides that for all beneficiaries receiving oxygen equipment paid for under section 1834(a) on December 31, 2005, the period of continuous use begins on January 1, 2006. M. Other Issues: Health Care Information Transparency, Health Information Technology, and Medicare Payment Structures Both Medicare's payment structures and the actual delivery of post acute care have evolved significantly over the past decade. Before the BBA, HHAs and other post-acute settings such as inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) were paid on the basis of cost. Since that time, we have implemented various legislative mandates that established prospective payment systems in these settings. The PPS methodologies used in these settings rely on patient-level clinical information to provide pricing, support the provision of high quality services, and encourage the efficient delivery of care. CMS is exploring refinements to the existing provider-oriented “silos” to create a more seamless system for payment and delivery of post-acute care (PAC) under Medicare. This new model could feature more consistent payments for the same type of care across different sites of service, value based purchasing incentives, and the collection of uniform clinical assessment information to support quality and discharge planning functions. CMS is considering a demonstration to determine whether incentive payments to HHAs impact improvements in the quality of care of Medicare beneficiaries. Section 5008 of the Deficit Reduction Act of 2005 (DRA) provides for a demonstration on uniform assessment and data collection across different sites of service. This 3-year demonstration project is to be established by January 1, 2008. We are in the early stages of developing a standard, comprehensive assessment instrument to be completed at hospital discharge and ultimately integrated with PAC assessments. The demonstration will enable us to test the usefulness of this instrument, and analyze cost and outcomes across different PAC sites. The lessons learned from this demonstration will inform efforts to improve the post-acute payment systems. We have evaluated the existing assessment instruments that managed care and other insurers use. These instruments will form the basis of our efforts to create a discharge assessment tool that can serve to facilitate post-hospital placement decisions; enhance the safety and quality of care during patient transfers through transmission of core information to a receiving provider; and provide baseline information for longitudinal follow-up of health and function. In the April 25, 2006 Inpatient Prospective Payment System proposed rule (71 FR 23996), we discussed in detail the Health Care Information Transparency Initiative and our efforts to promote effective use of Health Information Technology (HIT) as a means to help improve health care quality and improve efficiency. Specifically, with regard to the transparency initiative, we discussed several potential options for making pricing and quality information available to the public (71 FR 24120 through 24121). We solicited comments on ways the Department can encourage transparency in health care quality and pricing whether through its leadership on voluntary initiatives or through regulatory requirements. We also sought comments on the Department's statutory authority to impose such requirements. In addition, we discussed the potential for HIT to facilitate improvements in the quality and efficiency of health care services (71 FR 24100 through 24101). We solicited comments on our statutory authority to encourage the adoption and use of HIT. The 2007 Budget states that “the Administration supports the adoption of Health Information Technology (HIT) as a normal cost of doing business to ensure patients receive high quality care.” We also sought comments on the appropriate role of HIT in potential value-based purchasing programs, beyond the intrinsic incentives of a PPS to provide efficient care, encourage the avoidance of unnecessary costs, and increase quality of care. In addition, we sought comments on promotion of the use of effective HIT and how CMS can encourage its use in HHAs. We intend to consider both the health care information transparency initiative and the use of HIT as we refine and update all Medicare payment systems. Therefore, we sought comments on these initiatives as applied to the HH PPS in the August 3, 2006 proposed rule, including the Department's statutory authority to impose any such requirements. We stated that we may address these initiatives in the final HH PPS rule. For example, a HIT proposal could include adding a requirement that HHAs use HIT that is compliant with and certified by the Certification Commission for Health Information Technology (CCHIT) in the areas in which the technology is available. As noted previously, the CMS 
                        *Home Health Compare*
                         Web site contains home health quality information. We note that we are in the process of seeking input on these initiatives in various proposed Medicare 
                        ( print page 65902)
                        payment rules being issued this year. In particular, we intend to consider both the health care information initiative and the use of HIT as we refine and update all Medicare payment systems. III. Analysis of and Responses to Public Comments We received approximately 106 comments on the August 3, 2006 proposed rule. General *Comment:*
                         Several commenters raised concerns about combining several unrelated matters into a single public notice. The commenters believed the style to be confusing and counter to CMS' initiatives for better public communication. *Response:*
                         We recognize the commenters concern and note that we make every attempt to provide sufficient information in the 
                        **Federal Register**
                         document to clearly and specifically state the contents of the 
                        **Federal Register**
                         document. We note that we targeted a similarly situated audience in that suppliers of oxygen equipment, DME suppliers, and HHAs all provide services in the post-acute care setting. *Comment:*
                         Several commenters requested that telehealth services be directly funded. These commenters believe that utilization of telehealth services would save Medicare money by reducing hospitalization and decreasing the use of multiple medical services. *Response:*
                         Telehealth services are not a recognized visit or service under the HH PPS. Specifically, in section 1895(e)(1)(B) of the Act, telecommunications services are not considered a home health visit for the purposes of eligibility or payment under this title. *Comment:*
                         A commenter stated that CMS should indefinitely retain the 5 percent rural add-on. Other commenters recognized that it would take congressional action to extend the 5 percent rural add-on for rural providers. Nonetheless, these commenters supported an extension of the rural add-on period. In addition, commenters recommended that CMS examine the differences between the cost of providing home health services in a rural setting and those costs of providing home health services in an urban area. *Response:*
                         The rural add-on was a temporary add-on established by the DRA. Specifically, section 5201 of the DRA required, for home health services furnished in a rural area with respect to episodes and visits beginning on or after January 1, 2006 and before January 1, 2007, that we increase by 5 percent the payment amount that otherwise would be made for the services. The statute does not provide for a continuation of the rural add-on. We will continue to monitor the HH PPS to help ensure that home health providers continue to receive appropriate reimbursement for the services they provide. Market Basket *Comment:*
                         Several commenters believe that the proposed market basket update falls short of increased costs in the delivery of home health services. Specifically, they state that labor costs have risen significantly with the continuing shortage of nursing and therapy staff, transportation costs skyrocketed in 2005-2006 at a rate far greater than the estimated 2.2 percent that was set out in the 2006 rate setting rule, technology costs, and costs associated with regulatory compliance have grown. Some of these commenters believe the problem with the estimated market basket increase appears to stem from two weaknesses in the calculation formula: The use of FY 2000 cost reports and the accuracy of the projection. These commenters believe the FY 2000 cost reports are inaccurate because they only contained a portion of the operational changes that have occurred since the onset of the prospective payment system. *Response:*
                         The home health market basket is a fixed-weight Laspeyres-type price index, which measures the average change in the price of goods and services purchased by HHAs in providing an efficient level of home health care services. Furthermore, the projected estimated HH market basket has been fairly consistent with the actual market basket determination. Since the inception of the PPS in FY 2001 including years through CY 2005, the forecasted average annual increase of the home health market basket has been 3.3 percent while the actual average annual increase of the home health market basket has been 3.2 percent. With respect to the use of the FY 2000 cost reports, they represent the most recent and complete cost reports available at the time of the most recent rebasing of the home health market basket presented in the CY 2005 proposed rule. Our recent analysis of Medicare cost report data for 2001 through 2003 shows very similar cost weights, including those associated with compensation, to the FY 2000 based market basket. Therefore, we believe the use of the FY 2000 cost reports continue to accurately reflect a proxy of home health weights. We further note that for the final rule, we are using the 2006 3rd quarter forecast with historical data through 2006, 2nd quarter, which results in a forecast for the home health market basket for CY 2007 of 3.3 percent. This projection includes a higher forecast for the CPI for private transportation (2.2 percent) and higher forecast for the price of compensation (3.5 percent) compared to the forecast in the proposed rule of 0.3 percent and 3.4 percent, respectively. *Comment:*
                         One commenter suggested that CMS move away from using the CPI for private transportation to proxy price changes associated with transportation costs and substitute it with a more accurate reflection of home health care transportation experience. *Response:*
                         We believe the CPI for private transportation is an accurate proxy for the price changes associated with home health care agencies' transportation costs. This CPI measures the price changes of new and used motor vehicles, motor fuels, motor vehicle parts and equipment, maintenance and repair, and insurance costs. We believe that home health agencies incur all of these transportation costs. *Comment:*
                         One commenter suggested that the market basket weights assigned to each input should be re-examined every 2 years using cost report data that are less than 2 years old. The commenter also suggests that the validity of the weights should be periodically tested using audited cost report data. *Response:*
                         We rebase the home health market basket on a periodic basis. When we rebase a market basket, we examine the costs for each year since the most recent rebasing. In general, cost weights remain stable from year to year and become less so over a longer time period, such as 5 or more years. Additionally, we always use the most recent and complete cost report data at the time of rebasing. For the CY 2005 proposed rule, the most recent and complete cost report data available was for the year 2000. We are also confident in the validity of the Medicare cost report data received by the industry. Thus, we believe a formal audit is not required. However, as part of the standard rebasing methodology in calculating the cost report weights, we trim the data to remove the impact of outliers. *Comment:*
                         One commenter recommended that the shortfalls in annual cost increase projections be added to succeeding year inflation updates. The commenter stated, for example, the under-projection in 
                        ( print page 65903)
                        transportation cost increases in 2006 should be reflected in 2007 and 2008. *Response:*
                         We believe that the accuracy of the market basket updates has been reasonable, as evidenced by the last several years which contained average forecasted updates of 3.3 percent while actual average annual increase of the home health market basket has been 3.2 percent. *Comment:*
                         One commenter suggested that projections should be thoroughly evaluated and validated. The commenter is aware that CMS uses a proprietary system, Global Insights, Inc. (GII), in determining its projections and believes this system should be examined by a CMS Technical Expert Panel in the immediate future. *Response:*
                         GII is an independent firm that forecasts price proxies and other economic indicators. We believe that the projections we use are unbiased and consistent across all GII customers, both private and government. Moreover, we continue to work closely with GII to continually monitor the reasonableness of its projections. *Comment:*
                         Other commenters expressed support for a market basket update of 3.1 percent and a 15 percent adjustment to the standardized rates for dually eligible beneficiaries. *Response:*
                         We appreciate the support for the proposed market basket increase. Section 1895(b)(3)(B) of the Act requires the unadjusted national rate for CY 2007 to be increased by the applicable home health market basket index amount. The home health market basket for CY 2007 is forecasted to be 3.3 percent. We do not, however, have the statutory authority to establish a 15 percent adjustment to the standardized rates for dually eligible beneficiaries. *Comment:*
                         One commenter stated that home care providers should receive their full Medicare market basket update for 2007 and each subsequent year. *Response:*
                         HHAs will receive payments based on a full market basket update for services provided to Medicare beneficiaries for CY 2007 and subsequent years as provided at section 1895(b)(3)(B)(v) of the Act, subject to submitting the required quality measures and other possible legislative mandates. Quality/Pay for Reporting *Comment:*
                         A commenter recommended that CMS make the penalty for not submitting the required quality data budget neutral and thus increase the national standardized episode amount. This would provide a small reward for the majority of agencies that already comply with the data submission requirement. *Response:*
                         Section 1895(b)(3)(B)(V)(I) of the Act, added by section 5201(c)(2) of the DRA, stipulates that the market basket percentage increase be reduced by 2 percentage points for HHAs who fail to submit required data. The statute does not provide that the reduction in the market basket percentage increase be budget neutral. *Comment:*
                         Several commenters supported CMS' proposed and continued use of the OASIS instrument and reporting infrastructure in response to the DRA requirements. *Response:*
                         We appreciate the commenters' support for this decision. One of our goals is to allow HHAs to fulfill the DRA's quality data reporting requirements in the most efficient and least burdensome way possible. *Comment:*
                         Several commenters believe that CMS needs to continue to refine and enhance the OASIS assessment instrument and associated quality measures. *Response:*
                         As we stated previously, we intend to refine the current OASIS instrument and associated quality measures. We will also continue improving the assessment instrument's accuracy in reflecting both the health status and improvements in condition of our beneficiaries. *Comment:*
                         Several commenters confused the various HH Conditions of Participation requirements, that is, the completion, completeness, and accuracy of the OASIS assessment, with the reporting requirements established by the DRA. *Response:*
                         The proposed rule dealt solely with the requirements of section 5201(c)(2) of the DRA to specify the health quality data needed for quality measurements under the HH PPS. To meet the requirements established in the DRA, we proposed to rely on the data submitted by home health providers through the OASIS instrument. The regulations surrounding completion, completeness, timeliness or other rules associated with the OASIS were not affected by the HH PPS proposed rule. *Comment:*
                         A few commenters were concerned that the reporting timeframe established in the proposed rule is over before publication of the final rule. The commenters noted that prior notification of payment penalties associated with the DRA quality measures requirement could not be known before the reporting period commenced. *Response:*
                         We acknowledge the commenters' concern, but we believe our proposed approach adequately addresses these issues. Section 5201(c)(2) of the DRA amends the Act to such that “each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality. Such data shall be submitted in a form and manner, and at a time, specified by the Secretary.” In considering how to best implement this provision while still obtaining the needed quality measures, our approach was to use processes and mechanisms that were already in place and functioning, as the most efficient and appropriate way to meet the statutory requirements. Using historical data to determine the prospective update is similar to the methodology used for hospital pay for reporting. In this manner, by utilizing an existing system, we were able to provide the least burdensome measures on the providers, and would penalize only those providers who were not otherwise meeting the OASIS submission requirement under the home health Conditions of Participation. *Comment:*
                         One commenter supported CMS' initiative to refine the home health quality measures and to complement those measures with health information technology. This commenter stated that the proper use of new quality measures in certain areas coupled with the appropriate use of health information technology will help to promote quality care, efficiency, save Federal dollars, and satisfy the needs of our beneficiaries. *Response:*
                         We appreciate the commenter's support and will continue to pursue using health information technology to further the goals of providing appropriate payments for quality services under the HH PPS. Outlier Payments and Fixed Dollar Loss Ratio *Comment:*
                         A commenter expressed concerns with CMS' proposal to update the fixed dollar loss ratio in the final rule if current data become available. The commenter believes that CMS has an obligation to modify PPS outlier criteria each year until the 5 percent set aside is realized. Commenters urged CMS to ensure that data is available before the final rule is published. The commenter recommended that CMS provide an opportunity for review and comment before implementation of any change that reduces the likely number of episodes qualifying for outlier payments. Another commenter urged CMS to retain or increase the current outlier payment structure. *Response:*
                         Section 1895(b)(5) of the Act states that the “Secretary may provide for an addition or adjustment to the payment amount otherwise made in the case of outliers * * * [t]he total 
                        ( print page 65904)
                        amount * * * may not exceed 5 percent of the total payments projected or estimated to be made based on the” HH PPS. The statute makes clear that to the extent the Secretary chooses to provide for an outlier adjustment in HH PPS, such adjustment may not be more than 5 percent of the projected or estimated HH PPS payments. The statute does not provide for an outlier adjustment of 5 percent. At the time of publication of the August 3, 2006 proposed rule, we did not have more recent data, but noted that we may update the FDL ratio for CY 2007 depending on the availability of more recent data. We stated that depending on the availability of more recent data at the time of publication of the HH PPS final rule for CY 2007, we may, if necessary, implement an update to the FDL ratio for the CY 2007 update to the HH PPS rates. Subsequent to the publication of the August 3, 2006 proposed rule, we have now obtained more recent data, that is, CY 2005 home health claims data. Accordingly, for this final rule, we have used the same methodology and performed analysis using the CY 2005 data to update the FDL ratio for CY 2007. For CY 2007, we are not only retaining the current outlier payment structure but also increasing the FDL ratio to allow more episodes to qualify for outlier payments. This new FDL ratio is 0.67. Home Health Wage Index *Comment:*
                         Several commenters expressed serious concerns about the use of the pre-floor, pre-reclassified hospital wage index for adjusting for geographic variation in wages. These commenters believe that CMS has the regulatory authority to take immediate steps to implement a wage index that secures a reasonable level of parity with hospitals in the geographic areas served by HHAs. Specific recommendations include applying the State-specific rural floor to all urban areas and implementing a reclassification value proxy for HHAs operating in areas where hospitals have been reclassified. Commenters also made recommendations that CMS consider a wholesale revision and reform of the home health wage index. *Response:*
                         These commenters are referring to the rural floor and geographic reclassification applicable to hospital payments. The rural floor provision is provided at section 4410 of Public  Law 105-33 and is specific to hospitals. The reclassification provision provided at section 1886(d)(10) of the Act is also specific to hospitals. Because these floors and reclassifications apply only to hospitals, and not to HHAs, we believe the use of the most recent available pre-floor and pre-reclassified hospital wage index data results in the appropriate adjustment to the labor portion of home health costs as required at 1895(b)(4)(C). As to the revision and reform of the home health wage index, we further note that CMS has, along with the industry, explored the feasibility of developing a home health specific wage index. Because of the volatility of the home health wage data and the significant amount of resources that would be required to improve the quality of those data, we do not expect to propose a home health specific wage index until we can demonstrate that a home health specific wage index would be more reflective of the wages and salaries paid in a specific area, that it would significantly improve our ability to determine payment for HHAs, and that we can justify the resources required to collect the data, as well as the increased burden on providers. *Comment:*
                         One commenter was concerned about the wage index for CBSA 12940 “East Baton Rouge, Ascension, Livingston, West Baton Rouge, Louisiana.” The commenter stated that the proposed “wage index reflects a decrease from .8593 in CY 2006 to .8099 in CY 2007, a decrease of nearly 6%.” The commenter believes this must be the result of an error and that this wage index should be reviewed for accuracy. *Response:*
                         First, the wage index that is applied to payments for services furnished to home health patients in CY 2006 in CBSA 12940 is not 0.8593. In CY 2006, we apply a transition wage index of either 0.7967 or 0.8618 (depending on the State and county code where the beneficiary resides) to payments for home health services provided in CBSA 12940. This is clearly noted in Addendum A of the CY 2006 HH PPS final rule (70 FR 68161). The wage index value of 0.8593 would have been applied to payments for home health services rendered in CBSA 12940 had we not implemented a transition policy for CY 2006. As noted in the CY 2006 final rule (70 FR 68138), we implemented a transition policy based on the concern about the potential negative financial impact of moving to a CBSA-based wage index. The final wage index value for CBSA 12940 will be 0.8084 for CY 2007. Second, the change in the wage index value for CBSA 12940 is also due in part to the inclusion of wage data from the following counties: East and West Feliciana Counties, Iberville County, Pointe Coupee County, and St. Helena County. These five counties were previously classified as rural. However, under the CBSA designations, which we implemented beginning in CY 2006, they are now part of CBSA 12940. We further note that we employ processes to review the accuracy of the wage index. The home health wage index is derived from the pre-floor, pre-reclassified hospital wage index which is calculated based on cost report data from hospitals paid under the hospital inpatient prospective payment system (IPPS). All IPPS hospitals must complete the wage index survey (Worksheet S-3, Parts II and III) as part of their Medicare cost reports. Cost reports will be rejected if Worksheet S-3 is not completed. Additionally, intermediaries perform desk reviews on all hospitals' Worksheet S-3 wage data, and we run edits on the wage data to further ensure the accuracy and validity of the wage data. In addition, HHAs have the opportunity to submit comments on the hospital wage index data during the annual IPPS rulemaking period. Therefore, we believe our review processes result in an accurate reflection of the applicable wages for the areas given. *Comment:*
                         A commenter expressed concern because implementation of a CBSA-based wage index places Lake County, Illinois in the same CBSA as Racine, Wisconsin rather than in the CBSA-based wage index that includes Chicago. The commenter states that Lake County, Illinois draws from the same employment pool as does the Chicago metro area. The commenter further states that this situation requires dual licensure in order for HHAs in Illinois to hire nurses from Wisconsin. *Response:*
                         Lake County, Illinois is not included in the same CBSA with Racine, Wisconsin. Racine County is in CBSA 39540 and has a CY 2007 wage index of 0.9356. Lake County, Illinois is included with Kenosha County, Wisconsin in CBSA 29404. Lake County and Kenosha County are adjacent counties in the States of Illinois and Wisconsin, respectively. The CY 2007 wage index for CBSA 29404 is 1.0570. OMB considers Lake County and Kenosha County to be part of the same Metropolitan Division. OMB defines a “metropolitan division” as “a county or group of counties within a core-based statistical area that contains a core with a population of at least 2.5 million. A metropolitan division consists of one or more main counties that represent an employment center or centers, plus adjacent counties associated with the main county or counties through commuting ties.” This information is available at the following Web address: 
                        *http://www.whitehouse.gov/​omb/​bulletins/​b03-04.html.*
                         We believe that 
                        ( print page 65905)
                        the OMB geographic designations generally reflect the general labor market. State participation in the Nurse Licensure Compact alleviates the need for nurses to be licensed in multiple states. The state of Wisconsin participates in the Nurse Licensure Compact but Illinois does not. Illinois' participation in the Nurse Licensure Compact would alleviate the need for nurses to be licensed in both states. *Comment:*
                         Other commenters had issues with the decreases in wage index that they will experience in the move to a full CBSA-based wage index in CY 2007. *Response:*
                         We appreciate the detailed concerns sent by the commenters regarding the impact of the wage index update for their specific areas. We note that there will always be some areas that experience an increase in wage index values while others experience a decrease in wage index values. Variability in wage index values occurs each year as wage index values fluctuate from year to year based on the changes to the hospital wage data. As a result, wage index values within the system increase or decrease. We are aware of the changes to wage index values may be due in part to the adoption of the revised OMB designations, and in light of these concerns, we provided a one-year transition period for CY 2006. As to the appropriateness of what CBSA a particular area has been designated into, CBSA designations are determined by the Office of Management and Budget (OMB). We continue to believe that OMB's CBSA designations reflect the most recent available geographic classifications and are a reasonable and appropriate way to define geographic areas for purposes of determining wage index values. *Comment:*
                         One commenter recommended that CMS apply a transition policy that would phase in large and unexpected wage index reductions over a two-year period, similar to the transition CMS applied for the IPPS conversion to CBSAs. *Response:*
                         As noted previously, we implemented a one-year transition policy as a means to gradually introduce the changes and impact of a CBSA-based wage index to the HH PPS. We believe that the transitional one-year period was appropriate and do not agree that a longer transition period is necessary or appropriate. We again note that fluctuations in each wage index would be expected even if we did not adopt the revised OMB designations. *Comment:*
                         Commenters raised concerns with CMS' proposal to continue to use the CY 2005 rural wage index for areas where there is no rural hospital data to compute a wage index. Commenters also raised concerns with the alternative methodology that we discussed, that is, basing the imputed rural wage index on data from the state's Census Division. Commenters believe that this type of situation highlights the need to move away from using pre-floor, pre-reclassified hospital wage data for the home health wage index. Commenters recommended a number of alternative methodologies for imputing a wage index value for areas where there are no rural hospital data to compute a wage index value. The commenters all believe that an imputed proxy should be reflective of the most local data available. Almost all of these comments specifically refer to the wage index for rural Massachusetts. *Response:*
                         As noted above, several commenters recommended alternative methodologies for imputing a rural wage index. One recommended alternative was to use CAH data to impute a wage index for rural Massachusetts. However, CAHs are not required to submit the cost reporting worksheets that we use to compute the hospital wage index. Requiring CAHs to do so would impose an additional data collection burden on them. Additionally, those data would then need to be collected and audited. Therefore, we believe this option would be unduly burdensome and inefficient. Another alternative that was recommended was to use the rural wage index from the single state closest to the Massachusetts rural area. Rhode Island is the closest State to the Massachusetts rural area, but Rhode Island has no rural areas. The commenter acknowledged this and proposed using the wage index for Connecticut. We do not believe that using the rural wage index from the closest State is appropriate because this methodology is not easy to apply to other states where this situation could arise. Another alternative that was recommended was to use the same methodology that we use to calculate an “imputed rural floor” for PPS hospitals with no rural areas (69 FR 49111). This methodology compares the three States that lack rural hospital wage data (Rhode Island, New Jersey, and Massachusetts) to those three States as a class. As the commenter recognized, this approach does not match the criterion for using rural data. The commenter also recognized that since it uses data from hospitals in New Jersey, it does not meet the criterion of using the most local data available. We agree with the commenter that this is not the optimum alternative for imputing a rural wage index for the HH PPS. A fourth alternative that was recommended was to use the average wage index from contiguous CBSAs as an acceptable proxy for a rural wage index. A fifth alternative that was suggested was to use BLS wage data to derive a ratio of rural wages to wages in an urban MSA within the State. That ratio could then be multiplied by the wage index from the urban MSA to derive an estimated wage index for the rural area. We do not believe that using the BLS data to impute a rural wage index is the best alternative as it does not meet our criterion of using pre-floor, pre-reclassified hospital data. Also, using the BLS wage data would require a determination as to which health sector occupations to consider. This alternative methodology would also not weight the occupations appropriately. In contrast, the pre-floor, pre-reclassified hospital wage data encompasses wages and hours, that is, actual utilization per occupation. Using OMB's geographic classification system, the entire rural Massachusetts area, consists of Dukes and Nantucket Counties. Both of these counties are islands. This creates a unique set of circumstances to consider. As we stated in the August 3, 2006 proposed rule, we also believe that an imputed proxy should (1) use pre-floor, pre-reclassified hospital data, (2) use rural wage data, (3) be easy to evaluate, and (4) be easily updatable from year-to-year. After a thorough review of the comments received and a further review of the needs and concerns inherent in this situation, we agree with the commenters that an additional criterion should be added, that is, that the most “local” data available should be used to impute a rural wage index. We have re-evaluated our proposed method of imputing a rural wage index, (that is, using the CY 2005 wage index) and have decided that a more appropriate proxy is needed. Although our proposed methodology uses local, rural pre-floor, pre-reclassified hospital wage data, this method is not updateable from year-to-year. In addition, we now believe that the alternative methodology noted in the August 3, 2006 proposed rule (that is, using an average of the wage indexes in the Census Division) is not optimal because although it uses pre-floor, pre-reclassified hospital wage data from rural areas, it does not use the most local data available. We believe that the alternative methodology of using the wage index from contiguous CBSAs best meets our criteria for imputing a rural wage index and represents an appropriate wage index proxy for rural areas without 
                        ( print page 65906)
                        hospital wage data. While it does not use rural data, it does use pre-floor, pre-reclassified hospital wage data, it is easy to evaluate, it is updateable from year to year, and it uses the most local data available. Therefore, we are revising our methodology for imputing a wage index for rural areas without hospital wage data. We will use the average wage index from all CBSAs that are contiguous to that rural area if the rural area does not have rural hospital wage data. In determining an imputed rural wage index, we interpret “contiguous” as sharing a border. In the case of Massachusetts, the entire rural area consists of Dukes and Nantucket Counties. We determined that the borders of Dukes and Nantucket Counties are “contiguous” with Barnstable and Bristol Counties. The wage indexes for Barnstable (1.2539) and Bristol (1.0783) are averaged resulting in an imputed rural wage index of 1.1661 for rural Massachusetts for CY 2007. While we believe that this policy could be readily applied to other rural areas that lack hospital wage data (possibly due to hospitals converting to a different provider type (such as a CAH) that does not submit the appropriate wage data), should a similar situation arise in the future, we may re-examine this policy. However, we do not believe that this final policy is appropriate for Puerto Rico. As noted in the August 3, 2006 proposed rule, there are sufficient economic differences between the hospitals in the United States and those in Puerto Rico, including the fact that hospitals in Puerto Rico are paid on blended Federal/Commonwealth-specific rates that a separate distinct policy for Puerto Rico is necessary. Consequently, any alternative methodology for imputing a wage index for rural Puerto Rico would need to take into account those differences. Our policy of imputing a rural wage index based on the wage index(es) of CBSAs contiguous to that rural area does not recognize the unique circumstances of Puerto Rico. We received neither comments on our proposed approach to impute a wage index for rural areas in Puerto Rico nor any alternative suggestions. While we have not yet identified an alternative methodology for imputing a wage index for rural Puerto Rico, we will continue to evaluate the feasibility of using existing hospital wage data and, possibly, wage data from other sources. Accordingly, we will continue to use the most recent wage index previously available for Puerto Rico, that is, the wage index from 2004, which is 0.4047. Health Care Information Transparency and Health Information Technology *Comment:*
                         One commenter addressed our discussion of health care information transparency and health information technology. The commenter disagreed with our implication that public comment was previously solicited from the home health community via the 2006 IPPS proposed rule published on August 25, 2006. However, the commenter is pleased that CMS has initiated a public dialogue in this area. The commenter suggests that CMS conduct a technology inventory in home health services to determine utilization and perceived roadblocks to expanded utilization. The commenter also believes that any such mandate must be accompanied by adjustments in payments. Additional commenters raised concerns about the potential impact of health information technology. Commenters do not believe that CMS has sufficiently supported the significant investments agencies have had to make in the past several years to establish and maintain HIT capabilities. Commenter concerns focused on the potential financial impact on providers who have invested significantly in HIT. Commenters believe that HIT requires a shared investment between providers and purchasers of care, to include CMS. *Response:*
                         As explained in the proposed rule, we intend to consider both the health care information transparency initiative and the use of HIT as we refine and update all Medicare payment systems. As previously stated, the 2007 Budget states that “the Administration supports the adoption of health information technology (HIT) as a normal cost of doing business to ensure patients receive high quality care.” We are not including specific recommendations in this final rule. However, we appreciate the input and recommendations provided in the use of HIT and welcome further comments on this important topic from HHAs. *Comment:*
                         One commenter stated that the public does not understand how Medicare's HH PPS works. The commenter believes that a prospective system is a “soft” reimbursement methodology, as payment rates have little relationship to home health pricing noting that in some instances the HH PPS payment far exceeds charges and in other instances the payment falls short of charges. *Response:*
                         We are actively pursuing the goal of price and quality transparency generally in the health care system. We have already released payment information on inpatient services and ambulatory surgical centers and are considering how to do so in other care settings. We agree that any pricing information released publicly should be clearly understood by the public, both consumers and patients. We recognize that Medicare payment for home health services captures a wide variety of costs and that payment rates may not always exactly match the costs for specific patients. However, as a prospective payment system, HH PPS payments estimate the average cost of providing services and are designed to recognize the higher costs associated with care for more severely ill patients. As such, the information could be of great interest to individual patients and the general public when they consider treatment options. It may also be important for patients and their families to understand what services the payment covers, to assist in planning for their health care needs. The price of home health care is also an important component of price information in broader episodes of care. For example, a patient hospitalized with congestive heart failure may have a variety of post-acute care options, including being discharged home without home health services. The ability to identify the cost of different services, including home health, in a total episode of care allows patients, providers, and the Medicare program to be better educated about the value of different mixes of services. This type of analysis, including knowing the price of home health services, could provide valuable data such as re-admission information and indicating the value of specific care sites to patients. We are not including specific recommendations in this final rule. However, we will continue to identify price and quality information that could be publicly released to help inform patient and consumer health care decisions and encourage higher value health care. We welcome further comments on this important topic from HHAs. Consolidated Billing and Supply Issues *Comment:*
                         One commenter requested that CMS exclude HCPCS Code A7043 (vacuum drainage bottle and tubing for use with implanted catheter) from the HH PPS. The commenter believes that the regulations authorize CMS to exclude prosthetic devices and items related to prosthetic devices that are covered under Part B from the HH PPS. The commenter stated that the Pleurx pleural catheter and vacuum drainage bottle meet the definition of a prosthetic device because they replace the malfunctioning pleura by artificially 
                        ( print page 65907)
                        draining the pleura. Additionally, the commenter believes that the HH PPS rates do not adequately compensate HHAs when they care for beneficiaries requiring the Pleurx pleural catheter and vacuum drainage bottle. *Response:*
                         We addressed consolidated billing requirements in the Final Rule for the HH PPS published on July 3, 2000 (65 FR 41139). Medical supplies are a covered home health service and are bundled into the payment rate under the HH PPS. Section 1861(m)(5) specifically includes catheters and catheter supplies as a covered home health service. Therefore, vacuum drainage bottles and tubing for use with an implanted catheter are bundled medical supplies while the patient is under a home health episode of care. Moreover, as we have consistently noted in responding to comments, the statute does not provide for an exception or carve-out of medical supplies from the PPS rate for patients under a plan of care under the HH PPS. The costs of all such supplies are included in the HH PPS rate (see 65 FR 41139). We disagree with the commenter that the HH PPS rates do not adequately compensate HHAs when they care for beneficiaries requiring vacuum drainage bottles and tubing for use with the implanted catheter because this medical supply was included within the original list of 199 non-routine medical codes subject to home health consolidated billing effective October 1, 2000. While the HCPCS code for vacuum drainage bottles has changed, the cost of vacuum drainage bottles was included in the original case-mix weights used to determine the HH PPS rates (65 FR 41138). *Comment:*
                         Several commenters raised concerns about being unable to obtain the same brand of single-use urinary catheter from their HHA that they received directly from a DMEPOS supplier prior to receiving home health. These commenters believed that excluding HCPCS code A4353, which includes single-use catheters, would allow them to receive their catheters directly from the DMEPOS supplier. A number of commenters also request that HHAs be allowed to omit a patient's chronic urinary condition from the patient's specific home health plan of care which they say will allow the patient to continue to obtain the same name brand of single-use catheter they were using prior to receiving home health. *Response:*
                         As noted above, medical supplies are bundled into the HH PPS payment rate and cannot be excluded from that rate. As to this specific item under HCPCS code A4353, that item is considered to be a medical supply and accordingly bundled into the HH PPS payment rate. We remind the commenters that if they believe that a product is not adequately described in the existing HCPCS Level II code set, they may submit an application to CMS to revise the code set, using the format and guidance provided on CMS' HCPCS Web site at 
                        *www.cms.hhs.gov/​medhcpcsgeninfo.* We note that under consolidated billing, the billing for those medical supplies is the responsibility of the HHA. If the patient's physician determines that a particular feature of a given supply is medically necessary for the patient, the physician may specify the designated feature in the physician's order for the supply and in the plan of care. If the HHA determines that there exists an appropriate substitute for the supply ordered by the physician, it may provide that patient with the appropriate substitute supply. If the home health patient does not agree with the HHA that the substitute supply is appropriate, the patient should contact us through the Medicare Hotline at 1-800-MEDICARE (1-800-633-4227). This toll-free helpline is available 24 hours a day, 7 days a week to answer questions. Beneficiaries can speak to a customer service representative in English or Spanish. TTY users should call 1-877-486-2048. We disagree with the request that a HHA omit a medical condition from a plan of care in order to allow the patient to obtain desired medical supplies outside of the plan of care. The regulations at 42 CFR 484.18 require that the plan of care covers all pertinent diagnoses, including types of services and equipment required. In addition to calling 1-800-MEDICARE, if the home health patient believes that she is not receiving the necessary Medicare covered supplies, she may call the Regional Home Health Intermediary (RHHI) or CMS regional office. Under the Contacts section of our Web site at 
                        *http://www.cms.hhs.gov/​center/​hha.asp*
                         we provide information on how to contact the RHHIs and CMS regional offices. HH PPS Refinements *Comment:*
                         One commenter urged CMS to undertake a review of the HH PPS and make appropriate adjustments to the case-mix weights before 2008. Another commenter requested that there be a review of LUPA rates, and to subsequently increase the LUPA rates to ensure that they cover the costs of providing care to those patients. One commenter recommended that an “add-on” to the HH PPS payment be made for dually eligible beneficiaries in order to recognize the added costs incurred by such patients. The same commenter also believes that the costs associated with wound care are not adequately paid for in the current case-mix system. *Response:*
                         Our ongoing research agenda on the HH PPS refinements encompasses review of case-mix adjustment and other payment adjustment provisions under the HH PPS. Our continuing work also includes review of overall system performance to the extent data permit analysis of this topic. We intend to address certain aspects of the HH PPS, which could include LUPA rates, when we initiate a refinement regulation. We also note it is common with new payment systems for providers to go through a period of adaptation. The adaptation process influences the data we use to study refinements, and those data lag by up to a year from the time a service is rendered to when the claim is submitted and processed into a standard analytical file. Our study results will be more effective and provide a better basis for policy proposals when the data used in the studies reflect the “end point” of the adaptation period. Assuming that the necessary data files will become complete, we believe that the end point of the adaptation period will allow us to pursue a refinement rule in the near future. *Comment:*
                         A commenter recommended that CMS establish a home health technical advisory group to regularly review and update the multitude of component parts of the HH PPS reimbursement methodology. *Response:*
                         We appreciate the comment; however, we do not believe such a group is necessary at this time. We have always received input from the industry on various aspects of our Medicare payment systems, and we anticipate this practice will continue into the future. Additionally, for the past few years, we have conducted “open-door” forums to provide the public with an opportunity to provide input and comment on the HH PPS and related issues. Finally, as part of ongoing refinement research, a technical expert panel (TEP) addressed the various aspects of the HH PPS for possible refinements to the system. We strongly believe that specific refinements to the HH PPS, if appropriate, should be addressed in a single refinement regulation. In doing so, the causes and effects that any particular refinement would have on the rest of the system could be taken into effect, eliminating the risk of 
                        ( print page 65908)
                        implementing any one refinement in a vacuum and resulting in a complete and responsible refinement to the system. Classes of Oxygen and Oxygen Equipment Statutory Authority *Comment:*
                         One commenter asserted that the statute does not give authority for CMS to create new classes for these items and that payments must be made at the rate set by statute. *Response:*
                         We disagree. Section 1834(a)(9)(D) of the Act provides authority to create separate classes and payment amounts for any item of oxygen and oxygen equipment as long as they are budget neutral, that is, the separate classes and payment amounts do not result in expenditures for any year to be more or less than expenditures that would otherwise have been made if the classes had not been established. New Oxygen Generating Portable Equipment Technology *Comment:*
                         One commenter commended CMS for recognizing the many benefits that oxygen generating portable equipment (OGPE) can provide. Some commenters urged that the proposed payment rate for OGPE be increased to provide adequate compensation for suppliers and to encourage suppliers to invest in the new technologies. Two commenters asked CMS to reconsider the proposed payment rates for OGPE to accurately reflect the cost of the equipment; which is claimed to range from $2,500 to $3,500. Some commenters recommended that CMS should not implement the proposed payment rates changes at this time and that setting new payment rates should be delayed until sufficient data is gathered to identify the costs of oxygen services. *Response:*
                         We appreciate the support for our proposal to create a new payment category for OGPE. We do not agree with the commenters who suggested delaying the new categories because we are concerned that maintaining the current system could create incentives for suppliers to utilize older technology rather than newer technology that may be more appropriate for certain beneficiaries. We believe that it is appropriate and necessary to implement a new payment class for OGPE in order to ensure access to these items; therefore, we will finalize a new payment category for OGPE. In the proposed rule, we explained that there are currently two different types of OGPE: transfilling units that work independently or in conjunction with standard, stationary oxygen concentrators to fill portable oxygen canisters in the home; or portable oxygen concentrators that meet both the patient's stationary and portable oxygen needs. In both cases, the supplier can bill for both the monthly payment for oxygen and oxygen equipment (currently averaging $199.84) and the portable equipment add-on (currently averaging $31.79). In establishing the new payment rate for OGPE, we proposed to consider the savings that would be generated from use of these new technologies. The savings would come from not having to make payments for portable oxygen contents for beneficiary owned portable systems that generate their own oxygen. The new, enhanced monthly payment for OGPE would be paid in conjunction with the monthly payment for stationary equipment. The combined monthly payments for stationary oxygen equipment and OGPE would provide extra payments to suppliers of the newer technology portable oxygen equipment, with the extra payments being directly linked to the savings generated for the program by eliminating the need to make future payments for portable oxygen contents. The proposed add-on for OGPE of $64 was derived using a multiple step process described in section I of the provisions of the proposed regulation. As explained above, this process would involve determining savings generated from not having to pay proposed monthly payments of $55 for portable oxygen contents during the beneficiary ownership period and applying the savings evenly over the 36-month OGPE rental period. A total payment of $241 was proposed for stationary equipment ($177) plus the OGPE add-on payment ($64). The final process for calculating the OGPE add-on payment, like the proposed process, involved determining savings generated from not having to pay final monthly payments of $77.45 for portable oxygen contents during the beneficiary ownership period and applying the savings evenly over the 36-month OGPE rental period. To determine these savings we multiplied $77.45 by 24 months (number of months in the equipment ownership period) to get $1,858.80. We divided $1,858.80 by the 36 months of the rental period to get the OGPE add-on of $51.63 per month. However, as explained above in the discussion of the final methodology necessary to assure annual budget neutrality of the new classes of oxygen and oxygen equipment, distribution of use of items in the various classes over five years is factored into the calculation used to determine the budget neutrality adjustment factor. Therefore, the final payment rates for the new classes are based on current utilization and an assumption of the number of beneficiaries that will be using OGPE in the future. The total payment for stationary equipment and OGPE for 2007 is $250.03 ($198.40 for stationary + $51.63 for OGPE). The total payment for stationary equipment and OGPE is estimated to be $250.03 in 2008, $244.84 in 2009, and $241.02 in 2010; this compares to the total payment in the proposed rule of $241. We also note that in response to comments on the budget neutrality of our proposal, the final national limited monthly payment rates for each oxygen class were computed using weighted average fee schedule amounts instead of straight average fee schedule amounts. As a result, we have used slightly different numbers in our responses to comments than we used in the proposed rule. Our revised budget neutrality analysis is discussed in full below. *Comment:*
                         One commenter stated that CMS needs to provide assurance that payment rates will not decrease, except in the case of competitive bidding, and that each year the rates will be increased by the percentage change in the Consumer Price Index for Urban Consumers (CPI-U), the covered item update factor that is generally established as the annual update for DME, unless otherwise indicated. *Response:*
                         We cannot provide assurance that oxygen payment rates will never be decreased in the future or that rates will always be increased by the CPI-U update. CMS is required to implement provisions of law passed by Congress, including the covered item updates to the fee schedule amounts for oxygen and oxygen equipment. Further, in order to maintain annual budget neutrality for the oxygen payment classes as required by Section 1834(a)(9)(D)(ii) of the Act, CMS may need to adjust the payment amounts as appropriate. Definition of Modality *Comment:*
                         Many commenters asked us to clarify the definition of “modality.” The commenters stated that the definition should be based on clinical characteristics of the beneficiary rather than physical characteristics of the device such that: a stationary oxygen class of patients who are moribund, bed bound with limited need to leave the home; a portable oxygen class of patients who require oxygen at night only and have limited mobility; and an ambulatory oxygen class of patients 
                        ( print page 65909)
                        whose oxygen needs include support for frequent ambulation. The commenters state that the HCPCS code should be modified to ensure that each respective clinical class can be identified. *Response:*
                         Medicare currently pays for two classes of oxygen equipment, stationary and portable. For the stationary class, there are three modalities that Medicare pays the same “modality neutral” payment rate for: concentrators, liquid cylinders and gaseous tanks. For the portable class, Medicare makes a modality neutral payment for all types of portable equipment. For the final rule, we are adding a new payment class for OGPE and new separate payment classes for delivery of stationary and portable oxygen contents. As has always been the case, a physician may order a specific oxygen equipment modality based on the clinical needs of the patient, and the supplier is bound by that order. However, there is currently no Medicare national coverage determination (NCD) that establishes medical necessity criteria for different oxygen modalities. Therefore, at this time, we do not believe it is necessary or appropriate to separate oxygen and oxygen equipment into different classes based on the clinical characteristics of different beneficiary populations. *Comment:*
                         A few commenters asked us to clarify the medical policy that defines the criteria allowing patients to switch from one modality of oxygen equipment to another modality. The commenters also asked CMS to create a payment policy to pay suppliers for this type of equipment change. Some commenters recommended that CMS instruct its DME program safeguard contractor (PSC) to incorporate specific medical necessity coverage requirements in a local coverage determination (LCD) that specifies under what circumstances or diagnoses a beneficiary could change from one modality of equipment to another, how suppliers will be paid for furnishing a new equipment modality to a beneficiary, and specific documentation requirements for both the supplier and physician for a change in modality. *Response:*
                         A physician prescription for home oxygen is required for coverage for home oxygen equipment. Generally, the physician prescribes the units of oxygen the patient needs and the beneficiary works with the supplier in deciding the modality of the oxygen equipment. In the final rule, we are allowing beneficiaries the option to change modalities during their rental period (this policy modification is discussed below); however, as we proposed in section L of the proposed rule, a new 36-month rental period would not begin in order to comply with the modality neutral payment rules for oxygen and oxygen equipment that we developed in accordance with sections 1834(a)(5) and (9) of the Act. Even if Medicare coverage rules and medical necessity criteria for different modalities of oxygen equipment were established in an NCD or LCD, there would be no effect on Medicare payments for specific types of items furnished under each payment class. It is important to note, however, that Medicare coverage and medical necessity for oxygen and oxygen equipment is outside the scope of this rulemaking effort. Stationary and Portable Oxygen Contents *Comment:*
                         One commenter asked for justification of the 65 percent and 35 percent apportionment of the payment for oxygen contents. We also received comments recommending the same payment rate for all types of oxygen contents because oxygen contents are the same regardless of the weight of the container. One commenter recommended we keep the reduction of approximately $22 to stationary equipment (from $199 to $177) and reallocate the excess savings to (a) portable gaseous oxygen contents and/or equipment, increasing the rates to $75 to $80 and applying the increased rate to portable gaseous oxygen equipment furnished during the equipment rental period and portable gaseous oxygen contents furnished after the equipment rental period and (b) portable liquid oxygen contents and/or equipment, increasing the rates to $90 to $95 and applying the increased rate to portable liquid oxygen equipment furnished during the equipment rental period and portable liquid oxygen contents furnished after the equipment rental period. *Response:*
                         In the proposed rule, we proposed to apportion the current oxygen contents rate of $156 per month by 65 percent and 35 percent based on the weight of the containers and other factors that might make delivery of stationary oxygen contents more expensive than delivery of portable oxygen contents. Stationary oxygen containers are larger and heavier than the portable oxygen containers; therefore, we proposed to apportion a greater amount of the payment to delivery of stationary oxygen contents. We received comments indicating that the average monthly costs of furnishing both types of oxygen contents are the same despite the fact that stationary oxygen contents are bulkier than portable oxygen contents. This is because stationary oxygen contents are delivered and refilled at a lower frequency than portable oxygen contents. Therefore, we are modifying the proposed payment rates for the two types of oxygen contents based on an even (that is, 50-50 percent) split in the current $154.90 weighted average payment amount for both stationary and portable oxygen contents. As a result, we will be paying the same monthly rate of $77.45 for delivery of each of stationary oxygen contents and portable oxygen contents. We will therefore continue to pay $154.90 in cases where both stationary and portable oxygen contents are medically necessary and are delivered. A payment of $77.45 per month rather than $55 per month for delivery of portable oxygen contents will further ensure that beneficiaries will receive necessary contents for their portable oxygen systems and is consistent with a suggestion from one commenter that payment for delivery of portable gaseous oxygen contents should be from $75 to $80. Most patients currently use gaseous portable oxygen systems as opposed to liquid portable gaseous systems or portable concentrators. A very small number of beneficiaries use stationary liquid or gaseous systems, and, in most cases, the supplier that delivers stationary oxygen contents for beneficiaries who use both stationary and portable liquid or gaseous systems would also be the supplier of the portable oxygen contents as well. Therefore, we believe that reducing the proposed payment for stationary oxygen contents from $101 to $77.45 is appropriate in light of the increased payment for portable oxygen contents. *Comment:*
                         One commenter suggested that CMS establish a delivery fee for each time a supplier delivers oxygen. *Response:*
                         The longstanding Medicare policy for payment for delivery of DME and other supplier expenses is that payment for these costs are included in the single payment made for furnishing the equipment. This policy is based on section 1834(a)(5) of the Act, which provides that a monthly payment amount recognized under section 1834(a)(9) be paid for oxygen and oxygen equipment, and section 1834(a)(9), which mandates that monthly payment (or fee schedule) amounts be calculated based on payments made in 1986 under the reasonable charge payment methodology. The reasonable charges that were used to calculate the fee schedule payment amounts included delivery costs and all other costs for furnishing the equipment. Therefore, 
                        ( print page 65910)
                        the cost associated with the delivery of oxygen contents is included in the fee schedule payment amounts for stationary and portable oxygen contents. Furthermore, section 1834(a)(9)(D)(i) of the Act requires that monthly payment rates are to be established for each class of oxygen and oxygen equipment. Since total Medicare expenditures under the new classes and payment amounts will be the same as they would have been under the old classes and fee schedule amounts, we believe that the new payment rates incorporate the delivery costs that made up part of the old fee schedule amounts. *Comment:*
                         One commenter was concerned that the payment rate for delivery of oxygen contents for beneficiary-owned portable oxygen equipment would not be enough to cover the number of tanks or cylinders needed for each beneficiary. The commenter indicated that under the previous payment methodology where monthly payments for oxygen and oxygen equipment were made as long as medical necessity continued, suppliers were able to offset costs associated with delivering portable oxygen contents with the payment made for the stationary oxygen and oxygen equipment. The commenter expressed concern that the proposed $55 monthly payment for delivery of portable oxygen contents will not cover the costs of delivering more than 11 portable tanks per month. In addition, the commenter stated that this figure does not include the cost of delivery. Another commenter noted that the current fee schedule amount of approximately $21 per month would not cover the costs of one delivery per month of portable oxygen contents, and that this will force suppliers to adopt a policy whereby the beneficiary must pick up tanks from the supplier's store. *Response:*
                         We agree with the commenters that the payment rate for portable oxygen contents of $21 is insufficient as a monthly payment for the delivery of portable oxygen contents, and therefore; we are finalizing our proposal to increase it in this final rule. We are dividing $154.90, the current weighted average payment amount for both stationary and portable oxygen contents evenly so that the payment rate for portable oxygen contents will be increased from the current weighted average payment amount of $20.77 to $77.45 per month. The revised payment rate for stationary oxygen contents will also be $77.45 per month. These monthly payment rates include delivery of tanks and cylinders, a service that the supplier is required to perform in order to be in compliance with standards set forth at § 424.57(c)(12). Based on comments received on this issue, we believe that the finalized payment rate of $77.45 will adequately pay suppliers for delivery of stationary or portable oxygen contents. We are therefore confident that the payment rate adequately covers the supplier's costs of delivering oxygen contents. *Comment:*
                         One commenter asked for clarification on payment if there is a change in equipment due to medical necessity. For example, the commenter asked whether a new 36-month rental period starts when there is an increase in the patient's oxygen volume that would require delivery of more portable oxygen tanks. *Response:*
                         As we discuss more fully below, suppliers can furnish another capped rental item or type of oxygen equipment with a physician prescription or if the beneficiary would like newer technology or an upgraded item. However, unless the change in equipment is based on medical necessity, a new rental period will not start. In addition, because there is no distinction made between oxygen equipment modalities for payment purposes under the Medicare program, we would not consider a change from one modality to another to be a change in the type of equipment furnished to a beneficiary. Accordingly, a new period of continuous use would not start in those circumstances. Budget Neutrality *Comment:*
                         Several commenters claimed that the proposed rates were not budget neutral. They claimed that the calculation of decreased expenditures that would result from a $22 reduction in payment for stationary equipment is underestimated and that such payment reduction translates to savings ranging from $239 million to $260 million. One commenter stated that the proposed rule was not budget neutral for each year as required by statute. Another commenter pointed out that the 2004 data did not have specific utilization rates for portable concentrators or transfilling systems since separate HCPCS codes did not exist for these services at that time. *Response:*
                         We have revised the offset/budget neutrality calculations that we proposed based on comments received and have modified the payment rates for the classes of oxygen accordingly. First, in response to the commenter that expressed concern with our use of 2004 data, we have updated our analysis by using the latest available data from the SADMERC on the number of beneficiaries for which claims were received from July 1, 2006 through September 30, 2006, for HCPCS codes E0424, E0431, E0434, E0439, E1390, E1391, and E1392 to determine the distribution of beneficiaries among the categories of stationary and portable oxygen equipment. This data is used to count the number of beneficiaries using items in each equipment class. The number and percent distribution of beneficiaries using the different categories of equipment are shown in table 10. These latest data show 0.3 percent of beneficiaries using portable concentrators. While using these later claims gives us data on users of portable concentrators, we do not have data on beneficiaries using transfilling systems since the code for such equipment began on October 1, 2006. Thus, for purposes of calculating rates, we had to make an assumption about the percent of beneficiaries who will use OGPE equipment (which include both portable concentrators and transfilling systems) after the new classes and payment rates go into effect. From comments received, we assumed a shift of 5 percent of beneficiaries towards OGPE for our budget neutrality calculations. We will revisit this assumption on an annual basis and make adjustments through program instructions to rates applicable to years after 2007 if actual utilization of oxygen equipment by beneficiaries is different from our assumptions. Table 10.—Categories of Oxygen Users
Equipment/Modality
Number of 
                                 beneficiaries
Percent of users 
                                 (percent)Stationary Equipment Only
327,863
31.3Liquid/Gas Stationary AND Portable Equipment
57,950
5.5Concentrator AND Portable Equipment
657,948
62.8( print page 65911)Stationary AND Oxygen Generating Portable Equipment
3,248
0.3Total Number of Beneficiaries
1,047,009
100.0
 As in the proposed rule, we used a five year period for determining the rate changes because the reasonable useful lifetime policy for DME equipment allows beneficiaries to elect to obtain a new item after five years of use. Therefore, we assumed that Medicare would make three years of rental payments and two years of payment for oxygen contents. To calculate budget neutral rates, as in the proposed rule, we compared estimates of Medicare spending for oxygen equipment and contents based on current classes of items and payment rates with estimates of the spending that Medicare would make based on the new classes and payment rates outlined in this final rule. In order to further address the concerns of commenters that the payment rates for the new classes be budget neutral, we compared the payment rates for the new classes to the current, weighted average monthly payment amounts for oxygen and oxygen equipment (for example, $199.84 for stationary equipment), as opposed to comparing them to the straight average monthly payment amounts rounded to the nearest dollar (for example, $199 for stationary equipment). Based on the concerns expressed by commenters regarding the importance of assuring the budget neutrality of the new classes of oxygen and oxygen equipment, we are using the average of the current monthly payments per State weighted by actual utilization by State to establish a more precise average Medicare payment for each class of oxygen and oxygen equipment. To estimate total expenditures for oxygen and oxygen equipment for a given year, we multiplied the monthly payment rate for each category of equipment by the total number of users of each such category, then by the percent of users at the midpoint of each of three equipment rental years, then by 12 for the number of months in a year. Then, we multiplied the monthly payment rate for each category of oxygen contents by the total number of users of each such category, then by the percent of users at the midpoint of each of two beneficiary ownership years, then by 12 for the number of months in a year. We added the estimated spending for equipment and contents to obtain the five year total of payments for equipment and contents. We used data from the September 2006 OIG report, entitled “Medicare Home Oxygen Equipment: Cost and Servicing” (OEI-09-04-00420), on the distribution of the number of beneficiaries using stationary concentrators by the number of months rented that showed the following percentages of oxygen users at the midpoint of each year: 61 percent for the first year, 36 percent for the second year, 26 percent for the third year, 19 percent for the fourth year, and 14 percent for the fifth year. We then used this same methodology to estimate Medicare spending incorporating the payment rate changes in this final rule. Since spending is greater under the payment rate changes in this final rule, we applied a budget neutrality adjustment to the monthly payment amount for stationary equipment in order to achieve the same expenditures that would be spent under payment rates without the changes in the final rule. In response to comments received about our proposed methodology not being budget neutral annually, we calculated budget-neutral rates for a five-year period from 2006 to 2010, applying the methodology described above. The complete, detailed budget neutrality analysis, data, and payment rate calculations are available at the following internet website: 
                        *http://www.cms.hhs.gov/​DMEPOSFeeSched/​*.  This results in smaller budget-neutrality adjustments in the early years and larger ones in the later years because the increased expenditures in the first three years results primarily from the OGPE add-on payment. The full effect of the higher payments for portable oxygen contents will not be realized until 2010, which will be the second year of the equipment ownership for beneficiaries who have been renting oxygen equipment on a continuous basis since 2006. Table 11 shows the 2007 budget neutral monthly payment rates and our estimates of the budget neutral monthly payment rates for 2008 through 2010 for the five classes of oxygen and oxygen equipment, in addition to the combined rates for stationary and portable oxygen contents. The rates for stationary equipment decrease by year to offset the new OGPE class and the increase in the portable contents rate. Table 12 shows the 2007 monthly payment rates and our estimates of the monthly payment rates for 2008 through 2010 for four of the most common combinations of oxygen equipment. Table 11.—Current Weighted Average Monthly Payment Amounts Compared to Proposed and Final Monthly Payment Rates for Classes of Oxygen and Oxygen Equipment
Oxygen class
Current
Proposed
Final 2007
2008*
2009*
2010***During Equipment Rental Period (36 Months)**Stationary Equipment (offset needed)
$199.84
$177.00
                                 (−22.84)
$198.40
                                 (−1.44)
$198.40
                                 (−1.44)
$193.21
                                 (−6.63)
$189.39
                                 (−10.45)Portable Add-on
31.79
32.00
31.79
31.79
31.79
31.79OGPE Add-on
N/A
64.00
51.63
51.63
51.63
51.63
 
 
 Oxygen class
Current
Proposed
Final 2007
2008
2009
2010**Contents Payments After Equipment Ownership**Stationary & Portable Contents
154.90
156.00
154.90
154.90
154.90
154.90Portable Contents Only
20.77
55.00
77.45
77.45
77.45
77.45Stationary Contents Only
N/A
$101.00
$77.45
$77.45
$77.45
$77.45*Rates for 2008 and beyond are budget-neutral based on assumed OGPE utilization of 5 percent. Actual OGPE utilization will be reviewed on an annual basis and rates will be adjusted, if necessary, through program instructions to ensure annual budget neutrality.
 Table 12.—Payments for Various Combinations of Oxygen Equipment
[Estimated for calendar years 2008 thru 2010]
Categories of equipment
During rental period
Contents after ownershipConcentrator only:2007/2008
$198.40
$02009
193.21
02010
189.39
0Concentrator + gaseous portable:2007/2008
230.19 (198.40 + 31.79)
77.452009
225.00 (193.21 + 31.79)
77.452010
221.18 (189.39 + 31.79)
77.45Concentrator + OGPE:2007/2008
250.03 (198.40 + 51.63)
02009
244.84 (193.21 + 51.63)
02010
241.02 (189.39 + 51.63)
0Liquid stationary & portable:2007/2008
230.19 (198.40 + 31.79)
154.90 (77.45 × 2)2009
225.00 (193.21 + 31.79)
154.90 (77.45 × 2)2010
221.18 (189.39 + 31.79)
154.90 (77.45 × 2)
 These estimates assume that 5 percent of oxygen users will use OGPE equipment in all years. However, we will monitor actual use and, as part of our annual budget-neutrality determination, we will revise rates through program instructions under the methodology specified in this final rule if actual OGPE usage is different from our assumption. We also plan to revise the payment rates in the future based on updated data on the distribution of beneficiaries using oxygen equipment and the number of months they use the equipment. These rates apply to all beneficiaries who use oxygen equipment on or after January 1, 2007, including both new and existing users. *Comment:*
                         Some expressed concern that the proposed payment amounts for portable oxygen equipment and portable oxygen contents are not sufficient to offset the cost of providing these systems. The commenters recommend reallocating the savings that comes from the proposed reduction of the stationary class to upwardly adjust the monthly payment for portable equipment and contents. Some commenters strongly urged CMS to offset any future cuts in home oxygen concentrator payments with appropriate increases in other classes of oxygen specifically portable and ambulatory classes. *Response:*
                         We have changed the payment amounts based on comments received and have increased portable contents payment amount from approximately $20.77 to $77.45 per month and have increased the add-on rate for OGPE from approximately $31.79 (the current portable add-on rate during the rental period) to $51.63 per month. We have also recalculated the offsets for budget neutrality and in order to maintain budget neutrality, and will not be reducing stationary payments from approximately $199.84 to $177 as proposed. The stationary equipment payment will be $198.40 in 2007, and is projected to be $198.40 in 2008, $193.21 in 2009, and $189.39 in 2010, based on current calculations discussed above. The fees for 2008 and later would be adjusted on an annual basis, if necessary, to ensure the annual budget neutrality of the change in payment classes and rates. We will annually reevaluate the actual distribution of oxygen equipment and make any adjustment in the payment amounts through program instructions that are necessary to maintain annual budget neutrality as required by section 1834(a)(9)(D)(ii) of the Act. Data *Comment:*
                         A few commenters were concerned about the lack of data provided that established the budget neutrality proposal and asked CMS to release the data and assumptions. A few commenters stated that the proposed rule did not conform to the requirements of the Data Quality Act (DQA) that require Agencies to provide information on sources of the disseminated information as well as supporting data and models in a scientific, financial, or statistical context so the public may question the objectivity of the data and source. *Response:*
                         The DQA requires agencies to, among other things, issue guidelines to ensure and maximize the quality, objectivity, utility, and integrity of information disseminated by the agency. While the DQA applies to a wide variety of information dissemination activities and all types of media, it has not been established that the DQA applies to rulemaking. Nevertheless, we are providing extensive details in this final rule about the data and methodology used to calculate budget neutrality. Consistent with our guidelines for information quality assurance, the information upon which we relied is from a reliable source that uses accepted methods for data collection and analysis, and we reviewed the quality of the information before using it. Where CMS is responsible for disseminating influential information (that is, information that will have a substantial impact on important public policies or important private sector decisions), we ensure that there is a high degree of transparency about the data and methods to facilitate its reproducibility by qualified third parties. To the extent 
                        ( print page 65913)
                        the data upon which we rely is not confidential, our guidelines call for identification and documentation of data sets in producing estimates and projections, and for clear descriptions of the methods used. Transition *Comment:*
                         Some commenters asked CMS to allow for a grace period during which suppliers could transfer patients, with their consent, to other modalities. Many commenters urged CMS to allow for a grandfathering process so that those who began renting oxygen on January 1, 2006 would be under former payment rates and policies. These commenters argued that the final rule should only apply prospectively. *Response:*
                         The final rule, including the new oxygen payment classes and rates, will be effective on January 1, 2007. However, as explained above and illustrated in table 11, the new payment rates will be annually adjusted if necessary to ensure budget neutrality. We disagree with the comment that we allow for a grandfathering provision whereby beneficiaries who began renting equipment on January 1, 2006 be allowed to continue under the former payment rates and policies. Such an approach would deny such beneficiaries the opportunity to obtain access to the new technology equipment. We will periodically reevaluate actual distribution and make any adjustment in payment amounts through program instructions that are necessary to maintain annual budget neutrality as required by statute. Adjustments in payment amounts will be determined based on the model we are using to ensure annual budget neutrality as explained above. As we discuss below, we will allow for changes in modalities during the rental period if the beneficiary requests an upgrade or if the physician provides a new order for the equipment modality. *Comment:*
                         One commenter strongly urged CMS to adopt a blended rate during a three-year transition policy. Traditionally CMS has established blended rates by taking 75 percent of the original rate and 25 percent of the new rate during the first year; 50 percent and 50 percent in the second year; and 25 percent and 75 percent in the third year. *Response:*
                         As explained above, we have revised the calculation of the budget-neutral oxygen equipment payment amounts in response to comments. Our revised approach calculates the budget-neutral rates that will apply for the first five years based on our estimates of the number of beneficiaries that will use specific types of equipment during each of these years. We have also determined that we may need to adjust the rates on an annual basis after the fifth year to ensure that budget neutrality is maintained. Based on our calculations, we do not believe that the blended percentages recommended by the commenter would result in budget neutral payment amounts. Deficit Reduction Act Requirements Rental Cap *Comment:*
                         Numerous commenters were concerned that the 36-month rental period for oxygen equipment will not help beneficiaries and will create undue hardship for them because they will lose services that they have valued for years. Moreover, they stated that current Medicare benefit guidelines, as well as guidelines issued by all major national insurance companies, State Medicaid programs and all home care industry accreditation organizations, have always classified oxygen equipment as “high maintenance equipment needing frequent maintenance service which is not recommended or advisable for patients to own.” Other commenters predicted that hospital admissions will likely be increased as a result of the cap. These commenters argued that capping home oxygen services would direct patients toward the most expensive part of our health care system, which is hospitalization. Another commenter felt it was inappropriate to transfer title to this equipment to a patient because medical oxygen is a prescribed drug. The commenter believes that allowing beneficiaries to assume ownership is akin to giving them the source of a controlled substance. *Response:*
                         The Congress mandated in section 1834(a)(5)(F)(ii)(I) of the Act (added by section 5101(b)(1) of the DRA) that on the first day that begins after the 36th continuous month during which payment is made for rented oxygen equipment, title to the oxygen equipment must transfer to the beneficiary. Section 1834(a)(5)(F)(ii)(II) provides that the Secretary must make reasonable and necessary maintenance and servicing payments for the equipment after the beneficiary assumes ownership of it and we are planning to do so, as detailed in the provisions of this final rule and in response to comments received regarding maintenance and servicing of beneficiary-owned equipment. Suppliers will be paid on a monthly basis for the delivery of oxygen contents in tanks and cylinders in accordance with the requirements of section 1834(a)(5)(F)(ii)(II) of the Act. As part of this ongoing service, we expect suppliers to deliver tanks and cylinders in proper working condition. As a result, we believe that beneficiary-owned equipment will be properly maintained and that beneficiaries will not suffer undue hardship as a result of the title transfer provisions. We also do not see how the title transfer provisions will affect how much oxygen beneficiaries use, since oxygen must be prescribed by a physician and delivered by a supplier in accordance with that prescription. *Comment:*
                         Several commenters remarked that, as beneficiaries, they cannot afford to take care of their oxygen equipment once title to the equipment has transferred to them and request that we reconsider the rule. One commenter noted that his/her portable equipment must be replaced at least a couple of times a year due to malfunctions. *Response:*
                         Although section 1834(a)(5)(F) of the Act requires beneficiary ownership of oxygen equipment after 36 continuous rental payments are made, this subparagraph also mandates that payment be made for reasonable and necessary maintenance and servicing of the beneficiary-owned equipment. The provisions of this final rule describe the changes we are making in the regulations to ensure that the beneficiary will continue to have access to equipment that will function for the entire reasonable useful lifetime established for the equipment. In accordance with existing regulations, if the equipment has been in continuous use for the equipment's useful lifetime, the beneficiary may elect to obtain new equipment. However, we note that a beneficiary would not be required to obtain new oxygen equipment as long as the equipment continued to function properly. In addition, as we discuss below, we are finalizing a provision under which a supplier may be required to replace the item at no charge to the beneficiary if the equipment does not function for the entire useful lifetime. In addition to meeting the annual Part B deductible, for assigned claims, the beneficiary is only responsible for paying 20 percent of the allowed charge for reasonable and necessary maintenance and servicing of beneficiary-owned equipment. We believe that these policies will help limit beneficiary costs once title to oxygen equipment has transferred. *Comment:*
                         One commenter expressed concern about the 13-month rental period for capped rental DME and recommended that CMS reconsider the assignment of certain products to the capped rental category, particularly 
                        ( print page 65914)
                        those that sell for under $250.00 or rent for under $25.00 per month. The commenter argued that the expense of submitting and processing claims for 13 months exceeds any savings from short-term rentals. *Response:*
                         The statute only allows for purchase of DME that is: inexpensive or routinely purchased (section 1834(a)(2)(A) of the Act); a power-driven wheelchair (section 1834(a)(7)(A)(iii) of the Act); or customized (section 1834(a)(4) of the Act). In accordance with the statute, inexpensive DME includes equipment having a purchase price of $150 or less and routinely purchased DME is equipment that is acquired at least 75 percent of the time by purchase. In accordance with section 1834(a)(7) of the Act, capped rental DME is DME not described in any of the other payment categories in paragraphs (2) through (6) of section 1834(a) of the Act. We do not have authority to redefine these categories because they are statutorily based. Transfer of Title *Comment:*
                         A commenter noted that the loss of title to the oxygen equipment will serve as a disincentive for suppliers to invest in advancing oxygen equipment technology. As a result, manufacturers will shift their research and development efforts away from the development of smaller, longer-lasting portable systems and instead, focus on the development of cheaper devices. *Response:*
                         We are obligated to implement section 1834(a)(5)(F)(ii)(I) of the Act, which requires that on the first day that begins after the 36th continuous month in which rental payments are made for oxygen equipment, the supplier transfer title to the equipment to the beneficiary. However, we disagree with the commenter that this rule will act to stymie advancements in oxygen equipment technology and are finalizing policies in this rule that we believe will properly incentivize suppliers to invest in new oxygen technology. In the case of portable oxygen equipment, the purpose of establishing an additional payment class for OGPE is to increase payments for the newer, more efficient, but more expensive OGPE technologies. In addition, as discussed below, we are clarifying in this final rule that beneficiaries may select newer technology items or upgraded items during the equipment rental period by agreeing to sign an Advanced Beneficiary Notification (ABN). *Comment:*
                         Several commenters were concerned about the development of a secondary market for oxygen equipment resulting from individuals interested in selling their used equipment. They stated that the sale of these medical devices would not be monitored to ensure the condition of the device being sold, patient safety or clinical effectiveness. Several commenters requested that we work with the FDA to develop standardized guidelines that apply specifically to the public's resale of used medical devices. *Response:*
                         We are aware that there may be safety issues associated with the resale of used oxygen equipment, and our regulations would not supersede any other Federal or State laws that govern these transactions. However, section 1834(a)(5)(F)(ii)(I) specifically mandates beneficiary ownership of both stationary and portable oxygen equipment after 36 months of continuous use. It has long been common practice for suppliers to pick up beneficiary-owned DME after medical necessity ends, in cases where the beneficiary or relatives of the beneficiary make such a request. In order to minimize the possibility that beneficiaries will incorrectly dispose of oxygen equipment that is no longer medically necessary, we will encourage suppliers to advise beneficiaries that they can pick-up and store the beneficiary's oxygen equipment if the beneficiary no longer needs it. Suppliers would be paid for picking up and storing oxygen tanks and cylinders that are no longer medically necessary (see below for a full discussion of this modification to our maintenance and servicing proposal). We will also note in the final regulations that in cases where suppliers have picked up beneficiary-owned oxygen equipment under these circumstances and the beneficiary's medical necessity for the equipment subsequently resumes, the supplier must return to the beneficiary similar equipment of equal or greater value to the beneficiary-owned equipment that was picked up, unless the beneficiary elects to obtain new equipment because the reasonable useful lifetime for the previous equipment has expired, or unless a different oxygen modality is prescribed and the beneficiary signs an advanced beneficiary notice (ABN) (see below for a full discussion of this policy modification). *Comment:*
                         Several commenters urged that CMS and the Food and Drug Administration (FDA) discuss the ability of suppliers of oxygen contents for beneficiary-owned equipment to comply with 21 CFR 210 and 211. Further, the commenters stated that CMS must outline the process for reimbursing suppliers for any in-home services they would need to perform in the event of an FDA recall after the beneficiary takes title to the device. Another commenter noted that once the beneficiary takes ownership, many devices will no longer be trackable for recall purposes. Several commenters recommended that CMS develop safety standards that can be applied to beneficiary owned equipment. Standards would help ensure that beneficiaries/caregivers comply with Department of Transportation (DOT), FDA and the Compressed Gas Association oxygen guidelines as well as ensure that they do not inappropriately handle or dispose of cylinders. One commenter observed that the proposed rule provided no clarification on how many cylinders Medicare expects to be transferred in ownership to the patient. There are several factors that can influence the number of cylinders a patient receives, such as oxygen liter flow, activity level of the patient, and distance from the patient's residence to the supplier's warehouse. Given these variables, the commenter noted that a patient could receive from 2-6 cylinders at the time of set-up. Additionally, beneficiaries may receive more cylinders temporarily to accommodate travels outside of the supplier's service area. One commenter questioned how CMS will address instances where beneficiaries require more or less portable cylinders post title transfer. Another commenter requested that Medicare not require suppliers to transfer title to oxygen tanks to beneficiaries since it would be burdensome and unmanageable for suppliers to keep track of virtually identical tanks. Under the current regulatory framework for oxygen as a medical gas, one commenter noted that suppliers are not permitted to label oxygen containers with the beneficiary's name which makes it difficult to develop tracking systems to ensure that each patient's cylinders can be identified. One commenter estimated that beneficiaries use anywhere from 2 to 10 or more tanks of oxygen per week. Another commenter recommended that we not require transfer of title for both sets of cylinder vessels, but rather only those that are in use in the home and not the ones that the supplier refills in its business location. One commenter recommended that we retain the current, efficient approach where the supplier owns all the cylinders because this allows the supplier to use different cylinders with the same patient. Several commenters noted that our proposal to transfer title to both the oxygen cylinder that is being filled and the one in the beneficiary's home is unworkable given 
                        ( print page 65915)
                        its impact on supplier's operations and the regulatory framework for oxygen as a medical gas. The FDA guidance defines the custody, control and management of filling liquid container to be in compliance when the filling company owns the liquid containers. When the patient owns the liquid containers after 36 months, the company would no longer be able to fill the container without extensive testing prior to filling because the containers would be considered by FDA to be out of the filler's control. In addition, the filling company would no longer be assured that the container was maintained in accordance with the manufacturer's specification. The DOT requires that the filling company have access to service and maintenance records in order to determine which inspections and tests to perform and at what frequency. If this information is not available to the filler, then the FDA mandates additional testing which requires more sophisticated testing equipment than the typical supplier of home medical oxygen has available. Similarly, in accordance with DOT regulations, a cylinder filled with a hazardous material may not be offered for transportation unless it was filled by the owner of the cylinder or with the owner's consent. This requires that the manufacturer of the medical oxygen, that is, the company that fills the oxygen container under FDA regulations, to have the equipment owner's permission prior to refilling the container. After the patient owns the oxygen equipment, compliance with this regulation will be very difficult for the supplier, especially if the transfilling is done by a third-party. The new supplier has no knowledge of how the compressed gas cylinders have been stored and maintained and how or when federally-mandated hydrostatic testing has been performed. The commenter predicted that it is likely that the new supplier will decline to service the cylinders for fear of employee injury and subsequent liability. Several commenters urged us to confer with the FDA about the application of FDA regulations to patient owned cylinders. *Response:*
                         We are aware that oxygen tanks and cylinders must be handled in accordance with Federal statutes and regulations and expect that suppliers' equipment will meet the requirements set forth in these statutes and regulations before they transfer title to the equipment to the beneficiaries. Once title transfers, the supplier will still be required to deliver refilled oxygen contents in tanks and cylinders. We are also aware that beneficiaries might not know about other Federal laws that govern the disposal and resale of oxygen equipment. Although CMS doesn't administer or enforce these laws, we believe it is appropriate to take steps to ensure that beneficiaries are made aware of them. Therefore, we are adding a provision to the final rule that would require suppliers to educate beneficiaries at the time of title transfer about safety issues associated with disposing of oxygen equipment that is no longer medically necessary, and to advise beneficiaries that they must comply with any applicable Federal, State, and local laws that govern the disposal or resale of oxygen equipment. In addition, as we stated above, we would encourage suppliers to advise beneficiaries that they can pick-up and store the tanks once they are no longer medically necessary, and Medicare would pay for this service (discussed below). Further, suppliers could offer to buy the tanks back from the beneficiary. In the proposed rule, we proposed that the title to two sets of cylinders or tanks would be transferred to the beneficiary after 36 months of continuous rental. That is, title would transfer for one set of cylinders or tanks that the beneficiary would use at home, and title would transfer for a second set that would be refilled at the supplier's location. The number of tanks or cylinders is dependent on how many tanks or cylinders a beneficiary uses and how many tank or cylinder deliveries a supplier makes during a given month. After considering the comments, we have concluded that it is unrealistic and inappropriate to require suppliers to comply with a policy where beneficiaries own specific tanks that must be refilled by suppliers for specific beneficiaries. Therefore, we are changing this policy in this final rule. Even though the beneficiary owns the equipment, the supplier may switch out the tanks or cylinders with their tank and cylinder supply, similar to how propane tanks are refilled in the market today. Just as owners of propane tanks receive different tanks each time they need replacement contents, we are clarifying in this final rule that this propane tank model will be the practice under Medicare with delivery and refilling of oxygen contents for beneficiary-owned oxygen tanks and cylinders. Because this policy modification will enable suppliers to continue swapping tanks and cylinders for beneficiaries, as they currently do, we believe that suppliers should also be able to handle recall situations as they currently do. In the case of other beneficiary-owned oxygen equipment such as concentrators, we expect suppliers to handle recalls in the same way manner that they currently handle recalls of other beneficiary-owned DME, such as power-driven wheelchairs. The decision regarding whether such services would be considered reasonable and necessary maintenance and servicing would be made by the Medicare contractor. For example, if suppliers currently bill and are paid by Medicare contractors for labor and parts when performing in-home services needed in the event of an FDA recall after the beneficiary takes title to a DME device such as a power wheelchair, then they should continue this practice. If the supplier has never furnished DME paid on a purchase basis by Medicare or capped rental items, they should consult with the Medicare contractor to determine if these services would be considered reasonable and necessary maintenance and servicing. *Comment:*
                         One commenter stated that the OIG study on oxygen entitled “Medicare Home Oxygen Equipment: Cost and Servicing,” is flawed and presents an inaccurate representation of Medicare “equipment and servicing.” *Response:*
                         The commenter provides no factual information to support their claim that the findings of this study are flawed. Although none of the policies of this final rule are based solely on the findings in this report, we do believe that the information in the report is credible and provides useful information regarding the maintenance and servicing of and costs of oxygen concentrators as reported by suppliers. Since we did not author the OIG study on oxygen, any concerns or comments about the contents of this report should be addressed to the Department of Health and Human Services, Office of the Inspector General. *Comment:*
                         A commenter requested access to the Medicare Common Working File (CWF), the system that houses beneficiary specific information regarding Medicare eligibility and past claims history, in order to obtain beneficiary specific information such as whether the beneficiary has received the “same or similar” equipment from another supplier in the past. The commenter stated that suppliers must also be able to access historical usage data so that they may understand whether they will be paid for the equipment and services they are being asked to provide within 2 to 4 hours of the typical referral. Another commenter suggested that if access to information in the CWF was not possible, CMS must establish criteria for using ABNs to notify the beneficiaries of their financial 
                        ( print page 65916)
                        responsibility if there is “same or similar” medical equipment. *Response:*
                         The request for access to the CWF is outside the scope of this rulemaking process. We note that general criteria for use of the ABN can be found in Chapter 30 of the Medicare Claims Processing Manual, located at 
                        *http://www.cms.hhs.gov/​Manuals/​IOM/​list.asp*. *Comment:*
                         Several commenters questioned whether Medicare would require suppliers to transfer title to capped rental items and oxygen equipment to beneficiaries who have not paid their coinsurance or deductibles under Part B. One commenter recommended that we provide an exception to the title transfer requirement if a beneficiary has failed to pay his or her coinsurance for a significant period (such as more than 6 months) across the course of the 36-month rental period. The commenter also suggested that we could take responsibility, once the title transfers, for attempting to collect the amount of missed coinsurance payments from the beneficiary or pay the supplier's bad debt for unpaid deductibles and coinsurance. Several commenters urged that we clarify this provision in the final rule and recommended that title to the equipment should not transfer to the patient until payment is made in full for all services rendered through the 36th month. (Medicare typically pays the 36th month's rate approximately 30 days later). *Response:*
                         Section 5101 of the DRA is clear that the title to equipment transfers from the supplier to the beneficiary on the first day that begins after the 13th continuous month in which payment is made for capped rental items and on the first day that begins after the 36th continuous month in which payment is made for oxygen equipment. The statute mandates that ownership transfer after the 13th and 36th continuous month for capped rental items and oxygen equipment, and does not make transfer of ownership contingent on payment of beneficiary coinsurance. We believe that suppliers have a sufficient period of time to collect any outstanding beneficiary coinsurance during the rental period before title is required to be transferred. In addition, our rules would not preclude a supplier from seeking unpaid coinsurance or deductible amounts from a beneficiary after title has transferred. CMS or the carrier will have the discretion to review cases that allow suppliers to stop furnishing an item to a beneficiary, if warranted. *Comment:*
                         Some commenters are concerned that the proposed rule does not provide sufficient clarity and specificity for stakeholders and Medicare beneficiaries alike to fully recognize the impact the final rule will have on beneficiaries when it becomes effective. The commenters predicted that the complexity of oxygen equipment, as well as the fact that each different type of equipment carries with it different safety and routine maintenance requirements, will be overwhelming for the average Medicare beneficiary. *Response:*
                         We recognize that equipment maintenance may be overwhelming for some beneficiaries and, as we explain in more detail below, we are revising the final rule to allow for payment every six months for general maintenance and servicing of certain beneficiary-owned oxygen equipment. These payments would be made in addition to payment for any reasonable and necessary replacement parts and repairs that are non-routine and not covered by the manufacturer's warranty. We intend to monitor the implementation of these provisions to ensure beneficiary safety. Back Up Equipment *Comment:*
                         Some suppliers furnish backup oxygen equipment for use by beneficiaries in the event of power failures or malfunction of primary oxygen equipment. Several commenters requested that the final rule state that since Medicare has not made any rental payments for backup oxygen equipment, title to this equipment should not transfer to the beneficiary. The commenters believe that title to backup equipment does not transfer under the coverage rules established under Medicare contractor local coverage determinations (LCDs) for oxygen equipment. *Response:*
                         We agree with the commenters that the title for backup oxygen equipment would not transfer to the beneficiary after 36 months because Medicare does not make rental payments for this equipment. In addition, the LCDs referred to by the commenters correctly reflect Medicare's policy that equipment is not medically necessary if it is identical or similar to equipment already in use by the beneficiary and is used to meet the same set of medical needs. That is, backup equipment is a second piece of equipment used for precautionary reasons to deal with an emergency in case the primary piece of equipment malfunctions rather than to meet a different set of medical needs. Therefore, the beneficiary-ownership provision would not apply to backup oxygen equipment. Payment for Oxygen, Oxygen Equipment and Capped Rental DME *Comment:*
                         Several commenters requested that a new rental period begin whenever a change in supplier takes place, regardless of the reason. One commenter indicated that now that payments for oxygen equipment will be limited to 36 months of continuous use, the administrative burden on suppliers, such as ascertaining how many Medicare rental payments have already been made for specific items used by specific beneficiaries, will increase. The new suppliers will need additional resources to complete a thorough screening of all new patients to determine the amount of Medicare payments that may be made for specific items. *Response:*
                         Longstanding policy found in § 414.230(g) regarding a change in suppliers during a period of continuous use of rented DME indicates that a change in supplier will not result in a new rental episode. In accordance with the amendments made by section 5101 of the DRA to section 1834(a)(7)(A) of the Act, and section 1834(a)(5) of the Act, payment may not extend over a period of continuous use of longer than 13 or 36 months, respectively, for capped rental items and oxygen equipment. For the reasons indicated below, we are applying the policy in § 414.230(g) to all beneficiary-owned capped rental items and oxygen equipment. *Comment:*
                         One commenter requested that we acknowledge those situations in which the title is not held by a supplier that rents oxygen equipment or cylinders to beneficiaries. The commenter indicated that it is common practice for a supplier to rent equipment from a manufacturer and never hold title to the equipment, but stated that the 36-month rental cap for oxygen equipment fails to address this common problem. *Response:*
                         We understand that in some instances, suppliers furnish oxygen equipment to beneficiaries that they themselves have rented from manufacturers or leasing companies. However, under section 1834(a)(5)(F)(ii)(I) of the Act (added by section 5101(b)(1)(B) of the DRA), suppliers are required to transfer title of oxygen equipment to beneficiaries on the first day that begins after the 36th month during which payment is made for the equipment. In addition, under section 1834(a)(7)(A)(ii) of the Act (added by section 5101(a)(1) of the DRA), suppliers are required to transfer title of capped rental equipment to beneficiaries on the first day that begins 
                        ( print page 65917)
                        after the 13th month during which payment is made for the equipment. Therefore, regardless of what arrangements a supplier might make with a manufacturer or leasing company, the supplier must be in a position to transfer title to the equipment in accordance with these statutory provisions. Payment for Maintenance and Servicing *Comment:*
                         One commenter requested that during the period of continuous use, suppliers be permitted to continue the current practice of replacing equipment in need of service or repair with equipment of the same type that is in good working order. The commenter further requested that the rule build in the added costs of administration and delivery if the original piece of equipment must be delivered to the patient. *Response:*
                         We recognize that under current practice, suppliers sometimes choose to replace oxygen or capped rental equipment, rather than repair it, during the rental period, and as we discuss below, we have decided to allow this practice to continue. However, as discussed in detail in the proposed rule, we continue to be concerned that beneficiaries be protected from situations where equipment may be replaced with equipment of lesser value prior to the transfer of title to the equipment. Therefore, we would require that the replacement equipment must be in the same or better condition as the equipment being replaced. Delivery of the equipment is included in the monthly rental payment amount. *Comment:*
                         Several commenters stated that the proposed rule does not address the service components that are currently provided to beneficiaries which may require trained and qualified personnel to administer. These services include: Verifying oxygen purity, oxygen dose verification, verification of alarm system functions, cleaning and replacement of filters, disposable oxygen accessories, 24-hour, 7-day per week on-call and emergency support, patient training, and clinical professional support. The proposed rule also does not address that some manufacturers require equipment maintenance, which requires disassembly of the device, to be performed every 5,000 hours and this must be performed at the supplier's facility. This additional equipment maintenance requires suppliers to incur the additional costs of picking up the equipment and providing loaner equipment. One commenter stated that regular maintenance takes place in the patient's home, on average, every 90 days. Another commenter provided a statistic from the June 2006 Morrison Informatics Inc. study, which demonstrated that non-equipment costs comprise 72 percent of suppliers' total costs. Commenters also noted that the new quality standards confirm that the non-equipment professional and administrative services cost categories reported in the Morrison study are legitimate costs that should be recognized in the Medicare payment for home oxygen. Further, the rule does not address reimbursement for licensed respiratory therapists who conduct in-home clinical patient assessments according to written or verbal physician orders for beneficiaries who own oxygen equipment. The commenters urged CMS to allow patients to continue receiving these assessments, but note that this activity will only be sustainable if CMS establishes a new HCPCS code and appropriate reimbursement rate. The commenter noted that suppliers cannot provide these assessments without fair reimbursement rates because it could constitute an illegal inducement and raise other fraud and abuse concerns. Commenters stated that we need to establish regular and ongoing payment after ownership transfers to support beneficiary access to necessary clinical, support, and other services. *Response:*
                         Section 1834(a)(5)(F)(ii)(II) of the Act requires CMS to pay separately for any reasonable and necessary maintenance and servicing after the beneficiary assumes ownership of oxygen equipment, and section 1834(a)(7)(A)(iv) of the Act requires the same in the case of capped rental DME items. We proposed to use the standard in § 414.210(e) of our regulations to define the “maintenance and servicing” for which Medicare would make payment under section 5101 of the DRA. We also proposed to apply our existing policy of not covering certain routine or periodic servicing of purchased equipment, such as testing, cleaning, regulating, changing filters, and general inspection, that could be done by the beneficiary or caregiver, and referred to chapter 15, section 110.2B of the Medicare Benefit Policy Manual for further guidance on what types of routine maintenance would not be covered. After considering comments that raise concerns regarding a beneficiary's ability to properly maintain his or her oxygen equipment, as well as safety issues that could arise if the equipment is not properly maintained, we have decided to revise our policy in the final rule under which, beginning 6 months after title to oxygen equipment transfers to the beneficiary, the supplier may bill for general maintenance and servicing of certain beneficiary-owned oxygen equipment once every 6 months. We believe that allowing payment every 6 months is reasonable based on findings by the Department of Health and Human Services, Office of the Inspector General, in a September 2006 report entitled “Medicare Home Oxygen Equipment: Cost and Servicing,” that the current frequency of suppliers in checking concentrators (every four months, on average) exceeds the guidelines of the two major manufacturers that accounted for two-thirds of the concentrators rented by beneficiaries sampled for purposes of the report. In addition, according to guidelines from two major concentrator manufacturers, comprehensive preventative maintenance need only performed annually or after several thousand hours of use. Under this policy, suppliers could bill for general maintenance and servicing of all oxygen equipment except liquid or gaseous equipment (stationary and portable) because these types of systems consist primarily of tanks or cylinders, as well as replacement supplies and accessories (for example, masks and tubing) which we proposed to pay for separately, and we would expect that as a part of the tank and cylinder filling process, suppliers would check to ensure that the tanks and cylinders were functioning properly. However, we will make payment for the pick-up and storage or disposal of tanks and cylinders that are no longer medically needed by the beneficiary. We are also specifying that the general maintenance and servicing payments for oxygen equipment other than liquid and gaseous equipment would not begin until at least 6 months after the date that title to the equipment transfers because suppliers should only be transferring title to equipment that is in good working order and that has been routinely maintained. Payment for general maintenance and servicing would be limited to 30 minutes of labor, which we believe will adequately compensate suppliers based on findings by the OIG in the same September 2006 report that many routine maintenance activities performed by suppliers on concentrators could be performed in less than 5 minutes. Finally, as we explained above, these payments for general maintenance and servicing would be made in addition to payment for reasonable and necessary repairs of beneficiary-owned oxygen equipment. Suppliers would be able to bill for such 
                        ( print page 65918)
                        non-routine maintenance, to the extent that the parts and labor are not covered by the manufacturer's warranty, beginning immediately after the beneficiary assumes ownership of the equipment, and as we proposed, payment would be made for the parts in a lump sum amount based on the carrier's consideration of the cost for the item because this is consistent with how we currently pay for replacement parts for other beneficiary-owned DME. We would also make an additional labor payment if such non-routine maintenance is performed at the same time as general maintenance, as long as the non-routine repair takes longer than 30 minutes. In addition, we are finalizing our proposal to pay on a purchase basis for all supplies and accessories (
                        *e.g.*, tubing, masks, cannulas, etc.) necessary for the effective use of beneficiary-owned oxygen equipment. In addition, to further limit the possibility raised by commenters that beneficiaries will incorrectly dispose of tanks and cylinders, we are modifying our proposal to allow suppliers to submit a bill for picking up beneficiary-owned oxygen tanks and cylinders that are no longer medically necessary should a beneficiary request such a pick-up. The supplier could submit this bill any time after the beneficiary has acquired ownership to the tanks or cylinders. This pick-up allowance would not apply to other types of oxygen equipment, such as concentrators, because beneficiary storage of such equipment does not raise safety concerns. In-home clinical patient assessments by licensed respiratory therapists fall outside the scope of the Medicare Part B benefit for DME. *Comment:*
                         Several commenters requested that Medicare develop standard protocols for routine maintenance of oxygen equipment and reimburse suppliers for providing this service. Several commenters requested that the non-routine maintenance include: inspection of internal components for dust, debris, wear; internal filter changes; oxygen purity testing that requires an oxygen analyzer device; coil cleaning and any maintenance that requires breaking internal seals. Several commenters requested that “routine maintenance” and “non-routine maintenance” be clearly defined in the final rule, specifically for oxygen and capped rental DME. Several commenters proposed that routine maintenance be defined as follows: wiping down outside surfaces of oxygen devices, changing the external cabinet filter, changing oxygen tubing and cleaning and replacing oxygen humidifier bottles. *Response:*
                         As we explained above, we are modifying our maintenance and servicing proposal for oxygen equipment to allow for general maintenance and servicing of oxygen equipment other than liquid or gaseous oxygen equipment. Medicare will pay for up to 30 minutes of labor spent performing general, routine maintenance during each of these maintenance calls. Medicare will also pay separately for any replacement parts that are necessary to properly service the equipment during these calls, and for labor associated with any non-routine maintenance required as part of the visit if it takes longer than the 30 minutes we are already paying for under the general maintenance and servicing policy. However, to the extent that a supplier services beneficiary-owned oxygen equipment more often than every six months, or services beneficiary-owned capped rental items at any time, Medicare will only make payments for non-routine maintenance and servicing. In the proposed rule, we stated that examples of the types of maintenance and servicing that would be covered as non-routine maintenance of oxygen equipment and capped rental DME can be found in section 110.2.B of Chapter 15 of the Medicare Benefit Policy Manual (Pub. 100-02). This policy has been in the manual for many years and we have never experienced any major problems associated with interpretation of these guidelines on what constitutes reasonable and necessary maintenance and servicing. We also believe that the examples provided in the manual represent good, general guidance that will enable beneficiaries and suppliers to discern what types of maintenance and servicing would be covered. We therefore do not believe that it is necessary to provide a listing of every service that constitutes routine and non-routine maintenance. *Comment:*
                         Several commenters recommended that we develop a methodology to provide for emergency services for beneficiary-owned equipment. Commenters also requested that this emergency mechanism, including after-hours care, in-home assessments, patient education and adherence monitoring, take into account the value of the therapists' time, mileage reimbursement expense and related costs. One commenter noted that patients rely on the 24-hour, 7-day-a-week on-call service to answer major and minor questions related to their equipment. A large percentage of these calls result in an in-home visit after hours and on the weekend. *Response:*
                         Payment will be made for any reasonable and necessary maintenance and servicing of beneficiary-owned DME, including emergency situations. In addition, consistent with current Medicare policies, payment for rental of loaner equipment would be made while repairs of beneficiary-owned equipment are provided. In-home clinical patient assessments by licensed respiratory therapists fall outside the scope of the Medicare Part B benefit for DME. *Comment:*
                         One commenter predicts that a number of beneficiaries may hire a third party to perform routine maintenance tasks that the beneficiary would otherwise be responsible for performing once he or she takes title to oxygen equipment to ensure that there is no chance for error. As a result, these beneficiaries may likely pay more for home oxygen therapy than they are paying under the current provisions. *Response:*
                         As we discussed above, we are allowing payment for general maintenance and servicing of beneficiary-owned oxygen equipment other than liquid or gaseous oxygen equipment. In addition, a liquid or gaseous system consists of only tanks or cylinders, which we would expect a supplier to maintain as part of the filling process, and supplies, which we will pay for separately. As a result, we expect that a beneficiary's maintenance costs will not be significantly higher under this rule than it was under the previous rules. *Comment:*
                         One commenter recommended that we conduct a study in a clearly-defined marketplace to ascertain the level of hospitalizations, emergency room visits, physician office visits, or other Part A/B expenses incurred by beneficiaries as a result of their being unable to access a qualified supplier after they assume ownership of the medical equipment under the new rules. *Response:*
                         We disagree that such a study is necessary. As described in detail above, we have provided for appropriate payments for maintenance, servicing, and repairs of beneficiary-owned equipment. Therefore, we believe that beneficiaries will have sufficient access to qualified suppliers after assuming ownership of equipment. *Comment:*
                         A few commenters noted that the proposed rule does not provide any guidelines or timetable as to how often Medicare will pay to replace the disposable supplies associated with home oxygen therapy, such as cannulas, oxygen tubing, humidification bottles, adaptors, and filters. These components 
                        ( print page 65919)
                        require frequent replacement and are currently included in the monthly Medicare rental fee. As the proposed rule is currently drafted, suppliers would be required to provide replacements of necessary supplies for free and commenters believe that this will lead to a reduction in the number of suppliers that furnish oxygen. *Response:*
                         Medicare has traditionally paid for supplies and accessories that are necessary to use in conjunction with the beneficiary-owned DME item. This policy can be found in section 110.3 of Chapter 15 of the Medicare Benefit Policy Manual (Pub. 100-02). We proposed to apply this policy to supplies and accessories used in conjunction with beneficiary-owned oxygen equipment and capped rental items and did not receive comments opposing this proposal. Therefore, we are finalizing our proposal to pay separately for these supplies and accessories as often as is reasonable and necessary. *Comment:*
                         Several commenters are concerned that serious health problems could affect a Medicare beneficiary's ability to understand and take responsibility for routine maintenance and servicing of his or her oxygen equipment. Commenters noted that some beneficiaries are physically and mentally unable to perform the necessary routine maintenance on equipment, and it is simply unsafe to impose the responsibility for maintaining this equipment on beneficiaries. Another commenter noted that even the OIG's September 2006 Oxygen Report, entitled “Medicare Home Oxygen Equipment: Cost and Servicing” (OEI-09-04-00420), reinforced the point that a certain percentage of patients will not be able to perform routine maintenance by stating that “50 percent of the service visits conducted through the surveyed patients included what has been describes routine maintenance.” Other commenters noted that transferring the burden of maintenance and repair of sophisticated oxygen technologies to the beneficiary and, therefore, the total management of their home oxygen therapy regimen, presents serious risk to patient safety and care. Commenters also indicated that oxygen and oxygen equipment are more technically complex than other types of DME and can cause serious injury if improperly maintained and serviced. *Response:*
                         Although we believe that the one commenter misquoted the OIG report and took their data out of context, we agree with the commenters' general concerns regarding the ability of beneficiaries to properly maintain their oxygen equipment once they acquire title to it and are revising the rule to permit payments for general maintenance and servicing of certain beneficiary-owned equipment as explained above. *Comment:*
                         Several commenters suggested that we establish HCPCS codes to adequately describe the parts and repair services that will be covered and reimbursed for beneficiary-owned oxygen equipment. Another commenter requested that we implement a national policy and fee schedule for repair parts and labor that is eligible for either a Consumer Price Index (CPI) or Medicare Economic Index (MEI) adjustment annually. The fee schedule should reflect the fully-loaded costs of providing repair, not just repair parts and labor. A standardized approach will address those instances where a supplier goes out of business and is unable to assist in maintaining equipment. Another commenter indicated that services that are currently included as part of the monthly bundled rate for oxygen and equipment would no longer be provided after the 36th month unless a HCPCS code and allowable is developed. *Response:*
                         We have generally given the carrier discretion to determine rates for labor and parts with respect to the non-routine repair of beneficiary-owned equipment based on reasonable charges and believe that this methodology results in adequate reimbursement to suppliers. However, should these commenters wish to make specific requests or recommendations for addition of specific codes for replacement parts, we would encourage them to participate in the HCPCS editorial process, which is described online at: 
                        *http://www.cms.hhs.gov/​MedHCPCSGenInfo/​.* *Comment:*
                         Several commenters request that we provide guidance on the type of documentation that CMS expects suppliers to obtain to support repair claims. They stated that DME MACs and CMS must have clear policies outlining when Medicare will pay for repairs and the documentation it will require to support those claims. *Response:*
                         In accordance with the rules at § 414.210(e), Medicare carriers have long had discretion to require any documentation from suppliers that is necessary to enable them to make determinations regarding whether maintenance and servicing of beneficiary-owned DME is reasonable and necessary. The carriers provide guidance to suppliers regarding the specific documentation that is needed for these purposes. *Comment:*
                         Several commenters requested that “labor” be redefined to start when the technician leaves the facility and ends when he or she returns to the shop. The labor time charge should not be just for technician time in the home or shop. The commenters noted that the current parts and labor fees do not take into consideration any travel time or time to evaluate the equipment. *Response:*
                         Medicare payment for labor is based on 15-minute increments for time when the technician is working on the equipment. Separate payment is not allowed for delivery and service charges for DME such as travel time to and from the beneficiary's home. Such payment is included in the payment for the item or service. This policy has been in place for many years and we have not encountered serious problems with access to repair of beneficiary-owned DME. However, this policy does allow for additional payment for extraordinary expenses in rare or unusual circumstances as specified in current program instructions. This policy can be found in section 60 of Chapter 20 of the Medicare Claims Processing Manual (Pub. 100-04). This payment determination for travel is at the discretion of the carrier. Payment for Replacement of Equipment *Comment:*
                         Many commenters expressed concern about our equipment replacement proposal. Numerous commenters believed that this provision places an unreasonable economic burden on suppliers. Commenters indicated that we should specify that, once ownership shifts to the patient, it becomes the patient's responsibility to maintain and repair the equipment. Some commenters believe that, given the 5-year useful life of the equipment, the circumstances that would require equipment to be replaced may be so far removed from the date that title transferred that there would be no plausible connection between the supplier's actions and a conclusion that the supplier delivered substandard equipment. Commenters noted that the proposed rule does not allow for the supplier to receive a new continuous rental period for replacement equipment which is not yet patient-owned, so it is inequitable to require a supplier to replace free of charge the patient-owned equipment that prematurely fails because the patient did not maintain it in accordance with the manufacturer's guidelines. This situation should be remedied by providing for a new continuous rental should the beneficiary's action during the ownership useful lifetime period result 
                        ( print page 65920)
                        in the premature failure of the equipment. Commenters also complained that routine maintenance often must be performed by the user and that the supplier has no means to ensure when or if this was done or done correctly. Several commenters indicated that manufacturer warranties for oxygen equipment are void if the title is transferred. Therefore, requiring that the supplier that furnished the oxygen equipment replace at no cost items that, under Medicare rules, did not last for the entire reasonable useful lifetime would subject suppliers to undue financial burden. *Response:*
                         We expect that equipment furnished by the supplier will function for the entire period established under Medicare regulations and program instructions as the equipment's reasonable useful lifetime. If this is not the case, then the supplier has not furnished a quality item of durable medical equipment for which they have been paid. If suppliers have information or data that proves that specific types of DME do not routinely last for 5 years, they can furnish this information to CMS for consideration in possibly establishing a new reasonable useful lifetime for equipment. *Comment:*
                         A commenter stated that suppliers are financially unable to furnish additional equipment in the event it needs to be replaced after the title is transferred. Another commenter noted that once the title is transferred, patients may find it difficult to locate an oxygen supplier that is willing or able to provide them with a loaner unit on short notice. *Response:*
                         We expect that oxygen equipment and capped rental items furnished by the supplier will function for the entire period established under Medicare regulations and program instructions as the reasonable useful lifetime. As long as suppliers are furnishing items that meet this standard, they should not generally need to replace beneficiary-owned items and should not suffer the kind of financial hardship envisioned by the commenter. In addition, we believe that the modifications to our maintenance and servicing policy will limit the possibility that oxygen equipment will not be properly maintained after the beneficiary acquires title to it. Accordingly, we are finalizing our proposal to require that suppliers replace malfunctioning oxygen equipment that does not last for its reasonable useful lifetime, however, as explained more fully below, we are modifying it to allow carriers greater discretion in determining when a supplier must replace the item at no charge to the beneficiary or the Medicare program. We are also finalizing the same proposal with respect to capped rental DME. The replacement item must be equipment of equal or greater value to the equipment being replaced. We have never encountered major problems associated with beneficiaries obtaining servicing of equipment. Due to the current abundance of oxygen suppliers, we believe that this will also be the case with regard to servicing of beneficiary-owned oxygen equipment. *Comment:*
                         A commenter noted that our current definition of “useful life” exceeds the warranty that manufacturers typically provide on most of the current oxygen technologies, and expressed concern that forcing a supplier to be financially responsible for a device beyond the manufacturer's warranty period would impose a significant financial burden on suppliers. The commenter stated that Medicare should modify its definition of “useful life” and develop technology or equipment-specific definitions. Another commenter noted that it is unclear in the rule if we are basing “lifetime” on manufacturer warranty or some other basis. The commenter stated that basing our definition of “lifetime” on the manufacturer warranty could be problematic since an equipment's “lifetime” varies widely by manufacturer and type of equipment. *Response:*
                         Under § 414.220(f) of our regulations, the reasonable useful lifetime of durable medical equipment is either the period established through program instructions or, in the absence of program instructions, the period determined by our carriers (at least five years). These periods are not based on manufacturer warranties. If suppliers have information or data that proves that specific types of durable medical equipment do not routinely last for five years, they can furnish this information to CMS for consideration in possibly establishing a new reasonable useful lifetime for equipment. In addition, consistent with how we currently measure the reasonable useful lifetime for capped rental items, we would measure the reasonable useful lifetime for oxygen equipment beginning on the date that the equipment is furnished to the beneficiary. *Comment:*
                         Several commenters requested that we not adopt the proposal that a supplier be required to replace equipment once accumulated repair costs exceed 60 percent of the cost to replace the equipment. Although the commenters acknowledged that the 60 percent threshold was based on a similar replacement provision for artificial limbs, the commenters do not believe that the proposal is appropriate since unlike oxygen, artificial limbs do not require regular maintenance or additional supplies that must be regularly replaced in order to function properly. The commenters also noted that the proposed rule does not define “replacement cost” and how such cost would be calculated in determining the 60 percent threshold. According to the commenters, the proposal is not clear regarding whether the “replacement cost” is the original cost to Medicare of the equipment being replaced, the Medicare fee schedule amount, or the fair market value of the item. Several commenters requested that we eliminate the 60 percent analysis and reimburse at the cost of each incident of repair rather than the accumulation of repairs. Several commenters noted that given the 5-year useful lifetime of the equipment, the circumstances that would require equipment to be replaced may be so far removed from the date that title transferred that there would be no plausible connection between the supplier's actions and a conclusion that the supplier delivered substandard equipment. Several commenters requested that responsibility for the equipment shift to the patient once the title transfers because the supplier will not have any record of routine maintenance in years four and five, placing the supplier in the position of having to replace equipment that may not have been properly maintained. One commenter suggested that we could establish a supplier responsibility period of 30 days following transfer of title that would require replacement if the repair costs were 60 percent of the replacement cost. Some commenters indicated that we appear to be trying to balance appropriate coverage for needed non-warranty repairs with beneficiary protection from receiving poor quality equipment via the proposed rule that covers repairs until they accumulate to 60 percent of the replacement cost. Some commenters indicated that some equipment, such as semi-electric hospital beds and power wheelchairs, have component parts that can be quite expensive to repair/replace and that these costs could easily exceed the 60 percent trigger but still be in the equipment's useful lifetime. Repairs of such equipment are often a function of active use, not poor quality of defective equipment. One commenter remarked that there are areas of the proposed rule that present legal concerns because Medicare does not have statutory authority to implement these requirements. The 
                        ( print page 65921)
                        commenter is unaware of any statutory requirement for the repair or replacement of patient-owned equipment or for the use of a 60 percent threshold. Moreover, CMS has not conducted any independent laboratory studies or manufacturer surveys of DME or oxygen equipment to determine if the 5-year “average useful life” is accurate or current before making it subject to such a provision. *Response:*
                         We agree with the commenters that the proposed 60 percent threshold may not be pertinent in all cases and have revised the final rule to reflect a more general policy. Equipment furnished must function for the entire period established under Medicare regulations and program instructions as the reasonable useful lifetime. We are modifying our proposal to permit our contractors to use the 60 percent repair threshold at their discretion when making case-by-case determinations on whether a supplier must replace equipment that does not function during the reasonable useful lifetime. However, we continue to believe that the 60 percent threshold is a useful factor for our carriers to consider because it is probative of whether the beneficiary has been furnished with, and the Medicare program has paid for, a substandard item. The replacement item must be equipment of equal or greater value to the equipment being replaced. Under § 414.210(f) of our regulations, the reasonable useful lifetime for DME is five years, unless we determine otherwise. For a capped rental DME item, § 414.229(b) of our regulations specifies that the monthly fee schedule amount for rental of the item equals ten percent of the purchase price for the item; therefore, the replacement cost of the item is equal to the rental fee schedule amount multiplied by ten. For oxygen equipment, there is no established purchase price for Medicare purposes, so the replacement cost of an item will be established by the carrier on an individual, case-by-case basis using information such as invoices to determine the replacement cost of the item. With respect to beneficiary-owned oxygen equipment, “repair” costs will not include the costs of labor associated with general maintenance and servicing of the equipment. *Comment:*
                         One commenter requested that we provide information about how equipment failures due to beneficiary neglect or abuse will be determined. Another commenter questioned who is responsible for providing the replacement equipment in the event that there is more than one supplier involved, for example, if the beneficiary moves. *Response:*
                         We are finalizing a policy that would allow CMS or the carrier to make determinations if replacement equipment is warranted. We will be monitoring the number of replacement equipment provided to a beneficiary. In the case that a beneficiary is abusing or neglecting the equipment, CMS or the carrier may determine that the supplier is not responsible for furnishing replacement equipment. *Comment:*
                         One commenter suggested that in lieu of prohibiting the replacement of equipment during the period of continuous use, CMS can require that the beneficiary receive title to equipment that is of comparable quality to the equipment delivered at the beginning of the period of continuous use. *Response:*
                         As we explained above, we have decided to modify our proposal and allow suppliers to furnish different equipment during the rental period as long as the equipment is of equal or greater value as the equipment being replaced. *Comment:*
                         Several commenters questioned that under the proposed regulations, a new period of continuous use would begin only when beneficiary-owned equipment is lost, stolen or irreparably damaged. The commenter requested that a new period of continuous use begin when a supplier furnishes replacement equipment during the period of continuous use. Otherwise, suppliers replacing lost equipment will be forced to transfer title to two devices, but receive payment only for one. Alternatively, commenters suggested allowing the carriers to make the determination whether to initiate a new period of continuous use on a case-by-case basis. Two commenters stated that while they agree with the proposed provision that a new period of continuous use would begin when beneficiary-owned equipment is lost, stolen, or irreparably damaged, they questioned our decision to apply this exception only to beneficiary-owned equipment. The commenters noted that when equipment is lost, stolen, or irreparably damaged during the period of continuous use and a supplier furnishes replacement equipment, a new period of continuous use should begin; otherwise, the regulation would impose a patently unfair result when rented equipment is lost or damaged through no fault of the supplier. The commenters suggested if this is the case, CMS should allow carriers to make the determination whether to initiate a new period of continuous use on a case-by-case basis to ensure a more balanced application of the requirement to transfer equipment ownership to beneficiaries. *Response:*
                         Current rules regarding replacement of capped rental items located at § 414.229(g) allow for replacement of rented items if the carrier determines that the item is lost or irreparably damaged. In the proposed rule, we inadvertently deleted this text when we proposed to revise § 414.229(g), although we never intended to change this longstanding policy, which reflects our belief that suppliers should be compensated for furnishing a new rental item if the item is needed as a result of circumstances beyond the supplier's control. Therefore, as part of this final rule, we will reincorporate this policy in our regulations but will move it to § 414.210(f), the general section on replacement of equipment, so that the policy applies to all rented items. To be consistent with what we proposed in the context of beneficiary-owned items, we will also specify that this policy would also apply if an item is stolen. However, we continue to believe that a new period of continuous use should not automatically begin whenever the beneficiary changes equipment (that is, from equipment falling under one HCPCS code to different but similar equipment described by another HCPCS code). This is consistent with longstanding policy relating to payment for DME. This policy can be found in section 30.5.4 of Chapter 20 of the Medicare Claims Processing Manual (Pub. 100-04). In no case can a new rental period begin for a change in equipment from one product within a HCPCS code to another product within the same HCPCS code or from one oxygen modality within a payment class to another oxygen modality within a payment class. Items falling within the same HCPCS code and paid based on the same payment rules and fee schedule amounts are considered the same item or service for Medicare purposes. Likewise, oxygen modalities falling under the same payment class and paid based on the same payment rules and fee schedule amounts are considered the same item or service for Medicare purposes. Oxygen modality changes are generally done for the convenience of the beneficiary, and not because they are medically necessary. The Medicare NCD and contractor LCDs establish medical necessity criteria for oxygen and oxygen equipment, but do not establish separate medical necessity criteria for different types or modalities of stationary or portable oxygen equipment. We also note that beneficiaries who wish to exchange 
                        ( print page 65922)
                        equipment or oxygen modalities during the rental period for reasons other than medical necessity can be required to sign an ABN. Periods of Continuous Use *Comment:*
                         Several commenters requested that we clarify how a “break in service” applies to short-term or intermittent usage of home oxygen therapy. They stated that patients that fall within the Group II oxygen coverage guidelines may not be sufficiently hypoxemic to require ongoing oxygen therapy and their short-term use should not be included in the 36-month continuous rental period. They also stated that other “breaks in service” that should not count towards the period include skilled nursing facility stays or acute care admissions any longer than a month. The commenters noted that current rules at § 414.230(c) state that an interruption in the use of the equipment of not longer than 60 consecutive days plus the days remaining in the rental month in which use ceases is temporary, regardless of the reason for the interruption. Current Medicare program instructions indicate that a new rental period begins in cases where the interruption is greater than 60 days plus the days remaining in the rental month in which use ceases if it is supported by new medical necessity documentation. The commenters believe that there is no basis for CMS to apply different break-in-service rules to oxygen. One commenter stated that beneficiary enrollment/disenrollment in Medicare managed care plans further complicates our proposals on switching equipment and consistent assignment during the rental period. The commenter indicated that a single beneficiary may be in traditional Medicare, enroll in one HMO, disenroll and go back on transitional Medicare, then enroll in a different HMO all in one rental period. The commenter questioned how these scenarios can possibly be addressed in a reasonable manner under the proposed rule. *Response:*
                         The rules for defining a period of continuous use for which we make payments for DME were first adopted in an October 9, 1991 interim final rule with comment (56 FR 50821). In that rule, we stated that we believed certain language in the House Committee Report accompanying section 4062(b)(1) of the Omnibus Reconciliation Act of 1987 (Pub. L. 100-203) (which authorized the implementation of the DME fee schedules) indicated that Congress did not intend for a period of continuous use to automatically terminate each time there was a break in service. Therefore, we stated that an interruption in the rental period of not longer than 60 days plus the days remaining in the rental month in which the use ceases would be considered a temporary suspension of the period of continuous use pending resumption of medical need. This precedent, which we finalized in a December 3, 1992 final rule (57 FR 57109), has now become longstanding Medicare policy, has worked well throughout the years and has addressed all of the situations highlighted by the commenters (e.g., short term use of DME, breaks-in-service, etc.). Therefore, we believe that these rules should continue to apply. In accordance with § 414.230(c) and current program instructions found in section 30.5.4 of Chapter 20 of the Medicare Claims Processing Manual (Pub. 100-04), if the interruption is less than 60 consecutive days plus the days remaining in the rental month in which use ceases, contractors will not begin a new rental period. Also, when an interruption continues beyond the end of the rental month in which the use ceases, contractors will not make payment for additional rental until use of the item resumes. Contractors will establish a new date of service when use resumes. Unpaid months of interruption do not count toward the 15-month limit. These policies will apply to beneficiary-owned oxygen equipment and capped rental DME. In addition, because Medicare makes payment for a rental item on the date of delivery of the item, and payment for each subsequent rental month on the same day, or “anniversary date” for that month, if the break in service is short, the supplier would still be paid for that rental month. *Comment:*
                         Several commenters were concerned about the impact and interaction of the proposed DRA policy and payment changes and the competitive bidding provisions. One commenter noted that certain DRA provisions and planned competitive bidding provisions overlap and conflict. The commenters requested that we clarify the conflicts in both final rules. The commenter stated that, for example, a rule conflict exists when a contract supplier is forced to accept an oxygen patient with only 6 months rental left in the 36-month rental period. To address this conflict, the commenter suggested that we allow the 36-month period to start over again whenever a patient switches suppliers if less than 36 months of continuous use have transpired. *Response:*
                         We will address issues that pertain to the Medicare DMEPOS Competitive Bidding Program in the final rule for that program. *Comment:*
                         Several commenters requested that we clarify which supplier's equipment transfers to the beneficiary if the beneficiary has two residences in different areas and uses a local supplier in each area. They stated that “snow birds” may face hurdles in maintaining access to equipment unless a new period of continuous use begins when they change suppliers. The commenters suggested that extended travel outside of the supplier's service area should not be counted toward the period of continuous use to the extent the supplier is not paid for furnishing the oxygen equipment during that period. Another commenter noted that the proposed rule does not address how suppliers that coordinate services for patients who travel after they have purchased the equipment will be reimbursed. Another commenter indicated that the proposed rule was unclear on the methodology for those who have two homes during different times of the year. The supplier in the new area will not have the full 36 months to collect reimbursement. *Response:*
                         We expect that travel arrangements for beneficiaries with oxygen equipment would be handled by suppliers in the same manner that such instances are currently arranged for beneficiaries with capped rental items. Capped rental items have been paid under these circumstances and addressed through program instructions since 1989. The capped rental policies that apply when a beneficiary changes suppliers are listed in section 30.5.4 of chapter 20 of the Medicare Claims Processing Manual (Pub. 100-04) and indicate that if a beneficiary changes suppliers during or after the rental period, this does not result in new rental episode. The equipment furnished to the beneficiary at the time that transfer of title is required by the statute and this final rule is the equipment for which the beneficiary would receive title to. Beneficiary Safeguards *Comment:*
                         One commenter stated that we should add an additional safeguard to protect beneficiaries if their initial supplier decides to discontinue service once title of the oxygen equipment transfers to the beneficiary. The commenter recommended that we add a new paragraph in § 414.226(g) requiring the supplier that furnishes the oxygen equipment throughout the rental period to notify the beneficiary no later than 3 months before the end of the rental period that the supplier will no longer continue to provide services once the transfer of title takes place. The commenter believes this will give the 
                        ( print page 65923)
                        beneficiary adequate notice and time to find another comparable supplier and will not leave a gap in their service once ownership takes place. The commenter noted that current DME Quality Standards establish certain “consumer services,” but they do not address this issue. *Response:*
                         We agree with this comment but believe that 2 months is a more reasonable period of time in terms of how much advance notice should be given to beneficiaries in these situations. We have revised § 414.226(g) to require the supplier to notify the beneficiary no later than 2 months before the end of the rental period if the supplier will no longer continue to maintain and service the equipment, and/or deliver oxygen contents, once the transfer of title takes place. Likewise, in order to be consistent with our policies, we are revising § 414.229(g) to require the supplier of a capped rental item to disclose no later than two months before title transfers whether it will continue to maintain and service the item. Because we recognize that there may be isolated cases where a supplier cannot satisfy this requirement (such as if the supplier goes out of business), we (or our carriers) will also allow for exceptions on a case-by-case basis. *Comment:*
                         One commenter stated that we should require suppliers to re-train beneficiaries (and/or their caregivers) on the services they will need to perform on oxygen equipment at the time the suppliers transfer ownership and to verify in writing that the beneficiary/caregiver has actually performed the tasks for which they will be responsible to ensure that they are capable of doing so. The commenter recommended that we add an additional safeguard in § 414.226(g) that would require the supplier at the time of transfer to re-train the beneficiary and/or caregiver with respect to information regarding preparation of formulas, features, routine use, troubleshooting, cleaning, maintenance, safety conditions, and infection control. The commenter stated that although these requirements are currently contained in the DME Quality Standards, their supplier is only required to verify that the beneficiary received the instructions and information at the time of setup, not that he or she understood them or could perform them. The commenter believes that re-training and verification in writing by the supplier that the beneficiary and/or caregiver can actually carry out the tasks could prevent serious injuries and life-threatening situations in the future. *Response:*
                         We do not believe that it is necessary to revise § 414.226(g) as recommended. The DRA requires CMS to pay separately for any reasonable and necessary maintenance and servicing of capped rental or oxygen equipment after title transfers to the beneficiary. We proposed to continue our longstanding policy of paying for reasonable and necessary repairs and non-routine maintenance and servicing that a beneficiary cannot perform. In response to comments, we have also decided to add an exception in the final rule under which, beginning 6 months after title to oxygen equipment transfers to the beneficiary, the supplier may bill for general maintenance and servicing of certain beneficiary-owned oxygen equipment once every 6 months. As for routine maintenance that may be necessary beyond what Medicare will pay for, we also note, as we did in the proposed rule, that by the time title transfers for oxygen equipment and capped rental items, beneficiaries and/or their caregivers should be very familiar with their equipment and the routine maintenance that is required to maintain it. In addition, we note that we would expect that at the time of title transfer, suppliers would provide beneficiaries with operating manuals describing their equipment and the servicing that must be done to maintain it. Beneficiaries could also access many of these manuals on manufacturer Web sites. *Comment:*
                         One commenter was concerned that if the beneficiary safeguards are imposed at the same time as reduced reimbursement, the viability of many oxygen suppliers will be threatened, thus affecting patient access to oxygen equipment and contents. *Response:*
                         We appreciate the comment. However, we believe that the provisions discussed in the proposed rule and in this final rule with respect to oxygen equipment, oxygen contents, and capped rental DME items are necessary to ensure that our beneficiaries receive the appropriate equipment and service both during the rental period and after they assume title to the item. In addition, the beneficiary safeguards that we are implementing with this final rule reflect what we believe to be fair business practices, are consistent with our DMEPOS Quality Standards, and should not impose undue burdens on the suppliers. We have clarified our proposals in a number of places after considering all of the comments received in order to reduce the burden on suppliers. *Comment:*
                         One commenter recommended that in conjunction with this rule, we should impose safeguards (for instance, limits on the number of times a beneficiary can switch suppliers) that prevent beneficiaries from gaming the system. *Response:*
                         We do not agree that having no limits on the number of times that a beneficiary can switch suppliers will encourage gaming because under this rule, changing suppliers does not result in a new period of continuous use. Although we cannot envision every conceivable gaming scenario, we believe that we have fully considered the needs of beneficiaries in adopting this rule and that the protections we are implementing will strongly discourage gaming by unscrupulous suppliers. *Comment:*
                         One commenter agreed with our proposed beneficiary safeguards since suppliers should be furnishing items in good working order and are otherwise bound by regulations at § 424.57(c)(15) to accept returns from beneficiaries of substandard items. *Response:*
                         We appreciate the support of our proposed beneficiary safeguards. We believe that these changes in concert with the implementation of the DMEPOS quality standards will ensure that beneficiaries receive quality equipment and appropriate services throughout the rental period and after title transfer. *Comment:*
                         We received numerous comments regarding our continuity of equipment proposal. Commenters stated that our attempt to ensure that suppliers do not substitute substandard equipment to patients just before the required transfer of title is too restrictive. Several commenters recommended that suppliers be allowed to exchange and/or change a beneficiary's equipment during the period of medical need, provided this exchange/change is documented. However, commenters were concerned that the proposed rule does not define a change in medical condition or provide enough detail to understand how and when patients will be entitled to switch oxygen modalities, or how it will be documented so that suppliers will be paid appropriately and promptly. Commenters also asked for additional clarity regarding our interpretation of “modality” and asked for specific circumstances when patients may be changed from one type of equipment to another. Commenters recommended that we allow suppliers to judiciously exchange or change a patient's equipment during the period of medical need provided that this exchange or change is sufficiently documented and that the supplier certifies that the new equipment is not a lesser-quality device. Commenters also recommended that we instruct our DME 
                        ( print page 65924)
                        Program Safeguard Contractor (PSC) medical directors to incorporate specific medical necessity coverage and documentation requirements in the revised Oxygen and Oxygen Equipment LCD before the proposed January 1, 2007 implementation date of this regulation. Specifically, the revised LCD should address: (a) Under what circumstances or diagnoses it is medically necessary to change from one oxygen modality or equipment type to another; (b) how suppliers will be reimbursed for changing equipment; and (c) specific documentation requirements for both the supplier and the physician to ensure that the contractors can make appropriate coverage determination. Commenters also raised concerns about the potential impact the continuity of equipment proposals could have on beneficiary access to new oxygen technology. They stated that there are fairly common circumstances where a supplier must exchange equipment in order to best serve the beneficiary. For example, if suppliers cannot exchange equipment, they may have to perform a complex repair in the patient's home. Suppliers should not be placed in a situation where they have to choose between not being able to provide service to the beneficiary at the time of need versus providing a higher level of equipment and taking a financial loss over the remaining rental period if they are unable to switch to the prescribed level of equipment. Commenters recommended that the proposed rule be modified to clarify that it is acceptable for a supplier to exchange equipment if (a) the exchange is for same or similar equipment; or (b) the exchange is to equipment that better matches a physician's order. Commenters also stated that it is unreasonable to mandate a supplier to continue to service a beneficiary if the beneficiary is non-compliant with the supplier's instruction on the safe and appropriate use of the medical equipment. They recommended that the oxygen supplier be responsible for transferring title for the total number of liquid oxygen vessels or oxygen cylinders that would be present in the patient's home at one time. *Response:*
                         We appreciate the concerns presented by the commenters. Medicare pays for two classes of equipment, stationary and portable. For the stationary class, there are three modalities that Medicare pays the same “modality neutral” payment rate for: concentrator, liquid cylinders, and gaseous tanks. For the portable class, Medicare makes a modality neutral payment for all types of portable equipment. As we explained above, we are finalizing our proposal to add a new payment class for oxygen-generating portable equipment and separate classes for delivery of stationary and portable oxygen contents. As has always been the case, a physician may order a specific oxygen equipment modality based on the clinical needs of the patient; and the supplier is bound by that order. In addition, there is currently no Medicare national coverage determination (NCD) that establishes medical necessity criteria for different oxygen modalities. The carrier would still maintain the ability to determine that a change in equipment is warranted for reasons other than those described above. Instructions for the DME PSC contractors are not part of rulemaking, and will be handled under local carrier coverage policies. After considering all of the comments, we are finalizing a policy that would allow for four general exceptions to the rule that a supplier may not exchange equipment during the rental period. We believe that these exceptions are flexible enough to allow beneficiaries and suppliers to exchange equipment where appropriate, but limited enough to protect beneficiaries from a situation where their equipment could be replaced with less valuable equipment just prior to the date when they acquire ownership of it. In all cases, the replacement item must be equipment of equal or greater value to the equipment being replaced. (1) The supplier replaces an item with the same, or equivalent, make and model of equipment because the item initially furnished was lost, stolen, irreparably damaged, is being repaired, or no longer functions. (2) The physician orders different equipment for the beneficiary. If the need for different equipment is based on medical necessity, then the order must indicate why the equipment initially furnished is no longer medically necessary, and the supplier must retain this order in the beneficiary's medical record. (3) The beneficiary chooses to obtain a newer technology item or upgraded item and signs an ABN. (4) CMS or its carriers determine that a change in equipment is warranted. *Comment:*
                         We received numerous comments regarding our proposal to require that a supplier that furnishes rented oxygen equipment or capped rental items to the beneficiary must continue to furnish that item throughout the whole rental period except in certain situations. These comments focused on varying scenarios where patients move or choose to switch suppliers due to dissatisfaction with their service. Commenters were concerned that patients in these situations will experience an access-to-care issue as few suppliers will accept such a patient if he/she has only a few months left on the rental schedule but would be expected to provide oxygen equipment, including the back-up and other un-reimbursed equipment. This will create inequities as a supplier might be required to provide a brand new piece of equipment to a beneficiary for 10 months of the 36 months, as an example, and this de facto diminished reimbursement could deter suppliers from offering services to Medicare beneficiaries and diminish beneficiary access to oxygen supplies. Commenters recommended that we specify that a new 36-month period begins in conjunction with this provision. *Response:*
                         In an October 9, 1991 interim final rule with comment period (56 FR 50821), we first adopted our policy that precludes a new period of continuous use from beginning when a beneficiary changes suppliers. In adopting that policy, we looked to the House Committee Report that accompanied the enactment of the Omnibus Budget Reconciliation Act of 1987 (Pub. L. 100-203), which authorized implementation of the fee schedules for DME. The House report stated that a change in suppliers during an otherwise uninterrupted period should be considered continuous. Therefore, we adopted § 414.230(g), which provides that if the beneficiary changes suppliers during or after the equipment rental period, that change would not result in a new rental period. Since we first adopted this policy, we believe that suppliers have been able to adequately accommodate beneficiaries who change suppliers, and we see no reason to change this policy now. After reviewing the comments on this issue, we have maintained our proposal requiring a supplier who furnishes rented oxygen equipment/capped rental for the first month for which payment is made to continue to furnish that item throughout the 36/13-month period of continuous use for as long as it is medically necessary, except in the following cases: The item becomes subject to a competitive acquisition program;
                    A beneficiary relocates on either a temporary or permanent basis to an area that is outside the normal service area of the initial supplier;
                    The beneficiary chooses to obtain equipment from a different supplier; or
                    Other cases in which CMS or the carrier determine that an exception is warranted. 
 
 We continue to believe that these policies are necessary to ensure that beneficiaries have adequate access to oxygen equipment and capped rental items because they protect beneficiaries from a situation in which an unscrupulous supplier could try to take back the equipment just before the rental period expires in order to retain title to it. We note, however, that our rules would not require a supplier to accept a beneficiary as a customer simply because a beneficiary chooses to change suppliers. In addition, we note that we are considering certain policies that would address how contract suppliers are reimbursed if they must begin furnishing items to beneficiaries midway through the rental period under a competitive bidding program, and we expect to fully address this issue in the final rule that implements the Medicare DMEPOS Competitive Bidding Program. *Comment:*
                         One commenter noted that our literal interpretation of the DRA would require suppliers to track equipment by serial number in order to make sure the beneficiary receives title to the equipment that the supplier furnished originally. The commenter stated that this will be very difficult for suppliers to accomplish and suggested that during the period of continuous use, suppliers be permitted to continue the current practice of simply replacing equipment in need of service or repair with equipment of the same type that is in good working order. This practice will allow suppliers to streamline their operations and serve beneficiaries more efficiently equipment that must be repaired or serviced at the supplier's facility. The commenter further stated that we can address this issue simply by requiring that the beneficiary receive title to equipment that is of comparable quality to the equipment delivered at the beginning of the period of continuous use. Another commenter stated that we should not impede service delivery by restricting replacement of equipment during the capped rental period. The commenter indicated the equipment requirement would limit the ability of the new patient to try new or different equipment/enhanced technology. *Response:*
                         Suppliers have access to and frequently use current inventory tracking technology that allows them to easily track specific items they take from their inventory and furnish to a patient in their home. This is a normal part of the supplier's business. As explained above, suppliers of oxygen tanks and cylinders do not need to track specific tanks and cylinders belonging to beneficiaries. In addition, as explained above, this final rule allows the suppler to replace equipment during the rental period in certain situations. *Comment:*
                         One commenter remarked that the proposed rule states that the current supplier or beneficiary is responsible for finding a new supplier if a beneficiary needs to relocate from one service area to another service area during the rental period. The commenter indicated that this should be limited to the beneficiary since it is the choice of the beneficiary to relocate and not that of the supplier. *Response:*
                         While the proposal states that the supplier or beneficiary would need to arrange for another supplier in the new area to furnish the item, it does not mandate that the supplier, rather than the beneficiary, must make these arrangements. In cases where the supplier elects not to provide this service to the beneficiary, the beneficiary or caregiver for the beneficiary would need to make these arrangements. This proposal is consistent with current practice and is being adopted as part of this final rule. Assignment *Comment:*
                         We received numerous comments on the Medicare assignment proposal. Some commenters requested clarification of our notice requirements about Medicare assignment to ensure it is consistent with the general rule that participating suppliers agree to accept assignment on an annual basis and can modify their status as a participating supplier as well. They also requested clarification that suppliers disclose to beneficiaries their intent to accept assignment on all claims for the duration of the rental period, and stated that the supplier should be able to clarify under what circumstances assignment would no longer be appropriate, such as if the beneficiary is no longer eligible for coverage. Some commenters noted that we do not have the authority to change Medicare assignment terms and should not require suppliers to disclose their intentions regarding assignment for the entire duration of the rental periods. Commenters indicated that current Medicare supplier standards require a supplier to inform patients of whether or not it will accept assignment for one month at a time (per claim) and that it is unreasonable for us to expect a supplier to commit to accepting assignment for the entire rental period when policies, payment levels or other things could change by the end of the first year. Some commenters requested that we not adopt our proposal to post assignment statistics for each supplier on our website, but that if we proceed with publication, we should coordinate this effort with suppliers to ensure correct information is distributed to the public. Some commenters observed that we do not indicate how often we will make web postings and how we will verify the accuracy of postings. This could result in an inaccurate picture of a supplier's assignment history since suppliers could choose not to accept assignment for a variety of reasons, which a basic percentage will not demonstrate. If we intend to post assignment information, commenters believe that we should give suppliers 30 days notice, as well as an opportunity to review information prior to posting and to correct erroneous information or identify the risks posed by erroneous information. Commenters indicated that we cannot require suppliers to enter into private contracts for the duration of the period of continuous use. Finally, commenters stated that we must clarify in the final regulation whether a supplier may accept assignment for a portion of the rental period, since allowing this type of assignment arrangement would still further the stated intent to create a reasonable rule for suppliers and ensure that beneficiaries have the information necessary to make informed choices. *Response:*
                         Under Medicare, DME suppliers can accept assignment on a claim-by-claim basis. If a supplier accepts assignment, the supplier agrees to request direct payment from Medicare for the item, to accept 80 percent of the Medicare allowed payment amount for the item from the carrier, and to charge the beneficiary not more than the remaining 20 percent of the Medicare approved payment amount, plus any unmet deductible. If a supplier elects not to accept assignment, Medicare pays the beneficiary 80 percent of the Medicare allowed payment amount, after subtracting any unmet deductible, and there is no limit under Title XVIII of the Act on the amount the supplier can charge the beneficiary for rental of the DME item. The beneficiary, in these situations, is financially responsible for the difference between 80 percent of the Medicare allowed payment amount and the amount the supplier charges for the rental of the DME item. Suppliers can also sign a participation agreement where they agree voluntarily, before a calendar year, to accept assignment for all Medicare items and services furnished to a beneficiary for the following calendar year. Current supplier participation agreements are renewable annually. In the proposed rule, we did not propose to change the current voluntary 
                        ( print page 65926)
                        participation agreement. Nor did we propose to change acceptance of assignment on a claim-by-claim basis for suppliers who do not sign participation agreements. However, we did point out that the calendar year participation agreements do not coincide with a beneficiary's full period of medical need in cases where such need extends for more than a calendar year or where such a period overlaps calendar years. While a supplier may renew its participation agreement annually, a beneficiary would not know, before choosing a supplier, the intentions of the supplier regarding acceptance of assignment of all claims during the 13-month or 36-month rental period. We proposed to require suppliers to give beneficiaries advance notice of the possible extent of their financial liability during the period of medical need in which monthly rental payments are made for the equipment so that they can use this information to make an informed choice of supplier. We proposed that before furnishing the oxygen equipment or a capped rental item, the supplier must disclose to the beneficiary its intentions regarding whether it will accept assignment of all monthly rental claims for the equipment during the period of medical need, up to and including the 36th month of continuous use for oxygen equipment or the 13th rental month of continuous use for capped rental DME in which rental payments could potentially be made. We indicated that we believe it is reasonable for the supplier to disclose to each beneficiary its intentions regarding acceptance of assignment as this decision has a direct financial effect on the beneficiary. While we proposed to require an up-front declaration on assignment intentions, a supplier would not be bound by such declaration unless the supplier chooses to do so. For example, a supplier who routinely signs participation agreements and intends to accept assignment for all months during a beneficiary's period of medical need may choose to let such information be known to the beneficiary. Such supplier might want to use such information as a marketing advantage. A supplier's declaration could indicate that the supplier intends to accept assignment for a portion of the period of medical need. A beneficiary could use such information from such supplier and compare it with the declaration from another supplier who intends to accept assignment for the entire period of medical need and make a selection between such two suppliers. While we proposed that a supplier's intentions could be expressed in the form of a written agreement between the supplier and a beneficiary, we did not propose to require a binding written agreement. A supplier could select the form of the declaration. If a supplier chose to offer a written agreement, the nature of such agreement would be between the supplier and the beneficiary. We believe that the required declaration is consistent with and complements the voluntary participation agreement because they represent different things; the former is a beneficiary-specific declaration of intentions applicable to the beneficiary's period of medical need but is not binding, while the latter is a voluntary agreement that applies to claims for all beneficiaries served for a calendar year and is binding. Assignment applies with respect to covered-Medicare services. Thus, a supplier's declaration of assignment acceptance would only apply to covered-Medicare services. In the proposed rule, we indicated that in order to promote informed beneficiary choices, we plan to post information on a CMS and/or CMS contractor Web site(s) indicating supplier specific information on oxygen equipment and capped rental items such as (1) the percentage of beneficiaries for whom each supplier accepted assignment during a prior period of time (for example, a quarter), and/or (2) the percentage of cases in which the supplier accepted assignment during the beneficiary's entire rental period. We do not agree with the commenters who asked that we not post information about assignment statistics for each supplier. We believe that such information is necessary to promote informed beneficiary choices of suppliers. It would not be possible to promote more informed beneficiary choices among suppliers if we did not publish such information. Publication of such information is consistent with the Agency's goal of promoting transparency. We expect that the supplier-specific assignment information that we post would be derived from Medicare paid claims data. We plan to give suppliers the opportunity to review information prior to posting the first time we post information. After a period of time, we believe that the assignment information for a supplier is likely to be relatively stable. Thus, rather than delaying the posting of information on an ongoing basis by providing an opportunity to review information prior to each posting, we would post the information and allow a supplier to contact us or the carrier if a supplier believes that erroneous information was posted. We have not decided how often we would post assignment statistics. *Comment:*
                         One commenter asked for clarification on whether or not in-home clinical assessments will be part of patient care after they have received home oxygen therapy for 36 months. The commenter strongly encouraged us to allow patients to continue to receive these assessments according to physician orders. The commenter noted that this activity is sustainable only if we establish a new code and an appropriate reimbursement rate. *Response:*
                         In-home clinical assessments are the responsibility of the physician, not the supplier and are therefore outside the scope of the DME benefit. It is the obligation of the physician to ensure that beneficiaries continue to be evaluated, as medically necessary. IV. Provisions of the Final Regulations In this final rule, we generally adopt the provisions of the August 3, 2006 proposed rule. We have, however, changed the methodology we will use to impute a wage index for rural areas. We will calculate a rural wage index by averaging the wage indexes from all CBSAs that we believe are contiguous to that rural area if that rural area lacks rural hospital wage data. In addition, we are revising the fixed-dollar loss ratio used in the calculation of the outlier payment to reflect the most recent available data. We are finalizing a policy regarding change of equipment during a rental period to allow for changes under four general scenarios: (1) The supplier replaces an item with the same, or equivalent, make and model of equipment because the item initially furnished was lost, stolen, irreparably damaged, is being repaired, or no longer functions; (2) the physician orders different equipment for the beneficiary. If the need for different equipment is based on medical necessity, then the order must indicate why the equipment initially furnished is no longer medically necessary and the supplier must retain this order in the beneficiary medical record; (3) the beneficiary chooses to obtain a newer technology item or upgraded item and signs an advanced beneficiary notice (ABN); or (4) CMS or the carrier determines that a change in equipment is warranted. The Medicare contractor can also determine that a change in equipment is warranted for additional reasons. We reincorporated a policy that we inadvertently deleted from section 414.229(g) of our current regulations in the proposed rule with regard to replacement of equipment to allow for 
                        ( print page 65927)
                        replacement of rented capped rental items in cases where the item is lost or irreparably damaged. We stated that we would be continuing that policy, applying it to all rented items, and also applying it to cases where an item has been stolen. We also stated that we would move that policy from § 414.229(g) to § 414.210(f) since it would now apply to all rented items. We have revised the policy that requires suppliers to replace beneficiary-owned equipment that they furnished that fails to function for the full period established as the reasonable useful lifetime for the equipment. The need for the replacement of the equipment will not automatically be mandated merely because the repair costs are greater than 60 percent of the cost to replace the item. Rather, the determination regarding the need for replacement will be made by the Medicare contractor on an individual case-by-case basis. We added a provision to require suppliers to provide information to beneficiaries at the time of title transfer for oxygen equipment on how to safely dispose of oxygen equipment that is no longer medically necessary and advise that beneficiaries must comply with all Federal, State, and local laws that apply to the disposal, transport, and resale of oxygen equipment. We have revised the policy for maintenance and servicing of beneficiary-owned oxygen equipment so that beginning 6 months after title to oxygen equipment transfers to the beneficiary, the supplier may bill for general maintenance and servicing of beneficiary-owned oxygen equipment once every 6 months. Payment for each of these general maintenance calls would be limited to 30 minutes of labor, plus the reasonable cost for any replacement parts. Under this policy, suppliers could bill for general maintenance and servicing of all oxygen equipment except liquid or gaseous oxygen equipment (stationary and portable). We are also specifying that these general maintenance and servicing payments would not begin until at least 6 months after the date that title to the equipment transfers. Finally, we will make these payments for general maintenance and servicing in addition to payment for any non-routine repairs needed for beneficiary-owned oxygen equipment. Suppliers would be able to bill for such non-routine maintenance beginning immediately after the beneficiary assumes ownership of the equipment. We have revised the provisions regarding transfer of title for oxygen tanks to clarify that, although Medicare payments for oxygen equipment are limited to 36 months and the statute requires transfer of ownership after 36 months, the arrangement between the supplier and beneficiary allows the supplier to replace the beneficiary-owned tanks with new or different tanks of equal or greater value when the supplier picks up empty tanks to be refilled with oxygen contents and delivers refilled tanks back to the beneficiary. We have also revised the provisions to allow for a servicing payment when suppliers pick up tanks that are no longer medically necessary. We have also made several clarifying changes to the regulation text. We have also added a provision that would require a supplier to disclose at least 2 months before the date that the beneficiary will assume ownership of oxygen equipment or a capped rental item whether the supplier can maintain and service the item after the title transfers and, in the case of oxygen equipment, whether the supplier can deliver oxygen contents. We or our carriers would have discretion to make exceptions to this requirement on a case-by-case basis. V. Collection of Information Requirements Under the Paperwork Reduction Act of 1995, we are required to provide 30-day notice in the 
                        **Federal Register**
                         and solicit public comment when a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues: The need for the information collection and its usefulness in carrying out the proper functions of our agency.
                    The accuracy of our estimate of the information collection burden.
                    The quality, utility, and clarity of the information to be collected.
                    Recommendations to minimize the information collection burden on the affected public, including automated collection techniques. We are soliciting public comment on each of these issues for the following sections of this document that contain information collection requirements: Section 414.2267 Oxygen and Oxygen Equipment This section requires the supplier to disclose to the beneficiary, prior to the furnishing of oxygen equipment, whether or not it will accept assignment of all monthly rental claims for the duration of the rental period. The burden associated with this requirement is the time and effort put forth by the supplier to educate the beneficiary and to disclose information regarding its intent to accept assignment. While this information collection is subject to the PRA, we believe this requirement meets the requirements of 5 CFR 1320.3(b)(2), and as such, the burden associated with this requirement is exempt from the PRA. This section requires a supplier to retain the physician's order submitted for a different type of equipment in the patient's medical record and to disclose to the beneficiary its intentions regarding whether it will accept assignment of all monthly rental claims for the duration of the rental period. The burden associated with this requirement is the time and effort put forth by the supplier to retain and disclose the required information. While this information collection is subject to the PRA, we believe this requirement meets the requirements of 5 CFR 1320.3(b)(2), and as such, the burden associated with this requirement is exempt from the PRA. Section 414.229 Other Durable Medical Equipment—Capped Rental Items This section requires a supplier to retain the physician's order submitted for a different type of equipment in the patient's medical record and to disclose to the beneficiary its intentions regarding whether it will accept assignment of all monthly rental claims for the duration of the rental period. The burden associated with this requirement is the time and effort put forth by the supplier to retain and disclose the required information. While this information collection is subject to the PRA, we believe this requirement meets the requirements of 5 CFR 1320.3(b)(2), and as such, the burden associated with this requirement is exempt from the PRA. If you comment on these information collection and recordkeeping requirements, please mail copies directly to the following: Centers for Medicare & Medicaid Services, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attn: Melissa Musotto, [CMS-1304-F], Room C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850; and Office of Information and Regulatory Affairs, Office of Management and Budget, Room 10235, New Executive Office Building, Washington, DC 
                        ( print page 65928)
                        20503, Attn: Carolyn Lovett, CMS Desk Officer, CMS-1304-F, 
                        *carolyn_lovett@omb.eop.gov*. Fax (202) 395-6974. VI. Regulatory Impact Analysis A. Overall Impact We have examined the impacts of this rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132. Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibility of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). This final rule will be a major rule, as defined in Title 5, United States Code, section 804(2), because we estimate the impact to the Medicare program, and the annual effects to the overall economy, will be more than $100 million. The update set forth in this final rule will apply to Medicare payments under the HH PPS in CY 2007. Accordingly, the following analysis describes the impact in CY 2007 only. We estimate that there will be an additional $440 million in CY 2007 expenditures attributable to the CY 2007 estimated home health market basket update of 3.3 percent. We estimate that the effect of the wage index update will bring CY 2007 expenditures to $410 million. The RFA requires agencies to analyze options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small government agencies. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $6 million to $29 million in any 1 year. For purposes of the RFA, approximately 75 percent of HHAs are considered small businesses according to the Small Business Administration's size standards with total revenues of $11.5 million or less in any 1 year. Individuals and States are not included in the definition of a small entity. As stated above, this final rule will provide an update to all HHAs for CY 2007 as required by statute. This final rule will have a significant positive effect upon small entities that are HHAs. Based on our analysis of 2003 claims data, we also estimate that approximately 90 percent of registered DME suppliers are considered small businesses according to the Small Business Administration's size standards. The size standard for NAICS code, 532291, Home Health Equipment Rental is $6 million. (
                        *see http://www.sba.gov/​size/​sizetable2002.html,*
                         read May 9, 2005.) This final rule will reduce payments for oxygen equipment and capped rental items and, therefore, will have a significant negative effect upon small entities that are DME suppliers overall. However, as explained in detail below, we believe that Medicare payments will still be adequate for the items affected by this rule and that suppliers whose primary line of business involves furnishing these items will remain profitable. In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 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. We have determined that this final rule will not have a significant economic impact on the operations of a substantial number of small rural hospitals. Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4) also requires that agencies assess anticipated costs and benefits before issuing any rule that may result in expenditures in any 1 year by State, local, or tribal governments, in the aggregate, or by the private sector, of $120 million. We believe this final rule will not mandate expenditures in that amount. Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. We have reviewed this rule under the threshold criteria of Executive Order 13132, Federalism. We have determined that this final rule will not have substantial direct effects on the rights, roles, and responsibilities of States. B. Anticipated Effects 1. Home Health PPS This final rule will update the HH PPS rates contained in Pub. 100-20, One Time Notification, Transmittal 211, published February 10, 2006. We updated the rates in the CY 2006 final rule (70 FR 68132, November 9, 2005) through Transmittal 211 to take account of the DRA changes, specifically the 0 percent update and the rural add-on. The impact analysis of this final rule presents the projected effects of the change from the CY 2006 transition wage index (50/50 blend of MSA-based and CBSA-based designations) to the CY 2007 CBSA-based designations in determining the wage index used to calculate the HH PPS rates for CY 2007. We estimate the effects by estimating payments while holding all other payment variables constant. We use the best data available, but we do not attempt to predict behavioral responses to these changes, and we do not make adjustments for future changes in such variables as days or case-mix. This analysis incorporates the latest estimates of growth in service use and payments under the Medicare home health benefit, based on the latest available Medicare claims from 2004. We note that certain events may combine to limit the scope or accuracy of our impact analysis, because such an analysis is future-oriented and, thus, susceptible to forecasting errors due to other changes in the forecasted impact time period. Some examples of such possible events are newly-legislated general Medicare program funding changes made by the Congress, or changes specifically related to HHAs. In addition, changes to the Medicare program may continue to be made as a result of the BBA, the BBRA, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, the MMA, the DRA, or new statutory provisions. Although these changes may not be specific to the HH PPS, the nature of the Medicare program is such that the changes may interact, and the complexity of the interaction of these changes could make it difficult to predict accurately the full scope of the impact upon HHAs. Our discussion for this final rule will focus on the impact of changes in the wage index, most notably the adoption of the full CBSA designations. The impacts of the updated wage data are shown in Table 13 below. The breakdown of the various impacts displayed in the table follows. The rows display the estimated effect of the changes on different categories. The first row of figures represents the 
                        ( print page 65929)
                        estimated effects on all facilities. The next 2 rows show the effect on urban and rural facilities. This is followed, in the next 4 rows, by impacts on urban and rural facilities based on whether they are a hospital-based or freestanding facility. The next 20 rows show the effect on urban and rural facilities based on the census region in which they are located. The first column shows the breakdown of all HHAs by urban or rural status, hospital-based or freestanding status, and census division. The second column in the table shows the number of facilities in the impact database. A facility is considered urban if it is located in a CBSA and, conversely, rural if it is not located in a CBSA. The third column of the table shows the effect of the annual update to the wage index. This represents the effect of using the most recent wage data available to determine the estimated home health market basket update. The total impact of this change is −0.2 percent; however, there are distributional effects of the change. The fourth column of the table shows the effect of all the changes on the CY 2007 payments. The estimated market basket update of 3.3 percentage points is constant for all providers and is included in this column. Although the market basket increase for CY 2007 is 3.3 percent, fluctuations in the wage index impact the projected payments as well. The total impact of the wage index update is −0.2 percent. Therefore, including effects of the wage index, we project that total aggregate payments will increase by 3.1 percent, assuming that facilities do not change their care delivery and billing practices in response. As can be seen from this table, the combined effects of all of the changes, including the updated wage index and the market basket increase of 3.3 percent, will vary by specific types of providers and by location. For example, HHAs in the rural Pacific show the largest estimated increase in payment at 11.0 percent, while HHAs in the rural Mountain census division show the smallest increase in payments at 0.5 percent. Rural HHAs do somewhat better than urban HHAs, seeing an estimated increase in payments of 3.6 percent and 3.1 percent respectively. Amongst the different type of facility categories, freestanding rural HHAs do best, with an estimated increase in payments of 3.8 percent. Hospital-based urban HHAs are next with an estimated increase in payments of 3.4 percent, followed by hospital-based rural and freestanding urban HHAs following with estimated increases of 3.2 percent and 3.0 percent respectively. Table 13.—Projected Impact of CY 2007 Update to the HH PPS
Number of 
                                 facilities
Updated 
                                 wage data  
                                 (percent)
Total CY 
                                 2007 change  
                                 (percent)Total
7,370
−0.2
3.1Urban
5,273
−0.2
3.1Rural
2,097
0.3
3.6Hospital based urban
1,988
0.1
3.4Freestanding urban
3,285
−0.3
3.0Hospital based rural
1,201
−0.1
3.2Freestanding rural
896
0.5
3.8**Urban by Region**New England
254
−1.2
2.1Middle Atlantic
423
−0.2
3.1South Atlantic
913
−0.4
2.8East North Central
886
0.4
3.7East South Central
222
−0.6
2.7West North Central
304
0.1
3.4West South Central
1,300
−0.8
2.5Mountain
281
1.6
4.9Pacific
649
0.4
3.7Outlying
41
−4.2
1.0**Rural by Region**New England
43
−1.1
2.2Middle Atlantic
82
0.1
3.4South Atlantic
239
−0.7
2.6East North Central
284
1.6
5.0East South Central
215
0.1
3.4West North Central
488
0.2
3.5West South Central
475
−0.4
2.8Mountain
173
−2.7
0.5Pacific
88
7.5
11.0Outlying
10
8.9
12.5
 The impact of the wage index for CY 2007 is shown in Addendum C to this document. Addendum C to this document shows a side-by-side comparison, by State and county code, of the CY 2006 transition wage index, which was a 50/50 blend of MSA-based and CBSA-based pre-floor, pre-reclassified hospital wage indexes, and pre-floor, pre-reclassified hospital wage index for the CY 2007 HH PPS update. In the last column of Addendum C to this document, we show the percentage change in the wage index from CY 2006 to the wage index for CY 2007. We estimate that there will be an additional $410 million in CY 2007 expenditures attributable to the CY 2007 estimated 
                        ( print page 65930)
                        market basket increase of 3.3 percent and the wage index update of ^0.2 percent. Thus, the anticipated expenditures outlined in this final rule will exceed the $100 million annual threshold for a major rule as defined in 5 U.S.C. section 804(2). This final rule will have a positive effect on providers of Medicare home health services by increasing their Medicare payment rates. We anticipate that very few HHAs will not submit the quality data required by section 1895(b)(3)(B)(v)(II) of the Act necessary to receive the full market basket percentage increase. Submission of OASIS data is a Medicare condition of participation for HHAs. Therefore, we expect that very few HHAs would be subject to the 2 percent reduction in payments in CY 2007. As indicated in the rule, most HHAs that do not report OASIS provide pediatric, non-Medicare, or personal care only. However, CMS is aware of instances of non-compliance among a very small portion of HHAs with regard to OASIS submission. For the purposes of the CY 2007 impact analysis, we anticipate that less than 1 percent of HHAs, involving less than 1 percent of total Medicare HH payments, would fail to submit quality data and hence will be subject to the 2 percent reduction. This is not enough to impact the estimated $410 million in additional expenditures. Finally, we do not believe there is a differential impact due to the aggregate nature of the update. We do not anticipate specific effects on other providers. 2. Oxygen and Oxygen Equipment Provisions As mandated by the DRA of 2005, this final rule limits to 36 months the total number of continuous months for which Medicare will pay for oxygen equipment, after which the title to the oxygen equipment will be transferred from the supplier to the beneficiary. Since Medicare currently pays for oxygen equipment on a monthly basis for as long as it is medically necessary, this change will result in savings to Medicare. In addition, the DRA mandates that Medicare continue to make monthly payments for furnishing contents for beneficiary-owned oxygen equipment, as well as payments for reasonable and necessary maintenance and servicing of beneficiary-owned oxygen equipment. Approximately one million beneficiaries now receive oxygen therapy. Although monthly rental payments already have been reduced by 30 percent by section 4552 of the Balanced Budget Act of 1997 and approximately 10 percent by section 302(c)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Medicare allowed charges rose to $2.72 billion by 2005, a 68 percent increase since 1998 that reflects the growing use. Before the amendments to section 1834(a)(5) of the Act made by the DRA, Medicare continued to make rental payments for as long as medical necessity continued, even when the total payments greatly exceeded the cost of purchasing the equipment and the supplier retained title to the equipment. We believe the DRA amendments to the Act will result in a loss of revenue to suppliers that will no longer receive payments for oxygen equipment after the 36th month of continuous use. Based on data for items furnished in calendar year 2005, oxygen concentrators accounted for approximately 94 percent of Medicare utilization for stationary oxygen systems, in terms of both allowed charges and allowed services. Since oxygen concentrators can typically be purchased for $1,000 or less, we believe that 36 months of payment at approximately $200 per month will ensure the supplier is reimbursed for its cost for furnishing the equipment. The $200 allowed payment amount may be re-adjusted in the future to assure that payments are adequate, but not excessive. This could be accomplished though the competitive acquisition programs mandated by section 1847 of the Act or in accordance with our authority for adjusting fee schedule amounts at section 1842(b)(8) and (9) of the Act. Based on data gathered by the OIG in the course of developing their September 2006 report (OEI-09-04-00420), approximately 22 percent of Medicare beneficiaries rented oxygen equipment for 36 months or longer and approximately 16 percent of Medicare beneficiaries rented oxygen equipment for 48 months or longer. In section IV, “Provisions of the Final Regulation” section of this preamble, we are allowing beneficiaries to obtain replacement oxygen equipment in cases where their equipment has been in continuous use for the reasonable useful lifetime of the equipment. Unless CMS or its carriers establish a specific reasonable useful lifetime for oxygen equipment, the default lifetime for DME of 5 years will apply. The main effect of this rule on suppliers is that they will not be able to receive payment for the equipment beyond 36 months for approximately 22 percent of Medicare patients. They will also not be able to receive payment for furnishing the same item to subsequent patients in these cases since they lose title to the equipment. In the case of oxygen concentrator systems and portable oxygen transfilling systems, delivery of oxygen contents is not necessary, and therefore, payment will not be made for the furnishing of contents for these types of beneficiary owned equipment. Under the old payment rules, payment for oxygen concentrators used for stationary equipment purposes would have continued at approximately $200 per month for the entire period of medical need. Section 5101(b) of the DRA mandates that payment for oxygen equipment end and that title to the equipment transfer after 36 months of continuous use. In the case of liquid and gaseous oxygen systems, suppliers will continue to be paid for furnishing oxygen contents for beneficiary-owned systems. The current statewide monthly payment amounts for oxygen and oxygen equipment that would be paid during the 36-month period of continuous use for beneficiaries who only use stationary equipment range from $194.48 to $200.41, with the weighted average statewide fee being $199.84. The current statewide monthly payment amount for furnishing oxygen contents for beneficiary owned equipment range from $137.54 to $198.12, with the weighted average statewide fee being $154.90. The average decrease in Medicare fee schedule amounts that may result from the DRA changes for liquid and gaseous systems after the 36-month period (that is, shift from monthly payments for equipment and contents to monthly payments for contents only), is expected to be $44.94 ($199.84-$154.90). Therefore, this is the level of monthly reimbursement that would be lost after the 36-month period for suppliers that furnish oxygen and oxygen equipment to beneficiaries in these situations and who continue to furnish contents to these beneficiaries. Based on current fee schedule amounts for all oxygen and oxygen equipment, this equates to an average reduction in payment (from $199.84 to $154.90) of approximately 22 percent. At the current monthly statewide fee schedule rates, which range from $194.48 to $200.41, suppliers of oxygen equipment are expected to be paid from $7,001.28 to $7,214.76 over 36 months. By comparison, a medical center operated by the Department of Veterans Affairs (VA) in Tampa, Florida, is the largest VA center in terms of number of veterans on oxygen therapy and services approximately 1,000 patients on oxygen by contracting with a locally based manufacturer to purchase the oxygen concentrators for $895 each. The medical center contracts with a local 
                        ( print page 65931)
                        supplier for $90 to deliver and set up the concentrator to the patient's home. This local supplier also provides service and maintenance of the equipment at any time throughout the year for $48 per service episode. If the equipment needs to be replaced, the local supplier will furnish another concentrator for a $90 fee. The VA total payments over 5 years for an oxygen concentrator used by a veteran in this center plus payment for 10 episodes of maintenance and servicing, assuming servicing every 6 months, will be $1,435, compared to total Medicare allowed charges of $7,164, on average, for a Medicare beneficiary. Based on this comparison, the Medicare payment amounts and methodology appear to be more than adequate. We do not anticipate that transfer of ownership for oxygen equipment to the beneficiary after 36 months of continuous use will be a significant financial burden to suppliers because the effect is limited to a maximum of 36 percent of a supplier's Medicare business and because suppliers of oxygen equipment primarily furnish lower cost oxygen concentrators. We also do not anticipate a significant change in the rate of assignment of claims for oxygen equipment based on our belief that suppliers will be adequately reimbursed for furnishing the oxygen equipment. In accordance with the statute and this final rule, suppliers will also receive payments for reasonable and necessary maintenance and servicing of beneficiary-owned oxygen equipment, including a general maintenance and servicing payment for certain oxygen equipment every 6 months, beginning 6 months after the date that the beneficiary assumes ownership of the equipment. Finally, the new oxygen and oxygen equipment classes and national payment amounts that are established as part of this final rule, will likely result in a shift in utilization between the various oxygen equipment modalities, which could impact supplier revenues and sales volume for certain oxygen equipment manufacturers. However, since the payment amounts will be budget-neutral in accordance with section 1834(a)(9)(D)(ii) of the Act, there will not be a significant impact on overall Medicare payments to suppliers. 3. Capped Rental DME This final rule, which limits to 13 months the total number of continuous months for which Medicare would pay for capped rental DME, after which the ownership of the capped rental item would be transferred from the supplier to the beneficiary, will result in significant savings for the Medicare program. Savings will be realized through: (1) The gradual elimination of rental payments for the 14th and 15th months of continuous use; and (2) changing the semi-annual payment for maintenance and servicing to payment only when reasonable and necessary maintenance and servicing is needed. We anticipate that suppliers may lose money due to the loss of 1 to 2 months rental in cases where beneficiaries need the item for more than 13 months and would not have otherwise selected the purchase option currently described in § 414.229(d). The average of the 2006 fee schedule amounts for all capped rental items for months 14 and 15 is approximately $152. We do not believe suppliers will suffer financially as a result of this provision based on data which show that in 2004, 97 percent of suppliers accepted assignment for beneficiaries who chose the purchase option (§ 414.229(d)) in the 10th month of a capped rental period. This is an indication that suppliers were willing to accept the Medicare payment as payment in full for the capped rental item, even though they had been informed that the beneficiary will take over ownership of the item after the 13th month of continuous use. Therefore, we do not anticipate that transfer of ownership for capped rental equipment to the beneficiary after 13 months of continuous use will be a significant financial burden to suppliers. For items for which the first rental payment falls on or after January 1, 2006, Medicare will only pay for maintenance and servicing as necessary. In a June 2002 report (OEI-03-00-00410), the Office of Inspector General (OIG) indicated that only 9 percent of the capped rental equipment with a June 2000 service date actually received any servicing between June and December 2000. Out of the $7.3 million Medicare paid for maintenance services from June 2000, OIG estimated that $6.5 million was paid for equipment that received no actual servicing. The OIG recommended to CMS in 2002 that we eliminate the semi-annual maintenance payment currently allowed for capped rental equipment and pay only for repairs when needed. The combination of these two factors provides strong evidence that the Medicare rules for paying for maintenance and servicing of capped rental equipment furnished before January 1, 2006, were not cost-effective. Impact on Beneficiaries The DRA provisions and this final rule will result in savings for Medicare beneficiaries using oxygen equipment and capped rental items. For capped rental items, Medicare payments will be made for 13 continuous months and for oxygen equipment, payments will be made for 36 continuous months. After the rental period for each category of equipment expires, ownership of the equipment will transfer from the suppliers to the beneficiaries. Beneficiaries will continue to be financially responsible for a 20 percent coinsurance payment during the 13- or 36-month rental periods for capped rental items and oxygen equipment, respectively. However, even though beneficiaries will still be required to make a 20 percent coinsurance payment in connection with each maintenance and servicing call, beneficiaries will no longer have to make a monthly 20 percent coinsurance payment for oxygen equipment after they own it, or a 20 percent coinsurance payment every 6 months for maintenance and servicing of beneficiary-owned capped rental items, even if maintenance and servicing is not needed. This will result in significant savings to beneficiaries. For example, before the DRA, Medicare and the beneficiary made continuous payments for the rental of oxygen equipment that totaled about $200 per month. Of this amount, the beneficiary paid coinsurance of $40 which will equal $480 for a single year's rental, $1,440 over 36 months, and $2,400 over 5 years. After the DRA, beneficiaries will only pay a coinsurance amount for up to 36 months for the rental of oxygen equipment, after which time they will own the equipment. Thus, the DRA oxygen provisions result in savings of approximately $480 if beneficiaries use the equipment for 4 years, and $960 if they use the equipment for 5 years. As a result of the provision of this final rule that allows for a general maintenance and servicing call every 6 months, beneficiaries could pay approximately $6 in coinsurance payments for assigned claims, and more for unassigned claims for supplier labor associated with these services. However, the beneficiary can elect not to have these services performed if they feel that their equipment is not in need of servicing. For capped rental items, beneficiaries will save coinsurance by not being responsible for any equipment payment after the 13th rental month or the automatic semi-annual maintenance and servicing payment that was approximately equal to 10 percent of the 
                        ( print page 65932)
                        purchase price for the equipment. Before the DRA, Medicare and the beneficiary would pay up to 15 months for capped rental items, and Medicare and the beneficiary would also pay for maintenance and servicing every 6 months. Thus, beneficiaries will save coinsurance payments related to both the equipment itself and the maintenance and servicing of that equipment. This final rule will assure beneficiaries that unless certain prescribed exceptions apply, suppliers that furnish the equipment for the first month will continue to furnish the equipment for the entire 36-month period of continuous use for oxygen equipment or the 13-month period of continuous use for capped rental. Beneficiaries will also be assured that their oxygen and capped rental equipment would not be impermissibly swapped by the supplier at any time during the rental period. Under the final rule, we require that a supplier may not provide different rented equipment to the beneficiary at any time during the 36 rental months for oxygen equipment or the 13 rental months for capped rental DME unless one of the following three exceptions apply: (1) The supplier replaces an item with the same, or equivalent, make and model of equipment because the item initially furnished was lost, stolen, irreparably damaged, is being repaired, or no longer functions; (2) The physician orders a different equipment for the beneficiary. If the need for different equipment is based on medical necessity, the order must indicate why the equipment initially furnished is no longer appropriate or medically necessary, and the supplier must retain this order in the beneficiary's medical record; (3) The beneficiary chooses to obtain a newer technology item or upgraded item and signs an ABN; or (4) CMS or the carrier determines that a change in equipment is warranted. We are requiring that suppliers inform beneficiaries whether they intend to accept or not accept assignment on all monthly rental claims during the 13-month rental period for capped rental items or the 36-month rental period for oxygen equipment in an upfront manner. This final rule will also assure beneficiaries that following the transfer of title, the supplier must replace an item at no cost to the beneficiary in cases where the carrier determines that the item furnished by the supplier will not last for the entire reasonable useful lifetime established for the equipment. In making this determination, the carrier may consider whether the accumulated costs of repair exceed 60 percent of the cost to replace the item. C. Accounting Statement As required by OMB Circular A-4 (available at 
                        *http://www.whitehouse.gov/​omb/​circulars/​a004/​a-4.pdf*), in Table 14 below, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this final rule. This table provides our best estimate of the increase in Medicare payments under the HH PPS as a result of the changes presented in this final rule based on the data for 7,370 HHAs in our database. All expenditures are classified as transfers to Medicare providers (that is, HHAs). Table 14.—Accounting Statement: Classification of Estimated Expenditures, From CY 2006 to CY 2007
[In millions]
Category
TransfersAnnualized Monetized Transfers
$410From Whom to Whom?
Federal Government to HHAs.
 In Table 15 below, we have prepared an accounting statement showing the classification of the expenditures associated with the DME provisions of this final rule. This table provides our best estimate of the decrease in Medicare payments under the DME benefit as a result of the changes presented in this final rule based on the 2004 allowed charge data for oxygen and capped rental DME in our database. All expenditures are classified as transfers to the Medicare program and its beneficiaries. Table 15.—Accounting Statement: Classification of Estimated Expenditures
[In millions]
Category
TransfersMonetized Transfers in FY 2007
$80Monetized Transfers in FY 2008
$130Monetized Transfers in FY 2009
$170Monetized Transfers in FY 2010
$220Monetized Transfers in FY 2011
$280From Whom to Whom?
Suppliers to Federal Government and beneficiaries.
 In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the Office of Management and Budget. List of Subjects 42 CFR Part 414 Administrative practice and procedure
Health facilities
Health professions
Kidney diseases
Medicare
Reporting and recordkeeping requirements 42 CFR Part 484 Health facilities
Health professions
Medicare
Reporting and recordkeeping requirements
 For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services amends 42 CFR chapter IV as set forth below: PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Subpart D—Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices
 1.The authority citation for part 414 continues to read as follows: Authority:
                            Secs. 1102, 1871, and 1881(b)(1) of the Social Security Act (42 U.S.C. 1302, 1395(hh), and 1395rr(b)(1)). 2.Amend § 414.210 as follows: A. Revise paragraph (e). B. Revise the introductory text to paragraph (f). C. Revise paragraph (f)(2). D. Add new paragraphs (f)(3) and (f)(4). The revisions read as follows: § 414.210
  
 (e) 
                                *Maintenance and servicing*
                                —(1)
                                *General rule*. Except as provided in paragraph (e)(2) of this section, the carrier pays the reasonable and necessary charges for maintenance and servicing of beneficiary-owned equipment. Reasonable and necessary charges are those made for parts and labor not otherwise covered under a manufacturer's or supplier's warranty. Payment is made for replacement parts in a lump sum based on the carrier's consideration of the item. The carrier establishes a reasonable fee for labor associated with repairing, maintaining, and servicing the item. Payment is not made for maintenance and servicing of a rented item other than the maintenance and servicing fee for other durable medical equipment as described in § 414.229(e). (2) 
                                *Additional maintenance and servicing payment for certain 
                                    ( print page 65933)
                                    beneficiary-owned oxygen equipment.*
                                 In addition to the maintenance and servicing payments described in paragraph (e)(1) of this section, the carrier makes a maintenance and servicing payment for oxygen equipment other than liquid and gaseous equipment (stationary and portable) as follows: (i) For the first 6-month period following the date on which title to the equipment transfers to the beneficiary in accordance with § 414.226(f), no payments are to be made. (ii) During each succeeding 6-month period, payment may be made for 30 minutes of labor for general maintenance and servicing of the equipment. (3) 
                                *Additional payment for picking up oxygen tanks and cylinders*. The carrier pays the reasonable and necessary charges for a supplier to pick up and store or dispose of beneficiary-owned oxygen tanks and cylinders that are no longer medically necessary. (4) 
                                *Exception to Maintenance and Servicing Payments*. For items purchased on or after June 1, 1989, no payment is made under the provisions of paragraph (e)(1) of this section for the maintenance and servicing of: (i) Items requiring frequent and substantial servicing, as defined in § 414.222(a); (ii) Capped rental items, as defined in § 414.229(a), that are not beneficiary-owned in accordance with § 414.229(d), § 414.229(f)(2), or § 414.229(h); and (iii) Oxygen equipment, as described in § 414.226, that is not beneficiary-owned in accordance with § 414.226(f). (5) 
                                *Supplier replacement of beneficiary-owned equipment based on accumulated repair costs*. A supplier that transfers title to oxygen equipment or a capped rental item to a beneficiary in accordance with § 414.226(f) or § 414.229(f)(2) is responsible for furnishing replacement equipment at no cost to the beneficiary or to the Medicare program if the carrier determines that the item furnished by the supplier will not last for the entire reasonable useful lifetime established for the equipment in accordance with § 414.210(f)(1). In making this determination, the carrier may consider whether the accumulated costs of repair exceed 60 percent of the cost to replace the item. (f) 
                                *Payment for replacement of equipment*. If an item of DME or a prosthetic or orthotic device paid for under this subpart has been in continuous use by the patient for the equipment's reasonable useful lifetime or if the carrier determines that the item is lost, stolen, or irreparably damaged, the patient may elect to obtain a new piece of equipment. 
 (2) If the beneficiary elects to obtain replacement oxygen equipment, payment is made in accordance with § 414.226(a). (3) If the beneficiary elects to obtain a replacement capped rental item, payment is made in accordance with § 414.229(a)(2) or (a)(3). (4) For all other beneficiary-owned items, if the beneficiary elects to obtain replacement equipment, payment is made on a purchase basis.
 3.Amend § 414.226 by— A. Revising paragraph (a) and the heading of paragraph (b). B. Revising paragraph (b)(3). C. Adding paragraphs (b)(4) and (b)(5). D. Redesignating paragraph (d) as paragraph (e). E. Redesignating paragraph (c) as paragraph (d). F. Revising newly redesignated paragraph (d). G. Adding a new paragraph (c). H. Revising newly redesignated paragraph (e)(1) introductory text. I. Revising newly redesignated paragraph (e)(1)(i). J. Revising newly redesignated paragraph (e)(2)(i). K. Revising newly redesignated paragraph (e)(2)(ii). L. Adding new paragraphs (f) and (g). The revisions and additions read as follows: § 414.226
  (a) 
                                *Payment rules*
                                —(1) 
                                *Oxygen equipment*. Payment for rental of oxygen equipment is made based on a monthly fee schedule amount during the period of medical need, but for no longer than a period of continuous use of 36 months. A period of continuous use is determined under the provisions in § 414.230. (2) 
                                *Oxygen contents*. Payment for purchase of oxygen contents is made based on a monthly fee schedule amount until medical necessity ends. (b) 
                                *Monthly fee schedule amount for items furnished prior to 2007*. 
 (3) For 1991 through 2006, the fee schedule amounts for items described in paragraphs (b)(1)(iii) and (iv) of this section are determined using the methodology contained in § 414.220(d), (e), and (f). (4) For 1991 through 2006, the fee schedule amounts for items described in paragraphs (b)(1)(i) and (ii) of this section are determined using the methodology contained in § 414.220(d), (e), and (f). (5) For 2005 and 2006, the fee schedule amounts determined under paragraph (b)(4) of this section are reduced using the methodology described in section 1834(a)(21)(A) of the Act. (c) 
                                *Monthly fee schedule amount for items furnished for years after 2006*. (1) For 2007, national limited monthly payment rates are calculated and paid as the monthly fee schedule amounts for the following classes of items: (i) Stationary oxygen equipment (including stationary concentrators) and oxygen contents (stationary and portable). (ii) Portable equipment only (gaseous or liquid tanks). (iii) Oxygen generating portable equipment only. (iv) Stationary oxygen contents only. (v) Portable oxygen contents only. (2) The national limited monthly payment rate for items described in paragraph (c)(1)(i) of this section is equal to the weighted average fee schedule amount established under paragraph (b)(5) of this section reduced by $1.44. (3) The national limited monthly payment rate for items described in paragraph (c)(1)(ii) of this section is equal to the weighted average of the fee schedule amounts established under paragraph (b)(5) of this section. (4) The national limited monthly payment rate for items described in paragraph (c)(1)(iii) of this section is equal to the national limited monthly payment rate established under paragraph (c)(5) of this section, multiplied by 24, and divided by 36. (5) The national limited monthly payment rate for items described in paragraphs (c)(1)(iv) and (c)(1)(v) of this section is equal to 50 percent of the weighted average fee schedule amounts established under paragraph (b)(3) of this section for items described in paragraph (b)(1)(iii) of this section. (6) Beginning in 2008, CMS makes an annual adjustment to the national limited monthly payment rates for each class of items described in paragraph (c)(1) of this section to ensure that such payment rates do not result in expenditures for any year that are more or less than the expenditures that would have been made if such classes had not been established. (d) 
                                *Application of monthly fee schedule amounts.*
                                 (1) The fee schedule amount for items described in paragraph (c)(1)(i) of this section is paid when the beneficiary rents stationary oxygen equipment. (2) Subject to the limitation set forth in paragraph (e)(2) of this section, the fee schedule amount for items described 
                                ( print page 65934)
                                in paragraphs (c)(1)(ii) and (c)(1)(iii) of this section is paid when the beneficiary rents portable oxygen equipment. (3) The fee schedule amount for items described in paragraph (c)(1)(iv) of this section is paid when the beneficiary owns stationary oxygen equipment that requires delivery of gaseous or liquid oxygen contents. (4) The fee schedule amount for items described in paragraph (c)(1)(v) of this section is paid when the beneficiary owns portable oxygen equipment described in paragraph (c)(1)(ii) of this section, or rents portable oxygen equipment described in paragraph (c)(1)(ii) of this section and does not rent stationary oxygen equipment. (e) 
                                *Volume adjustments*. (1) The fee schedule amount for an item described in paragraph (c)(1)(i) of this section is adjusted as follows: (i) If the attending physician prescribes an oxygen flow rate exceeding four liters per minute, the fee schedule amount is increased by 50 percent, subject to the limit in paragraph (e)(2) of this section. 
 (2) * * * (i) The sum of the monthly fee schedule amount for the items described in paragraphs (c)(1)(i) and (c)(1)(ii) or (c)(1)(iii) of this section; or (ii) The adjusted fee schedule amount described in paragraph (e)(1)(i) of this section. 
 (f) 
                                *Ownership of equipment*. On the first day that begins after the 36th continuous month in which payment is made for oxygen equipment under paragraph (a)(1) of this section, the supplier must transfer title to the oxygen equipment to the beneficiary. At the time of title transfer, the supplier must provide information to the beneficiary on how to safely dispose of oxygen equipment that is no longer medically necessary and advise that the beneficiary must comply with all Federal, State, and local laws that apply to the disposal, transport, and resale of oxygen equipment. (g) 
                                *Additional supplier requirements for rentals that begin on or after January 1, 2007.*
                                 (1) The supplier that furnishes oxygen equipment for the first month during which payment is made under this section must continue to furnish the equipment until medical necessity ends, or the 36-month period of continuous use ends, whichever is earlier, unless— (i) The item becomes subject to a competitive acquisition program implemented in accordance with section 1847(a) of the Act; (ii) The beneficiary relocates to an area that is outside the normal service area of the supplier that initially furnished the equipment; (iii) The beneficiary elects to obtain oxygen equipment from a different supplier prior to the expiration of the 36-month rental period; or (iv) CMS or the carrier determines that an exception should apply in an individual case based on the circumstances. (2) Oxygen equipment furnished under this section may not be replaced by the supplier prior to the expiration of the 36-month rental period unless: (i) The supplier replaces an item with the same, or equivalent, make and model of equipment because the item initially furnished was lost, stolen, irreparably damaged, is being repaired, or no longer functions; (ii) A physician orders different equipment for the beneficiary. If the order is based on medical necessity, then the order must indicate why the equipment initially furnished is no longer medically necessary and the supplier must retain this order in the beneficiary's medical record; (iii) The beneficiary chooses to obtain a newer technology item or upgraded item and signs an advanced beneficiary notice (ABN); or (iv) CMS or the carrier determines that a change in equipment is warranted. (3) Before furnishing oxygen equipment, the supplier must disclose to the beneficiary its intentions regarding whether it will accept assignment of all monthly rental claims for the duration of the rental period. A supplier's intentions could be expressed in the form of a written agreement between the supplier and the beneficiary. (4) No later than two months before the date on which the supplier must transfer title to oxygen equipment to the beneficiary, the supplier must disclose to the beneficiary— (i) Whether it can maintain and service the equipment after the beneficiary acquires title to it; and (ii) Whether it can continue to deliver oxygen contents to the beneficiary after the beneficiary acquires title to the equipment.
 4.Amend § 414.229 by— A. Revising paragraphs (a), (f) and (g). B. Adding paragraph (h). The revisions and additions read as follows: § 414.229
  (a) 
                                *General payment rule.*
                                 Payment is made for other durable medical equipment that is not subject to the payment provisions set forth in § 414.220 through § 414.228 as follows: (1) For items furnished prior to January 1, 2006, payment is made on a rental or purchase option basis in accordance with the rules set forth in paragraphs (b) through (e) of this section. (2) For items other than power-driven wheelchairs furnished on or after January 1, 2006, payment is made in accordance with the rules set forth in paragraph (f) of this section. (3) For power-driven wheelchairs furnished on or after January 1, 2006, payment is made in accordance with the rules set forth in paragraphs (f) or (h) of this section. 
 (f) 
                                *Rules for capped rental items furnished beginning on or after January 1, 2006.*
                                 (1) For items furnished on or after January 1, 2006, payment is made based on a monthly rental fee schedule amount during the period of medical need, but for no longer than a period of continuous use of 13 months. A period of continuous use is determined under the provisions in § 414.230. (2) The supplier must transfer title to the item to the beneficiary on the first day that begins after the 13th continuous month in which payments are made under paragraph (f)(1) of this section. (3) Payment for maintenance and servicing of beneficiary-owned equipment is made in accordance with § 414.210(e). (g) 
                                *Additional supplier requirements for capped rental items that are furnished beginning on or after January 1, 2007*. (1) The supplier that furnishes an item for the first month during which payment is made using the methodology described in paragraph (f)(1) of this section must continue to furnish the equipment until medical necessity ends, or the 13-month period of continuous use ends, whichever is earlier, unless— (i) The item becomes subject to a competitive acquisition program implemented in accordance with section 1847(a) of the Act; (ii) The beneficiary relocates to an area that is outside the normal service area of the supplier that initially furnished the equipment; (iii) The beneficiary elects to obtain the equipment from a different supplier prior to the expiration of the 13-month rental period; or (iv) CMS or the carrier determines that an exception should apply in an individual case based on the circumstances. (2) A capped rental item furnished under this section may not be replaced by the supplier prior to the expiration of the 13-month rental period unless: 
                                ( print page 65935) (i) The supplier replaces an item with the same, or equivalent, make and model of equipment because the item initially furnished was lost, stolen, irreparably damaged, is being repaired, or no longer functions; (ii) A physician orders different equipment for the beneficiary. If the need for different equipment is based on medical necessity, then the order must indicate why the equipment initially furnished is no longer medically necessary and the supplier must retain this order in the beneficiary's medical record; (iii) The beneficiary chooses to obtain a newer technology item or upgraded item and signs an advanced beneficiary notice (ABN); or (iv) CMS or the carrier determines that a change in equipment is warranted. (3) Before furnishing a capped rental item, the supplier must disclose to the beneficiary its intentions regarding whether it will accept assignment of all monthly rental claims for the duration of the rental period. A supplier's intentions could be expressed in the form of a written agreement between the supplier and the beneficiary. (4) No later than two months before the date on which the supplier must transfer title to a capped rental item to the beneficiary, the supplier must disclose to the beneficiary whether it can maintain and service the item after the beneficiary acquires title to it. CMS or its carriers may make exceptions to this requirement on a case-by-case basis. (h) 
                                *Purchase of power-driven wheelchairs furnished on or after January 1, 2006.*
                                 Suppliers must offer beneficiaries the option to purchase power-driven wheelchairs at the time the equipment is initially furnished. Payment is made on a lump-sum purchase basis if the beneficiary chooses this option.
 5.Amend § 414.230 by— A. Revising paragraph (b). B. Revising paragraph (f). The revisions read as follows: § 414.230
  
 (b) 
                                *Continuous use.*
                                 (1) A period of continuous use begins with the first month of medical need and lasts until a beneficiary's medical need for a particular item of durable medical equipment ends. (2) In the case of a beneficiary receiving oxygen equipment on December 31, 2005, the period of continuous use for the equipment begins on January 1, 2006. 
 (f) 
                                *New equipment.*
                                 (1) If a beneficiary changes equipment or requires additional equipment based on a physician's prescription, and the new or additional equipment is found to be necessary, a new period of continuous use begins for the new or additional equipment. A new period of continuous use does not begin for base equipment that is modified by an addition. (2) A new period of continuous use does not begin when a beneficiary changes from one stationary oxygen equipment modality to another or from one portable oxygen equipment modality to another.
 PART 484—HOME HEALTH SERVICES
 6.The authority citation for part 484 continues to read as follows: Authority:
                            Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395(hh)) unless otherwise indicated. 7.Amend § 484.225 as follows: A. Revise paragraph (f). B. Redesignate paragraph (g) as paragraph (h). C. Add new paragraph (g). D. Revise newly redesignated paragraph (h). E. Add new paragraph (i). The revisions and additions read as follows: § 484.225
  
 (f) For calendar year 2005, the unadjusted national prospective 60-day episode payment rate is equal to the rate from the previous calendar year, increased by the applicable home health market basket minus 0.8 percentage points. (g) For calendar year 2006, the unadjusted national prospective 60-day episode payment rate is equal to the rate from calendar year 2005. (h) For 2007 and subsequent calendar years, in the case of a home health agency that submits home health quality data, as specified by the Secretary, the unadjusted national prospective 60-day episode rate is equal to the rate for the previous calendar year increased by the applicable home health market basket index amount. (i) For 2007 and subsequent calendar years, in the case of a home health agency that does not submit home health quality data, as specified by the Secretary, the unadjusted national prospective 60-day episode rate is equal to the rate for the previous calendar year increased by the applicable home health market basket index amount minus 2 percentage points. Any reduction of the percentage change will apply only to the calendar year involved and will not be taken into account in computing the prospective payment amount for a subsequent calendar year.
 (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare—Hospital Insurance; and Program No. 93.774, Medicare—Supplementary Medical Insurance Program) Dated: October 20, 2006. Leslie V. Norwalk, Acting Administrator, Centers for Medicare & Medicaid Services. Michael O. Leavitt, Secretary.
 Note: The following addenda will not be published in the Code of Federal Regulations. 
 
 Addendum A.—CY 2007 Wage Index for Rural Areas by CBSA; Applicable  Pre-Floor and Pre-Reclassified Hospital Wage Index
CBSA code
Nonurban area
Wage 
                                 index01
Alabama
0.759102
Alaska
1.066103
Arizona
0.890804
Arkansas
0.730705
California
1.145406
Colorado
0.932507
Connecticut
1.170908
Delaware
0.970510
Florida
0.859411
Georgia
0.759312
Hawaii
1.044813
Idaho
0.812014
Illinois
0.832015
Indiana
0.853816
Iowa
0.868117
Kansas
0.799818
Kentucky
0.776819
Louisiana
0.743820
Maine
0.844321
Maryland
0.892622
Massachusetts 1
1.166123
Michigan
0.906224
Minnesota
0.915325
Mississippi
0.773826
Missouri
0.792727
Montana
0.859028
Nebraska
0.867729
Nevada
0.894430
New Hampshire
1.085331
New Jersey 232
New Mexico
0.833233
New York
0.823234
North Carolina
0.858835
North Dakota
0.721536
Ohio
0.865837
Oklahoma
0.762938
Oregon
0.975339
Pennsylvania
0.832040
Puerto Rico 3
0.404741
Rhode Island 242
South Carolina
0.856643
South Dakota
0.848044
Tennessee
0.782745
Texas
0.796546
Utah
0.814047
Vermont
0.974448
Virgin Islands
0.846749
Virginia
0.794050
Washington
1.026351
West Virginia
0.760752
Wisconsin
0.955353
Wyoming
0.929565
Guam
0.96111
                             There are no short-term, acute care hospitals located in rural areas in Massachusetts from which to calculate a wage index for CY07. Therefore, the rural wage index for Massachusetts will be imputed using the methodology discussed in Section III of this rule.2
                             All counties within the State are classified as urban.3
                             There are no short-term, acute care hospitals located in rural areas in Puerto Rico from which to calculate a wage index for CY07. Therefore, we will continue to use the wage index from CY05 which was the last year in which we had “rural” hospital data.
 Addendum B.—CY 2007 Wage Index for Urban Areas by CBSA; Applicable Pre-Floor and Pre-Reclassified Hospital Wage Index
CBSA code
Urban area (constituent counties)
Wage index10180
Abilene, TX.
0.8000Callahan County, TXJones County, TXTaylor County, TX10380
Aguadilla-Isabela-San Sebastia
                                
                                n, PR
0.3915Aguada Municipio, PRAguadilla Municipio, PRAn
                                
                                asco Municipio, PRIsabela Municipio, PRLares Municipio, PRMoca Municipio, PRRinco
                                
                                n Municipio, PRSan Sebastia
                                
                                n Municipio, PR10420
Akron, OH
0.8654Portage County, OHSummit County, OH10500
Albany, GA
0.8991Baker County, GADougherty County, GALee County, GATerrell County, GAWorth County, GA10580
Albany-Schenectady-Troy, NY
0.8720Albany County, NYRensselaer County, NYSaratoga County, NYSchenectady County, NYSchoharie County, NY10740
Albuquerque, NM
0.9458Bernalillo County, NMSandoval County, NMTorrance County, NMValencia County, NM10780
Alexandria, LA
0.8006Grant Parish, LARapides Parish, LA10900
Allentown-Bethlehem-Easton, PA-NJ
0.9947( print page 65937)Warren County, NJCarbon County, PALehigh County, PANorthampton County, PA11020
Altoona, PA
0.8812Blair County, PA11100
Amarillo, TX
0.9169Armstrong County, TXCarson County, TXPotter County, TXRandall County, TX11180
Ames, IA
0.9760Story County, IA111260
Anchorage, AK
1.2023Anchorage Municipality, AKMatanuska-Susitna Borough, AK11300
Anderson, IN
0.8681Madison County, IN11340
Anderson, SC
0.9017Anderson County, SC11460
Ann Arbor, MI
1.0826Washtenaw County, MI11500
Anniston-Oxford, AL
0.7770Calhoun County, AL11540
Appleton, WI
0.9455Calumet County, WIOutagamie County, WI11700
Asheville, NC
0.9216Buncombe County, NCHaywood County, NCHenderson County, NCMadison County, NC2020
Athens-Clarke County, GA
0.9856Clarke County, GAMadison County, GAOconee County, GAOglethorpe County, GA12060
Atlanta-Sandy Springs-Marietta, GA
0.9762Barrow County, GABartow County, GAButts County, GACarroll County, GACherokee County, GAClayton County, GACobb County, GACoweta County, GADawson County, GADeKalb County, GADouglas County, GAFayette County, GAForsyth County, GAFulton County, GAGwinnett County, GAHaralson County, GAHeard County, GAHenry County, GAJasper County, GALamar County, GAMeriwether County, GANewton County, GAPaulding County, GAPickens County, GAPike County, GARockdale County, GASpalding County, GAWalton County, GA12100
Atlantic City, NJ
1.1831Atlantic County, NJ2220
Auburn-Opelika, AL
0.8096Lee County, AL( print page 65938)12260
Augusta-Richmond County, GA-SC
0.9667Burke County, GAColumbia County, GAMcDuffie County, GARichmond County, GAAiken County, SCEdgefield County, SC12420
Austin-Round Rock, TX
0.9344Bastrop County, TXCaldwell County, TXHays County, TXTravis County, TXWilliamson County, TX12540
Bakersfield, CA
1.0725Kern County, CA12580
Baltimore-Towson, MD
1.0088Anne Arundel County, MDBaltimore County, MDCarroll County, MDHarford County, MDHoward County, MDQueen Anne's County, MDBaltimore City, MD12620
Bangor, ME
0.9711Penobscot County, ME12700
Barnstable Town, MA
1.2539Barnstable County, MA12940
Baton Rouge, LA
0.8084Ascension Parish, LAEast Baton Rouge Parish, LAEast Feliciana Parish, LAIberville Parish, LALivingston Parish, LAPointe Coupee Parish, LASt. Helena Parish, LAWest Baton Rouge Parish, LAWest Feliciana Parish, LA12980
Battle Creek, MI
0.9762Calhoun County, MI13020
Bay City, MI
0.9251Bay County, MI13140
Beaumont-Port Arthur, TX
0.8595Hardin County, TXJefferson County, TXOrange County, TX13380
Bellingham, WA
1.1104Whatcom County, WA13460
Bend, OR
1.0743Deschutes County, OR13644
Bethesda-Frederick-Gaithersburg, MD
1.0903Frederick County, MDMontgomery County, MD13740
Billings, MT
0.8712Carbon County, MTYellowstone County, MT13780
Binghamton, NY
0.8786Broome County, NYTioga County, NY13820
Birmingham-Hoover, AL
0.8894Bibb County, ALBlount County, ALChilton County, ALJefferson County, ALSt. Clair County, ALShelby County, ALWalker County, AL13900
Bismarck, ND
0.7240Burleigh County, NDMorton County, ND13980
Blacksburg-Christiansburg-Radford, VA
0.8213( print page 65939)Giles County, VAMontgomery County, VAPulaski County, VARadford City, VA14020
Bloomington, IN
0.8533Greene County, INMonroe County, INOwen County, IN14060
Bloomington-Normal, IL
0.8944McLean County, IL14260
Boise City-Nampa, ID
0.9401Ada County, IDBoise County, IDCanyon County, IDGem County, IDOwyhee County, ID14484
Boston-Quincy, MA
1.1679Norfolk County, MAPlymouth County, MASuffolk County, MA14500
Boulder, CO
1.0350Boulder County, CO14540
Bowling Green, KY
0.8148Edmonson County, KYWarren County, KY14740
Bremerton-Silverdale, WA
1.0913Kitsap County, WA14860
Bridgeport-Stamford-Norwalk, CT
1.2659Fairfield County, CT15180
Brownsville-Harlingen, TX
0.9430Cameron County, TX15260
Brunswick, GA
1.0164Brantley County, GAGlynn County, GAMcIntosh County, GA15380
Buffalo-Niagara Falls, NY
0.9424Erie County, NYNiagara County, NY15500
Burlington, NC
0.8674Alamance County, NC15540
Burlington-South Burlington, VT
0.9474Chittenden County, VTFranklin County, VTGrand Isle County, VT15764
Cambridge-Newton-Framingham, MA
1.0970Middlesex County, MA5804
Camden, NJ
1.0392Burlington County, NJCamden County, NJGloucester County, NJ15940
Canton-Massillon, OH
0.9031Carroll County, OHStark County, OH15980
Cape Coral-Fort Myers, FL
0.9342Lee County, FL16180
Carson City, NV
1.0025Carson City, NV16220
Casper, WY
0.9145Natrona County, WY16300
Cedar Rapids, IA
0.8888Benton County, IAJones County, IALinn County, IA16580
Champaign-Urbana, IL
0.9644Champaign County, ILFord County, ILPiatt County, IL16620
Charleston, WV
0.8542Boone County, WVClay County, WV( print page 65940)Kanawha County, WVLincoln County, WVPutnam County, WV16700
Charleston-North Charleston, SC
0.9145Berkeley County, SCCharleston County, SCDorchester County, SC16740
Charlotte-Gastonia-Concord, NC-SC
0.9554Anson County, NCCabarrus County, NCGaston County, NCMecklenburg County, NCUnion County, NCYork County, SC16820
Charlottesville, VA
1.0125Albemarle County, VAFluvanna County, VAGreene County, VANelson County, VACharlottesville City, VA16860
Chattanooga, TN-GA
0.8948Catoosa County, GADade County, GAWalker County, GAHamilton County, TNMarion County, TNSequatchie County, TN16940
Cheyenne, WY
0.9060Laramie County, WY16974
Chicago-Naperville-Joliet, IL
1.0751Cook County, ILDeKalb County, ILDuPage County, ILGrundy County, ILKane County, ILKendall County, ILMcHenry County, ILWill County, IL17020
Chico, CA
1.1053Butte County, CA17140
Cincinnati-Middletown, OH-KY-IN
0.9601Dearborn County, INFranklin County, INOhio County, INBoone County, KYBracken County, KYCampbell County, KYGallatin County, KYGrant County, KYKenton County, KYPendleton County, KYBrown County, OHButler County, OHClermont County, OHHamilton County, OHWarren County, OH17300
Clarksville, TN-KY
0.8436Christian County, KYTrigg County, KYMontgomery County, TNStewart County, TN17420
Cleveland, TN
0.8109Bradley County, TNPolk County, TN17460
Cleveland-Elyria-Mentor, OH
0.9400Cuyahoga County, OHGeauga County, OHLake County, OHLorain County, OHMedina County, OH( print page 65941)17660
Coeur d'Alene, ID
0.9344Kootenai County, ID17780
College Station-Bryan, TX
0.9045Brazos County, TXBurleson County, TXRobertson County, TX17820
Colorado Springs, CO
0.9701El Paso County, COTeller County, CO17860
Columbia, MO
0.8542Boone County, MOHoward County, MO17900
Columbia, SC
0.8933Calhoun County, SCFairfield County, SCKershaw County, SCLexington County, SCRichland County, SCSaluda County, SC17980
Columbus, GA-AL
0.8239Russell County, ALChattahoochee County, GAHarris County, GAMarion County, GAMuscogee County, GA18020
Columbus, IN
0.9318Bartholomew County, IN18140
Columbus, OH
1.0107Delaware County, OHFairfield County, OHFranklin County, OHLicking County, OHMadison County, OHMorrow County, OHPickaway County, OHUnion County, OH18580
Corpus Christi, TX
0.8564Aransas County, TXNueces County, TXSan Patricio County, TX18700
Corvallis, OR
1.1546Benton County, OR19060
Cumberland, MD-WV
0.8446Allegany County, MDMineral County, WV19124
Dallas-PlanoIrving, TX
1.0075Collin County, TXDallas County, TXDelta County, TXDenton County, TXEllis County, TXHunt County, TXKaufman County, TXRockwall County, TX19140
Dalton, GA
0.9093Murray County, GAWhitfield County, GA19180
Danville, IL
0.9266Vermilion County, IL19260
Danville, VA
0.8451Pittsylvania County, VADanville City, VA19340
Davenport-Moline-Rock Island, IA-IL
0.8846Henry County, ILMercer County, ILRock Island County, ILScott County, IA19380
Dayton, OH
0.9037Greene County, OHMiami County, OH( print page 65942)Montgomery County, OHPreble County, OH19460
Decatur, AL
0.8159Lawrence County, ALMorgan County, AL19500
Decatur, IL
0.8172Macon County, IL19660
Deltona-Daytona Beach-Ormond Beach, FL
0.9263Volusia County, FL19740
Denver-Aurora, CO
1.0930Adams County, COArapahoe County, COBroomfield County, COClear Creek County, CODenver County, CODouglas County, COElbert County, COGilpin County, COJefferson County, COPark County, CO19780
Des Moines, IA
0.9214Dallas County, IAGuthrie County, IAMadison County, IAPolk County, IAWarren County, IA19804
Detroit-Livonia-Dearborn, MI
1.0281Wayne County, MI20020
Dothan, AL
0.7381Geneva County, ALHenry County, ALHouston County, AL20100
Dover, DE
0.9847Kent County, DE20220
Dubuque, IA
0.9133Dubuque County, IA20260
Duluth, MN-WI
1.0042Carlton County, MNSt. Louis County, MNDouglas County, WI20500
Durham, NC
0.9826Chatham County, NCDurham County, NCOrange County, NCPerson County, NC20740
Eau Claire, WI
0.9630Chippewa County, WIEau Claire County, WI20764
Edison, NJ
1.1190Middlesex County, NJMonmouth County, NJOcean County, NJSomerset County, NJ20940
El Centro, CA
0.9076Imperial County, CA21060
Elizabethtown, KY
0.8697Hardin County, KYLarue County, KY21140
Elkhart-Goshen, IN
0.9426Elkhart County, IN21300
Elmira, NY
0.8240Chemung County, NY21340
El Paso, TX
0.9053El Paso County, TX21500
Erie, PA
0.8827Erie County, PA21604
Essex County, MA
1.0418Essex County, MA21660
Eugene-Springfield, OR
1.0876Lane County, OR( print page 65943)21780
Evansville, IN-KY
0.9071Gibson County, INPosey County, INVanderburgh County, INWarrick County, INHenderson County, KYWebster County, KY21820
Fairbanks, AK
1.1059Fairbanks North Star Borough, AK21940
Fajardo, PR
0.4036Ceiba Municipio, PRFajardo Municipio, PRLuquillo Municipio, PR22020
Fargo, ND-MN
0.8250Cass County, NDClay County, MN22140
Farmington, NM
0.8589San Juan County, NM22180
Fayetteville, NC
0.8945Cumberland County, NCHoke County, NC22220
Fayetteville-Springdale-Rogers, AR-MO
0.8865Benton County, ARMadison County, ARWashington County, ARMcDonald County, MO22380
Flagstaff, AZ
1.1601Coconino County, AZ22420
Flint, MI
1.0969Genesee County, MI22500
Florence, SC
0.8388Darlington County, SCFlorence County, SC22520
Florence-Muscle Shoals, AL
0.7843Colbert County, ALLauderdale County, AL22540
Fond du Lac, WI
1.0063Fond du Lac County, WI22660
Fort Collins-Loveland, CO
0.9544Larimer County, CO22744
Fort Lauderdale-Pompano Beach-Deerfield Beach, FL
1.0133Broward County, FL22900
Fort Smith, AR-OK
0.7731Crawford County, ARFranklin County, ARSebastian County, ARLe Flore County, OKSequoyah County, OK23020
Fort Walton Beach-Crestview-Destin, FL
0.8643Okaloosa County, FL23060
Fort Wayne, IN
0.9517Allen County, INWells County, INWhitley County, IN23104
Fort Worth-Arlington, TX
0.9569Johnson County, TXParker County, TXTarrant County, TXWise County, TX23420
Fresno, CA
1.0943Fresno County, CA23460
Gadsden, AL
0.8066Etowah County, AL23540
Gainesville, FL
0.9277Alachua County, FLGilchrist County, FL23580
Gainesville, GA
0.8958Hall County, GA23844
Gary, IN
0.9334Jasper County, IN( print page 65944)Lake County, INNewton County, INPorter County, IN24020
Glens Falls, NY
0.8324Warren County, NYWashington County, NY24140
Goldsboro, NC
0.9171Wayne County, NC24220
Grand Forks, ND-MN
0.7949Polk County, MNGrand Forks County, ND24300
Grand Junction, CO
0.9668Mesa County, CO24340
Grand Rapids-Wyoming, MI
0.9455Barry County, MIIonia County, MIKent County, MINewaygo County, MI24500
Great Falls, MT
0.8598Cascade County, MT24540
Greeley, CO
0.9602Weld County, CO24580
Green Bay, WI
0.9787Brown County, WIKewaunee County, WIOconto County, WI24660
Greensboro-High Point, NC
0.8866Guilford County, NCRandolph County, NCRockingham County, NC24780
Greenville, NC
0.9432Greene County, NCPitt County, NC24860
Greenville, SC
0.9804Greenville County, SCLaurens County, SCPickens County, SC25020
Guayama, PR
0.3235Arroyo Municipio, PRGuayama Municipio, PRPatillas Municipio, PR25060
Gulfport-Biloxi, MS
0.8915Hancock County, MSHarrison County, MSStone County, MS25180
Hagerstown-Martinsburg, MD-WV
0.9038Washington County, MDBerkeley County, WVMorgan County, WV25260
Hanford-Corcoran, CA
1.0282Kings County, CA25420
Harrisburg-Carlisle, PA
0.9402Cumberland County, PADauphin County, PAPerry County, PA25500
Harrisonburg, VA
0.9073Rockingham County, VAHarrisonburg City, VA25540
Hartford-West Hartford-East Hartford, CT
1.0894Hartford County, CTLitchfield County, CTMiddlesex County, CTTolland County, CT25620
Hattiesburg, MS
0.7430Forrest County, MSLamar County, MSPerry County, MS25860
Hickory-Lenoir-Morganton, NC
0.9010Alexander County, NCBurke County, NC( print page 65945)Caldwell County, NCCatawba County, NC259801
Hinesville-Fort Stewart, GA
0.9178Liberty County, GALong County, GA26100
Holland-Grand Haven, MI
0.9163Ottawa County, MI26180
Honolulu, HI
1.1096Honolulu County, HI26300
Hot Springs, AR
0.8782Garland County, AR26380
Houma-Bayou Cane-Thibodaux, LA
0.8082Lafourche Parish, LATerrebonne Parish, LA26420
Houston-Baytown-Sugar Land, TX
1.0008Austin County, TXBrazoria County, TXChambers County, TXFort Bend County, TXGalveston County, TXHarris County, TXLiberty County, TXMontgomery County, TXSan Jacinto County, TXWaller County, TX26580
Huntington-Ashland, WVKYOH
0.8997Boyd County, KYGreenup County, KYLawrence County, OHCabell County, WVWayne County, WV26620
Huntsville, AL
0.9007Limestone County, ALMadison County, AL26820
Idaho Falls, ID
0.9088Bonneville County, IDJefferson County, ID26900
Indianapolis, IN
0.9895Boone County, INBrown County, INHamilton County, INHancock County, INHendricks County, INJohnson County, INMarion County, INMorgan County, INPutnam County, INShelby County, IN26980
Iowa City, IA
0.9714Johnson County, IAWashington County, IA27060
Ithaca, NY
0.9928Tompkins County, NY27100
Jackson, MI
0.9560Jackson County, MI27140
Jackson, MS
0.8271Copiah County, MSHinds County, MSMadison County, MSRankin County, MSSimpson County, MS27180
Jackson, TN
0.8853Chester County, TNMadison County, TN27260
Jacksonville, FL
0.9165Baker County, FLClay County, FLDuval County, FLNassau County, FLSt. Johns County, FL( print page 65946)27340
Jacksonville, NC
0.8231Onslow County, NC27500
Janesville, WI
0.9655Rock County, WI27620
Jefferson City, MO
0.8332Callaway County, MOCole County, MOMoniteau County, MOOsage County, MO>27740
Johnson City, TN
0.8043Carter County, TNUnicoi County, TNWashington County, TN27780
Johnstown, PA
0.8620Cambria County, PA27860
Jonesboro, AR
0.7662Craighead County, ARPoinsett County, AR27900
Joplin, MO
0.8605Jasper County, MONewton County, MO28020
Kalamazoo-Portage, MI
1.0704Kalamazoo County, MIVan Buren County, MI28100
Kankakee-Bradley, IL
1.0083Kankakee County, IL28140
Kansas City, MOKS
0.9495Franklin County, KSJohnson County, KSLeavenworth County, KSLinn County, KSMiami County, KSWyandotte County, KSBates County, MOCaldwell County, MOCass County, MOClay County, MOClinton County, MOJackson County, MOLafayette County, MOPlatte County, MORay County, MO28420
Kennewick-Richland-Pasco, WA
1.0343Benton County, WAFranklin County, WA28660
Killeen-TempleFort Hood, TX
0.8901Bell County, TXCoryell County, TXLampasas County, TX28700
Kingsport-Bristol-Bristol, TNVA
0.7985Hawkins County, TNSullivan County, TNBristol City, VAScott County, VAWashington County, VA28740
Kingston, NY
0.9367Ulster County, NY28940
Knoxville, TN
0.8249Anderson County, TNBlount County, TNKnox County, TNLoudon County, TNUnion County, TN29020
Kokomo, IN
0.9669Howard County, INTipton County, IN29100
La Crosse, WIMN
0.9426Houston County, MNLa Crosse County, WI29140
Lafayette, IN
0.8931( print page 65947)Benton County, INCarroll County, INTippecanoe County, IN29180
Lafayette, LA
0.8289Lafayette Parish, LASt. Martin Parish, LA29340
Lake Charles, LA
0.7914Calcasieu Parish, LACameron Parish, LA29404
Lake County-Kenosha County, IL-WI
1.0570Lake County, ILKenosha County, WI29460
Lakeland, FL
0.8879Polk County, FL29540
Lancaster, PA
0.9589Lancaster County, PA29620
Lansing-East Lansing, MI
1.0088Clinton County, MIEaton County, MIIngham County, MI29700
Laredo, TX
0.7811Webb County, TX29740
Las Cruces, NM
0.9273Dona Ana County, NM29820
Las Vegas-Paradise, NV
1.1430Clark County, NV29940
Lawrence, KS
0.8365Douglas County, KS30020
Lawton, OK
0.8065Comanche County, OK30140
Lebanon, PA
0.8679Lebanon County, PA30300
Lewiston, ID-WA
0.9853Nez Perce County, IDAsotin County, WA30340
LewistonAuburn, ME
0.9126Androscoggin County, ME30460
Lexington-Fayette, KY
0.9181Bourbon County, KYClark County, KYFayette County, KYJessamine County, KYScott County, KYWoodford County, KY30620
Lima, OH
0.9042Allen County, OH30700
Lincoln, NE
1.0092Lancaster County, NESeward County, NE30780
Little Rock-North Little Rock, AR
0.8890Faulkner County, ARGrant County, ARLonoke County, ARPerry County, ARPulaski County, ARSaline County, AR30860
Logan, UT-ID
0.9022Franklin County, IDCache County, UT30980
Longview, TX
0.8788Gregg County, TXRusk County, TXUpshur County, TX31020
Longview, WA
1.0011Cowlitz County, WA31084
Los Angeles-Long Beach-Glendale, CA
1.1760Los Angeles County, CA31140
Louisville, KY-IN
0.9118Clark County, INFloyd County, IN( print page 65948)Harrison County, INWashington County, INBullitt County, KYHenry County, KYJefferson County, KYMeade County, KYNelson County, KYOldham County, KYShelby County, KYSpencer County, KYTrimble County, KY31180
Lubbock, TX
0.8613Crosby County, TXLubbock County, TX31340
Lynchburg, VA
0.8694Amherst County, VAAppomattox County, VABedford County, VACampbell County, VABedford City, VALynchburg City, VA31420
Macon, GA
0.9519Bibb County, GACrawford County, GAJones County, GAMonroe County, GATwiggs County, GA31460
Madera, CA
0.8154Madera County, CA31540
Madison, WI
1.0840Columbia County, WIDane County, WIIowa County, WI31700
Manchester-Nashua, NH
1.0243Hillsborough County, NHMerrimack County, NH31900
Mansfield, OH
0.9271Richland County, OH32420
Mayagu
                                
                                ez, PR
0.3848Hormigueros Municipio, PRMayagu
                                
                                ez Municipio, PR32580
McAllen-Edinburg-Pharr, TX
0.8773Hidalgo County, TX32780
Medford, OR
1.0818Jackson County, OR32820
Memphis, TN-MS-AR
0.9373Crittenden County, ARDeSoto County, MSMarshall County, MSTate County, MSTunica County, MSFayette County, TNShelby County, TNTipton County, TN32900
Merced, CA
1.1471Merced County, CA33124
Miami-Miami Beach-Kendall, FL
0.9812Miami-Dade County, FL33140
Michigan City-La Porte, IN
0.9118LaPorte County, IN33260
Midland, TX
0.9786Midland County, TX33340
Milwaukee-Waukesha-West Allis, WI
1.0218Milwaukee County, WIOzaukee County, WIWashington County, WIWaukesha County, WI33460
Minneapolis-St. Paul-Bloomington, MN-WI
1.0946Anoka County, MNCarver County, MN( print page 65949)Chisago County, MNDakota County, MNHennepin County, MNIsanti County, MNRamsey County, MNScott County, MNSherburne County, MNWashington County, MNWright County, MNPierce County, WISt. Croix County, WI33540
Missoula, MT
0.8928Missoula County, MT33660
Mobile, AL
0.7913Mobile County, AL33700
Modesto, CA
1.1729Stanislaus County, CA33740
Monroe, LA
0.7997Ouachita Parish, LAUnion Parish, LA33780
Monroe, MI
0.9707Monroe County, MI33860
Montgomery, AL
0.8009Autauga County, ALElmore County, ALLowndes County, ALMontgomery County, AL34060
Morgantown, WV
0.8423Monongalia County, WVPreston County, WV34100
Morristown, TN
0.7933Grainger County, TNHamblen County, TNJefferson County, TN34580
Mount Vernon-Anacortes, WA
1.0517Skagit County, WA34620
Muncie, IN
0.8562Delaware County, IN34740
Muskegon-Norton Shores, MI
0.9941Muskegon County, MI34820
Myrtle Beach-Conway-North Myrtle Beach, SC
0.8810Horry County, SC34900
Napa, CA
1.3374Napa County, CA34940
Naples-Marco Island, FL
0.9941Collier County, FL34980
Nashville-Davidson-Murfreesboro, TN
0.9847Cannon County, TNCheatham County, TNDavidson County, TNDickson County, TNHickman County, TNMacon County, TNRobertson County, TNRutherford County, TNSmith County, TNSumner County, TNTrousdale County, TNWilliamson County, TNWilson County, TN35004
Nassau-Suffolk, NY
1.2662Nassau County, NYSuffolk County, NY35084
Newark-Union, NJ-PA
1.1892Essex County, NJHunterdon County, NJMorris County, NJSussex County, NJUnion County, NJPike County, PA( print page 65950)35300
New Haven-Milford, CT
1.1953New Haven County, CT35380
New Orleans-Metairie-Kenner, LA
0.8831Jefferson Parish, LAOrleans Parish, LAPlaquemines Parish, LASt. Bernard Parish, LASt. Charles Parish, LASt. John the Baptist Parish, LASt. Tammany Parish, LA35644
New York-Wayne-White Plains, NY-NJ
1.3177Bergen County, NJHudson County, NJPassaic County, NJBronx County, NYKings County, NYNew York County, NYPutnam County, NYQueens County, NYRichmond County, NYRockland County, NYWestchester County, NY35660
Niles-Benton Harbor, MI
0.8915Berrien County, MI35980
Norwich-New London, CT
1.1932New London County, CT36084
Oakland-Fremont-Hayward, CA
1.5819Alameda County, CAContra Costa County, CA36100
Ocala, FL
0.8867Marion County, FL36140
Ocean City, NJ
1.0472Cape May County, NJ36220
Odessa, TX
1.0073Ector County, TX36260
Ogden-Clearfield, UT
0.8995Davis County, UTMorgan County, UTWeber County, UT36420
Oklahoma City, OK
0.8843Canadian County, OKCleveland County, OKGrady County, OKLincoln County, OKLogan County, OKMcClain County, OKOklahoma County, OK36500
Olympia, WA
1.1081Thurston County, WA36540
Omaha-Council Bluffs, NE-IA
0.9450Harrison County, IAMills County, IAPottawattamie County, IACass County, NEDouglas County, NESarpy County, NESaunders County, NEWashington County, NE36740
Orlando, FL
0.9452Lake County, FLOrange County, FLOsceola County, FLSeminole County, FL36780
Oshkosh-Neenah, WI
0.9315Winnebago County, WI36980
Owensboro, KY
0.8748Daviess County, KYHancock County, KYMcLean County, KY37100
Oxnard-Thousand Oaks-Ventura, CA
1.1546( print page 65951)Ventura County, CA37340
Palm Bay-Melbourne-Titusville, FL
0.9443Brevard County, FL37460
Panama City-Lynn Haven, FL
0.8027Bay County, FL37620
Parkersburg-Marietta, WV-OH
0.7977Washington County, OHPleasants County, WVWirt County, WVWood County, WV37700
Pascagoula, MS
0.8215George County, MSJackson County, MS37860
Pensacola-Ferry Pass-Brent, FL
0.8000Escambia County, FLSanta Rosa County, FL37900
Peoria, IL
0.8982Marshall County, ILPeoria County, ILStark County, ILTazewell County, ILWoodford County, IL37964
Philadelphia, PA
1.0996Bucks County, PAChester County, PADelaware County, PAMontgomery County, PAPhiladelphia County, PA38060
Phoenix-Mesa-Scottsdale, AZ
1.0287Maricopa County, AZPinal County, AZ38220
Pine Bluff, AR
0.8383Cleveland County, ARJefferson County, ARLincoln County, AR38300
Pittsburgh, PA
0.8674Allegheny County, PAArmstrong County, PABeaver County, PAButler County, PAFayette County, PAWashington County, PAWestmoreland County, PA38340
Pittsfield, MA
1.0266Berkshire County, MA38540
Pocatello, ID
0.9400Bannock County, IDPower County, ID38660
Ponce, PR
0.4842Juana Di
                                
                                az Municipio, PRPonce Municipio, PRVillalba Municipio, PR38860
Portland-South Portland-Biddeford, ME
0.9908Cumberland County, MESagadahoc County, MEYork County, ME38900
Portland-Vancouver-Beaverton, OR-WA
1.1416Clackamas County, ORColumbia County, ORMultnomah County, ORWashington County, ORYamhill County, ORClark County, WASkamania County, WA38940
Port St. Lucie-Fort Pierce, FL
0.9833Martin County, FLSt. Lucie County, FL39100
Poughkeepsie-Newburgh-Middletown, NY
1.0911Dutchess County, NYOrange County, NY( print page 65952)39140
Prescott, AZ
0.9836Yavapai County, AZ39300
Providence-New Bedford-Fall River, RI-MA
1.0783Bristol County, MABristol County, RIKent County, RINewport County, RIProvidence County, RIWashington County, RI39340
Provo-Orem, UT
0.9537Juab County, UTUtah County, UT39380
Pueblo, CO
0.8753Pueblo County, CO39460
Punta Gorda, FL
0.9405Charlotte County, FL39540
Racine, WI
0.9356Racine County, WI39580
Raleig-hCary, NC
0.9864Franklin County, NCJohnston County, NCWake County, NC39660
Rapid City, SD
0.8833Meade County, SDPennington County, SD39740
Reading, PA
0.9622Berks County, PA39820
Redding, CA
1.3198Shasta County, CA39900
Reno-Sparks, NV
1.1963Storey County, NVWashoe County, NV40060
Richmond, VA
0.9177Amelia County, VACaroline County, VACharles City County, VAChesterfield County, VACumberland County, VADinwiddie County, VAGoochland County, VAHanover County, VAHenrico County, VAKing and Queen County, VAKing William County, VALouisa County, VANew Kent County, VAPowhatan County, VAPrince George County, VASussex County, VAColonial Heights City, VAHopewell City, VAPetersburg City, VARichmond City, VA40140
Riverside-San Bernardino-Ontario, CA
1.0904Riverside County, CASan Bernardino County, CA40220
Roanoke, VA
0.8647Botetourt County, VACraig County, VAFranklin County, VARoanoke County, VARoanoke City, VASalem City, VA40340
Rochester, MN
1.1408Dodge County, MNOlmsted County, MNWabasha County, MN40380
Rochester, NY
0.8994Livingston County, NYMonroe County, NY( print page 65953)Ontario County, NYOrleans County, NYWayne County, NY40420
Rockford, IL
0.9989Boone County, ILWinnebago County, IL40484
Rockingham County-Strafford County, NH
1.0159Rockingham County, NHStrafford County, NH40580
Rocky Mount, NC
0.8854Edgecombe County, NCNash County, NC40660
Rome, GA
0.9193Floyd County, GA40900
Sacramento—Arden-Arcade—Roseville, CA
1.3372El Dorado County, CAPlacer County, CASacramento County, CAYolo County, CA40980
Saginaw-Saginaw Township North, MI
0.8874Saginaw County, MI41060
St. Cloud, MN
1.0362Benton County, MNStearns County, MN41100
St. George, UT
0.9265Washington County, UT41140
St. Joseph, MO-KS
1.0118Doniphan County, KSAndrew County, MOBuchanan County, MODeKalb County, MO41180
St. Louis, MO-IL
0.9005Bond County, ILCalhoun County, ILClinton County, ILJersey County, ILMacoupin County, ILMadison County, ILMonroe County, ILSt. Clair County, ILCrawford County, MOFranklin County, MOJefferson County, MOLincoln County, MOSt. Charles County, MOSt. Louis County, MOWarren County, MOWashington County, MOSt. Louis City, MO41420
Salem, OR
1.0438Marion County, ORPolk County, OR41500
Salinas, CA
1.4337Monterey County, CA41540
Salisbury, MD
0.8953Somerset County, MDWicomico County, MD41620
Salt Lake City, UT
0.9402Salt Lake County, UTSummit County, UTTooele County, UT41660
San Angelo, TX
0.8362Irion County, TXTom Green County, TX41700
San Antonio, TX
0.8844Atascosa County, TXBandera County, TXBexar County, TXComal County, TXGuadalupe County, TX( print page 65954)Kendall County, TXMedina County, TXWilson County, TX41740
San Diego-Carlsbad-San Marcos, CA
1.1354San Diego County, CA41780
Sandusky, OH
0.9302Erie County, OH41884
San Francisco-San Mateo-Redwood City, CA
1.5165Marin County, CASan Francisco County, CASan Mateo County, CA41900
San Germa
                                
                                n-Cabo Rojo, PR
0.4885Cabo Rojo Municipio, PRLajas Municipio, PRSabana Grande Municipio, PRSan Germa
                                
                                n Municipio, PR41940
San Jose-Sunnyvale-Santa Clara, CA
1.5543San Benito County, CASanta Clara County, CA41980
San Juan-Caguas-Guaynabo, PR
0.4452Aguas Buenas Municipio, PRAibonito Municipio, PRArecibo Municipio, PRBarceloneta Municipio, PRBarranquitas Municipio, PRBayamo
                                
                                n Municipio, PRCaguas Municipio, PRCamuy Municipio, PRCano
                                
                                vanas Municipio, PRCarolina Municipio, PRCatan
                                
                                o Municipio, PRCayey Municipio, PRCiales Municipio, PRCidra Municipio, PRComeri
                                
                                o Municipio, PRCorozal Municipio, PRDorado Municipio, PRFlorida Municipio, PRGuaynabo Municipio, PRGurabo Municipio, PRHatillo Municipio, PRHumacao Municipio, PRJuncos Municipio, PRLas Piedras Municipio, PRLoi
                                
                                za Municipio, PRManati
                                
                                 Municipio, PRMaunabo Municipio, PRMorovis Municipio, PRNaguabo Municipio, PRNaranjito Municipio, PROrocovis Municipio, PRQuebradillas Municipio, PRRi
                                
                                o Grande Municipio, PRSan Juan Municipio, PRSan Lorenzo Municipio, PRToa Alta Municipio, PRToa Baja Municipio, PRTrujillo Alto Municipio, PRVega Alta Municipio, PRVega Baja Municipio, PRYabucoa Municipio, PR42020
San Luis Obispo-Paso Robles, CA
1.1598San Luis Obispo County, CA42044
Santa Ana-Anaheim-Irvine, CA
1.1473Orange County, CA42060
Santa Barbara-Santa Maria-Goleta, CA
1.1091Santa Barbara County, CA42100
Santa Cruz-Watsonville, CA
1.5457Santa Cruz County, CA42140
Santa Fe, NM
1.0824( print page 65955)Santa Fe County, NM42220
Santa Rosa-Petaluma, CA
1.4464Sonoma County, CA42260
Sarasota-Bradenton-Venice, FL
0.9868Manatee County, FLSarasota County, FL42340
Savannah, GA
0.9351Bryan County, GAChatham County, GAEffingham County, GA42540
Scranton-Wilkes-Barre, PA
0.8347Lackawanna County, PALuzerne County, PAWyoming County, PA42644
Seattle-Bellevue-Everett, WA
1.1434King County, WASnohomish County, WA42680
Sebastian-Vero Beach, FL
0.957343100
Sheboygan, WI
0.9026Sheboygan County, WI43300
Sherman-Denison, TX
0.8502Grayson County, TX43340
Shreveport-Bossier City, LA
0.8865Bossier Parish, LACaddo Parish, LADe Soto Parish, LA43580
Sioux City, IA-NE-SD
0.9200Woodbury County, IADakota County, NEDixon County, NEUnion County, SD43620
Sioux Falls, SD
0.9559Lincoln County, SDMcCook County, SDMinnehaha County, SDTurner County, SD43780
South Bend-Mishawaka, IN-MI
0.9842St. Joseph County, INCass County, MI43900
Spartanburg, SC
0.9174Spartanburg County, SC44060
Spokane, WA
1.0447Spokane County, WA44100
Springfield, IL
0.8890Menard County, ILSangamon County, IL44140
Springfield, MA
1.0079Franklin County, MAHampden County, MAHampshire County, MA44180
Springfield, MO
0.8469Christian County, MODallas County, MOGreene County, MOPolk County, MOWebster County, MO44220
Springfield, OH
0.8593Clark County, OH44300
State College, PA
0.8784Centre County, PA44700
Stockton, CA
1.1442San Joaquin County, CA44940
Sumter, SC
0.8083Sumter County, SC45060
Syracuse, NY
0.9691Madison County, NYOnondaga County, NYOswego County, NY45104
Tacoma, WA
1.0789Pierce County, WA( print page 65956)45220
Tallahassee, FL
0.8942Gadsden County, FLJefferson County, FLLeon County, FLWakulla County, FL45300
Tampa-St. Petersburg-Clearwater, FL
0.9144Hernando County, FLHillsborough County, FLPasco County, FLPinellas County, FL45460
Terre Haute, IN
0.8765Clay County, INSullivan County, INVermillion County, INVigo County, IN45500
Texarkana, TX-Texarkana, AR
0.8104Miller County, ARBowie County, TX45780
Toledo, OH
0.9586Fulton County, OHLucas County, OHOttawa County, OHWood County, OH45820
Topeka, KS
0.8730Jackson County, KSJefferson County, KSOsage County, KSShawnee County, KSWabaunsee County, KS45940
Trenton-Ewing, NJ
1.0835Mercer County, NJ46060
Tucson, AZ
0.9202Pima County, AZ46140
Tulsa, OK
0.8103Creek County, OKOkmulgee County, OKOsage County, OKPawnee County, OKRogers County, OKTulsa County, OKWagoner County, OK46220
Tuscaloosa, AL
0.8542Greene County, ALHale County, ALTuscaloosa County, AL46340
Tyler, TX
0.8811Smith County, TX46540
Utica-Rome, NY
0.8396Herkimer County, NYOneida County, NY46660
Valdosta, GA
0.8369Brooks County, GAEchols County, GALanier County, GALowndes County, GA46700
Vallejo-Fairfield, CA
1.5137Solano County, CA47020
Victoria, TX
0.8560Calhoun County, TXGoliad County, TXVictoria County, TX47220
Vineland-Millville-Bridgeton, NJ
0.9832Cumberland County, NJ47260
Virginia Beach-Norfolk-Newport News, VA-NC
0.8790Currituck County, NCGloucester County, VAIsle of Wight County, VAJames City County, VAMathews County, VASurry County, VA( print page 65957)York County, VAChesapeake City, VAHampton City, VANewport News City, VANorfolk City, VAPoquoson City, VAPortsmouth City, VASuffolk City, VAVirginia Beach City, VAWilliamsburg City, VA47300
Visalia-Porterville, CA
0.9968Tulare County, CA47380
Waco, TX
0.8633McLennan County, TX47580
Warner Robins, GA
0.8380Houston County, GA47644
Warren-Farmington Hills-Troy, MI
1.0054Lapeer County, MILivingston County, MIMacomb County, MIOakland County, MISt. Clair County, MI47894
Washington-Arlington-Alexandria, DC-VA-MD-WV
1.1054District of Columbia, DCCalvert County, MDCharles County, MDPrince George's County, MDArlington County, VAClarke County, VAFairfax County, VAFauquier County, VALoudoun County, VAPrince William County, VASpotsylvania County, VAStafford County, VAWarren County, VAAlexandria City, VAFairfax City, VAFalls Church City, VAFredericksburg City, VAManassas City, VAManassas Park City, VAJefferson County, WV47940
Waterloo-Cedar Falls, IA
0.8408Black Hawk County, IABremer County, IAGrundy County, IA48140
Wausau, WI
0.9722Marathon County, WI48260
Weirton-Steubenville, WV-OH
0.8063Jefferson County, OHBrooke County, WVHancock County, WV48300
Wenatchee, WA
1.0346Chelan County, WADouglas County, WA48424
West Palm Beach-Boca Raton-Boynton Beach, FL
0.9649Palm Beach County, FL48540
Wheeling, WV-OH
0.7010Belmont County, OHMarshall County, WVOhio County, WV48620
Wichita, KS
0.9063Butler County, KSHarvey County, KSSedgwick County, KSSumner County, KS48660
Wichita Falls, TX
0.8311Archer County, TXClay County, TX( print page 65958)Wichita County, TX48700
Williamsport, PA
0.8139Lycoming County, PA48864
Wilmington, DE-MD-NJ
1.0684New Castle County, DECecil County, MDSalem County, NJ48900
Wilmington, NC
0.9835Brunswick County, NCNew Hanover County, NCPender County, NC49020
Winchester, VA-WV
1.0091Frederick County, VAWinchester City, VAHampshire County, WV49180
Winston-Salem, NC
0.9276Davie County, NCForsyth County, NCStokes County, NCYadkin County, NC49340
Worcester, MA
1.0722Worcester County, MA49420
Yakima, WA
0.9847Yakima County, WA49500
Yauco, PR
0.3854Gua
                                
                                nica Municipio, PRGuayanilla Municipio, PRPen
                                
                                uelas Municipio, PRYauco Municipio, PR49620
York-Hanover, PA
0.9397York County, PA49660
Youngstown-Warren-Boardman, OH-PA
0.8802Mahoning County, OHTrumbull County, OHMercer County, PA49700
Yuba City, CA
1.0730Sutter County, CAYuba County, CA49740
Yuma, AZ
0.9109Yuma County, AZ1
                             At this time, there are no hospitals in these urban areas on which to base a wage index. Therefore, the urban wage index value is based on the average wage index of all urban areas within the State.
 Addendum C.—Comparison of HH PPS Transition Wage Index for CY 2006 and Pre-Floor and Pre-Reclassified Hospital Wage Index For CY 2007
SSA state/county code
County name
CBSA No.
CY 2006 HH PPS transition wage index
CY2007 CBSA-based wage index
Percent change CY2006-CY200701000
Autauga County, Alabama
33860
0.8618
0.8009
−7.0701010
Baldwin County, Alabama
99901
0.7654
0.7591
−0.8201020
Barbour County, Alabama
99901
0.7439
0.7591
2.0401030
Bibb County, Alabama
13820
0.8196
0.8894
8.5201040
Blount County, Alabama
13820
0.8980
0.8894
−0.9601050
Bullock County, Alabama
99901
0.7439
0.7591
2.0401060
Butler County, Alabama
99901
0.7439
0.7591
2.0401070
Calhoun County, Alabama
11500
0.7682
0.7770
1.1501080
Chambers County, Alabama
99901
0.7439
0.7591
2.0401090
Cherokee County, Alabama
99901
0.7439
0.7591
2.0401100
Chilton County, Alabama
13820
0.8196
0.8894
8.5201110
Choctaw County, Alabama
99901
0.7439
0.7591
2.0401120
Clarke County, Alabama
99901
0.7439
0.7591
2.0401130
Clay County, Alabama
99901
0.7439
0.7591
2.0401140
Cleburne County, Alabama
99901
0.7439
0.7591
2.0401150
Coffee County, Alabama
99901
0.7439
0.7591
2.0401160
Colbert County, Alabama
22520
0.8272
0.7843
−5.1901170
Conecuh County, Alabama
99901
0.7439
0.7591
2.04( print page 65959)01180
Coosa County, Alabama
99901
0.7439
0.7591
2.0401190
Covington County, Alabama
99901
0.7439
0.7591
2.0401200
Crenshaw County, Alabama
99901
0.7439
0.7591
2.0401210
Cullman County, Alabama
99901
0.7439
0.7591
2.0401220
Dale County, Alabama
99901
0.7574
0.7591
0.2201230
Dallas County, Alabama
99901
0.7439
0.7591
2.0401240
De Kalb County, Alabama
99901
0.7439
0.7591
2.0401250
Elmore County, Alabama
33860
0.8618
0.8009
−7.0701260
Escambia County, Alabama
99901
0.7439
0.7591
2.0401270
Etowah County, Alabama
23460
0.7938
0.8066
1.6101280
Fayette County, Alabama
99901
0.7439
0.7591
2.0401290
Franklin County, Alabama
99901
0.7439
0.7591
2.0401300
Geneva County, Alabama
20020
0.7577
0.7381
−2.5901310
Greene County, Alabama
46220
0.8039
0.8542
6.2601320
Hale County, Alabama
46220
0.8039
0.8542
6.2601330
Henry County, Alabama
20020
0.7577
0.7381
−2.5901340
Houston County, Alabama
20020
0.7711
0.7381
−4.2801350
Jackson County, Alabama
99901
0.7439
0.7591
2.0401360
Jefferson County, Alabama
13820
0.8980
0.8894
−0.9601370
Lamar County, Alabama
99901
0.7439
0.7591
2.0401380
Lauderdale County, Alabama
22520
0.8272
0.7843
−5.1901390
Lawrence County, Alabama
19460
0.8469
0.8159
−3.6601400
Lee County, Alabama
12220
0.8100
0.8096
−0.0501410
Limestone County, Alabama
26620
0.9146
0.9007
−1.5201420
Lowndes County, Alabama
33860
0.8025
0.8009
−0.2001430
Macon County, Alabama
99901
0.7439
0.7591
2.0401440
Madison County, Alabama
26620
0.9146
0.9007
−1.5201450
Marengo County, Alabama
99901
0.7439
0.7591
2.0401460
Marion County, Alabama
99901
0.7439
0.7591
2.0401470
Marshall County, Alabama
99901
0.7439
0.7591
2.0401480
Mobile County, Alabama
33660
0.7876
0.7913
0.4701490
Monroe County, Alabama
99901
0.7439
0.7591
2.0401500
Montgomery County, Alabama
33860
0.8618
0.8009
−7.0701510
Morgan County, Alabama
19460
0.8469
0.8159
−3.6601520
Perry County, Alabama
99901
0.7439
0.7591
2.0401530
Pickens County, Alabama
99901
0.7439
0.7591
2.0401540
Pike County, Alabama
99901
0.7439
0.7591
2.0401550
Randolph County, Alabama
99901
0.7439
0.7591
2.0401560
Russell County, Alabama
17980
0.8560
0.8239
−3.7501570
St Clair County, Alabama
13820
0.8980
0.8894
−0.9601580
Shelby County, Alabama
13820
0.8980
0.8894
−0.9601590
Sumter County, Alabama
99901
0.7439
0.7591
2.0401600
Talladega County, Alabama
99901
0.7439
0.7591
2.0401610
Tallapoosa County, Alabama
99901
0.7439
0.7591
2.0401620
Tuscaloosa County, Alabama
46220
0.8705
0.8542
−1.8701630
Walker County, Alabama
13820
0.8196
0.8894
8.5201640
Washington County, Alabama
99901
0.7439
0.7591
2.0401650
Wilcox County, Alabama
99901
0.7439
0.7591
2.0401660
Winston County, Alabama
99901
0.7439
0.7591
2.0402013
Aleutians County East, Alaska
99902
1.1933
1.0661
−10.6602016
Aleutians County West, Alaska
99902
1.1933
1.0661
−10.6602020
Anchorage County, Alaska
11260
1.1840
1.2023
1.5502030
Angoon County, Alaska
99902
1.1933
1.0661
−10.6602040
Barrow-North Slope County, Alaska
99902
1.1933
1.0661
−10.6602050
Bethel County, Alaska
99902
1.1933
1.0661
−10.6602060
Bristol Bay Borough County, Alaska
99902
1.1933
1.0661
−10.6602068
Denali County, Alaska
99902
1.1933
1.0661
−10.6602070
Bristol Bay County, Alaska
99902
1.1933
1.0661
−10.6602080
Cordova-Mc Carthy County, Alaska
99902
1.1933
1.0661
−10.6602090
Fairbanks County, Alaska
21820
1.1648
1.1059
−5.0602100
Haines County, Alaska
99902
1.1933
1.0661
−10.6602110
Juneau County, Alaska
99902
1.1933
1.0661
−10.6602120
Kenai-Cook Inlet County, Alaska
99902
1.1933
1.0661
−10.6602122
Kenai Peninsula Borough, Alaska
99902
1.1933
1.0661
−10.6602130
Ketchikan County, Alaska
99902
1.1933
1.0661
−10.6602140
Kobuk County, Alaska
99902
1.1933
1.0661
−10.6602150
Kodiak County, Alaska
99902
1.1933
1.0661
−10.6602160
Kuskokwin County, Alaska
99902
1.1933
1.0661
−10.66( print page 65960)02164
Lake and Peninsula Borough, Alaska
99902
1.1933
1.0661
−10.6602170
Matanuska County, Alaska
11260
1.1892
1.2023
1.1002180
Nome County, Alaska
99902
1.1933
1.0661
−10.6602185
North Slope Borough, Alaska
99902
1.1933
1.0661
−10.6602188
Northwest Arctic Borough, Alaska
99902
1.1933
1.0661
−10.6602190
Outer Ketchikan County, Alaska
99902
1.1933
1.0661
−10.6602200
Prince Of Wales County, Alaska
99902
1.1933
1.0661
−10.6602201
Prince of Wales-Outer Ketchikan  Census Area,AK
99902
1.1933
1.0661
−10.6602210
Seward County, Alaska
99902
1.1933
1.0661
−10.6602220
Sitka County, Alaska
99902
1.1933
1.0661
−10.6602230
Skagway-Yakutat County, Alaska
99902
1.1933
1.0661
−10.6602231
Skagway-Yakutat-Angoon Census Area,  Alaska
99902
1.1933
1.0661
−10.6602232
Skagway-Hoonah-Angoon Census Area, Alaska
99902
1.1933
1.0661
−10.6602240
Southeast Fairbanks County, Alaska
99902
1.1933
1.0661
−10.6602250
Upper Yukon County, Alaska
99902
1.1933
1.0661
−10.6602260
Valdz-Chitna-Whitier County, Alaska
99902
1.1933
1.0661
−10.6602261
Valdex-Cordove Census Area, Alaska
99902
1.1933
1.0661
−10.6602270
Wade Hampton County, Alaska
99902
1.1933
1.0661
−10.6602280
Wrangell-Petersburg County, Alaska
99902
1.1933
1.0661
−10.6602282
Yakutat Borough, Alaska
99902
1.1933
1.0661
−10.6602290
Yukon-Koyukuk County, Alaska
99902
1.1933
1.0661
−10.6603000
Apache County, Arizona
99903
0.8907
0.8908
0.0103010
Cochise County, Arizona
99903
0.8907
0.8908
0.0103020
Coconino County, Arizona
22380
1.1969
1.1601
−3.0703030
Gila County, Arizona
99903
0.8907
0.8908
0.0103040
Graham County, Arizona
99903
0.8907
0.8908
0.0103050
Greenlee County, Arizona
99903
0.8907
0.8908
0.0103055
La Paz County, Arizona
99903
0.8907
0.8908
0.0103060
Maricopa County, Arizona
38060
1.0127
1.0287
1.5803070
Mohave County, Arizona
99903
0.9962
0.8908
−10.5803080
Navajo County, Arizona
99903
0.8907
0.8908
0.0103090
Pima County, Arizona
46060
0.9007
0.9202
2.1603100
Pinal County, Arizona
38060
1.0127
1.0287
1.5803110
Santa Cruz County, Arizona
99903
0.8907
0.8908
0.0103120
Yavapai County, Arizona
39140
0.9457
0.9836
4.0103130
Yuma County, Arizona
49740
0.9126
0.9109
−0.1904000
Arkansas County, Arkansas
99904
0.7605
0.7307
−3.9204010
Ashley County, Arkansas
99904
0.7605
0.7307
−3.9204020
Baxter County, Arkansas
99904
0.7605
0.7307
−3.9204030
Benton County, Arkansas
22220
0.8661
0.8865
2.3604040
Boone County, Arkansas
99904
0.7605
0.7307
−3.9204050
Bradley County, Arkansas
99904
0.7605
0.7307
−3.9204060
Calhoun County, Arkansas
99904
0.7605
0.7307
−3.9204070
Carroll County, Arkansas
99904
0.7605
0.7307
−3.9204080
Chicot County, Arkansas
99904
0.7605
0.7307
−3.9204090
Clark County, Arkansas
99904
0.7605
0.7307
−3.9204100
Clay County, Arkansas
99904
0.7605
0.7307
−3.9204110
Cleburne County, Arkansas
99904
0.7605
0.7307
−3.9204120
Cleveland County, Arkansas
38220
0.8212
0.8383
2.0804130
Columbia County, Arkansas
99904
0.7605
0.7307
−3.9204140
Conway County, Arkansas
99904
0.7605
0.7307
−3.9204150
Craighead County, Arkansas
27860
0.7911
0.7662
−3.1504160
Crawford County, Arkansas
22900
0.8238
0.7731
−6.1504170
Crittenden County, Arkansas
32820
0.9407
0.9373
−0.3604180
Cross County, Arkansas
99904
0.7605
0.7307
−3.9204190
Dallas County, Arkansas
99904
0.7605
0.7307
−3.9204200
Desha County, Arkansas
99904
0.7605
0.7307
−3.9204210
Drew County, Arkansas
99904
0.7605
0.7307
−3.9204220
Faulkner County, Arkansas
30780
0.8747
0.8890
1.6304230
Franklin County, Arkansas
22900
0.7987
0.7731
−3.2104240
Fulton County, Arkansas
99904
0.7605
0.7307
−3.9204250
Garland County, Arkansas
26300
0.8375
0.8782
4.8604260
Grant County, Arkansas
30780
0.8246
0.8890
7.8104270
Greene County, Arkansas
99904
0.7605
0.7307
−3.9204280
Hempstead County, Arkansas
99904
0.7605
0.7307
−3.9204290
Hot Spring County, Arkansas
99904
0.7605
0.7307
−3.9204300
Howard County, Arkansas
99904
0.7605
0.7307
−3.9204310
Independence County, Arkansas
99904
0.7605
0.7307
−3.92( print page 65961)04320
Izard County, Arkansas
99904
0.7605
0.7307
−3.9204330
Jackson County, Arkansas
99904
0.7605
0.7307
−3.9204340
Jefferson County, Arkansas
38220
0.8680
0.8383
−3.4204350
Johnson County, Arkansas
99904
0.7605
0.7307
−3.9204360
Lafayette County, Arkansas
99904
0.7605
0.7307
−3.9204370
Lawrence County, Arkansas
99904
0.7605
0.7307
−3.9204380
Lee County, Arkansas
99904
0.7605
0.7307
−3.9204390
Lincoln County, Arkansas
38220
0.8212
0.8383
2.0804400
Little River County, Arkansas
99904
0.7605
0.7307
−3.9204410
Logan County, Arkansas
99904
0.7605
0.7307
−3.9204420
Lonoke County, Arkansas
30780
0.8747
0.8890
1.6304430
Madison County, Arkansas
22220
0.8203
0.8865
8.0704440
Marion County, Arkansas
99904
0.7605
0.7307
−3.9204450
Miller County, Arkansas
45500
0.8283
0.8104
−2.1604460
Mississippi County, Arkansas
99904
0.7605
0.7307
−3.9204470
Monroe County, Arkansas
99904
0.7605
0.7307
−3.9204480
Montgomery County, Arkansas
99904
0.7605
0.7307
−3.9204490
Nevada County, Arkansas
99904
0.7605
0.7307
−3.9204500
Newton County, Arkansas
99904
0.7605
0.7307
−3.9204510
Ouachita County, Arkansas
99904
0.7605
0.7307
−3.9204520
Perry County, Arkansas
30780
0.8246
0.8890
7.8104530
Phillips County, Arkansas
99904
0.7605
0.7307
−3.9204540
Pike County, Arkansas
99904
0.7605
0.7307
−3.9204550
Poinsett County, Arkansas
27860
0.7828
0.7662
−2.1204560
Polk County, Arkansas
99904
0.7605
0.7307
−3.9204570
Pope County, Arkansas
99904
0.7605
0.7307
−3.9204580
Prairie County, Arkansas
99904
0.7605
0.7307
−3.9204590
Pulaski County, Arkansas
30780
0.8747
0.8890
1.6304600
Randolph County, Arkansas
99904
0.7605
0.7307
−3.9204610
St Francis County, Arkansas
99904
0.7605
0.7307
−3.9204620
Saline County, Arkansas
30780
0.8747
0.8890
1.6304630
Scott County, Arkansas
99904
0.7605
0.7307
−3.9204640
Searcy County, Arkansas
99904
0.7605
0.7307
−3.9204650
Sebastian County, Arkansas
22900
0.8238
0.7731
−6.1504660
Sevier County, Arkansas
99904
0.7605
0.7307
−3.9204670
Sharp County, Arkansas
99904
0.7605
0.7307
−3.9204680
Stone County, Arkansas
99904
0.7605
0.7307
−3.9204690
Union County, Arkansas
99904
0.7605
0.7307
−3.9204700
Van Buren County, Arkansas
99904
0.7605
0.7307
−3.9204710
Washington County, Arkansas
22220
0.8661
0.8865
2.3604720
White County, Arkansas
99904
0.7605
0.7307
−3.9204730
Woodruff County, Arkansas
99904
0.7605
0.7307
−3.9204740
Yell County, Arkansas
99904
0.7605
0.7307
−3.9205000
Alameda County, California
36084
1.5346
1.5819
3.0805010
Alpine County, California
99905
1.0915
1.1454
4.9405020
Amador County, California
99905
1.0915
1.1454
4.9405030
Butte County, California
17020
1.0511
1.1053
5.1605040
Calaveras County, California
99905
1.0915
1.1454
4.9405050
Colusa County, California
99905
1.0915
1.1454
4.9405060
Contra Costa County, California
36084
1.5346
1.5819
3.0805070
Del Norte County, California
99905
1.0915
1.1454
4.9405080
Eldorado County, California
40900
1.3056
1.3372
2.4205090
Fresno County, California
23420
1.0483
1.0943
4.3905100
Glenn County, California
99905
1.0915
1.1454
4.9405110
Humboldt County, California
99905
1.0915
1.1454
4.9405120
Imperial County, California
20940
0.9841
0.9076
−7.7705130
Inyo County, California
99905
1.0915
1.1454
4.9405140
Kern County, California
12540
1.0470
1.0725
2.4405150
Kings County, California
25260
1.0406
1.0282
−1.1905160
Lake County, California
99905
1.0915
1.1454
4.9405170
Lassen County, California
99905
1.0915
1.1454
4.9405200
Los Angeles County, California
31084
1.1783
1.1760
−0.2005210
Los Angeles County, California
31084
1.1783
1.1760
−0.2005300
Madera County, California
31460
0.9571
0.8154
−14.8105310
Marin County, California
41884
1.4994
1.5165
1.1405320
Mariposa County, California
99905
1.0915
1.1454
4.9405330
Mendocino County, California
99905
1.0915
1.1454
4.9405340
Merced County, California
32900
1.1109
1.1471
3.26( print page 65962)05350
Modoc County, California
99905
1.0915
1.1454
4.9405360
Mono County, California
99905
1.0915
1.1454
4.9405370
Monterey County, California
41500
1.4128
1.4337
1.4805380
Napa County, California
34900
1.3313
1.3374
0.4605390
Nevada County, California
99905
1.0915
1.1454
4.9405400
Orange County, California
42044
1.1559
1.1473
−0.7405410
Placer County, California
40900
1.3056
1.3372
2.4205420
Plumas County, California
99905
1.0915
1.1454
4.9405430
Riverside County, California
40140
1.1027
1.0904
−1.1205440
Sacramento County, California
40900
1.3056
1.3372
2.4205450
San Benito County, California
41940
1.2937
1.5543
20.1405460
San Bernardino County, California
40140
1.1027
1.0904
−1.1205470
San Diego County, California
41740
1.1413
1.1354
−0.5205480
San Francisco County, California
41884
1.4994
1.5165
1.1405490
San Joaquin County, California
44700
1.1307
1.1442
1.1905500
San Luis Obispo County, California
42020
1.1349
1.1598
2.1905510
San Mateo County, California
41884
1.4994
1.5165
1.1405520
Santa Barbara County, California
42060
1.1694
1.1091
−5.1605530
Santa Clara County, California
41940
1.5109
1.5543
2.8705540
Santa Cruz County, California
42100
1.5166
1.5457
1.9205550
Shasta County, California
39820
1.2203
1.3198
8.1505560
Sierra County, California
99905
1.0915
1.1454
4.9405570
Siskiyou County, California
99905
1.0915
1.1454
4.9405580
Solano County, California
46700
1.4460
1.5137
4.6805590
Sonoma County, California
42220
1.3493
1.4464
7.2005600
Stanislaus County, California
33700
1.1885
1.1729
−1.3105610
Sutter County, California
49700
1.0921
1.0730
−1.7505620
Tehama County, California
99905
1.0915
1.1454
4.9405630
Trinity County, California
99905
1.0915
1.1454
4.9405640
Tulare County, California
47300
1.0123
0.9968
−1.5305650
Tuolumne County, California
99905
1.0915
1.1454
4.9405660
Ventura County, California
37100
1.1622
1.1546
−0.6505670
Yolo County, California
40900
1.1460
1.3372
16.6805680
Yuba County, California
49700
1.0921
1.0730
−1.7506000
Adams County, Colorado
19740
1.0723
1.0930
1.9306010
Alamosa County, Colorado
99906
0.9380
0.9325
−0.5906020
Arapahoe County, Colorado
19740
1.0723
1.0930
1.9306030
Archuleta County, Colorado
99906
0.9380
0.9325
−0.5906040
Baca County, Colorado
99906
0.9380
0.9325
−0.5906050
Bent County, Colorado
99906
0.9380
0.9325
−0.5906060
Boulder County, Colorado
14500
0.9734
1.0350
6.3306070
Chaffee County, Colorado
99906
0.9380
0.9325
−0.5906080
Cheyenne County, Colorado
99906
0.9380
0.9325
−0.5906090
Clear Creek County, Colorado
19740
1.0052
1.0930
8.7306100
Conejos County, Colorado
99906
0.9380
0.9325
−0.5906110
Costilla County, Colorado
99906
0.9380
0.9325
−0.5906120
Crowley County, Colorado
99906
0.9380
0.9325
−0.5906130
Custer County, Colorado
99906
0.9380
0.9325
−0.5906140
Delta County, Colorado
99906
0.9380
0.9325
−0.5906150
Denver County, Colorado
19740
1.0723
1.0930
1.9306160
Dolores County, Colorado
99906
0.9380
0.9325
−0.5906170
Douglas County, Colorado
19740
1.0723
1.0930
1.9306180
Eagle County, Colorado
99906
0.9380
0.9325
−0.5906190
Elbert County, Colorado
19740
1.0052
1.0930
8.7306200
El Paso County, Colorado
17820
0.9468
0.9701
2.4606210
Fremont County, Colorado
99906
0.9380
0.9325
−0.5906220
Garfield County, Colorado
99906
0.9380
0.9325
−0.5906230
Gilpin County, Colorado
19740
1.0052
1.0930
8.7306240
Grand County, Colorado
99906
0.9380
0.9325
−0.5906250
Gunnison County, Colorado
99906
0.9380
0.9325
−0.5906260
Hinsdale County, Colorado
99906
0.9380
0.9325
−0.5906270
Huerfano County, Colorado
99906
0.9380
0.9325
−0.5906280
Jackson County, Colorado
99906
0.9380
0.9325
−0.5906290
Jefferson County, Colorado
19740
1.0723
1.0930
1.9306300
Kiowa County, Colorado
99906
0.9380
0.9325
−0.5906310
Kit Carson County, Colorado
99906
0.9380
0.9325
−0.5906320
Lake County, Colorado
99906
0.9380
0.9325
−0.5906330
La Plata County, Colorado
99906
0.9380
0.9325
−0.59( print page 65963)06340
Larimer County, Colorado
22660
1.0122
0.9544
−5.7106350
Las Animas County, Colorado
99906
0.9380
0.9325
−0.5906360
Lincoln County, Colorado
99906
0.9380
0.9325
−0.5906370
Logan County, Colorado
99906
0.9380
0.9325
−0.5906380
Mesa County, Colorado
24300
0.9550
0.9668
1.2406390
Mineral County, Colorado
99906
0.9380
0.9325
−0.5906400
Moffat County, Colorado
99906
0.9380
0.9325
−0.5906410
Montezuma County, Colorado
99906
0.9380
0.9325
−0.5906420
Montrose County, Colorado
99906
0.9380
0.9325
−0.5906430
Morgan County, Colorado
99906
0.9380
0.9325
−0.5906440
Otero County, Colorado
99906
0.9380
0.9325
−0.5906450
Ouray County, Colorado
99906
0.9380
0.9325
−0.5906460
Park County, Colorado
19740
1.0052
1.0930
8.7306470
Phillips County, Colorado
99906
0.9380
0.9325
−0.5906480
Pitkin County, Colorado
99906
0.9380
0.9325
−0.5906490
Prowers County, Colorado
99906
0.9380
0.9325
−0.5906500
Pueblo County, Colorado
39380
0.8623
0.8753
1.5106510
Rio Blanco County, Colorado
99906
0.9380
0.9325
−0.5906520
Rio Grande County, Colorado
99906
0.9380
0.9325
−0.5906530
Routt County, Colorado
99906
0.9380
0.9325
−0.5906540
Saguache County, Colorado
99906
0.9380
0.9325
−0.5906550
San Juan County, Colorado
99906
0.9380
0.9325
−0.5906560
San Miguel County, Colorado
99906
0.9380
0.9325
−0.5906570
Sedgwick County, Colorado
99906
0.9380
0.9325
−0.5906580
Summit County, Colorado
99906
0.9380
0.9325
−0.5906590
Teller County, Colorado
17820
0.9424
0.9701
2.9406600
Washington County, Colorado
99906
0.9380
0.9325
−0.5906610
Weld County, Colorado
24540
0.9570
0.9602
0.3306620
Yuma County, Colorado
99906
0.9380
0.9325
−0.5906630
Broomfield County, Colorado
19740
1.0723
1.0930
1.9307000
Fairfield County, Connecticut
14860
1.2394
1.2659
2.1407010
Hartford County, Connecticut
25540
1.1073
1.0894
−1.6207020
Litchfield County, Connecticut
25540
1.1073
1.0894
−1.6207030
Middlesex County, Connecticut
25540
1.1073
1.0894
−1.6207040
New Haven County, Connecticut
35300
1.2042
1.1953
−0.7407050
New London County, Connecticut
35980
1.1345
1.1932
5.1707060
Tolland County, Connecticut
25540
1.1073
1.0894
−1.6207070
Windham County, Connecticut
99907
1.1730
1.1709
−0.1808000
Kent County, Delaware
20100
0.9776
0.9847
0.7308010
New Castle County, Delaware
48864
1.0499
1.0684
1.7608020
Sussex County, Delaware
99908
0.9579
0.9705
1.3209000
Washington DC County, Dist Of Col
47894
1.0951
1.1054
0.9410000
Alachua County, Florida
23540
0.9388
0.9277
−1.1810010
Baker County, Florida
27260
0.8984
0.9165
2.0110020
Bay County, Florida
37460
0.8005
0.8027
0.2710030
Bradford County, Florida
99910
0.8623
0.8594
−0.3410040
Brevard County, Florida
37340
0.9839
0.9443
−4.0210050
Broward County, Florida
22744
1.0432
1.0133
−2.8710060
Calhoun County, Florida
99910
0.8623
0.8594
−0.3410070
Charlotte County, Florida
39460
0.9255
0.9405
1.6210080
Citrus County, Florida
99910
0.8623
0.8594
−0.3410090
Clay County, Florida
27260
0.9295
0.9165
−1.4010100
Collier County, Florida
34940
1.0139
0.9941
−1.9510110
Columbia County, Florida
99910
0.8623
0.8594
−0.3410120
Dade County, Florida
33124
0.9750
0.9812
0.6410130
De Soto County, Florida
99910
0.8623
0.8594
−0.3410140
Dixie County, Florida
99910
0.8623
0.8594
−0.3410150
Duval County, Florida
27260
0.9295
0.9165
−1.4010160
Escambia County, Florida
37860
0.8096
0.8000
−1.1910170
Flagler County, Florida
99910
0.8947
0.8594
−3.9510180
Franklin County, Florida
99910
0.8623
0.8594
−0.3410190
Gadsden County, Florida
45220
0.8688
0.8942
2.9210200
Gilchrist County, Florida
23540
0.9033
0.9277
2.7010210
Glades County, Florida
99910
0.8623
0.8594
−0.3410220
Gulf County, Florida
99910
0.8623
0.8594
−0.3410230
Hamilton County, Florida
99910
0.8623
0.8594
−0.3410240
Hardee County, Florida
99910
0.8623
0.8594
−0.3410250
Hendry County, Florida
99910
0.8623
0.8594
−0.34( print page 65964)10260
Hernando County, Florida
45300
0.9233
0.9144
−0.9610270
Highlands County, Florida
99910
0.8623
0.8594
−0.3410280
Hillsborough County, Florida
45300
0.9233
0.9144
−0.9610290
Holmes County, Florida
99910
0.8623
0.8594
−0.3410300
Indian River County, Florida
42680
0.9056
0.9573
5.7110310
Jackson County, Florida
99910
0.8623
0.8594
−0.3410320
Jefferson County, Florida
45220
0.8683
0.8942
2.9810330
Lafayette County, Florida
99910
0.8623
0.8594
−0.3410340
Lake County, Florida
36740
0.9464
0.9452
−0.1310350
Lee County, Florida
15980
0.9356
0.9342
−0.1510360
Leon County, Florida
45220
0.8688
0.8942
2.9210370
Levy County, Florida
99910
0.8623
0.8594
−0.3410380
Liberty County, Florida
99910
0.8623
0.8594
−0.3410390
Madison County, Florida
99910
0.8623
0.8594
−0.3410400
Manatee County, Florida
42260
0.9639
0.9868
2.3810410
Marion County, Florida
36100
0.8925
0.8867
−0.6510420
Martin County, Florida
38940
1.0123
0.9833
−2.8610430
Monroe County, Florida
99910
0.8623
0.8594
−0.3410440
Nassau County, Florida
27260
0.9295
0.9165
−1.4010450
Okaloosa County, Florida
23020
0.8872
0.8643
−2.5810460
Okeechobee County, Florida
99910
0.8623
0.8594
−0.3410470
Orange County, Florida
36740
0.9464
0.9452
−0.1310480
Osceola County, Florida
36740
0.9464
0.9452
−0.1310490
Palm Beach County, Florida
48424
1.0067
0.9649
−4.1510500
Pasco County, Florida
45300
0.9233
0.9144
−0.9610510
Pinellas County, Florida
45300
0.9233
0.9144
−0.9610520
Polk County, Florida
29460
0.8912
0.8879
−0.3710530
Putnam County, Florida
99910
0.8623
0.8594
−0.3410540
Johns County, Florida
27260
0.9295
0.9165
−1.4010550
St Lucie County, Florida
38940
1.0123
0.9833
−2.8610560
Santa Rosa County, Florida
37860
0.8096
0.8000
−1.1910570
Sarasota County, Florida
42260
0.9639
0.9868
2.3810580
Seminole County, Florida
36740
0.9464
0.9452
−0.1310590
Sumter County, Florida
99910
0.8623
0.8594
−0.3410600
Suwannee County, Florida
99910
0.8623
0.8594
−0.3410610
Taylor County, Florida
99910
0.8623
0.8594
−0.3410620
Union County, Florida
99910
0.8623
0.8594
−0.3410630
Volusia County, Florida
19660
0.9312
0.9263
−0.5310640
Wakulla County, Florida
45220
0.8683
0.8942
2.9810650
Walton County, Florida
99910
0.8623
0.8594
−0.3410660
Washington County, Florida
99910
0.8623
0.8594
−0.3411000
Appling County, Georgia
99911
0.7914
0.7593
−4.0611010
Atkinson County, Georgia
99911
0.7914
0.7593
−4.0611011
Bacon County, Georgia
99911
0.7914
0.7593
−4.0611020
Baker County, Georgia
10500
0.8397
0.8991
7.0711030
Baldwin County, Georgia
99911
0.7914
0.7593
−4.0611040
Banks County, Georgia
99911
0.7914
0.7593
−4.0611050
Barrow County, Georgia
12060
0.9793
0.9762
−0.3211060
Bartow County, Georgia
12060
0.9793
0.9762
−0.3211070
Ben Hill County, Georgia
99911
0.7914
0.7593
−4.0611080
Berrien County, Georgia
99911
0.7914
0.7593
−4.0611090
Bibb County, Georgia
31420
0.9360
0.9519
1.7011100
Bleckley County, Georgia
99911
0.7914
0.7593
−4.0611110
Brantley County, Georgia
15260
0.8739
1.0164
16.3111120
Brooks County, Georgia
46660
0.8516
0.8369
−1.7311130
Bryan County, Georgia
42340
0.9461
0.9351
−1.1611140
Bulloch County, Georgia
99911
0.7914
0.7593
−4.0611150
Burke County, Georgia
12260
0.8957
0.9667
7.9311160
Butts County, Georgia
12060
0.8980
0.9762
8.7111161
Calhoun County, Georgia
99911
0.7914
0.7593
−4.0611170
Camden County, Georgia
99911
0.7914
0.7593
−4.0611180
Candler County, Georgia
99911
0.7914
0.7593
−4.0611190
Carroll County, Georgia
12060
0.9793
0.9762
−0.3211200
Catoosa County, Georgia
16860
0.9088
0.8948
−1.5411210
Charlton County, Georgia
99911
0.7914
0.7593
−4.0611220
Chatham County, Georgia
42340
0.9461
0.9351
−1.1611230
Chattahoochee County, Georgia
17980
0.8560
0.8239
−3.7511240
Chattooga County, Georgia
99911
0.7914
0.7593
−4.06( print page 65965)11250
Cherokee County, Georgia
12060
0.9793
0.9762
−0.3211260
Clarke County, Georgia
12020
0.9855
0.9856
0.0111270
Clay County, Georgia
99911
0.7914
0.7593
−4.0611280
Clayton County, Georgia
12060
0.9793
0.9762
−0.3211281
Clinch County, Georgia
99911
0.7914
0.7593
−4.0611290
Cobb County, Georgia
12060
0.9793
0.9762
−0.3211291
Coffee County, Georgia
99911
0.7914
0.7593
−4.0611300
Colquitt County, Georgia
99911
0.7914
0.7593
−4.0611310
Columbia County, Georgia
12260
0.9778
0.9667
−1.1411311
Cook County, Georgia
99911
0.7914
0.7593
−4.0611320
Coweta County, Georgia
12060
0.9793
0.9762
−0.3211330
Crawford County, Georgia
31420
0.8805
0.9519
8.1111340
Crisp County, Georgia
99911
0.7914
0.7593
−4.0611341
Dade County, Georgia
16860
0.9088
0.8948
−1.5411350
Dawson County, Georgia
12060
0.8980
0.9762
8.7111360
Decatur County, Georgia
99911
0.7914
0.7593
−4.0611370
De Kalb County, Georgia
12060
0.9793
0.9762
−0.3211380
Dodge County, Georgia
99911
0.7914
0.7593
−4.0611381
Dooly County, Georgia
99911
0.7914
0.7593
−4.0611390
Dougherty County, Georgia
10500
0.8628
0.8991
4.2111400
Douglas County, Georgia
12060
0.9793
0.9762
−0.3211410
Early County, Georgia
99911
0.7914
0.7593
−4.0611420
Echols County, Georgia
46660
0.8516
0.8369
−1.7311421
Effingham County, Georgia
42340
0.9461
0.9351
−1.1611430
Elbert County, Georgia
99911
0.7914
0.7593
−4.0611440
Emanuel County, Georgia
99911
0.7914
0.7593
−4.0611441
Evans County, Georgia
99911
0.7914
0.7593
−4.0611450
Fannin County, Georgia
99911
0.7914
0.7593
−4.0611451
Fayette County, Georgia
12060
0.9793
0.9762
−0.3211460
Floyd County, Georgia
40660
0.8790
0.9193
4.5811461
Forsyth County, Georgia
12060
0.9793
0.9762
−0.3211462
Franklin County, Georgia
99911
0.7914
0.7593
−4.0611470
Fulton County, Georgia
12060
0.9793
0.9762
−0.3211471
Gilmer County, Georgia
99911
0.7914
0.7593
−4.0611480
Glascock County, Georgia
99911
0.7914
0.7593
−4.0611490
Glynn County, Georgia
15260
0.8739
1.0164
16.3111500
Gordon County, Georgia
99911
0.7914
0.7593
−4.0611510
Grady County, Georgia
99911
0.7914
0.7593
−4.0611520
Greene County, Georgia
99911
0.7914
0.7593
−4.0611530
Gwinnett County, Georgia
12060
0.9793
0.9762
−0.3211540
Habersham County, Georgia
99911
0.7914
0.7593
−4.0611550
Hall County, Georgia
23580
0.8520
0.8958
5.1411560
Hancock County, Georgia
99911
0.7914
0.7593
−4.0611570
Haralson County, Georgia
12060
0.8980
0.9762
8.7111580
Harris County, Georgia
17980
0.8560
0.8239
−3.7511581
Hart County, Georgia
99911
0.7914
0.7593
−4.0611590
Heard County, Georgia
12060
0.8980
0.9762
8.7111591
Henry County, Georgia
12060
0.9793
0.9762
−0.3211600
Houston County, Georgia
47580
0.8961
0.8380
−6.4811601
Irwin County, Georgia
99911
0.7914
0.7593
−4.0611610
Jackson County, Georgia
99911
0.7914
0.7593
−4.0611611
Jasper County, Georgia
12060
0.8980
0.9762
8.7111612
Jeff Davis County, Georgia
99911
0.7914
0.7593
−4.0611620
Jefferson County, Georgia
99911
0.7914
0.7593
−4.0611630
Jenkins County, Georgia
99911
0.7914
0.7593
−4.0611640
Johnson County, Georgia
99911
0.7914
0.7593
−4.0611650
Jones County, Georgia
31420
0.9360
0.9519
1.7011651
Lamar County, Georgia
12060
0.8980
0.9762
8.7111652
Lanier County, Georgia
46660
0.8516
0.8369
−1.7311660
Laurens County, Georgia
99911
0.7914
0.7593
−4.0611670
Lee County, Georgia
10500
0.8628
0.8991
4.2111680
Liberty County, Georgia
25980
0.8973
0.9178
2.2811690
Lincoln County, Georgia
99911
0.7914
0.7593
−4.0611691
Long County, Georgia
25980
0.8973
0.9178
2.2811700
Lowndes County, Georgia
46660
0.8516
0.8369
−1.7311701
Lumpkin County, Georgia
99911
0.7914
0.7593
−4.0611702
Mc Duffie County, Georgia
12260
0.9778
0.9667
−1.1411703
Mc Intosh County, Georgia
15260
0.8739
1.0164
16.31( print page 65966)11710
Macon County, Georgia
99911
0.7914
0.7593
−4.0611720
Madison County, Georgia
12020
0.9855
0.9856
0.0111730
Marion County, Georgia
17980
0.8363
0.8239
−1.4811740
Meriwether County, Georgia
12060
0.8980
0.9762
8.7111741
Miller County, Georgia
99911
0.7914
0.7593
−4.0611750
Mitchell County, Georgia
99911
0.7914
0.7593
−4.0611760
Monroe County, Georgia
31420
0.8805
0.9519
8.1111770
Montgomery County, Georgia
99911
0.7914
0.7593
−4.0611771
Morgan County, Georgia
99911
0.7914
0.7593
−4.0611772
Murray County, Georgia
19140
0.8623
0.9093
5.4511780
Muscogee County, Georgia
17980
0.8560
0.8239
−3.7511790
Newton County, Georgia
12060
0.9793
0.9762
−0.3211800
Oconee County, Georgia
12020
0.9855
0.9856
0.0111801
Oglethorpe County, Georgia
12020
0.9011
0.9856
9.3811810
Paulding County, Georgia
12060
0.9793
0.9762
−0.3211811
Peach County, Georgia
99911
0.8470
0.7593
−10.3511812
Pickens County, Georgia
12060
0.9793
0.9762
−0.3211820
Pierce County, Georgia
99911
0.7914
0.7593
−4.0611821
Pike County, Georgia
12060
0.8980
0.9762
8.7111830
Polk County, Georgia
99911
0.7914
0.7593
−4.0611831
Pulaski County, Georgia
99911
0.7914
0.7593
−4.0611832
Putnam County, Georgia
99911
0.7914
0.7593
−4.0611833
Quitman County, Georgia
99911
0.7914
0.7593
−4.0611834
Rabun County, Georgia
99911
0.7914
0.7593
−4.0611835
Randolph County, Georgia
99911
0.7914
0.7593
−4.0611840
Richmond County, Georgia
12260
0.9778
0.9667
−1.1411841
Rockdale County, Georgia
12060
0.9793
0.9762
−0.3211842
Schley County, Georgia
99911
0.7914
0.7593
−4.0611850
Screven County, Georgia
99911
0.7914
0.7593
−4.0611851
Seminole County, Georgia
99911
0.7914
0.7593
−4.0611860
Spalding County, Georgia
12060
0.9793
0.9762
−0.3211861
Stephens County, Georgia
99911
0.7914
0.7593
−4.0611862
Stewart County, Georgia
99911
0.7914
0.7593
−4.0611870
Sumter County, Georgia
99911
0.7914
0.7593
−4.0611880
Talbot County, Georgia
99911
0.7914
0.7593
−4.0611881
Taliaferro County, Georgia
99911
0.7914
0.7593
−4.0611882
Tattnall County, Georgia
99911
0.7914
0.7593
−4.0611883
Taylor County, Georgia
99911
0.7914
0.7593
−4.0611884
Telfair County, Georgia
99911
0.7914
0.7593
−4.0611885
Terrell County, Georgia
10500
0.8397
0.8991
7.0711890
Thomas County, Georgia
99911
0.7914
0.7593
−4.0611900
Tift County, Georgia
99911
0.7914
0.7593
−4.0611901
Toombs County, Georgia
99911
0.7914
0.7593
−4.0611902
Towns County, Georgia
99911
0.7914
0.7593
−4.0611903
Treutlen County, Georgia
99911
0.7914
0.7593
−4.0611910
Troup County, Georgia
99911
0.7914
0.7593
−4.0611911
Turner County, Georgia
99911
0.7914
0.7593
−4.0611912
Twiggs County, Georgia
31420
0.9360
0.9519
1.7011913
Union County, Georgia
99911
0.7914
0.7593
−4.0611920
Upson County, Georgia
99911
0.7914
0.7593
−4.0611921
Walker County, Georgia
16860
0.9088
0.8948
−1.5411930
Walton County, Georgia
12060
0.9793
0.9762
−0.3211940
Ware County, Georgia
99911
0.7914
0.7593
−4.0611941
Warren County, Georgia
99911
0.7914
0.7593
−4.0611950
Washington County, Georgia
99911
0.7914
0.7593
−4.0611960
Wayne County, Georgia
99911
0.7914
0.7593
−4.0611961
Webster County, Georgia
99911
0.7914
0.7593
−4.0611962
Wheeler County, Georgia
99911
0.7914
0.7593
−4.0611963
White County, Georgia
99911
0.7914
0.7593
−4.0611970
Whitfield County, Georgia
19140
0.8623
0.9093
5.4511971
Wilcox County, Georgia
99911
0.7914
0.7593
−4.0611972
Wilkes County, Georgia
99911
0.7914
0.7593
−4.0611973
Wilkinson County, Georgia
99911
0.7914
0.7593
−4.0611980
Worth County, Georgia
10500
0.8397
0.8991
7.0712005
Kalawao County, Hawaii
99912
1.0551
1.0448
−0.9812010
Hawaii County, Hawaii
99912
1.0551
1.0448
−0.9812020
Honolulu County, Hawaii
26180
1.1214
1.1096
−1.0512040
Kauai County, Hawaii
99912
1.0551
1.0448
−0.98( print page 65967)12050
Maui County, Hawaii
99912
1.0551
1.0448
−0.9813000
Ada County, Idaho
14260
0.9052
0.9401
3.8613010
Adams County, Idaho
99913
0.8567
0.8120
−5.2213020
Bannock County, Idaho
38540
0.9351
0.9400
0.5213030
Bear Lake County, Idaho
99913
0.8567
0.8120
−5.2213040
Benewah County, Idaho
99913
0.8567
0.8120
−5.2213050
Bingham County, Idaho
99913
0.8567
0.8120
−5.2213060
Blaine County, Idaho
99913
0.8567
0.8120
−5.2213070
Boise County, Idaho
14260
0.9075
0.9401
3.5913080
Bonner County, Idaho
99913
0.8567
0.8120
−5.2213090
Bonneville County, Idaho
26820
0.9259
0.9088
−1.8513100
Boundary County, Idaho
99913
0.8567
0.8120
−5.2213110
Butte County, Idaho
99913
0.8567
0.8120
−5.2213120
Camas County, Idaho
99913
0.8567
0.8120
−5.2213130
Canyon County, Idaho
14260
0.9052
0.9401
3.8613140
Caribou County, Idaho
99913
0.8567
0.8120
−5.2213150
Cassia County, Idaho
99913
0.8567
0.8120
−5.2213160
Clark County, Idaho
99913
0.8567
0.8120
−5.2213170
Clearwater County, Idaho
99913
0.8567
0.8120
−5.2213180
Custer County, Idaho
99913
0.8567
0.8120
−5.2213190
Elmore County, Idaho
99913
0.8567
0.8120
−5.2213200
Franklin County, Idaho
30860
0.9131
0.9022
−1.1913210
Fremont County, Idaho
99913
0.8567
0.8120
−5.2213220
Gem County, Idaho
14260
0.9075
0.9401
3.5913230
Gooding County, Idaho
99913
0.8567
0.8120
−5.2213240
Idaho County, Idaho
99913
0.8567
0.8120
−5.2213250
Jefferson County, Idaho
26820
0.9259
0.9088
−1.8513260
Jerome County, Idaho
99913
0.8567
0.8120
−5.2213270
Kootenai County, Idaho
17660
0.9372
0.9344
−0.3013280
Latah County, Idaho
99913
0.8567
0.8120
−5.2213290
Lemhi County, Idaho
99913
0.8567
0.8120
−5.2213300
Lewis County, Idaho
99913
0.8567
0.8120
−5.2213310
Lincoln County, Idaho
99913
0.8567
0.8120
−5.2213320
Madison County, Idaho
99913
0.8567
0.8120
−5.2213330
Minidoka County, Idaho
99913
0.8567
0.8120
−5.2213340
Nez Perce County, Idaho
30300
0.9492
0.9853
3.8013350
Oneida County, Idaho
99913
0.8567
0.8120
−5.2213360
Owyhee County, Idaho
14260
0.9075
0.9401
3.5913370
Payette County, Idaho
99913
0.8567
0.8120
−5.2213380
Power County, Idaho
38540
0.9224
0.9400
1.9113390
Shoshone County, Idaho
99913
0.8567
0.8120
−5.2213400
Teton County, Idaho
99913
0.8567
0.8120
−5.2213410
Twin Falls County, Idaho
99913
0.8567
0.8120
−5.2213420
Valley County, Idaho
99913
0.8567
0.8120
−5.2213430
Washington County, Idaho
99913
0.8567
0.8120
−5.2214000
Adams County, Illinois
99914
0.8286
0.8320
0.4114010
Alexander County, Illinois
99914
0.8286
0.8320
0.4114020
Bond County, Illinois
41180
0.8628
0.9005
4.3714030
Boone County, Illinois
40420
0.9984
0.9989
0.0514040
Brown County, Illinois
99914
0.8286
0.8320
0.4114050
Bureau County, Illinois
99914
0.8286
0.8320
0.4114060
Calhoun County, Illinois
41180
0.8628
0.9005
4.3714070
Carroll County, Illinois
99914
0.8286
0.8320
0.4114080
Cass County, Illinois
99914
0.8286
0.8320
0.4114090
Champaign County, Illinois
16580
0.9594
0.9644
0.5214100
Christian County, Illinois
99914
0.8286
0.8320
0.4114110
Clark County, Illinois
99914
0.8286
0.8320
0.4114120
Clay County, Illinois
99914
0.8286
0.8320
0.4114130
Clinton County, Illinois
41180
0.8958
0.9005
0.5214140
Coles County, Illinois
99914
0.8286
0.8320
0.4114141
Cook County, Illinois
16974
1.0787
1.0751
−0.3314150
Crawford County, Illinois
99914
0.8286
0.8320
0.4114160
Cumberland County, Illinois
99914
0.8286
0.8320
0.4114170
De Kalb County, Illinois
16974
1.0787
1.0751
−0.3314180
De Witt County, Illinois
99914
0.8286
0.8320
0.4114190
Douglas County, Illinois
99914
0.8286
0.8320
0.4114250
Du Page County, Illinois
16974
1.0787
1.0751
−0.3314310
Edgar County, Illinois
99914
0.8286
0.8320
0.41( print page 65968)14320
Edwards County, Illinois
99914
0.8286
0.8320
0.4114330
Effingham County, Illinois
99914
0.8286
0.8320
0.4114340
Fayette County, Illinois
99914
0.8286
0.8320
0.4114350
Ford County, Illinois
16580
0.8948
0.9644
7.7814360
Franklin County, Illinois
99914
0.8286
0.8320
0.4114370
Fulton County, Illinois
99914
0.8286
0.8320
0.4114380
Gallatin County, Illinois
99914
0.8286
0.8320
0.4114390
Greene County, Illinois
99914
0.8286
0.8320
0.4114400
Grundy County, Illinois
16974
1.0787
1.0751
−0.3314410
Hamilton County, Illinois
99914
0.8286
0.8320
0.4114420
Hancock County, Illinois
99914
0.8286
0.8320
0.4114421
Hardin County, Illinois
99914
0.8286
0.8320
0.4114440
Henderson County, Illinois
99914
0.8286
0.8320
0.4114450
Henry County, Illinois
19340
0.8724
0.8846
1.4014460
Iroquois County, Illinois
99914
0.8286
0.8320
0.4114470
Jackson County, Illinois
99914
0.8286
0.8320
0.4114480
Jasper County, Illinois
99914
0.8286
0.8320
0.4114490
Jefferson County, Illinois
99914
0.8286
0.8320
0.4114500
Jersey County, Illinois
41180
0.8958
0.9005
0.5214510
Jo Daviess County, Illinois
99914
0.8286
0.8320
0.4114520
Johnson County, Illinois
99914
0.8286
0.8320
0.4114530
Kane County, Illinois
16974
1.0787
1.0751
−0.3314540
Kankakee County, Illinois
28100
1.0721
1.0083
−5.9514550
Kendall County, Illinois
16974
1.0787
1.0751
−0.3314560
Knox County, Illinois
99914
0.8286
0.8320
0.4114570
Lake County, Illinois
29404
1.0606
1.0570
−0.3414580
La Salle County, Illinois
99914
0.8286
0.8320
0.4114590
Lawrence County, Illinois
99914
0.8286
0.8320
0.4114600
Lee County, Illinois
99914
0.8286
0.8320
0.4114610
Livingston County, Illinois
99914
0.8286
0.8320
0.4114620
Logan County, Illinois
99914
0.8286
0.8320
0.4114630
Mc Donough County, Illinois
99914
0.8286
0.8320
0.4114640
Mc Henry County, Illinois
16974
1.0787
1.0751
−0.3314650
Mclean County, Illinois
14060
0.9075
0.8944
−1.4414660
Macon County, Illinois
19500
0.8067
0.8172
1.3014670
Macoupin County, Illinois
41180
0.8628
0.9005
4.3714680
Madison County, Illinois
41180
0.8958
0.9005
0.5214690
Marion County, Illinois
99914
0.8286
0.8320
0.4114700
Marshall County, Illinois
37900
0.8586
0.8982
4.6114710
Mason County, Illinois
99914
0.8286
0.8320
0.4114720
Massac County, Illinois
99914
0.8286
0.8320
0.4114730
Menard County, Illinois
44100
0.8792
0.8890
1.1114740
Mercer County, Illinois
19340
0.8513
0.8846
3.9114750
Monroe County, Illinois
41180
0.8958
0.9005
0.5214760
Montgomery County, Illinois
99914
0.8286
0.8320
0.4114770
Morgan County, Illinois
99914
0.8286
0.8320
0.4114780
Moultrie County, Illinois
99914
0.8286
0.8320
0.4114790
Ogle County, Illinois
99914
0.9128
0.8320
−8.8514800
Peoria County, Illinois
37900
0.8870
0.8982
1.2614810
Perry County, Illinois
99914
0.8286
0.8320
0.4114820
Piatt County, Illinois
16580
0.8948
0.9644
7.7814830
Pike County, Illinois
99914
0.8286
0.8320
0.4114831
Pope County, Illinois
99914
0.8286
0.8320
0.4114850
Pulaski County, Illinois
99914
0.8286
0.8320
0.4114860
Putnam County, Illinois
99914
0.8286
0.8320
0.4114870
Randolph County, Illinois
99914
0.8286
0.8320
0.4114880
Richland County, Illinois
99914
0.8286
0.8320
0.4114890
Rock Island County, Illinois
19340
0.8724
0.8846
1.4014900
St Clair County, Illinois
41180
0.8958
0.9005
0.5214910
Saline County, Illinois
99914
0.8286
0.8320
0.4114920
Sangamon County, Illinois
44100
0.8792
0.8890
1.1114921
Schuyler County, Illinois
99914
0.8286
0.8320
0.4114940
Scott County, Illinois
99914
0.8286
0.8320
0.4114950
Shelby County, Illinois
99914
0.8286
0.8320
0.4114960
Stark County, Illinois
37900
0.8586
0.8982
4.6114970
Stephenson County, Illinois
99914
0.8286
0.8320
0.4114980
Tazewell County, Illinois
37900
0.8870
0.8982
1.2614981
Union County, Illinois
99914
0.8286
0.8320
0.41( print page 65969)14982
Vermilion County, Illinois
19180
0.8665
0.9266
6.9414983
Wabash County, Illinois
99914
0.8286
0.8320
0.4114984
Warren County, Illinois
99914
0.8286
0.8320
0.4114985
Washington County, Illinois
99914
0.8286
0.8320
0.4114986
Wayne County, Illinois
99914
0.8286
0.8320
0.4114987
White County, Illinois
99914
0.8286
0.8320
0.4114988
Whiteside County, Illinois
99914
0.8286
0.8320
0.4114989
Will County, Illinois
16974
1.0787
1.0751
−0.3314990
Williamson County, Illinois
99914
0.8286
0.8320
0.4114991
Winnebago County, Illinois
40420
0.9984
0.9989
0.0514992
Woodford County, Illinois
37900
0.8870
0.8982
1.2615000
Adams County, Indiana
99915
0.9165
0.8538
−6.8415010
Allen County, Indiana
23060
0.9750
0.9517
−2.3915020
Bartholomew County, Indiana
18020
0.9164
0.9318
1.6815030
Benton County, Indiana
29140
0.8738
0.8931
2.2115040
Blackford County, Indiana
99915
0.8682
0.8538
−1.6615050
Boone County, Indiana
26900
0.9893
0.9895
0.0215060
Brown County, Indiana
26900
0.9330
0.9895
6.0615070
Carroll County, Indiana
29140
0.8738
0.8931
2.2115080
Cass County, Indiana
99915
0.8682
0.8538
−1.6615090
Clark County, Indiana
31140
0.9272
0.9118
−1.6615100
Clay County, Indiana
45460
0.8321
0.8765
5.3415110
Clinton County, Indiana
99915
0.8680
0.8538
−1.6415120
Crawford County, Indiana
99915
0.8682
0.8538
−1.6615130
Daviess County, Indiana
99915
0.8682
0.8538
−1.6615140
Dearborn County, Indiana
17140
0.9675
0.9601
−0.7615150
Decatur County, Indiana
99915
0.8682
0.8538
−1.6615160
De Kalb County, Indiana
99915
0.9165
0.8538
−6.8415170
Delaware County, Indiana
34620
0.8930
0.8562
−4.1215180
Dubois County, Indiana
99915
0.8682
0.8538
−1.6615190
Elkhart County, Indiana
21140
0.9627
0.9426
−2.0915200
Fayette County, Indiana
99915
0.8682
0.8538
−1.6615210
Floyd County, Indiana
31140
0.9272
0.9118
−1.6615220
Fountain County, Indiana
99915
0.8682
0.8538
−1.6615230
Franklin County, Indiana
17140
0.9177
0.9601
4.6215240
Fulton County, Indiana
99915
0.8682
0.8538
−1.6615250
Gibson County, Indiana
21780
0.8726
0.9071
3.9515260
Grant County, Indiana
99915
0.8682
0.8538
−1.6615270
Greene County, Indiana
14020
0.8593
0.8533
−0.7015280
Hamilton County, Indiana
26900
0.9893
0.9895
0.0215290
Hancock County, Indiana
26900
0.9893
0.9895
0.0215300
Harrison County, Indiana
31140
0.9272
0.9118
−1.6615310
Hendricks County, Indiana
26900
0.9893
0.9895
0.0215320
Henry County, Indiana
99915
0.8682
0.8538
−1.6615330
Howard County, Indiana
29020
0.9508
0.9669
1.6915340
Huntington County, Indiana
99915
0.9165
0.8538
−6.8415350
Jackson County, Indiana
99915
0.8682
0.8538
−1.6615360
Jasper County, Indiana
23844
0.9067
0.9334
2.9415370
Jay County, Indiana
99915
0.8682
0.8538
−1.6615380
Jefferson County, Indiana
99915
0.8682
0.8538
−1.6615390
Jennings County, Indiana
99915
0.8682
0.8538
−1.6615400
Johnson County, Indiana
26900
0.9893
0.9895
0.0215410
Knox County, Indiana
99915
0.8682
0.8538
−1.6615420
Kosciusko County, Indiana
99915
0.8682
0.8538
−1.6615430
Lagrange County, Indiana
99915
0.8682
0.8538
−1.6615440
Lake County, Indiana
23844
0.9395
0.9334
−0.6515450
La Porte County, Indiana
33140
0.9069
0.9118
0.5415460
Lawrence County, Indiana
99915
0.8682
0.8538
−1.6615470
Madison County, Indiana
11300
0.9226
0.8681
−5.9115480
Marion County, Indiana
26900
0.9893
0.9895
0.0215490
Marshall County, Indiana
99915
0.8682
0.8538
−1.6615500
Martin County, Indiana
99915
0.8682
0.8538
−1.6615510
Miami County, Indiana
99915
0.8682
0.8538
−1.6615520
Monroe County, Indiana
14020
0.8447
0.8533
1.0215530
Montgomery County, Indiana
99915
0.8682
0.8538
−1.6615540
Morgan County, Indiana
26900
0.9893
0.9895
0.0215550
Newton County, Indiana
23844
0.9067
0.9334
2.9415560
Noble County, Indiana
99915
0.8682
0.8538
−1.66( print page 65970)15570
Ohio County, Indiana
17140
0.9675
0.9601
−0.7615580
Orange County, Indiana
99915
0.8682
0.8538
−1.6615590
Owen County, Indiana
14020
0.8593
0.8533
−0.7015600
Parke County, Indiana
99915
0.8682
0.8538
−1.6615610
Perry County, Indiana
99915
0.8682
0.8538
−1.6615620
Pike County, Indiana
99915
0.8682
0.8538
−1.6615630
Porter County, Indiana
23844
0.9395
0.9334
−0.6515640
Posey County, Indiana
21780
0.8713
0.9071
4.1115650
Pulaski County, Indiana
99915
0.8682
0.8538
−1.6615660
Putnam County, Indiana
26900
0.9330
0.9895
6.0615670
Randolph County, Indiana
99915
0.8682
0.8538
−1.6615680
Ripley County, Indiana
99915
0.8682
0.8538
−1.6615690
Rush County, Indiana
99915
0.8682
0.8538
−1.6615700
St Joseph County, Indiana
43780
0.9788
0.9842
0.5515710
Scott County, Indiana
99915
0.8959
0.8538
−4.7015720
Shelby County, Indiana
26900
0.9893
0.9895
0.0215730
Spencer County, Indiana
99915
0.8682
0.8538
−1.6615740
Starke County, Indiana
99915
0.8682
0.8538
−1.6615750
Steuben County, Indiana
99915
0.8682
0.8538
−1.6615760
Sullivan County, Indiana
45460
0.8522
0.8765
2.8515770
Switzerland County, Indiana
99915
0.8682
0.8538
−1.6615780
Tippecanoe County, Indiana
29140
0.8736
0.8931
2.2315790
Tipton County, Indiana
29020
0.9508
0.9669
1.6915800
Union County, Indiana
99915
0.8682
0.8538
−1.6615810
Vanderburgh County, Indiana
21780
0.8713
0.9071
4.1115820
Vermillion County, Indiana
45460
0.8321
0.8765
5.3415830
Vigo County, Indiana
45460
0.8321
0.8765
5.3415840
Wabash County, Indiana
99915
0.8682
0.8538
−1.6615850
Warren County, Indiana
99915
0.8682
0.8538
−1.6615860
Warrick County, Indiana
21780
0.8713
0.9071
4.1115870
Washington County, Indiana
31140
0.8995
0.9118
1.3715880
Wayne County, Indiana
99915
0.8682
0.8538
−1.6615890
Wells County, Indiana
23060
0.9750
0.9517
−2.3915900
White County, Indiana
99915
0.8682
0.8538
−1.6615910
Whitley County, Indiana
23060
0.9750
0.9517
−2.3916000
Adair County, Iowa
99916
0.8552
0.8681
1.5116010
Adams County, Iowa
99916
0.8552
0.8681
1.5116020
Allamakee County, Iowa
99916
0.8552
0.8681
1.5116030
Appanoose County, Iowa
99916
0.8552
0.8681
1.5116040
Audubon County, Iowa
99916
0.8552
0.8681
1.5116050
Benton County, Iowa
16300
0.8710
0.8888
2.0416060
Black Hawk County, Iowa
47940
0.8557
0.8408
−1.7416070
Boone County, Iowa
99916
0.8552
0.8681
1.5116080
Bremer County, Iowa
47940
0.8576
0.8408
−1.9616090
Buchanan County, Iowa
99916
0.8552
0.8681
1.5116100
Buena Vista County, Iowa
99916
0.8552
0.8681
1.5116110
Butler County, Iowa
99916
0.8552
0.8681
1.5116120
Calhoun County, Iowa
99916
0.8552
0.8681
1.5116130
Carroll County, Iowa
99916
0.8552
0.8681
1.5116140
Cass County, Iowa
99916
0.8552
0.8681
1.5116150
Cedar County, Iowa
99916
0.8552
0.8681
1.5116160
Cerro Gordo County, Iowa
99916
0.8552
0.8681
1.5116170
Cherokee County, Iowa
99916
0.8552
0.8681
1.5116180
Chickasaw County, Iowa
99916
0.8552
0.8681
1.5116190
Clarke County, Iowa
99916
0.8552
0.8681
1.5116200
Clay County, Iowa
99916
0.8552
0.8681
1.5116210
Clayton County, Iowa
99916
0.8552
0.8681
1.5116220
Clinton County, Iowa
99916
0.8552
0.8681
1.5116230
Crawford County, Iowa
99916
0.8552
0.8681
1.5116240
Dallas County, Iowa
19780
0.9669
0.9214
−4.7116250
Davis County, Iowa
99916
0.8552
0.8681
1.5116260
Decatur County, Iowa
99916
0.8552
0.8681
1.5116270
Delaware County, Iowa
99916
0.8552
0.8681
1.5116280
Des Moines County, Iowa
99916
0.8552
0.8681
1.5116290
Dickinson County, Iowa
99916
0.8552
0.8681
1.5116300
Dubuque County, Iowa
20220
0.9024
0.9133
1.2116310
Emmet County, Iowa
99916
0.8552
0.8681
1.5116320
Fayette County, Iowa
99916
0.8552
0.8681
1.51( print page 65971)16330
Floyd County, Iowa
99916
0.8552
0.8681
1.5116340
Franklin County, Iowa
99916
0.8552
0.8681
1.5116350
Fremont County, Iowa
99916
0.8552
0.8681
1.5116360
Greene County, Iowa
99916
0.8552
0.8681
1.5116370
Grundy County, Iowa
47940
0.8576
0.8408
−1.9616380
Guthrie County, Iowa
19780
0.9132
0.9214
0.9016390
Hamilton County, Iowa
99916
0.8552
0.8681
1.5116400
Hancock County, Iowa
99916
0.8552
0.8681
1.5116410
Hardin County, Iowa
99916
0.8552
0.8681
1.5116420
Harrison County, Iowa
36540
0.9077
0.9450
4.1116430
Henry County, Iowa
99916
0.8552
0.8681
1.5116440
Howard County, Iowa
99916
0.8552
0.8681
1.5116450
Humboldt County, Iowa
99916
0.8552
0.8681
1.5116460
Ida County, Iowa
99916
0.8552
0.8681
1.5116470
Iowa County, Iowa
99916
0.8552
0.8681
1.5116480
Jackson County, Iowa
99916
0.8552
0.8681
1.5116490
Jasper County, Iowa
99916
0.8552
0.8681
1.5116500
Jefferson County, Iowa
99916
0.8552
0.8681
1.5116510
Johnson County, Iowa
26980
0.9747
0.9714
−0.3416520
Jones County, Iowa
16300
0.8710
0.8888
2.0416530
Keokuk County, Iowa
99916
0.8552
0.8681
1.5116540
Kossuth County, Iowa
99916
0.8552
0.8681
1.5116550
Lee County, Iowa
99916
0.8552
0.8681
1.5116560
Linn County, Iowa
16300
0.8825
0.8888
0.7116570
Louisa County, Iowa
99916
0.8552
0.8681
1.5116580
Lucas County, Iowa
99916
0.8552
0.8681
1.5116590
Lyon County, Iowa
99916
0.8552
0.8681
1.5116600
Madison County, Iowa
19780
0.9132
0.9214
0.9016610
Mahaska County, Iowa
99916
0.8552
0.8681
1.5116620
Marion County, Iowa
99916
0.8552
0.8681
1.5116630
Marshall County, Iowa
99916
0.8552
0.8681
1.5116640
Mills County, Iowa
36540
0.9077
0.9450
4.1116650
Mitchell County, Iowa
99916
0.8552
0.8681
1.5116660
Monona County, Iowa
99916
0.8552
0.8681
1.5116670
Monroe County, Iowa
99916
0.8552
0.8681
1.5116680
Montgomery County, Iowa
99916
0.8552
0.8681
1.5116690
Muscatine County, Iowa
99916
0.8552
0.8681
1.5116700
O Brien County, Iowa
99916
0.8552
0.8681
1.5116710
Osceola County, Iowa
99916
0.8552
0.8681
1.5116720
Page County, Iowa
99916
0.8552
0.8681
1.5116730
Palo Alto County, Iowa
99916
0.8552
0.8681
1.5116740
Plymouth County, Iowa
99916
0.8552
0.8681
1.5116750
Pocahontas County, Iowa
99916
0.8552
0.8681
1.5116760
Polk County, Iowa
19780
0.9669
0.9214
−4.7116770
Pottawattamie County, Iowa
36540
0.9560
0.9450
−1.1516780
Poweshiek County, Iowa
99916
0.8552
0.8681
1.5116790
Ringgold County, Iowa
99916
0.8552
0.8681
1.5116800
Sac County, Iowa
99916
0.8552
0.8681
1.5116810
Scott County, Iowa
19340
0.8724
0.8846
1.4016820
Shelby County, Iowa
99916
0.8552
0.8681
1.5116830
Sioux County, Iowa
99916
0.8552
0.8681
1.5116840
Story County, Iowa
11180
0.9065
0.9760
7.6716850
Tama County, Iowa
99916
0.8552
0.8681
1.5116860
Taylor County, Iowa
99916
0.8552
0.8681
1.5116870
Union County, Iowa
99916
0.8552
0.8681
1.5116880
Van Buren County, Iowa
99916
0.8552
0.8681
1.5116890
Wapello County, Iowa
99916
0.8552
0.8681
1.5116900
Warren County, Iowa
19780
0.9669
0.9214
−4.7116910
Washington County, Iowa
26980
0.9171
0.9714
5.9216920
Wayne County, Iowa
99916
0.8552
0.8681
1.5116930
Webster County, Iowa
99916
0.8552
0.8681
1.5116940
Winnebago County, Iowa
99916
0.8552
0.8681
1.5116950
Winneshiek County, Iowa
99916
0.8552
0.8681
1.5116960
Woodbury County, Iowa
43580
0.9399
0.9200
−2.1216970
Worth County, Iowa
99916
0.8552
0.8681
1.5116980
Wright County, Iowa
99916
0.8552
0.8681
1.5117000
Allen County, Kansas
99917
0.8038
0.7998
−0.5017010
Anderson County, Kansas
99917
0.8038
0.7998
−0.50( print page 65972)17020
Atchison County, Kansas
99917
0.8038
0.7998
−0.5017030
Barber County, Kansas
99917
0.8038
0.7998
−0.5017040
Barton County, Kansas
99917
0.8038
0.7998
−0.5017050
Bourbon County, Kansas
99917
0.8038
0.7998
−0.5017060
Brown County, Kansas
99917
0.8038
0.7998
−0.5017070
Butler County, Kansas
48620
0.9164
0.9063
−1.1017080
Chase County, Kansas
99917
0.8038
0.7998
−0.5017090
Chautauqua County, Kansas
99917
0.8038
0.7998
−0.5017100
Cherokee County, Kansas
99917
0.8038
0.7998
−0.5017110
Cheyenne County, Kansas
99917
0.8038
0.7998
−0.5017120
Clark County, Kansas
99917
0.8038
0.7998
−0.5017130
Clay County, Kansas
99917
0.8038
0.7998
−0.5017140
Cloud County, Kansas
99917
0.8038
0.7998
−0.5017150
Coffey County, Kansas
99917
0.8038
0.7998
−0.5017160
Comanche County, Kansas
99917
0.8038
0.7998
−0.5017170
Cowley County, Kansas
99917
0.8038
0.7998
−0.5017180
Crawford County, Kansas
99917
0.8038
0.7998
−0.5017190
Decatur County, Kansas
99917
0.8038
0.7998
−0.5017200
Dickinson County, Kansas
99917
0.8038
0.7998
−0.5017210
Doniphan County, Kansas
41140
0.8780
1.0118
15.2417220
Douglas County, Kansas
29940
0.8537
0.8365
−2.0117230
Edwards County, Kansas
99917
0.8038
0.7998
−0.5017240
Elk County, Kansas
99917
0.8038
0.7998
−0.5017250
Ellis County, Kansas
99917
0.8038
0.7998
−0.5017260
Ellsworth County, Kansas
99917
0.8038
0.7998
−0.5017270
Finney County, Kansas
99917
0.8038
0.7998
−0.5017280
Ford County, Kansas
99917
0.8038
0.7998
−0.5017290
Franklin County, Kansas
28140
0.8758
0.9495
8.4217300
Geary County, Kansas
99917
0.8038
0.7998
−0.5017310
Gove County, Kansas
99917
0.8038
0.7998
−0.5017320
Graham County, Kansas
99917
0.8038
0.7998
−0.5017330
Grant County, Kansas
99917
0.8038
0.7998
−0.5017340
Gray County, Kansas
99917
0.8038
0.7998
−0.5017350
Greeley County, Kansas
99917
0.8038
0.7998
−0.5017360
Greenwood County, Kansas
99917
0.8038
0.7998
−0.5017370
Hamilton County, Kansas
99917
0.8038
0.7998
−0.5017380
Harper County, Kansas
99917
0.8038
0.7998
−0.5017390
Harvey County, Kansas
48620
0.9164
0.9063
−1.1017391
Haskell County, Kansas
99917
0.8038
0.7998
−0.5017410
Hodgeman County, Kansas
99917
0.8038
0.7998
−0.5017420
Jackson County, Kansas
45820
0.8480
0.8730
2.9517430
Jefferson County, Kansas
45820
0.8480
0.8730
2.9517440
Jewell County, Kansas
99917
0.8038
0.7998
−0.5017450
Johnson County, Kansas
28140
0.9483
0.9495
0.1317451
Kearny County, Kansas
99917
0.8038
0.7998
−0.5017470
Kingman County, Kansas
99917
0.8038
0.7998
−0.5017480
Kiowa County, Kansas
99917
0.8038
0.7998
−0.5017490
Labette County, Kansas
99917
0.8038
0.7998
−0.5017500
Lane County, Kansas
99917
0.8038
0.7998
−0.5017510
Leavenworth County, Kansas
28140
0.9483
0.9495
0.1317520
Lincoln County, Kansas
99917
0.8038
0.7998
−0.5017530
Linn County, Kansas
28140
0.8758
0.9495
8.4217540
Logan County, Kansas
99917
0.8038
0.7998
−0.5017550
Lyon County, Kansas
99917
0.8038
0.7998
−0.5017560
Mc Pherson County, Kansas
99917
0.8038
0.7998
−0.5017570
Marion County, Kansas
99917
0.8038
0.7998
−0.5017580
Marshall County, Kansas
99917
0.8038
0.7998
−0.5017590
Meade County, Kansas
99917
0.8038
0.7998
−0.5017600
Miami County, Kansas
28140
0.9483
0.9495
0.1317610
Mitchell County, Kansas
99917
0.8038
0.7998
−0.5017620
Montgomery County, Kansas
99917
0.8038
0.7998
−0.5017630
Morris County, Kansas
99917
0.8038
0.7998
−0.5017640
Morton County, Kansas
99917
0.8038
0.7998
−0.5017650
Nemaha County, Kansas
99917
0.8038
0.7998
−0.5017660
Neosho County, Kansas
99917
0.8038
0.7998
−0.5017670
Ness County, Kansas
99917
0.8038
0.7998
−0.5017680
Norton County, Kansas
99917
0.8038
0.7998
−0.5017690
Osage County, Kansas
45820
0.8480
0.8730
2.95( print page 65973)17700
Osborne County, Kansas
99917
0.8038
0.7998
−0.5017710
Ottawa County, Kansas
99917
0.8038
0.7998
−0.5017720
Pawnee County, Kansas
99917
0.8038
0.7998
−0.5017730
Phillips County, Kansas
99917
0.8038
0.7998
−0.5017740
Pottawatomie County, Kansas
99917
0.8038
0.7998
−0.5017750
Pratt County, Kansas
99917
0.8038
0.7998
−0.5017760
Rawlins County, Kansas
99917
0.8038
0.7998
−0.5017770
Reno County, Kansas
99917
0.8038
0.7998
−0.5017780
Republic County, Kansas
99917
0.8038
0.7998
−0.5017790
Rice County, Kansas
99917
0.8038
0.7998
−0.5017800
Riley County, Kansas
99917
0.8038
0.7998
−0.5017810
Rooks County, Kansas
99917
0.8038
0.7998
−0.5017820
Rush County, Kansas
99917
0.8038
0.7998
−0.5017830
Russell County, Kansas
99917
0.8038
0.7998
−0.5017840
Saline County, Kansas
99917
0.8038
0.7998
−0.5017841
Scott County, Kansas
99917
0.8038
0.7998
−0.5017860
Sedgwick County, Kansas
48620
0.9164
0.9063
−1.1017870
Seward County, Kansas
99917
0.8038
0.7998
−0.5017880
Shawnee County, Kansas
45820
0.8920
0.8730
−2.1317890
Sheridan County, Kansas
99917
0.8038
0.7998
−0.5017900
Sherman County, Kansas
99917
0.8038
0.7998
−0.5017910
Smith County, Kansas
99917
0.8038
0.7998
−0.5017920
Stafford County, Kansas
99917
0.8038
0.7998
−0.5017921
Stanton County, Kansas
99917
0.8038
0.7998
−0.5017940
Stevens County, Kansas
99917
0.8038
0.7998
−0.5017950
Sumner County, Kansas
48620
0.8597
0.9063
5.4217960
Thomas County, Kansas
99917
0.8038
0.7998
−0.5017970
Trego County, Kansas
99917
0.8038
0.7998
−0.5017980
Wabaunsee County, Kansas
45820
0.8480
0.8730
2.9517981
Wallace County, Kansas
99917
0.8038
0.7998
−0.5017982
Washington County, Kansas
99917
0.8038
0.7998
−0.5017983
Wichita County, Kansas
99917
0.8038
0.7998
−0.5017984
Wilson County, Kansas
99917
0.8038
0.7998
−0.5017985
Woodson County, Kansas
99917
0.8038
0.7998
−0.5017986
Wyandotte County, Kansas
28140
0.9483
0.9495
0.1318000
Adair County, Kentucky
99918
0.7812
0.7768
−0.5618010
Allen County, Kentucky
99918
0.7812
0.7768
−0.5618020
Anderson County, Kentucky
99918
0.7812
0.7768
−0.5618030
Ballard County, Kentucky
99918
0.7812
0.7768
−0.5618040
Barren County, Kentucky
99918
0.7812
0.7768
−0.5618050
Bath County, Kentucky
99918
0.7812
0.7768
−0.5618060
Bell County, Kentucky
99918
0.7812
0.7768
−0.5618070
Boone County, Kentucky
17140
0.9675
0.9601
−0.7618080
Bourbon County, Kentucky
30460
0.9032
0.9181
1.6518090
Boyd County, Kentucky
26580
0.9477
0.8997
−5.0618100
Boyle County, Kentucky
99918
0.7812
0.7768
−0.5618110
Bracken County, Kentucky
17140
0.8737
0.9601
9.8918120
Breathitt County, Kentucky
99918
0.7812
0.7768
−0.5618130
Breckinridge County, Kentucky
99918
0.7812
0.7768
−0.5618140
Bullitt County, Kentucky
31140
0.9272
0.9118
−1.6618150
Butler County, Kentucky
99918
0.7812
0.7768
−0.5618160
Caldwell County, Kentucky
99918
0.7812
0.7768
−0.5618170
Calloway County, Kentucky
99918
0.7812
0.7768
−0.5618180
Campbell County, Kentucky
17140
0.9675
0.9601
−0.7618190
Carlisle County, Kentucky
99918
0.7812
0.7768
−0.5618191
Carroll County, Kentucky
99918
0.7812
0.7768
−0.5618210
Carter County, Kentucky
99918
0.8622
0.7768
−9.9018220
Casey County, Kentucky
99918
0.7812
0.7768
−0.5618230
Christian County, Kentucky
17300
0.8284
0.8436
1.8318240
Clark County, Kentucky
30460
0.9032
0.9181
1.6518250
Clay County, Kentucky
99918
0.7812
0.7768
−0.5618260
Clinton County, Kentucky
99918
0.7812
0.7768
−0.5618270
Crittenden County, Kentucky
99918
0.7812
0.7768
−0.5618271
Cumberland County, Kentucky
99918
0.7812
0.7768
−0.5618290
Daviess County, Kentucky
36980
0.8780
0.8748
−0.3618291
Edmonson County, Kentucky
14540
0.8035
0.8148
1.4118310
Elliott County, Kentucky
99918
0.7812
0.7768
−0.5618320
Estill County, Kentucky
99918
0.7812
0.7768
−0.56( print page 65974)18330
Fayette County, Kentucky
30460
0.9032
0.9181
1.6518340
Fleming County, Kentucky
99918
0.7812
0.7768
−0.5618350
Floyd County, Kentucky
99918
0.7812
0.7768
−0.5618360
Franklin County, Kentucky
99918
0.7812
0.7768
−0.5618361
Fulton County, Kentucky
99918
0.7812
0.7768
−0.5618362
Gallatin County, Kentucky
17140
0.9675
0.9601
−0.7618390
Garrard County, Kentucky
99918
0.7812
0.7768
−0.5618400
Grant County, Kentucky
17140
0.9675
0.9601
−0.7618410
Graves County, Kentucky
99918
0.7812
0.7768
−0.5618420
Grayson County, Kentucky
99918
0.7812
0.7768
−0.5618421
Green County, Kentucky
99918
0.7812
0.7768
−0.5618440
Greenup County, Kentucky
26580
0.9477
0.8997
−5.0618450
Hancock County, Kentucky
36980
0.8319
0.8748
5.1618460
Hardin County, Kentucky
21060
0.8330
0.8697
4.4118470
Harlan County, Kentucky
99918
0.7812
0.7768
−0.5618480
Harrison County, Kentucky
99918
0.7812
0.7768
−0.5618490
Hart County, Kentucky
99918
0.7812
0.7768
−0.5618500
Henderson County, Kentucky
21780
0.8713
0.9071
4.1118510
Henry County, Kentucky
31140
0.8555
0.9118
6.5818511
Hickman County, Kentucky
99918
0.7812
0.7768
−0.5618530
Hopkins County, Kentucky
99918
0.7812
0.7768
−0.5618540
Jackson County, Kentucky
99918
0.7812
0.7768
−0.5618550
Jefferson County, Kentucky
31140
0.9272
0.9118
−1.6618560
Jessamine County, Kentucky
30460
0.9032
0.9181
1.6518570
Johnson County, Kentucky
99918
0.7812
0.7768
−0.5618580
Kenton County, Kentucky
17140
0.9675
0.9601
−0.7618590
Knott County, Kentucky
99918
0.7812
0.7768
−0.5618600
Knox County, Kentucky
99918
0.7812
0.7768
−0.5618610
Larue County, Kentucky
21060
0.8330
0.8697
4.4118620
Laurel County, Kentucky
99918
0.7812
0.7768
−0.5618630
Lawrence County, Kentucky
99918
0.7812
0.7768
−0.5618640
Lee County, Kentucky
99918
0.7812
0.7768
−0.5618650
Leslie County, Kentucky
99918
0.7812
0.7768
−0.5618660
Letcher County, Kentucky
99918
0.7812
0.7768
−0.5618670
Lewis County, Kentucky
99918
0.7812
0.7768
−0.5618680
Lincoln County, Kentucky
99918
0.7812
0.7768
−0.5618690
Livingston County, Kentucky
99918
0.7812
0.7768
−0.5618700
Logan County, Kentucky
99918
0.7812
0.7768
−0.5618710
Lyon County, Kentucky
99918
0.7812
0.7768
−0.5618720
Mc Cracken County, Kentucky
99918
0.7812
0.7768
−0.5618730
Mc Creary County, Kentucky
99918
0.7812
0.7768
−0.5618740
Mc Lean County, Kentucky
36980
0.8319
0.8748
5.1618750
Madison County, Kentucky
99918
0.8377
0.7768
−7.2718760
Magoffin County, Kentucky
99918
0.7812
0.7768
−0.5618770
Marion County, Kentucky
99918
0.7812
0.7768
−0.5618780
Marshall County, Kentucky
99918
0.7812
0.7768
−0.5618790
Martin County, Kentucky
99918
0.7812
0.7768
−0.5618800
Mason County, Kentucky
99918
0.7812
0.7768
−0.5618801
Meade County, Kentucky
31140
0.8555
0.9118
6.5818802
Menifee County, Kentucky
99918
0.7812
0.7768
−0.5618830
Mercer County, Kentucky
99918
0.7812
0.7768
−0.5618831
Metcalfe County, Kentucky
99918
0.7812
0.7768
−0.5618850
Monroe County, Kentucky
99918
0.7812
0.7768
−0.5618860
Montgomery County, Kentucky
99918
0.7812
0.7768
−0.5618861
Morgan County, Kentucky
99918
0.7812
0.7768
−0.5618880
Muhlenberg County, Kentucky
99918
0.7812
0.7768
−0.5618890
Nelson County, Kentucky
31140
0.8555
0.9118
6.5818900
Nicholas County, Kentucky
99918
0.7812
0.7768
−0.5618910
Ohio County, Kentucky
99918
0.7812
0.7768
−0.5618920
Oldham County, Kentucky
31140
0.9272
0.9118
−1.6618930
Owen County, Kentucky
99918
0.7812
0.7768
−0.5618931
Owsley County, Kentucky
99918
0.7812
0.7768
−0.5618932
Pendleton County, Kentucky
17140
0.9675
0.9601
−0.7618960
Perry County, Kentucky
99918
0.7812
0.7768
−0.5618970
Pike County, Kentucky
99918
0.7812
0.7768
−0.5618971
Powell County, Kentucky
99918
0.7812
0.7768
−0.5618972
Pulaski County, Kentucky
99918
0.7812
0.7768
−0.5618973
Robertson County, Kentucky
99918
0.7812
0.7768
−0.56( print page 65975)18974
Rockcastle County, Kentucky
99918
0.7812
0.7768
−0.5618975
Rowan County, Kentucky
99918
0.7812
0.7768
−0.5618976
Russell County, Kentucky
99918
0.7812
0.7768
−0.5618977
Scott County, Kentucky
30460
0.9032
0.9181
1.6518978
Shelby County, Kentucky
31140
0.8555
0.9118
6.5818979
Simpson County, Kentucky
99918
0.7812
0.7768
−0.5618980
Spencer County, Kentucky
31140
0.8555
0.9118
6.5818981
Taylor County, Kentucky
99918
0.7812
0.7768
−0.5618982
Todd County, Kentucky
99918
0.7812
0.7768
−0.5618983
Trigg County, Kentucky
17300
0.8071
0.8436
4.5218984
Trimble County, Kentucky
31140
0.8555
0.9118
6.5818985
Union County, Kentucky
99918
0.7812
0.7768
−0.5618986
Warren County, Kentucky
14540
0.8035
0.8148
1.4118987
Washington County, Kentucky
99918
0.7812
0.7768
−0.5618988
Wayne County, Kentucky
99918
0.7812
0.7768
−0.5618989
Webster County, Kentucky
21780
0.8286
0.9071
9.4718990
Whitley County, Kentucky
99918
0.7812
0.7768
−0.5618991
Wolfe County, Kentucky
99918
0.7812
0.7768
−0.5618992
Woodford County, Kentucky
30460
0.9032
0.9181
1.6519000
Acadia County, Louisiana
99919
0.7831
0.7438
−5.0219010
Allen County, Louisiana
99919
0.7376
0.7438
0.8419020
Ascension County, Louisiana
12940
0.8618
0.8084
−6.2019030
Assumption County, Louisiana
99919
0.7376
0.7438
0.8419040
Avoyelles County, Louisiana
99919
0.7376
0.7438
0.8419050
Beauregard County, Louisiana
99919
0.7376
0.7438
0.8419060
Bienville County, Louisiana
99919
0.7376
0.7438
0.8419070
Bossier County, Louisiana
43340
0.8749
0.8865
1.3319080
Caddo County, Louisiana
43340
0.8749
0.8865
1.3319090
Calcasieu County, Louisiana
29340
0.7846
0.7914
0.8719100
Caldwell County, Louisiana
99919
0.7376
0.7438
0.8419110
Cameron County, Louisiana
29340
0.7587
0.7914
4.3119120
Catahoula County, Louisiana
99919
0.7376
0.7438
0.8419130
Claiborne County, Louisiana
99919
0.7376
0.7438
0.8419140
Concordia County, Louisiana
99919
0.7376
0.7438
0.8419150
De Soto County, Louisiana
43340
0.8050
0.8865
10.1219160
East Baton Rouge County, Louisiana
12940
0.8618
0.8084
−6.2019170
East Carroll County, Louisiana
99919
0.7376
0.7438
0.8419180
East Feliciana County, Louisiana
12940
0.7967
0.8084
1.4719190
Evangeline County, Louisiana
99919
0.7376
0.7438
0.8419200
Franklin County, Louisiana
99919
0.7376
0.7438
0.8419210
Grant County, Louisiana
10780
0.7687
0.8006
4.1519220
Iberia County, Louisiana
99919
0.7376
0.7438
0.8419230
Iberville County, Louisiana
12940
0.7967
0.8084
1.4719240
Jackson County, Louisiana
99919
0.7376
0.7438
0.8419250
Jefferson County, Louisiana
35380
0.8995
0.8831
−1.8219260
Jefferson Davis County, Louisiana
99919
0.7376
0.7438
0.8419270
Lafayette County, Louisiana
29180
0.8340
0.8289
−0.6119280
Lafourche County, Louisiana
26380
0.7894
0.8082
2.3819290
La Salle County, Louisiana
99919
0.7376
0.7438
0.8419300
Lincoln County, Louisiana
99919
0.7376
0.7438
0.8419310
Livingston County, Louisiana
12940
0.8618
0.8084
−6.2019320
Madison County, Louisiana
99919
0.7376
0.7438
0.8419330
Morehouse County, Louisiana
99919
0.7376
0.7438
0.8419340
Natchitoches County, Louisiana
99919
0.7376
0.7438
0.8419350
Orleans County, Louisiana
35380
0.8995
0.8831
−1.8219360
Ouachita County, Louisiana
33740
0.8038
0.7997
−0.5119370
Plaquemines County, Louisiana
35380
0.8995
0.8831
−1.8219380
Pointe Coupee County, Louisiana
12940
0.7967
0.8084
1.4719390
Rapides County, Louisiana
10780
0.8033
0.8006
−0.3419400
Red River County, Louisiana
99919
0.7376
0.7438
0.8419410
Richland County, Louisiana
99919
0.7376
0.7438
0.8419420
Sabine County, Louisiana
99919
0.7376
0.7438
0.8419430
St Bernard County, Louisiana
35380
0.8995
0.8831
−1.8219440
St Charles County, Louisiana
35380
0.8995
0.8831
−1.8219450
St Helena County, Louisiana
12940
0.7967
0.8084
1.4719460
St James County, Louisiana
99919
0.8203
0.7438
−9.3319470
St John Baptist County, Louisiana
35380
0.8995
0.8831
−1.8219480
St Landry County, Louisiana
99919
0.7831
0.7438
−5.02( print page 65976)19490
St Martin County, Louisiana
29180
0.8340
0.8289
−0.6119500
St Mary County, Louisiana
99919
0.7376
0.7438
0.8419510
St Tammany County, Louisiana
35380
0.8995
0.8831
−1.8219520
Tangipahoa County, Louisiana
99919
0.7376
0.7438
0.8419530
Tensas County, Louisiana
99919
0.7376
0.7438
0.8419540
Terrebonne County, Louisiana
26380
0.7894
0.8082
2.3819550
Union County, Louisiana
33740
0.7686
0.7997
4.0519560
Vermilion County, Louisiana
99919
0.7376
0.7438
0.8419570
Vernon County, Louisiana
99919
0.7376
0.7438
0.8419580
Washington County, Louisiana
99919
0.7376
0.7438
0.8419590
Webster County, Louisiana
99919
0.8074
0.7438
−7.8819600
West Baton Rouge County, Louisiana
12940
0.8618
0.8084
−6.2019610
West Carroll County, Louisiana
99919
0.7376
0.7438
0.8419620
West Feliciana County, Louisiana
12940
0.7967
0.8084
1.4719630
Winn County, Louisiana
99919
0.7376
0.7438
0.8420000
Androscoggin County, Maine
30340
0.9331
0.9126
−2.2020010
Aroostook County, Maine
99920
0.8843
0.8443
−4.5220020
Cumberland County, Maine
38860
1.0382
0.9908
−4.5720030
Franklin County, Maine
99920
0.8843
0.8443
−4.5220040
Hancock County, Maine
99920
0.8843
0.8443
−4.5220050
Kennebec County, Maine
99920
0.8843
0.8443
−4.5220060
Knox County, Maine
99920
0.8843
0.8443
−4.5220070
Lincoln County, Maine
99920
0.8843
0.8443
−4.5220080
Oxford County, Maine
99920
0.8843
0.8443
−4.5220090
Penobscot County, Maine
12620
0.9993
0.9711
−2.8220100
Piscataquis County, Maine
99920
0.8843
0.8443
−4.5220110
Sagadahoc County, Maine
38860
1.0382
0.9908
−4.5720120
Somerset County, Maine
99920
0.8843
0.8443
−4.5220130
Waldo County, Maine
99920
0.8843
0.8443
−4.5220140
Washington County, Maine
99920
0.8843
0.8443
−4.5220150
York County, Maine
38860
1.0382
0.9908
−4.5721000
Allegany County, Maryland
19060
0.9317
0.8446
−9.3521010
Anne Arundel County, Maryland
12580
0.9897
1.0088
1.9321020
Baltimore County, Maryland
12580
0.9897
1.0088
1.9321030
Baltimore City County, Maryland
12580
0.9897
1.0088
1.9321040
Calvert County, Maryland
47894
1.0951
1.1054
0.9421050
Caroline County, Maryland
99921
0.9292
0.8926
−3.9421060
Carroll County, Maryland
12580
0.9897
1.0088
1.9321070
Cecil County, Maryland
48864
1.0499
1.0684
1.7621080
Charles County, Maryland
47894
1.0951
1.1054
0.9421090
Dorchester County, Maryland
99921
0.9292
0.8926
−3.9421100
Frederick County, Maryland
13644
1.1230
1.0903
−2.9121110
Garrett County, Maryland
99921
0.9292
0.8926
−3.9421120
Harford County, Maryland
12580
0.9897
1.0088
1.9321130
Howard County, Maryland
12580
0.9897
1.0088
1.9321140
Kent County, Maryland
99921
0.9292
0.8926
−3.9421150
Montgomery County, Maryland
13644
1.1230
1.0903
−2.9121160
Prince Georges County, Maryland
47894
1.0951
1.1054
0.9421170
Queen Annes County, Maryland
12580
0.9897
1.0088
1.9321180
St Marys County, Maryland
99921
0.9292
0.8926
−3.9421190
Somerset County, Maryland
41540
0.9147
0.8953
−2.1221200
Talbot County, Maryland
99921
0.9292
0.8926
−3.9421210
Washington County, Maryland
25180
0.9679
0.9038
−6.6221220
Wicomico County, Maryland
41540
0.9147
0.8953
−2.1221230
Worcester County, Maryland
99921
0.9292
0.8926
−3.9422000
Barnstable County, Massachusetts
12700
1.2600
1.2539
−0.4822010
Berkshire County, Massachusetts
38340
1.0181
1.0266
0.8322020
Bristol County, Massachusetts
39300
1.1072
1.0783
−2.6122030
Dukes County, Massachusetts
99922
1.0216
1.1661
14.1422040
Essex County, Massachusetts
21604
1.0858
1.0418
−4.0522060
Franklin County, Massachusetts
44140
1.0232
1.0079
−0.6422070
Hampden County, Massachusetts
44140
1.0256
1.0079
−1.7322080
Hampshire County, Massachusetts
44140
1.0256
1.0079
−1.7322090
Middlesex County, Massachusetts
15764
1.1175
1.0970
−1.8322120
Nantucket County, Massachusetts
99922
1.0216
1.1661
14.1422130
Norfolk County, Massachusetts
14484
1.1368
1.1679
2.7422150
Plymouth County, Massachusetts
14484
1.1368
1.1679
2.7422160
Suffolk County, Massachusetts
14484
1.1368
1.1679
2.74( print page 65977)22170
Worcester County, Massachusetts
49340
1.1103
1.0722
−3.4323000
Alcona County, Michigan
99923
0.8860
0.9062
2.2823010
Alger County, Michigan
99923
0.8860
0.9062
2.2823020
Allegan County, Michigan
99923
0.9170
0.9062
−1.1823030
Alpena County, Michigan
99923
0.8860
0.9062
2.2823040
Antrim County, Michigan
99923
0.8860
0.9062
2.2823050
Arenac County, Michigan
99923
0.8860
0.9062
2.2823060
Baraga County, Michigan
99923
0.8860
0.9062
2.2823070
Barry County, Michigan
24340
0.9107
0.9455
3.8223080
Bay County, Michigan
13020
0.9292
0.9251
−0.4423090
Benzie County, Michigan
99923
0.8860
0.9062
2.2823100
Berrien County, Michigan
35660
0.8879
0.8915
0.4123110
Branch County, Michigan
99923
0.8860
0.9062
2.2823120
Calhoun County, Michigan
12980
0.9826
0.9762
−0.6523130
Cass County, Michigan
43780
0.9306
0.9842
5.7623140
Charlevoix County, Michigan
99923
0.8860
0.9062
2.2823150
Cheboygan County, Michigan
99923
0.8860
0.9062
2.2823160
Chippewa County, Michigan
99923
0.8860
0.9062
2.2823170
Clare County, Michigan
99923
0.8860
0.9062
2.2823180
Clinton County, Michigan
29620
0.9794
1.0088
3.0023190
Crawford County, Michigan
99923
0.8860
0.9062
2.2823200
Delta County, Michigan
99923
0.8860
0.9062
2.2823210
Dickinson County, Michigan
99923
0.8860
0.9062
2.2823220
Eaton County, Michigan
29620
0.9794
1.0088
3.0023230
Emmet County, Michigan
99923
0.8860
0.9062
2.2823240
Genesee County, Michigan
22420
1.0655
1.0969
2.9523250
Gladwin County, Michigan
99923
0.8860
0.9062
2.2823260
Gogebic County, Michigan
99923
0.8860
0.9062
2.2823270
Grand Traverse County, Michigan
99923
0.8860
0.9062
2.2823280
Gratiot County, Michigan
99923
0.8860
0.9062
2.2823290
Hillsdale County, Michigan
99923
0.8860
0.9062
2.2823300
Houghton County, Michigan
99923
0.8860
0.9062
2.2823310
Huron County, Michigan
99923
0.8860
0.9062
2.2823320
Ingham County, Michigan
29620
0.9794
1.0088
3.0023330
Ionia County, Michigan
24340
0.9107
0.9455
3.8223340
Iosco County, Michigan
99923
0.8860
0.9062
2.2823350
Iron County, Michigan
99923
0.8860
0.9062
2.2823360
Isabella County, Michigan
99923
0.8860
0.9062
2.2823370
Jackson County, Michigan
27100
0.9304
0.9560
2.7523380
Kalamazoo County, Michigan
28020
1.0262
1.0704
4.3123390
Kalkaska County, Michigan
99923
0.8860
0.9062
2.2823400
Kent County, Michigan
24340
0.9418
0.9455
0.3923410
Keweenaw County, Michigan
99923
0.8860
0.9062
2.2823420
Lake County, Michigan
99923
0.8860
0.9062
2.2823430
Lapeer County, Michigan
47644
1.0009
1.0054
0.4523440
Leelanau County, Michigan
99923
0.8860
0.9062
2.2823450
Lenawee County, Michigan
99923
0.9801
0.9062
−7.5423460
Livingston County, Michigan
47644
1.0289
1.0054
−2.2823470
Luce County, Michigan
99923
0.8860
0.9062
2.2823480
Mackinac County, Michigan
99923
0.8860
0.9062
2.2823490
Macomb County, Michigan
47644
1.0009
1.0054
0.4523500
Manistee County, Michigan
99923
0.8860
0.9062
2.2823510
Marquette County, Michigan
99923
0.8860
0.9062
2.2823520
Mason County, Michigan
99923
0.8860
0.9062
2.2823530
Mecosta County, Michigan
99923
0.8860
0.9062
2.2823540
Menominee County, Michigan
99923
0.8860
0.9062
2.2823550
Midland County, Michigan
99923
0.9068
0.9062
−0.0723560
Missaukee County, Michigan
99923
0.8860
0.9062
2.2823570
Monroe County, Michigan
33780
0.9808
0.9707
−1.0323580
Montcalm County, Michigan
99923
0.8860
0.9062
2.2823590
Montmorency County, Michigan
99923
0.8860
0.9062
2.2823600
Muskegon County, Michigan
34740
0.9555
0.9941
4.0423610
Newaygo County, Michigan
24340
0.9107
0.9455
3.8223620
Oakland County, Michigan
47644
1.0009
1.0054
0.4523630
Oceana County, Michigan
99923
0.8860
0.9062
2.2823640
Ogemaw County, Michigan
99923
0.8860
0.9062
2.2823650
Ontonagon County, Michigan
99923
0.8860
0.9062
2.2823660
Osceola County, Michigan
99923
0.8860
0.9062
2.28( print page 65978)23670
Oscoda County, Michigan
99923
0.8860
0.9062
2.2823680
Otsego County, Michigan
99923
0.8860
0.9062
2.2823690
Ottawa County, Michigan
26100
0.9250
0.9163
−0.9423700
Presque Isle County, Michigan
99923
0.8860
0.9062
2.2823710
Roscommon County, Michigan
99923
0.8860
0.9062
2.2823720
Saginaw County, Michigan
40980
0.9165
0.8874
−3.1823730
St Clair County, Michigan
47644
1.0009
1.0054
0.4523740
St Joseph County, Michigan
99923
0.8860
0.9062
2.2823750
Sanilac County, Michigan
99923
0.8860
0.9062
2.2823760
Schoolcraft County, Michigan
99923
0.8860
0.9062
2.2823770
Shiawassee County, Michigan
99923
0.8860
0.9062
2.2823780
Tuscola County, Michigan
99923
0.8860
0.9062
2.2823790
Van Buren County, Michigan
28020
1.0262
1.0704
4.3123800
Washtenaw County, Michigan
11460
1.0783
1.0826
0.4023810
Wayne County, Michigan
19804
1.0286
1.0281
−0.0523830
Wexford County, Michigan
99923
0.8860
0.9062
2.2824000
Aitkin County, Minnesota
99924
0.9132
0.9153
0.2324010
Anoka County, Minnesota
33460
1.1075
1.0946
−1.1624020
Becker County, Minnesota
99924
0.9132
0.9153
0.2324030
Beltrami County, Minnesota
99924
0.9132
0.9153
0.2324040
Benton County, Minnesota
41060
0.9965
1.0362
3.9824050
Big Stone County, Minnesota
99924
0.9132
0.9153
0.2324060
Blue Earth County, Minnesota
99924
0.9132
0.9153
0.2324070
Brown County, Minnesota
99924
0.9132
0.9153
0.2324080
Carlton County, Minnesota
20260
0.9673
1.0042
3.8124090
Carver County, Minnesota
33460
1.1075
1.0946
−1.1624100
Cass County, Minnesota
99924
0.9132
0.9153
0.2324110
Chippewa County, Minnesota
99924
0.9132
0.9153
0.2324120
Chisago County, Minnesota
33460
1.1075
1.0946
−1.1624130
Clay County, Minnesota
22020
0.8486
0.8250
−2.7824140
Clearwater County, Minnesota
99924
0.9132
0.9153
0.2324150
Cook County, Minnesota
99924
0.9132
0.9153
0.2324160
Cottonwood County, Minnesota
99924
0.9132
0.9153
0.2324170
Crow Wing County, Minnesota
99924
0.9132
0.9153
0.2324180
Dakota County, Minnesota
33460
1.1075
1.0946
−1.1624190
Dodge County, Minnesota
40340
1.0132
1.1408
12.5924200
Douglas County, Minnesota
99924
0.9132
0.9153
0.2324210
Faribault County, Minnesota
99924
0.9132
0.9153
0.2324220
Fillmore County, Minnesota
99924
0.9132
0.9153
0.2324230
Freeborn County, Minnesota
99924
0.9132
0.9153
0.2324240
Goodhue County, Minnesota
99924
0.9132
0.9153
0.2324250
Grant County, Minnesota
99924
0.9132
0.9153
0.2324260
Hennepin County, Minnesota
33460
1.1075
1.0946
−1.1624270
Houston County, Minnesota
29100
0.9564
0.9426
−1.4424280
Hubbard County, Minnesota
99924
0.9132
0.9153
0.2324290
Isanti County, Minnesota
33460
1.1075
1.0946
−1.1624300
Itasca County, Minnesota
99924
0.9132
0.9153
0.2324310
Jackson County, Minnesota
99924
0.9132
0.9153
0.2324320
Kanabec County, Minnesota
99924
0.9132
0.9153
0.2324330
Kandiyohi County, Minnesota
99924
0.9132
0.9153
0.2324340
Kittson County, Minnesota
99924
0.9132
0.9153
0.2324350
Koochiching County, Minnesota
99924
0.9132
0.9153
0.2324360
Lac Qui Parle County, Minnesota
99924
0.9132
0.9153
0.2324370
Lake County, Minnesota
99924
0.9132
0.9153
0.2324380
Lake Of Woods County, Minnesota
99924
0.9132
0.9153
0.2324390
Le Sueur County, Minnesota
99924
0.9132
0.9153
0.2324400
Lincoln County, Minnesota
99924
0.9132
0.9153
0.2324410
Lyon County, Minnesota
99924
0.9132
0.9153
0.2324420
Mc Leod County, Minnesota
99924
0.9132
0.9153
0.2324430
Mahnomen County, Minnesota
99924
0.9132
0.9153
0.2324440
Marshall County, Minnesota
99924
0.9132
0.9153
0.2324450
Martin County, Minnesota
99924
0.9132
0.9153
0.2324460
Meeker County, Minnesota
99924
0.9132
0.9153
0.2324470
Mille Lacs County, Minnesota
99924
0.9132
0.9153
0.2324480
Morrison County, Minnesota
99924
0.9132
0.9153
0.2324490
Mower County, Minnesota
99924
0.9132
0.9153
0.2324500
Murray County, Minnesota
99924
0.9132
0.9153
0.2324510
Nicollet County, Minnesota
99924
0.9132
0.9153
0.23( print page 65979)24520
Nobles County, Minnesota
99924
0.9132
0.9153
0.2324530
Norman County, Minnesota
99924
0.9132
0.9153
0.2324540
Olmsted County, Minnesota
40340
1.1131
1.1408
2.4924550
Otter Tail County, Minnesota
99924
0.9132
0.9153
0.2324560
Pennington County, Minnesota
99924
0.9132
0.9153
0.2324570
Pine County, Minnesota
99924
0.9132
0.9153
0.2324580
Pipestone County, Minnesota
99924
0.9132
0.9153
0.2324590
Polk County, Minnesota
24220
0.7901
0.7949
0.6124600
Pope County, Minnesota
99924
0.9132
0.9153
0.2324610
Ramsey County, Minnesota
33460
1.1075
1.0946
−1.1624620
Red Lake County, Minnesota
99924
0.9132
0.9153
0.2324630
Redwood County, Minnesota
99924
0.9132
0.9153
0.2324640
Renville County, Minnesota
99924
0.9132
0.9153
0.2324650
Rice County, Minnesota
99924
0.9132
0.9153
0.2324660
Rock County, Minnesota
99924
0.9132
0.9153
0.2324670
Roseau County, Minnesota
99924
0.9132
0.9153
0.2324680
St Louis County, Minnesota
20260
1.0213
1.0042
−1.6724690
Scott County, Minnesota
33460
1.1075
1.0946
−1.1624700
Sherburne County, Minnesota
33460
1.1075
1.0946
−1.1624710
Sibley County, Minnesota
99924
0.9132
0.9153
0.2324720
Stearns County, Minnesota
41060
0.9965
1.0362
3.9824730
Steele County, Minnesota
99924
0.9132
0.9153
0.2324740
Stevens County, Minnesota
99924
0.9132
0.9153
0.2324750
Swift County, Minnesota
99924
0.9132
0.9153
0.2324760
Todd County, Minnesota
99924
0.9132
0.9153
0.2324770
Traverse County, Minnesota
99924
0.9132
0.9153
0.2324780
Wabasha County, Minnesota
40340
1.0132
1.1408
12.5924790
Wadena County, Minnesota
99924
0.9132
0.9153
0.2324800
Waseca County, Minnesota
99924
0.9132
0.9153
0.2324810
Washington County, Minnesota
33460
1.1075
1.0946
−1.1624820
Watonwan County, Minnesota
99924
0.9132
0.9153
0.2324830
Wilkin County, Minnesota
99924
0.9132
0.9153
0.2324840
Winona County, Minnesota
99924
0.9132
0.9153
0.2324850
Wright County, Minnesota
33460
1.1075
1.0946
−1.1624860
Yellow Medicine County, Minnesota
99924
0.9132
0.9153
0.2325000
Adams County, Mississippi
99925
0.7654
0.7738
1.1025010
Alcorn County, Mississippi
99925
0.7654
0.7738
1.1025020
Amite County, Mississippi
99925
0.7654
0.7738
1.1025030
Attala County, Mississippi
99925
0.7654
0.7738
1.1025040
Benton County, Mississippi
99925
0.7654
0.7738
1.1025050
Bolivar County, Mississippi
99925
0.7654
0.7738
1.1025060
Calhoun County, Mississippi
99925
0.7654
0.7738
1.1025070
Carroll County, Mississippi
99925
0.7654
0.7738
1.1025080
Chickasaw County, Mississippi
99925
0.7654
0.7738
1.1025090
Choctaw County, Mississippi
99925
0.7654
0.7738
1.1025100
Claiborne County, Mississippi
99925
0.7654
0.7738
1.1025110
Clarke County, Mississippi
99925
0.7654
0.7738
1.1025120
Clay County, Mississippi
99925
0.7654
0.7738
1.1025130
Coahoma County, Mississippi
99925
0.7654
0.7738
1.1025140
Copiah County, Mississippi
27140
0.7973
0.8271
3.7425150
Covington County, Mississippi
99925
0.7654
0.7738
1.1025160
Desoto County, Mississippi
32820
0.9407
0.9373
−0.3625170
Forrest County, Mississippi
25620
0.7601
0.7430
−2.2525180
Franklin County, Mississippi
99925
0.7654
0.7738
1.1025190
George County, Mississippi
37700
0.7895
0.8215
4.0525200
Greene County, Mississippi
99925
0.7654
0.7738
1.1025210
Grenada County, Mississippi
99925
0.7654
0.7738
1.1025220
Hancock County, Mississippi
25060
0.8818
0.8915
1.1025230
Harrison County, Mississippi
25060
0.8818
0.8915
1.1025240
Hinds County, Mississippi
27140
0.8347
0.8271
−0.9125250
Holmes County, Mississippi
99925
0.7654
0.7738
1.1025260
Humphreys County, Mississippi
99925
0.7654
0.7738
1.1025270
Issaquena County, Mississippi
99925
0.7654
0.7738
1.1025280
Itawamba County, Mississippi
99925
0.7654
0.7738
1.1025290
Jackson County, Mississippi
37700
0.8431
0.8215
−2.5625300
Jasper County, Mississippi
99925
0.7654
0.7738
1.1025310
Jefferson County, Mississippi
99925
0.7654
0.7738
1.1025320
Jefferson Davis County, Mississippi
99925
0.7654
0.7738
1.10( print page 65980)25330
Jones County, Mississippi
99925
0.7654
0.7738
1.1025340
Kemper County, Mississippi
99925
0.7654
0.7738
1.1025350
Lafayette County, Mississippi
99925
0.7654
0.7738
1.1025360
Lamar County, Mississippi
25620
0.7601
0.7430
−2.2525370
Lauderdale County, Mississippi
99925
0.7654
0.7738
1.1025380
Lawrence County, Mississippi
99925
0.7654
0.7738
1.1025390
Leake County, Mississippi
99925
0.7654
0.7738
1.1025400
Lee County, Mississippi
99925
0.7654
0.7738
1.1025410
Leflore County, Mississippi
99925
0.7654
0.7738
1.1025420
Lincoln County, Mississippi
99925
0.7654
0.7738
1.1025430
Lowndes County, Mississippi
99925
0.7654
0.7738
1.1025440
Madison County, Mississippi
27140
0.8347
0.8271
−0.9125450
Marion County, Mississippi
99925
0.7654
0.7738
1.1025460
Marshall County, Mississippi
32820
0.8516
0.9373
10.0625470
Monroe County, Mississippi
99925
0.7654
0.7738
1.1025480
Montgomery County, Mississippi
99925
0.7654
0.7738
1.1025490
Neshoba County, Mississippi
99925
0.7654
0.7738
1.1025500
Newton County, Mississippi
99925
0.7654
0.7738
1.1025510
Noxubee County, Mississippi
99925
0.7654
0.7738
1.1025520
Oktibbeha County, Mississippi
99925
0.7654
0.7738
1.1025530
Panola County, Mississippi
99925
0.7654
0.7738
1.1025540
Pearl River County, Mississippi
99925
0.7654
0.7738
1.1025550
Perry County, Mississippi
25620
0.7618
0.7430
−2.4725560
Pike County, Mississippi
99925
0.7654
0.7738
1.1025570
Pontotoc County, Mississippi
99925
0.7654
0.7738
1.1025580
Prentiss County, Mississippi
99925
0.7654
0.7738
1.1025590
Quitman County, Mississippi
99925
0.7654
0.7738
1.1025600
Rankin County, Mississippi
27140
0.8347
0.8271
−0.9125610
Scott County, Mississippi
99925
0.7654
0.7738
1.1025620
Sharkey County, Mississippi
99925
0.7654
0.7738
1.1025630
Simpson County, Mississippi
27140
0.7973
0.8271
3.7425640
Smith County, Mississippi
99925
0.7654
0.7738
1.1025650
Stone County, Mississippi
25060
0.8282
0.8915
7.6425660
Sunflower County, Mississippi
99925
0.7654
0.7738
1.1025670
Tallahatchie County, Mississippi
99925
0.7654
0.7738
1.1025680
Tate County, Mississippi
32820
0.8516
0.9373
10.0625690
Tippah County, Mississippi
99925
0.7654
0.7738
1.1025700
Tishomingo County, Mississippi
99925
0.7654
0.7738
1.1025710
Tunica County, Mississippi
32820
0.8516
0.9373
10.0625720
Union County, Mississippi
99925
0.7654
0.7738
1.1025730
Walthall County, Mississippi
99925
0.7654
0.7738
1.1025740
Warren County, Mississippi
99925
0.7654
0.7738
1.1025750
Washington County, Mississippi
99925
0.7654
0.7738
1.1025760
Wayne County, Mississippi
99925
0.7654
0.7738
1.1025770
Webster County, Mississippi
99925
0.7654
0.7738
1.1025780
Wilkinson County, Mississippi
99925
0.7654
0.7738
1.1025790
Winston County, Mississippi
99925
0.7654
0.7738
1.1025800
Yalobusha County, Mississippi
99925
0.7654
0.7738
1.1025810
Yazoo County, Mississippi
99925
0.7654
0.7738
1.1026000
Adair County, Missouri
99926
0.7930
0.7927
−0.0426010
Andrew County, Missouri
41140
0.9519
1.0118
6.2926020
Atchison County, Missouri
99926
0.7930
0.7927
−0.0426030
Audrain County, Missouri
99926
0.7930
0.7927
−0.0426040
Barry County, Missouri
99926
0.7930
0.7927
−0.0426050
Barton County, Missouri
99926
0.7930
0.7927
−0.0426060
Bates County, Missouri
28140
0.8718
0.9495
8.9126070
Benton County, Missouri
99926
0.7930
0.7927
−0.0426080
Bollinger County, Missouri
99926
0.7930
0.7927
−0.0426090
Boone County, Missouri
17860
0.8345
0.8542
2.3626100
Buchanan County, Missouri
41140
0.9519
1.0118
6.2926110
Butler County, Missouri
99926
0.7930
0.7927
−0.0426120
Caldwell County, Missouri
28140
0.8718
0.9495
8.9126130
Callaway County, Missouri
27620
0.8173
0.8332
1.9526140
Camden County, Missouri
99926
0.7930
0.7927
−0.0426150
Cape Girardeau County, Missouri
99926
0.7930
0.7927
−0.0426160
Carroll County, Missouri
99926
0.7930
0.7927
−0.0426170
Carter County, Missouri
99926
0.7930
0.7927
−0.0426180
Cass County, Missouri
28140
0.9483
0.9495
0.13( print page 65981)26190
Cedar County, Missouri
99926
0.7930
0.7927
−0.0426200
Chariton County, Missouri
99926
0.7930
0.7927
−0.0426210
Christian County, Missouri
44180
0.8244
0.8469
2.7326220
Clark County, Missouri
99926
0.7930
0.7927
−0.0426230
Clay County, Missouri
28140
0.9483
0.9495
0.1326240
Clinton County, Missouri
28140
0.9483
0.9495
0.1326250
Cole County, Missouri
27620
0.8173
0.8332
1.9526260
Cooper County, Missouri
99926
0.7930
0.7927
−0.0426270
Crawford County, Missouri
41180
0.8457
0.9005
6.4826280
Dade County, Missouri
99926
0.7930
0.7927
−0.0426290
Dallas County, Missouri
44180
0.8098
0.8469
4.5826300
Daviess County, Missouri
99926
0.7930
0.7927
−0.0426310
De Kalb County, Missouri
41140
0.8739
1.0118
15.7826320
Dent County, Missouri
99926
0.7930
0.7927
−0.0426330
Douglas County, Missouri
99926
0.7930
0.7927
−0.0426340
Dunklin County, Missouri
99926
0.7930
0.7927
−0.0426350
Franklin County, Missouri
41180
0.8958
0.9005
0.5226360
Gasconade County, Missouri
99926
0.7930
0.7927
−0.0426370
Gentry County, Missouri
99926
0.7930
0.7927
−0.0426380
Greene County, Missouri
44180
0.8244
0.8469
2.7326390
Grundy County, Missouri
99926
0.7930
0.7927
−0.0426400
Harrison County, Missouri
99926
0.7930
0.7927
−0.0426410
Henry County, Missouri
99926
0.7930
0.7927
−0.0426411
Hickory County, Missouri
99926
0.7930
0.7927
−0.0426412
Holt County, Missouri
99926
0.7930
0.7927
−0.0426440
Howard County, Missouri
17860
0.8152
0.8542
4.7826450
Howell County, Missouri
99926
0.7930
0.7927
−0.0426460
Iron County, Missouri
99926
0.7930
0.7927
−0.0426470
Jackson County, Missouri
28140
0.9483
0.9495
0.1326480
Jasper County, Missouri
27900
0.8582
0.8605
0.2726490
Jefferson County, Missouri
41180
0.8958
0.9005
0.5226500
Johnson County, Missouri
99926
0.7930
0.7927
−0.0426510
Knox County, Missouri
99926
0.7930
0.7927
−0.0426520
Laclede County, Missouri
99926
0.7930
0.7927
−0.0426530
Lafayette County, Missouri
28140
0.9483
0.9495
0.1326540
Lawrence County, Missouri
99926
0.7930
0.7927
−0.0426541
Lewis County, Missouri
99926
0.7930
0.7927
−0.0426560
Lincoln County, Missouri
41180
0.8958
0.9005
0.5226570
Linn County, Missouri
99926
0.7930
0.7927
−0.0426580
Livingston County, Missouri
99926
0.7930
0.7927
−0.0426590
Mc Donald County, Missouri
22220
0.8310
0.8865
6.6826600
Macon County, Missouri
99926
0.7930
0.7927
−0.0426601
Madison County, Missouri
99926
0.7930
0.7927
−0.0426620
Maries County, Missouri
99926
0.7930
0.7927
−0.0426630
Marion County, Missouri
99926
0.7930
0.7927
−0.0426631
Mercer County, Missouri
99926
0.7930
0.7927
−0.0426650
Miller County, Missouri
99926
0.7930
0.7927
−0.0426660
Mississippi County, Missouri
99926
0.7930
0.7927
−0.0426670
Moniteau County, Missouri
27620
0.8173
0.8332
1.9526680
Monroe County, Missouri
99926
0.7930
0.7927
−0.0426690
Montgomery County, Missouri
99926
0.7930
0.7927
−0.0426700
Morgan County, Missouri
99926
0.7930
0.7927
−0.0426710
New Madrid County, Missouri
99926
0.7930
0.7927
−0.0426720
Newton County, Missouri
27900
0.8582
0.8605
0.2726730
Nodaway County, Missouri
99926
0.7930
0.7927
−0.0426740
Oregon County, Missouri
99926
0.7930
0.7927
−0.0426750
Osage County, Missouri
27620
0.8173
0.8332
1.9526751
Ozark County, Missouri
99926
0.7930
0.7927
−0.0426770
Pemiscot County, Missouri
99926
0.7930
0.7927
−0.0426780
Perry County, Missouri
99926
0.7930
0.7927
−0.0426790
Pettis County, Missouri
99926
0.7930
0.7927
−0.0426800
Phelps County, Missouri
99926
0.7930
0.7927
−0.0426810
Pike County, Missouri
99926
0.7930
0.7927
−0.0426820
Platte County, Missouri
28140
0.9483
0.9495
0.1326821
Polk County, Missouri
44180
0.8098
0.8469
4.5826840
Pulaski County, Missouri
99926
0.7930
0.7927
−0.0426850
Putnam County, Missouri
99926
0.7930
0.7927
−0.0426860
Ralls County, Missouri
99926
0.7930
0.7927
−0.04( print page 65982)26870
Randolph County, Missouri
99926
0.7930
0.7927
−0.0426880
Ray County, Missouri
28140
0.9483
0.9495
0.1326881
Reynolds County, Missouri
99926
0.7930
0.7927
−0.0426900
Ripley County, Missouri
99926
0.7930
0.7927
−0.0426910
St Charles County, Missouri
41180
0.8958
0.9005
0.5226911
St Clair County, Missouri
99926
0.7930
0.7927
−0.0426930
St Francois County, Missouri
99926
0.7930
0.7927
−0.0426940
St Louis County, Missouri
41180
0.8958
0.9005
0.5226950
St Louis City County, Missouri
41180
0.8958
0.9005
0.5226960
Ste Genevieve County, Missouri
99926
0.7930
0.7927
−0.0426970
Saline County, Missouri
99926
0.7930
0.7927
−0.0426980
Schuyler County, Missouri
99926
0.7930
0.7927
−0.0426981
Scotland County, Missouri
99926
0.7930
0.7927
−0.0426982
Scott County, Missouri
99926
0.7930
0.7927
−0.0426983
Shannon County, Missouri
99926
0.7930
0.7927
−0.0426984
Shelby County, Missouri
99926
0.7930
0.7927
−0.0426985
Stoddard County, Missouri
99926
0.7930
0.7927
−0.0426986
Stone County, Missouri
99926
0.7930
0.7927
−0.0426987
Sullivan County, Missouri
99926
0.7930
0.7927
−0.0426988
Taney County, Missouri
99926
0.7930
0.7927
−0.0426989
Texas County, Missouri
99926
0.7930
0.7927
−0.0426990
Vernon County, Missouri
99926
0.7930
0.7927
−0.0426991
Warren County, Missouri
41180
0.8958
0.9005
0.5226992
Washington County, Missouri
41180
0.8457
0.9005
6.4826993
Wayne County, Missouri
99926
0.7930
0.7927
−0.0426994
Webster County, Missouri
44180
0.8244
0.8469
2.7326995
Worth County, Missouri
99926
0.7930
0.7927
−0.0426996
Wright County, Missouri
99926
0.7930
0.7927
−0.0427000
Beaverhead County, Montana
99927
0.8762
0.8590
−1.9627010
Big Horn County, Montana
99927
0.8762
0.8590
−1.9627020
Blaine County, Montana
99927
0.8762
0.8590
−1.9627030
Broadwater County, Montana
99927
0.8762
0.8590
−1.9627040
Carbon County, Montana
13740
0.8798
0.8712
−0.9827050
Carter County, Montana
99927
0.8762
0.8590
−1.9627060
Cascade County, Montana
24500
0.9052
0.8598
−5.0227070
Chouteau County, Montana
99927
0.8762
0.8590
−1.9627080
Custer County, Montana
99927
0.8762
0.8590
−1.9627090
Daniels County, Montana
99927
0.8762
0.8590
−1.9627100
Dawson County, Montana
99927
0.8762
0.8590
−1.9627110
Deer Lodge County, Montana
99927
0.8762
0.8590
−1.9627113
Yellowstone National Park, Montana
99927
0.8762
0.8590
−1.9627120
Fallon County, Montana
99927
0.8762
0.8590
−1.9627130
Fergus County, Montana
99927
0.8762
0.8590
−1.9627140
Flathead County, Montana
99927
0.8762
0.8590
−1.9627150
Gallatin County, Montana
99927
0.8762
0.8590
−1.9627160
Garfield County, Montana
99927
0.8762
0.8590
−1.9627170
Glacier County, Montana
99927
0.8762
0.8590
−1.9627180
Golden Valley County, Montana
99927
0.8762
0.8590
−1.9627190
Granite County, Montana
99927
0.8762
0.8590
−1.9627200
Hill County, Montana
99927
0.8762
0.8590
−1.9627210
Jefferson County, Montana
99927
0.8762
0.8590
−1.9627220
Judith Basin County, Montana
99927
0.8762
0.8590
−1.9627230
Lake County, Montana
99927
0.8762
0.8590
−1.9627240
Lewis And Clark County, Montana
99927
0.8762
0.8590
−1.9627250
Liberty County, Montana
99927
0.8762
0.8590
−1.9627260
Lincoln County, Montana
99927
0.8762
0.8590
−1.9627270
Mc Cone County, Montana
99927
0.8762
0.8590
−1.9627280
Madison County, Montana
99927
0.8762
0.8590
−1.9627290
Meagher County, Montana
99927
0.8762
0.8590
−1.9627300
Mineral County, Montana
99927
0.8762
0.8590
−1.9627310
Missoula County, Montana
33540
0.9473
0.8928
−5.7527320
Musselshell County, Montana
99927
0.8762
0.8590
−1.9627330
Park County, Montana
99927
0.8762
0.8590
−1.9627340
Petroleum County, Montana
99927
0.8762
0.8590
−1.9627350
Phillips County, Montana
99927
0.8762
0.8590
−1.9627360
Pondera County, Montana
99927
0.8762
0.8590
−1.9627370
Powder River County, Montana
99927
0.8762
0.8590
−1.9627380
Powell County, Montana
99927
0.8762
0.8590
−1.96( print page 65983)27390
Prairie County, Montana
99927
0.8762
0.8590
−1.9627400
Ravalli County, Montana
99927
0.8762
0.8590
−1.9627410
Richland County, Montana
99927
0.8762
0.8590
−1.9627420
Roosevelt County, Montana
99927
0.8762
0.8590
−1.9627430
Rosebud County, Montana
99927
0.8762
0.8590
−1.9627440
Sanders County, Montana
99927
0.8762
0.8590
−1.9627450
Sheridan County, Montana
99927
0.8762
0.8590
−1.9627460
Silver Bow County, Montana
99927
0.8762
0.8590
−1.9627470
Stillwater County, Montana
99927
0.8762
0.8590
−1.9627480
Sweet Grass County, Montana
99927
0.8762
0.8590
−1.9627490
Teton County, Montana
99927
0.8762
0.8590
−1.9627500
Toole County, Montana
99927
0.8762
0.8590
−1.9627510
Treasure County, Montana
99927
0.8762
0.8590
−1.9627520
Valley County, Montana
99927
0.8762
0.8590
−1.9627530
Wheatland County, Montana
99927
0.8762
0.8590
−1.9627540
Wibaux County, Montana
99927
0.8762
0.8590
−1.9627550
Yellowstone County, Montana
13740
0.8834
0.8712
−1.3828000
Adams County, Nebraska
99928
0.8657
0.8677
0.2328010
Antelope County, Nebraska
99928
0.8657
0.8677
0.2328020
Arthur County, Nebraska
99928
0.8657
0.8677
0.2328030
Banner County, Nebraska
99928
0.8657
0.8677
0.2328040
Blaine County, Nebraska
99928
0.8657
0.8677
0.2328050
Boone County, Nebraska
99928
0.8657
0.8677
0.2328060
Box Butte County, Nebraska
99928
0.8657
0.8677
0.2328070
Boyd County, Nebraska
99928
0.8657
0.8677
0.2328080
Brown County, Nebraska
99928
0.8657
0.8677
0.2328090
Buffalo County, Nebraska
99928
0.8657
0.8677
0.2328100
Burt County, Nebraska
99928
0.8657
0.8677
0.2328110
Butler County, Nebraska
99928
0.8657
0.8677
0.2328120
Cass County, Nebraska
36540
0.9560
0.9450
−1.1528130
Cedar County, Nebraska
99928
0.8657
0.8677
0.2328140
Chase County, Nebraska
99928
0.8657
0.8677
0.2328150
Cherry County, Nebraska
99928
0.8657
0.8677
0.2328160
Cheyenne County, Nebraska
99928
0.8657
0.8677
0.2328170
Clay County, Nebraska
99928
0.8657
0.8677
0.2328180
Colfax County, Nebraska
99928
0.8657
0.8677
0.2328190
Cuming County, Nebraska
99928
0.8657
0.8677
0.2328200
Custer County, Nebraska
99928
0.8657
0.8677
0.2328210
Dakota County, Nebraska
43580
0.9399
0.9200
−2.1228220
Dawes County, Nebraska
99928
0.8657
0.8677
0.2328230
Dawson County, Nebraska
99928
0.8657
0.8677
0.2328240
Deuel County, Nebraska
99928
0.8657
0.8677
0.2328250
Dixon County, Nebraska
43580
0.9019
0.9200
2.0128260
Dodge County, Nebraska
99928
0.8657
0.8677
0.2328270
Douglas County, Nebraska
36540
0.9560
0.9450
−1.1528280
Dundy County, Nebraska
99928
0.8657
0.8677
0.2328290
Fillmore County, Nebraska
99928
0.8657
0.8677
0.2328300
Franklin County, Nebraska
99928
0.8657
0.8677
0.2328310
Frontier County, Nebraska
99928
0.8657
0.8677
0.2328320
Furnas County, Nebraska
99928
0.8657
0.8677
0.2328330
Gage County, Nebraska
99928
0.8657
0.8677
0.2328340
Garden County, Nebraska
99928
0.8657
0.8677
0.2328350
Garfield County, Nebraska
99928
0.8657
0.8677
0.2328360
Gosper County, Nebraska
99928
0.8657
0.8677
0.2328370
Grant County, Nebraska
99928
0.8657
0.8677
0.2328380
Greeley County, Nebraska
99928
0.8657
0.8677
0.2328390
Hall County, Nebraska
99928
0.8657
0.8677
0.2328400
Hamilton County, Nebraska
99928
0.8657
0.8677
0.2328410
Harlan County, Nebraska
99928
0.8657
0.8677
0.2328420
Hayes County, Nebraska
99928
0.8657
0.8677
0.2328430
Hitchcock County, Nebraska
99928
0.8657
0.8677
0.2328440
Holt County, Nebraska
99928
0.8657
0.8677
0.2328450
Hooker County, Nebraska
99928
0.8657
0.8677
0.2328460
Howard County, Nebraska
99928
0.8657
0.8677
0.2328470
Jefferson County, Nebraska
99928
0.8657
0.8677
0.2328480
Johnson County, Nebraska
99928
0.8657
0.8677
0.2328490
Kearney County, Nebraska
99928
0.8657
0.8677
0.2328500
Keith County, Nebraska
99928
0.8657
0.8677
0.23( print page 65984)28510
Keya Paha County, Nebraska
99928
0.8657
0.8677
0.2328520
Kimball County, Nebraska
99928
0.8657
0.8677
0.2328530
Knox County, Nebraska
99928
0.8657
0.8677
0.2328540
Lancaster County, Nebraska
30700
1.0214
1.0092
−1.1928550
Lincoln County, Nebraska
99928
0.8657
0.8677
0.2328560
Logan County, Nebraska
99928
0.8657
0.8677
0.2328570
Loup County, Nebraska
99928
0.8657
0.8677
0.2328580
Mc Pherson County, Nebraska
99928
0.8657
0.8677
0.2328590
Madison County, Nebraska
99928
0.8657
0.8677
0.2328600
Merrick County, Nebraska
99928
0.8657
0.8677
0.2328610
Morrill County, Nebraska
99928
0.8657
0.8677
0.2328620
Nance County, Nebraska
99928
0.8657
0.8677
0.2328630
Nemaha County, Nebraska
99928
0.8657
0.8677
0.2328640
Nuckolls County, Nebraska
99928
0.8657
0.8677
0.2328650
Otoe County, Nebraska
99928
0.8657
0.8677
0.2328660
Pawnee County, Nebraska
99928
0.8657
0.8677
0.2328670
Perkins County, Nebraska
99928
0.8657
0.8677
0.2328680
Phelps County, Nebraska
99928
0.8657
0.8677
0.2328690
Pierce County, Nebraska
99928
0.8657
0.8677
0.2328700
Platte County, Nebraska
99928
0.8657
0.8677
0.2328710
Polk County, Nebraska
99928
0.8657
0.8677
0.2328720
Redwillow County, Nebraska
99928
0.8657
0.8677
0.2328730
Richardson County, Nebraska
99928
0.8657
0.8677
0.2328740
Rock County, Nebraska
99928
0.8657
0.8677
0.2328750
Saline County, Nebraska
99928
0.8657
0.8677
0.2328760
Sarpy County, Nebraska
36540
0.9560
0.9450
−1.1528770
Saunders County, Nebraska
36540
0.9109
0.9450
3.7428780
Scotts Bluff County, Nebraska
99928
0.8657
0.8677
0.2328790
Seward County, Nebraska
30700
0.9436
1.0092
6.9528800
Sheridan County, Nebraska
99928
0.8657
0.8677
0.2328810
Sherman County, Nebraska
99928
0.8657
0.8677
0.2328820
Sioux County, Nebraska
99928
0.8657
0.8677
0.2328830
Stanton County, Nebraska
99928
0.8657
0.8677
0.2328840
Thayer County, Nebraska
99928
0.8657
0.8677
0.2328850
Thomas County, Nebraska
99928
0.8657
0.8677
0.2328860
Thurston County, Nebraska
99928
0.8657
0.8677
0.2328870
Valley County, Nebraska
99928
0.8657
0.8677
0.2328880
Washington County, Nebraska
36540
0.9560
0.9450
−1.1528890
Wayne County, Nebraska
99928
0.8657
0.8677
0.2328900
Webster County, Nebraska
99928
0.8657
0.8677
0.2328910
Wheeler County, Nebraska
99928
0.8657
0.8677
0.2328920
York County, Nebraska
99928
0.8657
0.8677
0.2329000
Churchill County, Nevada
99929
0.9376
0.8944
−4.6129010
Clark County, Nevada
29820
1.1296
1.1430
1.1929020
Douglas County, Nevada
99929
0.9376
0.8944
−4.6129030
Elko County, Nevada
99929
0.9376
0.8944
−4.6129040
Esmeralda County, Nevada
99929
0.9376
0.8944
−4.6129050
Eureka County, Nevada
99929
0.9376
0.8944
−4.6129060
Humboldt County, Nevada
99929
0.9376
0.8944
−4.6129070
Lander County, Nevada
99929
0.9376
0.8944
−4.6129080
Lincoln County, Nevada
99929
0.9376
0.8944
−4.6129090
Lyon County, Nevada
99929
0.9376
0.8944
−4.6129100
Mineral County, Nevada
99929
0.9376
0.8944
−4.6129110
Nye County, Nevada
99929
1.0110
0.8944
−11.5329120
Carson City County, Nevada
16180
0.9961
1.0025
0.6429130
Pershing County, Nevada
99929
0.9376
0.8944
−4.6129140
Storey County, Nevada
39900
1.0335
1.1963
15.7529150
Washoe County, Nevada
39900
1.0982
1.1963
8.9329160
White Pine County, Nevada
99929
0.9376
0.8944
−4.6130000
Belknap County, New Hampshire
99930
1.0817
1.0853
0.3330010
Carroll County, New Hampshire
99930
1.0817
1.0853
0.3330020
Cheshire County, New Hampshire
99930
1.0817
1.0853
0.3330030
Coos County, New Hampshire
99930
1.0817
1.0853
0.3330040
Grafton County, New Hampshire
99930
1.0817
1.0853
0.3330050
Hillsboro County, New Hampshire
31700
1.0766
1.0243
−4.8630060
Merrimack County, New Hampshire
31700
1.0766
1.0243
−4.8630070
Rockingham County, New Hampshire
40484
1.0776
1.0159
−5.7330080
Strafford County, New Hampshire
40484
1.0776
1.0159
−5.73( print page 65985)30090
Sullivan County, New Hampshire
99930
1.0817
1.0853
0.3331000
Atlantic County, New Jersey
12100
1.1556
1.1831
2.3831100
Bergen County, New Jersey
35644
1.2420
1.3177
6.1031150
Burlington County, New Jersey
15804
1.0720
1.0392
−3.0631160
Camden County, New Jersey
15804
1.0720
1.0392
−3.0631180
Cape May County, New Jersey
36140
1.1254
1.0472
−6.9531190
Cumberland County, New Jersey
47220
0.9827
0.9832
0.0531200
Essex County, New Jersey
35084
1.1859
1.1892
0.2831220
Gloucester County, New Jersey
15804
1.0720
1.0392
−3.0631230
Hudson County, New Jersey
35644
1.2263
1.3177
7.4531250
Hunterdon County, New Jersey
35084
1.1525
1.1892
3.1831260
Mercer County, New Jersey
45940
1.0834
1.0835
0.0131270
Middlesex County, New Jersey
20764
1.1208
1.1190
−0.1631290
Monmouth County, New Jersey
20764
1.1255
1.1190
−0.5831300
Morris County, New Jersey
35084
1.1859
1.1892
0.2831310
Ocean County, New Jersey
20764
1.1255
1.1190
−0.5831320
Passaic County, New Jersey
35644
1.2420
1.3177
6.1031340
Salem County, New Jersey
48864
1.0697
1.0684
−0.1231350
Somerset County, New Jersey
20764
1.1208
1.1190
−0.1631360
Sussex County, New Jersey
35084
1.1859
1.1892
0.2831370
Union County, New Jersey
35084
1.1859
1.1892
0.2831390
Warren County, New Jersey
10900
1.0826
0.9947
−8.1232000
Bernalillo County, New Mexico
10740
0.9684
0.9458
−2.3332010
Catron County, New Mexico
99932
0.8599
0.8332
−3.1132020
Chaves County, New Mexico
99932
0.8599
0.8332
−3.1132025
Cibola County, New Mexico
99932
0.8599
0.8332
−3.1132030
Colfax County, New Mexico
99932
0.8599
0.8332
−3.1132040
Curry County, New Mexico
99932
0.8599
0.8332
−3.1132050
De Baca County, New Mexico
99932
0.8599
0.8332
−3.1132060
Dona Ana County, New Mexico
29740
0.8467
0.9273
9.5232070
Eddy County, New Mexico
99932
0.8599
0.8332
−3.1132080
Grant County, New Mexico
99932
0.8599
0.8332
−3.1132090
Guadalupe County, New Mexico
99932
0.8599
0.8332
−3.1132100
Harding County, New Mexico
99932
0.8599
0.8332
−3.1132110
Hidalgo County, New Mexico
99932
0.8599
0.8332
−3.1132120
Lea County, New Mexico
99932
0.8599
0.8332
−3.1132130
Lincoln County, New Mexico
99932
0.8599
0.8332
−3.1132131
Los Alamos County, New Mexico
99932
0.9692
0.8332
−14.0332140
Luna County, New Mexico
99932
0.8599
0.8332
−3.1132150
Mc Kinley County, New Mexico
99932
0.8599
0.8332
−3.1132160
Mora County, New Mexico
99932
0.8599
0.8332
−3.1132170
Otero County, New Mexico
99932
0.8599
0.8332
−3.1132180
Quay County, New Mexico
99932
0.8599
0.8332
−3.1132190
Rio Arriba County, New Mexico
99932
0.8599
0.8332
−3.1132200
Roosevelt County, New Mexico
99932
0.8599
0.8332
−3.1132210
Sandoval County, New Mexico
10740
0.9684
0.9458
−2.3332220
San Juan County, New Mexico
22140
0.8536
0.8589
0.6232230
San Miguel County, New Mexico
99932
0.8599
0.8332
−3.1132240
Santa Fe County, New Mexico
42140
1.0834
1.0824
−0.0932250
Sierra County, New Mexico
99932
0.8599
0.8332
−3.1132260
Socorro County, New Mexico
99932
0.8599
0.8332
−3.1132270
Taos County, New Mexico
99932
0.8599
0.8332
−3.1132280
Torrance County, New Mexico
10740
0.9124
0.9458
3.6632290
Union County, New Mexico
99932
0.8599
0.8332
−3.1132300
Valencia County, New Mexico
10740
0.9684
0.9458
−2.3333000
Albany County, New York
10580
0.8574
0.8720
1.7033010
Allegany County, New York
99933
0.8275
0.8232
−0.5233020
Bronx County, New York
35644
1.3326
1.3177
−1.1233030
Broome County, New York
13780
0.8562
0.8786
2.6233040
Cattaraugus County, New York
99933
0.8275
0.8232
−0.5233050
Cayuga County, New York
99933
0.8823
0.8232
−6.7033060
Chautauqua County, New York
99933
0.7849
0.8232
4.8833070
Chemung County, New York
21300
0.8250
0.8240
−0.1233080
Chenango County, New York
99933
0.8275
0.8232
−0.5233090
Clinton County, New York
99933
0.8275
0.8232
−0.5233200
Columbia County, New York
99933
0.8275
0.8232
−0.5233210
Cortland County, New York
99933
0.8275
0.8232
−0.5233220
Delaware County, New York
99933
0.8275
0.8232
−0.52( print page 65986)33230
Dutchess County, New York
39100
1.0683
1.0911
2.1333240
Erie County, New York
15380
0.9511
0.9424
−0.9133260
Essex County, New York
99933
0.8275
0.8232
−0.5233270
Franklin County, New York
99933
0.8275
0.8232
−0.5233280
Fulton County, New York
99933
0.8275
0.8232
−0.5233290
Genesee County, New York
99933
0.8602
0.8232
−4.3033300
Greene County, New York
99933
0.8275
0.8232
−0.5233310
Hamilton County, New York
99933
0.8275
0.8232
−0.5233320
Herkimer County, New York
46540
0.8358
0.8396
0.4533330
Jefferson County, New York
99933
0.8275
0.8232
−0.5233331
Kings County, New York
35644
1.3326
1.3177
−1.1233340
Lewis County, New York
99933
0.8275
0.8232
−0.5233350
Livingston County, New York
40380
0.9085
0.8994
−1.0033360
Madison County, New York
45060
0.9533
0.9691
1.6633370
Monroe County, New York
40380
0.9085
0.8994
−1.0033380
Montgomery County, New York
99933
0.8357
0.8232
−1.5033400
Nassau County, New York
35004
1.2719
1.2662
−0.4533420
New York County, New York
35644
1.3326
1.3177
−1.1233500
Niagara County, New York
15380
0.9511
0.9424
−0.9133510
Oneida County, New York
46540
0.8358
0.8396
0.4533520
Onondaga County, New York
45060
0.9533
0.9691
1.6633530
Ontario County, New York
40380
0.9085
0.8994
−1.0033540
Orange County, New York
39100
1.1049
1.0911
−1.2533550
Orleans County, New York
40380
0.9085
0.8994
−1.0033560
Oswego County, New York
45060
0.9533
0.9691
1.6633570
Otsego County, New York
99933
0.8275
0.8232
−0.5233580
Putnam County, New York
35644
1.3326
1.3177
−1.1233590
Queens County, New York
35644
1.3326
1.3177
−1.1233600
Rensselaer County, New York
10580
0.8574
0.8720
1.7033610
Richmond County, New York
35644
1.3326
1.3177
−1.1233620
Rockland County, New York
35644
1.3326
1.3177
−1.1233630
St Lawrence County, New York
99933
0.8275
0.8232
−0.5233640
Saratoga County, New York
10580
0.8574
0.8720
1.7033650
Schenectady County, New York
10580
0.8574
0.8720
1.7033660
Schoharie County, New York
10580
0.8574
0.8720
1.7033670
Schuyler County, New York
99933
0.8275
0.8232
−0.5233680
Seneca County, New York
99933
0.8275
0.8232
−0.5233690
Steuben County, New York
99933
0.8275
0.8232
−0.5233700
Suffolk County, New York
35004
1.2719
1.2662
−0.4533710
Sullivan County, New York
99933
0.8275
0.8232
−0.5233720
Tioga County, New York
13780
0.8562
0.8786
2.6233730
Tompkins County, New York
27060
0.9094
0.9928
9.1733740
Ulster County, New York
28740
0.8825
0.9367
6.1433750
Warren County, New York
24020
0.8559
0.8324
−2.7533760
Washington County, New York
24020
0.8559
0.8324
−2.7533770
Wayne County, New York
40380
0.9085
0.8994
−1.0033800
Westchester County, New York
35644
1.3326
1.3177
−1.1233900
Wyoming County, New York
99933
0.8275
0.8232
−0.5233910
Yates County, New York
99933
0.8275
0.8232
−0.5234000
Alamance County, N Carolina
15500
0.8962
0.8674
−3.2134010
Alexander County, N Carolina
25860
0.8921
0.9010
1.0034020
Alleghany County, N Carolina
99934
0.8501
0.8588
1.0234030
Anson County, N Carolina
16740
0.9106
0.9554
4.9234040
Ashe County, N Carolina
99934
0.8501
0.8588
1.0234050
Avery County, N Carolina
99934
0.8501
0.8588
1.0234060
Beaufort County, N Carolina
99934
0.8501
0.8588
1.0234070
Bertie County, N Carolina
99934
0.8501
0.8588
1.0234080
Bladen County, N Carolina
99934
0.8501
0.8588
1.0234090
Brunswick County, N Carolina
48900
0.9582
0.9835
2.6434100
Buncombe County, N Carolina
11700
0.9511
0.9216
−3.1034110
Burke County, N Carolina
25860
0.8921
0.9010
1.0034120
Cabarrus County, N Carolina
16740
0.9733
0.9554
−1.8434130
Caldwell County, N Carolina
25860
0.8921
0.9010
1.0034140
Camden County, N Carolina
99934
0.8501
0.8588
1.0234150
Carteret County, N Carolina
99934
0.8501
0.8588
1.0234160
Caswell County, N Carolina
99934
0.8501
0.8588
1.0234170
Catawba County, N Carolina
25860
0.8921
0.9010
1.0034180
Chatham County, N Carolina
20500
1.0139
0.9826
−3.09( print page 65987)34190
Cherokee County, N Carolina
99934
0.8501
0.8588
1.0234200
Chowan County, N Carolina
99934
0.8501
0.8588
1.0234210
Clay County, N Carolina
99934
0.8501
0.8588
1.0234220
Cleveland County, N Carolina
99934
0.8501
0.8588
1.0234230
Columbus County, N Carolina
99934
0.8501
0.8588
1.0234240
Craven County, N Carolina
99934
0.8501
0.8588
1.0234250
Cumberland County, N Carolina
22180
0.9416
0.8945
−5.0034251
Currituck County, N Carolina
47260
0.8799
0.8790
−0.1034270
Dare County, N Carolina
99934
0.8501
0.8588
1.0234280
Davidson County, N Carolina
99934
0.8779
0.8588
−2.1834290
Davie County, N Carolina
49180
0.8981
0.9276
3.2834300
Duplin County, N Carolina
99934
0.8501
0.8588
1.0234310
Durham County, N Carolina
20500
1.0139
0.9826
−3.0934320
Edgecombe County, N Carolina
40580
0.8915
0.8854
−0.6834330
Forsyth County, N Carolina
49180
0.8981
0.9276
3.2834340
Franklin County, N Carolina
39580
0.9863
0.9864
0.0134350
Gaston County, N Carolina
16740
0.9733
0.9554
−1.8434360
Gates County, N Carolina
99934
0.8501
0.8588
1.0234370
Graham County, N Carolina
99934
0.8501
0.8588
1.0234380
Granville County, N Carolina
99934
0.8501
0.8588
1.0234390
Greene County, N Carolina
24780
0.8944
0.9432
5.4634400
Guilford County, N Carolina
24660
0.9061
0.8866
−2.1534410
Halifax County, N Carolina
99934
0.8501
0.8588
1.0234420
Harnett County, N Carolina
99934
0.8501
0.8588
1.0234430
Haywood County, N Carolina
11700
0.8874
0.9216
3.8534440
Henderson County, N Carolina
11700
0.8874
0.9216
3.8534450
Hertford County, N Carolina
99934
0.8501
0.8588
1.0234460
Hoke County, N Carolina
22180
0.8939
0.8945
0.0734470
Hyde County, N Carolina
99934
0.8501
0.8588
1.0234480
Iredell County, N Carolina
99934
0.8501
0.8588
1.0234490
Jackson County, N Carolina
99934
0.8501
0.8588
1.0234500
Johnston County, N Carolina
39580
0.9863
0.9864
0.0134510
Jones County, N Carolina
99934
0.8501
0.8588
1.0234520
Lee County, N Carolina
99934
0.8501
0.8588
1.0234530
Lenoir County, N Carolina
99934
0.8501
0.8588
1.0234540
Lincoln County, N Carolina
99934
0.9128
0.8588
−5.9234550
Mc Dowell County, N Carolina
99934
0.8501
0.8588
1.0234560
Macon County, N Carolina
99934
0.8501
0.8588
1.0234570
Madison County, N Carolina
11700
0.9511
0.9216
−3.1034580
Martin County, N Carolina
99934
0.8501
0.8588
1.0234590
Mecklenburg County, N Carolina
16740
0.9733
0.9554
−1.8434600
Mitchell County, N Carolina
99934
0.8501
0.8588
1.0234610
Montgomery County, N Carolina
99934
0.8501
0.8588
1.0234620
Moore County, N Carolina
99934
0.8501
0.8588
1.0234630
Nash County, N Carolina
40580
0.8915
0.8854
−0.6834640
New Hanover County, N Carolina
48900
0.9582
0.9835
2.6434650
Northampton County, N Carolina
99934
0.8501
0.8588
1.0234660
Onslow County, N Carolina
27340
0.8236
0.8231
−0.0634670
Orange County, N Carolina
20500
1.0139
0.9826
−3.0934680
Pamlico County, N Carolina
99934
0.8501
0.8588
1.0234690
Pasquotank County, N Carolina
99934
0.8501
0.8588
1.0234700
Pender County, N Carolina
48900
0.9022
0.9835
9.0134710
Perquimans County, N Carolina
99934
0.8501
0.8588
1.0234720
Person County, N Carolina
20500
0.9353
0.9826
5.0634730
Pitt County, N Carolina
24780
0.9425
0.9432
0.0734740
Polk County, N Carolina
99934
0.8501
0.8588
1.0234750
Randolph County, N Carolina
24660
0.9061
0.8866
−2.1534760
Richmond County, N Carolina
99934
0.8501
0.8588
1.0234770
Robeson County, N Carolina
99934
0.8501
0.8588
1.0234780
Rockingham County, N Carolina
24660
0.8783
0.8866
0.9534790
Rowan County, N Carolina
99934
0.9128
0.8588
−5.9234800
Rutherford County, N Carolina
99934
0.8501
0.8588
1.0234810
Sampson County, N Carolina
99934
0.8501
0.8588
1.0234820
Scotland County, N Carolina
99934
0.8501
0.8588
1.0234830
Stanly County, N Carolina
99934
0.8501
0.8588
1.0234840
Stokes County, N Carolina
49180
0.8981
0.9276
3.2834850
Surry County, N Carolina
99934
0.8501
0.8588
1.0234860
Swain County, N Carolina
99934
0.8501
0.8588
1.02( print page 65988)34870
Transylvania County, N Carolina
99934
0.8501
0.8588
1.0234880
Tyrrell County, N Carolina
99934
0.8501
0.8588
1.0234890
Union County, N Carolina
16740
0.9733
0.9554
−1.8434900
Vance County, N Carolina
99934
0.8501
0.8588
1.0234910
Wake County, N Carolina
39580
0.9863
0.9864
0.0134920
Warren County, N Carolina
99934
0.8501
0.8588
1.0234930
Washington County, N Carolina
99934
0.8501
0.8588
1.0234940
Watauga County, N Carolina
99934
0.8501
0.8588
1.0234950
Wayne County, N Carolina
24140
0.8775
0.9171
4.5134960
Wilkes County, N Carolina
99934
0.8501
0.8588
1.0234970
Wilson County, N Carolina
99934
0.8501
0.8588
1.0234980
Yadkin County, N Carolina
49180
0.8981
0.9276
3.2834981
Yancey County, N Carolina
99934
0.8501
0.8588
1.0235000
Adams County, N Dakota
99935
0.7261
0.7215
−0.6335010
Barnes County, N Dakota
99935
0.7261
0.7215
−0.6335020
Benson County, N Dakota
99935
0.7261
0.7215
−0.6335030
Billings County, N Dakota
99935
0.7261
0.7215
−0.6335040
Bottineau County, N Dakota
99935
0.7261
0.7215
−0.6335050
Bowman County, N Dakota
99935
0.7261
0.7215
−0.6335060
Burke County, N Dakota
99935
0.7261
0.7215
−0.6335070
Burleigh County, N Dakota
13900
0.7574
0.7240
−4.4135080
Cass County, N Dakota
22020
0.8486
0.8250
−2.7835090
Cavalier County, N Dakota
99935
0.7261
0.7215
−0.6335100
Dickey County, N Dakota
99935
0.7261
0.7215
−0.6335110
Divide County, N Dakota
99935
0.7261
0.7215
−0.6335120
Dunn County, N Dakota
99935
0.7261
0.7215
−0.6335130
Eddy County, N Dakota
99935
0.7261
0.7215
−0.6335140
Emmons County, N Dakota
99935
0.7261
0.7215
−0.6335150
Foster County, N Dakota
99935
0.7261
0.7215
−0.6335160
Golden Valley County, N Dakota
99935
0.7261
0.7215
−0.6335170
Grand Forks County, N Dakota
24220
0.7901
0.7949
0.6135180
Grant County, N Dakota
99935
0.7261
0.7215
−0.6335190
Griggs County, N Dakota
99935
0.7261
0.7215
−0.6335200
Hettinger County, N Dakota
99935
0.7261
0.7215
−0.6335210
Kidder County, N Dakota
99935
0.7261
0.7215
−0.6335220
La Moure County, N Dakota
99935
0.7261
0.7215
−0.6335230
Logan County, N Dakota
99935
0.7261
0.7215
−0.6335240
Mc Henry County, N Dakota
99935
0.7261
0.7215
−0.6335250
Mc Intosh County, N Dakota
99935
0.7261
0.7215
−0.6335260
Mc Kenzie County, N Dakota
99935
0.7261
0.7215
−0.6335270
Mc Lean County, N Dakota
99935
0.7261
0.7215
−0.6335280
Mercer County, N Dakota
99935
0.7261
0.7215
−0.6335290
Morton County, N Dakota
13900
0.7574
0.7240
−4.4135300
Mountrail County, N Dakota
99935
0.7261
0.7215
−0.6335310
Nelson County, N Dakota
99935
0.7261
0.7215
−0.6335320
Oliver County, N Dakota
99935
0.7261
0.7215
−0.6335330
Pembina County, N Dakota
99935
0.7261
0.7215
−0.6335340
Pierce County, N Dakota
99935
0.7261
0.7215
−0.6335350
Ramsey County, N Dakota
99935
0.7261
0.7215
−0.6335360
Ransom County, N Dakota
99935
0.7261
0.7215
−0.6335370
Renville County, N Dakota
99935
0.7261
0.7215
−0.6335380
Richland County, N Dakota
99935
0.7261
0.7215
−0.6335390
Rolette County, N Dakota
99935
0.7261
0.7215
−0.6335400
Sargent County, N Dakota
99935
0.7261
0.7215
−0.6335410
Sheridan County, N Dakota
99935
0.7261
0.7215
−0.6335420
Sioux County, N Dakota
99935
0.7261
0.7215
−0.6335430
Slope County, N Dakota
99935
0.7261
0.7215
−0.6335440
Stark County, N Dakota
99935
0.7261
0.7215
−0.6335450
Steele County, N Dakota
99935
0.7261
0.7215
−0.6335460
Stutsman County, N Dakota
99935
0.7261
0.7215
−0.6335470
Towner County, N Dakota
99935
0.7261
0.7215
−0.6335480
Traill County, N Dakota
99935
0.7261
0.7215
−0.6335490
Walsh County, N Dakota
99935
0.7261
0.7215
−0.6335500
Ward County, N Dakota
99935
0.7261
0.7215
−0.6335510
Wells County, N Dakota
99935
0.7261
0.7215
−0.6335520
Williams County, N Dakota
99935
0.7261
0.7215
−0.6336000
Adams County, Ohio
99936
0.8874
0.8658
−2.4336010
Allen County, Ohio
30620
0.9172
0.9042
−1.42( print page 65989)36020
Ashland County, Ohio
99936
0.8874
0.8658
−2.4336030
Ashtabula County, Ohio
99936
0.9005
0.8658
−3.8536040
Athens County, Ohio
99936
0.8874
0.8658
−2.4336050
Auglaize County, Ohio
99936
0.8973
0.8658
−3.5136060
Belmont County, Ohio
48540
0.7161
0.7010
−2.1136070
Brown County, Ohio
17140
0.9675
0.9601
−0.7636080
Butler County, Ohio
17140
0.9283
0.9601
3.4336090
Carroll County, Ohio
15940
0.8935
0.9031
1.0736100
Champaign County, Ohio
99936
0.8874
0.8658
−2.4336110
Clark County, Ohio
44220
0.8688
0.8593
−1.0936120
Clermont County, Ohio
17140
0.9675
0.9601
−0.7636130
Clinton County, Ohio
99936
0.8874
0.8658
−2.4336140
Columbiana County, Ohio
99936
0.8837
0.8658
−2.0336150
Coshocton County, Ohio
99936
0.8874
0.8658
−2.4336160
Crawford County, Ohio
99936
0.9359
0.8658
−7.4936170
Cuyahoga County, Ohio
17460
0.9198
0.9400
2.2036190
Darke County, Ohio
99936
0.8874
0.8658
−2.4336200
Defiance County, Ohio
99936
0.8874
0.8658
−2.4336210
Delaware County, Ohio
18140
0.9867
1.0107
2.4336220
Erie County, Ohio
41780
0.8970
0.9302
3.7036230
Fairfield County, Ohio
18140
0.9867
1.0107
2.4336240
Fayette County, Ohio
99936
0.8874
0.8658
−2.4336250
Franklin County, Ohio
18140
0.9867
1.0107
2.4336260
Fulton County, Ohio
45780
0.9574
0.9586
0.1336270
Gallia County, Ohio
99936
0.8874
0.8658
−2.4336280
Geauga County, Ohio
17460
0.9198
0.9400
2.2036290
Greene County, Ohio
19380
0.9022
0.9037
0.1736300
Guernsey County, Ohio
99936
0.8874
0.8658
−2.4336310
Hamilton County, Ohio
17140
0.9675
0.9601
−0.7636330
Hancock County, Ohio
99936
0.8874
0.8658
−2.4336340
Hardin County, Ohio
99936
0.8874
0.8658
−2.4336350
Harrison County, Ohio
99936
0.8874
0.8658
−2.4336360
Henry County, Ohio
99936
0.8874
0.8658
−2.4336370
Highland County, Ohio
99936
0.8874
0.8658
−2.4336380
Hocking County, Ohio
99936
0.8874
0.8658
−2.4336390
Holmes County, Ohio
99936
0.8874
0.8658
−2.4336400
Huron County, Ohio
99936
0.8874
0.8658
−2.4336410
Jackson County, Ohio
99936
0.8874
0.8658
−2.4336420
Jefferson County, Ohio
48260
0.7819
0.8063
3.1236430
Knox County, Ohio
99936
0.8874
0.8658
−2.4336440
Lake County, Ohio
17460
0.9198
0.9400
2.2036450
Lawrence County, Ohio
26580
0.9477
0.8997
−5.0636460
Licking County, Ohio
18140
0.9867
1.0107
2.4336470
Logan County, Ohio
99936
0.8874
0.8658
−2.4336480
Lorain County, Ohio
17460
0.9198
0.9400
2.2036490
Lucas County, Ohio
45780
0.9574
0.9586
0.1336500
Madison County, Ohio
18140
0.9867
1.0107
2.4336510
Mahoning County, Ohio
49660
0.8726
0.8802
0.8736520
Marion County, Ohio
99936
0.8874
0.8658
−2.4336530
Medina County, Ohio
17460
0.9198
0.9400
2.2036540
Meigs County, Ohio
99936
0.8874
0.8658
−2.4336550
Mercer County, Ohio
99936
0.8874
0.8658
−2.4336560
Miami County, Ohio
19380
0.9022
0.9037
0.1736570
Monroe County, Ohio
99936
0.8874
0.8658
−2.4336580
Montgomery County, Ohio
19380
0.9022
0.9037
0.1736590
Morgan County, Ohio
99936
0.8874
0.8658
−2.4336600
Morrow County, Ohio
18140
0.9391
1.0107
7.6236610
Muskingum County, Ohio
99936
0.8874
0.8658
−2.4336620
Noble County, Ohio
99936
0.8874
0.8658
−2.4336630
Ottawa County, Ohio
45780
0.9248
0.9586
3.6536640
Paulding County, Ohio
99936
0.8874
0.8658
−2.4336650
Perry County, Ohio
99936
0.8874
0.8658
−2.4336660
Pickaway County, Ohio
18140
0.9867
1.0107
2.4336670
Pike County, Ohio
99936
0.8874
0.8658
−2.4336680
Portage County, Ohio
10420
0.8982
0.8654
−3.6536690
Preble County, Ohio
19380
0.8993
0.9037
0.4936700
Putnam County, Ohio
99936
0.8874
0.8658
−2.4336710
Richland County, Ohio
31900
0.9891
0.9271
−6.27( print page 65990)36720
Ross County, Ohio
99936
0.8874
0.8658
−2.4336730
Sandusky County, Ohio
99936
0.8874
0.8658
−2.4336740
Scioto County, Ohio
99936
0.8874
0.8658
−2.4336750
Seneca County, Ohio
99936
0.8874
0.8658
−2.4336760
Shelby County, Ohio
99936
0.8874
0.8658
−2.4336770
Stark County, Ohio
15940
0.8935
0.9031
1.0736780
Summit County, Ohio
10420
0.8982
0.8654
−3.6536790
Trumbull County, Ohio
49660
0.8726
0.8802
0.8736800
Tuscarawas County, Ohio
99936
0.8874
0.8658
−2.4336810
Union County, Ohio
18140
0.9391
1.0107
7.6236820
Van Wert County, Ohio
99936
0.8874
0.8658
−2.4336830
Vinton County, Ohio
99936
0.8874
0.8658
−2.4336840
Warren County, Ohio
17140
0.9675
0.9601
−0.7636850
Washington County, Ohio
37620
0.8270
0.7977
−3.5436860
Wayne County, Ohio
99936
0.8874
0.8658
−2.4336870
Williams County, Ohio
99936
0.8874
0.8658
−2.4336880
Wood County, Ohio
45780
0.9574
0.9586
0.1336890
Wyandot County, Ohio
99936
0.8874
0.8658
−2.4337000
Adair County, Oklahoma
99937
0.7512
0.7629
1.5637010
Alfalfa County, Oklahoma
99937
0.7512
0.7629
1.5637020
Atoka County, Oklahoma
99937
0.7512
0.7629
1.5637030
Beaver County, Oklahoma
99937
0.7512
0.7629
1.5637040
Beckham County, Oklahoma
99937
0.7512
0.7629
1.5637050
Blaine County, Oklahoma
99937
0.7512
0.7629
1.5637060
Bryan County, Oklahoma
99937
0.7512
0.7629
1.5637070
Caddo County, Oklahoma
99937
0.7512
0.7629
1.5637080
Canadian County, Oklahoma
36420
0.9028
0.8843
−2.0537090
Carter County, Oklahoma
99937
0.7512
0.7629
1.5637100
Cherokee County, Oklahoma
99937
0.7512
0.7629
1.5637110
Choctaw County, Oklahoma
99937
0.7512
0.7629
1.5637120
Cimarron County, Oklahoma
99937
0.7512
0.7629
1.5637130
Cleveland County, Oklahoma
36420
0.9028
0.8843
−2.0537140
Coal County, Oklahoma
99937
0.7512
0.7629
1.5637150
Comanche County, Oklahoma
30020
0.7872
0.8065
2.4537160
Cotton County, Oklahoma
99937
0.7512
0.7629
1.5637170
Craig County, Oklahoma
99937
0.7512
0.7629
1.5637180
Creek County, Oklahoma
46140
0.8565
0.8103
−5.3937190
Custer County, Oklahoma
99937
0.7512
0.7629
1.5637200
Delaware County, Oklahoma
99937
0.7512
0.7629
1.5637210
Dewey County, Oklahoma
99937
0.7512
0.7629
1.5637220
Ellis County, Oklahoma
99937
0.7512
0.7629
1.5637230
Garfield County, Oklahoma
99937
0.8124
0.7629
−6.0937240
Garvin County, Oklahoma
99937
0.7512
0.7629
1.5637250
Grady County, Oklahoma
36420
0.8237
0.8843
7.3637260
Grant County, Oklahoma
99937
0.7512
0.7629
1.5637270
Greer County, Oklahoma
99937
0.7512
0.7629
1.5637280
Harmon County, Oklahoma
99937
0.7512
0.7629
1.5637290
Harper County, Oklahoma
99937
0.7512
0.7629
1.5637300
Haskell County, Oklahoma
99937
0.7512
0.7629
1.5637310
Hughes County, Oklahoma
99937
0.7512
0.7629
1.5637320
Jackson County, Oklahoma
99937
0.7512
0.7629
1.5637330
Jefferson County, Oklahoma
99937
0.7512
0.7629
1.5637340
Johnston County, Oklahoma
99937
0.7512
0.7629
1.5637350
Kay County, Oklahoma
99937
0.7512
0.7629
1.5637360
Kingfisher County, Oklahoma
99937
0.7512
0.7629
1.5637370
Kiowa County, Oklahoma
99937
0.7512
0.7629
1.5637380
Latimer County, Oklahoma
99937
0.7512
0.7629
1.5637390
Le Flore County, Oklahoma
22900
0.7836
0.7731
−1.3437400
Lincoln County, Oklahoma
36420
0.8237
0.8843
7.3637410
Logan County, Oklahoma
36420
0.9028
0.8843
−2.0537420
Love County, Oklahoma
99937
0.7512
0.7629
1.5637430
Mc Clain County, Oklahoma
36420
0.9028
0.8843
−2.0537440
Mc Curtain County, Oklahoma
99937
0.7512
0.7629
1.5637450
Mc Intosh County, Oklahoma
99937
0.7512
0.7629
1.5637460
Major County, Oklahoma
99937
0.7512
0.7629
1.5637470
Marshall County, Oklahoma
99937
0.7512
0.7629
1.5637480
Mayes County, Oklahoma
99937
0.7512
0.7629
1.5637490
Murray County, Oklahoma
99937
0.7512
0.7629
1.56( print page 65991)37500
Muskogee County, Oklahoma
99937
0.7512
0.7629
1.5637510
Noble County, Oklahoma
99937
0.7512
0.7629
1.5637520
Nowata County, Oklahoma
99937
0.7512
0.7629
1.5637530
Okfuskee County, Oklahoma
99937
0.7512
0.7629
1.5637540
Oklahoma County, Oklahoma
36420
0.9028
0.8843
−2.0537550
Okmulgee County, Oklahoma
46140
0.7993
0.8103
1.3837560
Osage County, Oklahoma
46140
0.8565
0.8103
−5.3937570
Ottawa County, Oklahoma
99937
0.7512
0.7629
1.5637580
Pawnee County, Oklahoma
46140
0.7993
0.8103
1.3837590
Payne County, Oklahoma
99937
0.7512
0.7629
1.5637600
Pittsburg County, Oklahoma
99937
0.7512
0.7629
1.5637610
Pontotoc County, Oklahoma
99937
0.7512
0.7629
1.5637620
Pottawatomie County, Oklahoma
99937
0.8303
0.7629
−8.1237630
Pushmataha County, Oklahoma
99937
0.7512
0.7629
1.5637640
Roger Mills County, Oklahoma
99937
0.7512
0.7629
1.5637650
Rogers County, Oklahoma
46140
0.8565
0.8103
−5.3937660
Seminole County, Oklahoma
99937
0.7512
0.7629
1.5637670
Sequoyah County, Oklahoma
22900
0.8238
0.7731
−6.1537680
Stephens County, Oklahoma
99937
0.7512
0.7629
1.5637690
Texas County, Oklahoma
99937
0.7512
0.7629
1.5637700
Tillman County, Oklahoma
99937
0.7512
0.7629
1.5637710
Tulsa County, Oklahoma
46140
0.8565
0.8103
−5.3937720
Wagoner County, Oklahoma
46140
0.8565
0.8103
−5.3937730
Washington County, Oklahoma
99937
0.7512
0.7629
1.5637740
Washita County, Oklahoma
99937
0.7512
0.7629
1.5637750
Woods County, Oklahoma
99937
0.7512
0.7629
1.5637760
Woodward County, Oklahoma
99937
0.7512
0.7629
1.5638000
Baker County, Oregon
99938
0.9939
0.9753
−1.8738010
Benton County, Oregon
18700
1.0729
1.1546
7.6138020
Clackamas County, Oregon
38900
1.1266
1.1416
1.3338030
Clatsop County, Oregon
99938
0.9939
0.9753
−1.8738040
Columbia County, Oregon
38900
1.1266
1.1416
1.3338050
Coos County, Oregon
99938
0.9939
0.9753
−1.8738060
Crook County, Oregon
99938
0.9939
0.9753
−1.8738070
Curry County, Oregon
99938
0.9939
0.9753
−1.8738080
Deschutes County, Oregon
13460
1.0419
1.0743
3.1138090
Douglas County, Oregon
99938
0.9939
0.9753
−1.8738100
Gilliam County, Oregon
99938
0.9939
0.9753
−1.8738110
Grant County, Oregon
99938
0.9939
0.9753
−1.8738120
Harney County, Oregon
99938
0.9939
0.9753
−1.8738130
Hood River County, Oregon
99938
0.9939
0.9753
−1.8738140
Jackson County, Oregon
32780
1.0225
1.0818
5.8038150
Jefferson County, Oregon
99938
0.9939
0.9753
−1.8738160
Josephine County, Oregon
99938
0.9939
0.9753
−1.8738170
Klamath County, Oregon
99938
0.9939
0.9753
−1.8738180
Lake County, Oregon
99938
0.9939
0.9753
−1.8738190
Lane County, Oregon
21660
1.0818
1.0876
0.5438200
Lincoln County, Oregon
99938
0.9939
0.9753
−1.8738210
Linn County, Oregon
99938
0.9939
0.9753
−1.8738220
Malheur County, Oregon
99938
0.9939
0.9753
−1.8738230
Marion County, Oregon
41420
1.0442
1.0438
−0.0438240
Morrow County, Oregon
99938
0.9939
0.9753
−1.8738250
Multnomah County, Oregon
38900
1.1266
1.1416
1.3338260
Polk County, Oregon
41420
1.0442
1.0438
−0.0438270
Sherman County, Oregon
99938
0.9939
0.9753
−1.8738280
Tillamook County, Oregon
99938
0.9939
0.9753
−1.8738290
Umatilla County, Oregon
99938
0.9939
0.9753
−1.8738300
Union County, Oregon
99938
0.9939
0.9753
−1.8738310
Wallowa County, Oregon
99938
0.9939
0.9753
−1.8738320
Wasco County, Oregon
99938
0.9939
0.9753
−1.8738330
Washington County, Oregon
38900
1.1266
1.1416
1.3338340
Wheeler County, Oregon
99938
0.9939
0.9753
−1.8738350
Yamhill County, Oregon
38900
1.1266
1.1416
1.3339000
Adams County, Pennsylvania
99939
0.8305
0.8320
0.1839010
Allegheny County, Pennsylvania
38300
0.8853
0.8674
−2.0239070
Armstrong County, Pennsylvania
38300
0.8582
0.8674
1.0739080
Beaver County, Pennsylvania
38300
0.8853
0.8674
−2.0239100
Bedford County, Pennsylvania
99939
0.8305
0.8320
0.18( print page 65992)39110
Berks County, Pennsylvania
39740
0.9686
0.9622
−0.6639120
Blair County, Pennsylvania
11020
0.8944
0.8812
−1.4839130
Bradford County, Pennsylvania
99939
0.8305
0.8320
0.1839140
Bucks County, Pennsylvania
37964
1.0980
1.0996
0.1539150
Butler County, Pennsylvania
38300
0.8853
0.8674
−2.0239160
Cambria County, Pennsylvania
27780
0.8220
0.8620
4.8739180
Cameron County, Pennsylvania
99939
0.8305
0.8320
0.1839190
Carbon County, Pennsylvania
10900
0.9832
0.9947
1.1739200
Centre County, Pennsylvania
44300
0.8356
0.8784
5.1239210
Chester County, Pennsylvania
37964
1.0980
1.0996
0.1539220
Clarion County, Pennsylvania
99939
0.8305
0.8320
0.1839230
Clearfield County, Pennsylvania
99939
0.8305
0.8320
0.1839240
Clinton County, Pennsylvania
99939
0.8305
0.8320
0.1839250
Columbia County, Pennsylvania
99939
0.8408
0.8320
−1.0539260
Crawford County, Pennsylvania
99939
0.8305
0.8320
0.1839270
Cumberland County, Pennsylvania
25420
0.9273
0.9402
1.3939280
Dauphin County, Pennsylvania
25420
0.9273
0.9402
1.3939290
Delaware County, Pennsylvania
37964
1.0980
1.0996
0.1539310
Elk County, Pennsylvania
99939
0.8305
0.8320
0.1839320
Erie County, Pennsylvania
21500
0.8737
0.8827
1.0339330
Fayette County, Pennsylvania
38300
0.8853
0.8674
−2.0239340
Forest County, Pennsylvania
99939
0.8305
0.8320
0.1839350
Franklin County, Pennsylvania
99939
0.8305
0.8320
0.1839360
Fulton County, Pennsylvania
99939
0.8305
0.8320
0.1839370
Greene County, Pennsylvania
99939
0.8305
0.8320
0.1839380
Huntingdon County, Pennsylvania
99939
0.8305
0.8320
0.1839390
Indiana County, Pennsylvania
99939
0.8305
0.8320
0.1839400
Jefferson County, Pennsylvania
99939
0.8305
0.8320
0.1839410
Juniata County, Pennsylvania
99939
0.8305
0.8320
0.1839420
Lackawanna County, Pennsylvania
42540
0.8532
0.8347
−2.1739440
Lancaster County, Pennsylvania
29540
0.9694
0.9589
−1.0839450
Lawrence County, Pennsylvania
99939
0.8305
0.8320
0.1839460
Lebanon County, Pennsylvania
30140
0.8846
0.8679
−1.8939470
Lehigh County, Pennsylvania
10900
0.9832
0.9947
1.1739480
Luzerne County, Pennsylvania
42540
0.8532
0.8347
−2.1739510
Lycoming County, Pennsylvania
48700
0.8364
0.8139
−2.6939520
Mc Kean County, Pennsylvania
99939
0.8305
0.8320
0.1839530
Mercer County, Pennsylvania
49660
0.8198
0.8802
7.3739540
Mifflin County, Pennsylvania
99939
0.8305
0.8320
0.1839550
Monroe County, Pennsylvania
99939
0.8305
0.8320
0.1839560
Montgomery County, Pennsylvania
37964
1.0980
1.0996
0.1539580
Montour County, Pennsylvania
99939
0.8305
0.8320
0.1890 Nor
thampton County, Pennsylvania
10900
0.9832
0.9947
1.1739600
Northumberland County, Pennsylvania
99939
0.8305
0.8320
0.1839610
Perry County, Pennsylvania
25420
0.9273
0.9402
1.3939620
Philadelphia County, Pennsylvania
37964
1.0980
1.0996
0.1539630
Pike County, Pennsylvania
35084
1.1545
1.1892
3.0139640
Potter County, Pennsylvania
99939
0.8305
0.8320
0.1839650
Schuylkill County, Pennsylvania
99939
0.8305
0.8320
0.1839670
Snyder County, Pennsylvania
99939
0.8305
0.8320
0.1839680
Somerset County, Pennsylvania
99939
0.8189
0.8320
1.6039690
Sullivan County, Pennsylvania
99939
0.8305
0.8320
0.1839700
Susquehanna County, Pennsylvania
99939
0.8305
0.8320
0.1839710
Tioga County, Pennsylvania
99939
0.8305
0.8320
0.1839720
Union County, Pennsylvania
99939
0.8305
0.8320
0.1839730
Venango County, Pennsylvania
99939
0.8305
0.8320
0.1839740
Warren County, Pennsylvania
99939
0.8305
0.8320
0.1839750
Washington County, Pennsylvania
38300
0.8853
0.8674
−2.0239760
Wayne County, Pennsylvania
99939
0.8305
0.8320
0.1839770
Westmoreland County, Pennsylvania
38300
0.8853
0.8674
−2.0239790
Wyoming County, Pennsylvania
42540
0.8532
0.8347
−2.1739800
York County, Pennsylvania
49620
0.9347
0.9397
0.5340010
Adjuntas County, Puerto Rico
99940
0.3826
0.4047
5.7840020
Aguada County, Puerto Rico
10380
0.4807
0.3915
−18.5640030
Aguadilla County, Puerto Rico
10380
0.4807
0.3915
−18.5640040
Aguas Buenas County, Puerto Rico
41980
0.4687
0.4452
−5.0140050
Aibonito County, Puerto Rico
41980
0.4113
0.4452
8.2440060
Anasco County, Puerto Rico
10380
0.4491
0.3915
−12.83( print page 65993)40070
Arecibo County, Puerto Rico
41980
0.4367
0.4452
1.9540080
Arroyo County, Puerto Rico
25020
0.3393
0.3235
−4.6640090
Barceloneta County, Puerto Rico
41980
0.4687
0.4452
−5.0140100
Barranquitas County, Puerto Rico
41980
0.4113
0.4452
8.2440110
Bayamon County, Puerto Rico
41980
0.4687
0.4452
−5.0140120
Cabo Rojo County, Puerto Rico
41900
0.4447
0.4885
9.8540130
Caguas County, Puerto Rico
41980
0.4371
0.4452
1.8540140
Camuy County, Puerto Rico
41980
0.4367
0.4452
1.9540145
Canovanas County, Puerto Rico
41980
0.4687
0.4452
−5.0140150
Carolina County, Puerto Rico
41980
0.4687
0.4452
−5.0140160
Catano County, Puerto Rico
41980
0.4687
0.4452
−5.0140170
Cayey County, Puerto Rico
41980
0.4371
0.4452
1.8540180
Ceiba County, Puerto Rico
21940
0.4453
0.4036
−9.3640190
Ciales County, Puerto Rico
41980
0.4113
0.4452
8.2440200
Cidra County, Puerto Rico
41980
0.4371
0.4452
1.8540210
Coamo County, Puerto Rico
99940
0.3826
0.4047
5.7840220
Comerio County, Puerto Rico
41980
0.4687
0.4452
−5.0140230
Corozal County, Puerto Rico
41980
0.4687
0.4452
−5.0140240
Culebra County, Puerto Rico
99940
0.3826
0.4047
5.7840250
Dorado County, Puerto Rico
41980
0.4687
0.4452
−5.0140260
Fajardo County, Puerto Rico
21940
0.4453
0.4036
−9.3640265
Florida County, Puerto Rico
41980
0.4687
0.4452
−5.0140270
Guanica County, Puerto Rico
49500
0.4006
0.3854
−3.7940280
Guayama County, Puerto Rico
25020
0.3393
0.3235
−4.6640290
Guayanilla County, Puerto Rico
49500
0.4645
0.3854
−17.0340300
Guaynabo County, Puerto Rico
41980
0.4687
0.4452
−5.0140310
Gurabo County, Puerto Rico
41980
0.4371
0.4452
1.8540320
Hatillo County, Puerto Rico
41980
0.4367
0.4452
1.9540330
Hormigueros County, Puerto Rico
32420
0.4132
0.3848
−6.8740340
Humacao County, Puerto Rico
41980
0.4687
0.4452
−5.0140350
Isabela County, Puerto Rico
10380
0.4171
0.3915
−6.1440360
Jayuya County, Puerto Rico
99940
0.3826
0.4047
5.7840370
Juana Diaz County, Puerto Rico
38660
0.4910
0.4842
−1.3840380
Juncos County, Puerto Rico
41980
0.4687
0.4452
−5.0140390
Lajas County, Puerto Rico
41900
0.4127
0.4885
18.3740400
Lares County, Puerto Rico
10380
0.4171
0.3915
−6.1440410
Las Marias County, Puerto Rico
99940
0.3826
0.4047
5.7840420
Las Piedras County, Puerto Rico
41980
0.4687
0.4452
−5.0140430
Loiza County, Puerto Rico
41980
0.4687
0.4452
−5.0140440
Luquillo County, Puerto Rico
21940
0.4453
0.4036
−9.3640450
Manati County, Puerto Rico
41980
0.4687
0.4452
−5.0140460
Maricao County, Puerto Rico
99940
0.3826
0.4047
5.7840470
Maunabo County, Puerto Rico
41980
0.4113
0.4452
8.2440480
Mayaguez County, Puerto Rico
32420
0.4132
0.3848
−6.8740490
Moca County, Puerto Rico
10380
0.4807
0.3915
−18.5640500
Morovis County, Puerto Rico
41980
0.4687
0.4452
−5.0140510
Naguabo County, Puerto Rico
41980
0.4687
0.4452
−5.0140520
Naranjito County, Puerto Rico
41980
0.4687
0.4452
−5.0140530
Orocovis County, Puerto Rico
41980
0.4113
0.4452
8.2440540
Patillas County, Puerto Rico
25020
0.3393
0.3235
−4.6640550
Penuelas County, Puerto Rico
49500
0.4645
0.3854
−17.0340560
Ponce County, Puerto Rico
38660
0.4910
0.4842
−1.3840570
Quebradillas County, Puerto Rico
41980
0.4113
0.4452
8.2440580
Rincon County, Puerto Rico
10380
0.4171
0.3915
−6.1440590
Rio Grande County, Puerto Rico
41980
0.4687
0.4452
−5.0140610
Sabana Grande County, Puerto Rico
41900
0.4447
0.4885
9.8540620
Salinas County, Puerto Rico
99940
0.3826
0.4047
5.7840630
San German County, Puerto Rico
41900
0.4447
0.4885
9.8540640
San Juan County, Puerto Rico
41980
0.4687
0.4452
−5.0140650
San Lorenzo County, Puerto Rico
41980
0.4371
0.4452
1.8540660
San Sebastian County, Puerto Rico
10380
0.4171
0.3915
−6.1440670
Santa Isabel County, Puerto Rico
99940
0.3826
0.4047
5.7840680
Toa Alta County, Puerto Rico
41980
0.4687
0.4452
−5.0140690
Toa Baja County, Puerto Rico
41980
0.4687
0.4452
−5.0140700
Trujillo Alto County, Puerto Rico
41980
0.4687
0.4452
−5.0140710
Utuado County, Puerto Rico
99940
0.3826
0.4047
5.7840720
Vega Alta County, Puerto Rico
41980
0.4687
0.4452
−5.0140730
Vega Baja County, Puerto Rico
41980
0.4687
0.4452
−5.01( print page 65994)40740
Vieques County, Puerto Rico
99940
0.3826
0.4047
5.7840750
Villalba County, Puerto Rico
38660
0.4910
0.4842
−1.3840760
Yabucoa County, Puerto Rico
41980
0.4687
0.4452
−5.0140770
Yauco County, Puerto Rico
49500
0.4645
0.3854
−17.0341000
Bristol County, Rhode Island
39300
1.1012
1.0783
−2.0841010
Kent County, Rhode Island
39300
1.1012
1.0783
−2.0841020
Newport County, Rhode Island
39300
1.1012
1.0783
−2.0841030
Providence County, Rhode Island
39300
1.1012
1.0783
−2.0841050
Washington County, Rhode Island
39300
1.1012
1.0783
−2.0842000
Abbeville County, S Carolina
99942
0.8635
0.8566
−0.8042010
Aiken County, S Carolina
12260
0.9778
0.9667
−1.1442020
Allendale County, S Carolina
99942
0.8635
0.8566
−0.8042030
Anderson County, S Carolina
11340
0.9306
0.9017
−3.1142040
Bamberg County, S Carolina
99942
0.8635
0.8566
−0.8042050
Barnwell County, S Carolina
99942
0.8635
0.8566
−0.8042060
Beaufort County, S Carolina
99942
0.8635
0.8566
−0.8042070
Berkeley County, S Carolina
16700
0.9245
0.9145
−1.0842080
Calhoun County, S Carolina
17900
0.8844
0.8933
1.0142090
Charleston County, S Carolina
16700
0.9245
0.9145
−1.0842100
Cherokee County, S Carolina
99942
0.9127
0.8566
−6.1542110
Chester County, S Carolina
99942
0.8635
0.8566
−0.8042120
Chesterfield County, S Carolina
99942
0.8635
0.8566
−0.8042130
Clarendon County, S Carolina
99942
0.8635
0.8566
−0.8042140
Colleton County, S Carolina
99942
0.8635
0.8566
−0.8042150
Darlington County, S Carolina
22500
0.8789
0.8388
−4.5642160
Dillon County, S Carolina
99942
0.8635
0.8566
−0.8042170
Dorchester County, S Carolina
16700
0.9245
0.9145
−1.0842180
Edgefield County, S Carolina
12260
0.9778
0.9667
−1.1442190
Fairfield County, S Carolina
17900
0.8844
0.8933
1.0142200
Florence County, S Carolina
22500
0.8995
0.8388
−6.7542210
Georgetown County, S Carolina
99942
0.8635
0.8566
−0.8042220
Greenville County, S Carolina
24860
0.9821
0.9804
−0.1742230
Greenwood County, S Carolina
99942
0.8635
0.8566
−0.8042240
Hampton County, S Carolina
99942
0.8635
0.8566
−0.8042250
Horry County, S Carolina
34820
0.8934
0.8810
−1.3942260
Jasper County, S Carolina
99942
0.8635
0.8566
−0.8042270
Kershaw County, S Carolina
17900
0.8844
0.8933
1.0142280
Lancaster County, S Carolina
99942
0.8635
0.8566
−0.8042290
Laurens County, S Carolina
24860
0.9329
0.9804
5.0942300
Lee County, S Carolina
99942
0.8635
0.8566
−0.8042310
Lexington County, S Carolina
17900
0.9070
0.8933
−1.5142320
Mc Cormick County, S Carolina
99942
0.8635
0.8566
−0.8042330
Marion County, S Carolina
99942
0.8635
0.8566
−0.8042340
Marlboro County, S Carolina
99942
0.8635
0.8566
−0.8042350
Newberry County, S Carolina
99942
0.8635
0.8566
−0.8042360
Oconee County, S Carolina
99942
0.8635
0.8566
−0.8042370
Orangeburg County, S Carolina
99942
0.8635
0.8566
−0.8042380
Pickens County, S Carolina
24860
0.9821
0.9804
−0.1742390
Richland County, S Carolina
17900
0.9070
0.8933
−1.5142400
Saluda County, S Carolina
17900
0.8844
0.8933
1.0142410
Spartanburg County, S Carolina
43900
0.9394
0.9174
−2.3442420
Sumter County, S Carolina
44940
0.8377
0.8083
−3.5142430
Union County, S Carolina
99942
0.8635
0.8566
−0.8042440
Williamsburg County, S Carolina
99942
0.8635
0.8566
−0.8042450
York County, S Carolina
16740
0.9733
0.9554
−1.8443010
Aurora County, S Dakota
99943
0.8556
0.8480
−0.8943020
Beadle County, S Dakota
99943
0.8556
0.8480
−0.8943030
Bennett County, S Dakota
99943
0.8556
0.8480
−0.8943040
Bon Homme County, S Dakota
99943
0.8556
0.8480
−0.8943050
Brookings County, S Dakota
99943
0.8556
0.8480
−0.8943060
Brown County, S Dakota
99943
0.8556
0.8480
−0.8943070
Brule County, S Dakota
99943
0.8556
0.8480
−0.8943080
Buffalo County, S Dakota
99943
0.8556
0.8480
−0.8943090
Butte County, S Dakota
99943
0.8556
0.8480
−0.8943100
Campbell County, S Dakota
99943
0.8556
0.8480
−0.8943110
Charles Mix County, S Dakota
99943
0.8556
0.8480
−0.8943120
Clark County, S Dakota
99943
0.8556
0.8480
−0.8943130
Clay County, S Dakota
99943
0.8556
0.8480
−0.89( print page 65995)43140
Codington County, S Dakota
99943
0.8556
0.8480
−0.8943150
Corson County, S Dakota
99943
0.8556
0.8480
−0.8943160
Custer County, S Dakota
99943
0.8556
0.8480
−0.8943170
Davison County, S Dakota
99943
0.8556
0.8480
−0.8943180
Day County, S Dakota
99943
0.8556
0.8480
−0.8943190
Deuel County, S Dakota
99943
0.8556
0.8480
−0.8943200
Dewey County, S Dakota
99943
0.8556
0.8480
−0.8943210
Douglas County, S Dakota
99943
0.8556
0.8480
−0.8943220
Edmunds County, S Dakota
99943
0.8556
0.8480
−0.8943230
Fall River County, S Dakota
99943
0.8556
0.8480
−0.8943240
Faulk County, S Dakota
99943
0.8556
0.8480
−0.8943250
Grant County, S Dakota
99943
0.8556
0.8480
−0.8943260
Gregory County, S Dakota
99943
0.8556
0.8480
−0.8943270
Haakon County, S Dakota
99943
0.8556
0.8480
−0.8943280
Hamlin County, S Dakota
99943
0.8556
0.8480
−0.8943290
Hand County, S Dakota
99943
0.8556
0.8480
−0.8943300
Hanson County, S Dakota
99943
0.8556
0.8480
−0.8943310
Harding County, S Dakota
99943
0.8556
0.8480
−0.8943320
Hughes County, S Dakota
99943
0.8556
0.8480
−0.8943330
Hutchinson County, S Dakota
99943
0.8556
0.8480
−0.8943340
Hyde County, S Dakota
99943
0.8556
0.8480
−0.8943350
Jackson County, S Dakota
99943
0.8556
0.8480
−0.8943360
Jerauld County, S Dakota
99943
0.8556
0.8480
−0.8943370
Jones County, S Dakota
99943
0.8556
0.8480
−0.8943380
Kingsbury County, S Dakota
99943
0.8556
0.8480
−0.8943390
Lake County, S Dakota
99943
0.8556
0.8480
−0.8943400
Lawrence County, S Dakota
99943
0.8556
0.8480
−0.8943410
Lincoln County, S Dakota
43620
0.9635
0.9559
−0.7943420
Lyman County, S Dakota
99943
0.8556
0.8480
−0.8943430
Mc Cook County, S Dakota
43620
0.9093
0.9559
5.1243440
Mc Pherson County, S Dakota
99943
0.8556
0.8480
−0.8943450
Marshall County, S Dakota
99943
0.8556
0.8480
−0.8943460
Meade County, S Dakota
39660
0.8769
0.8833
0.7343470
Mellette County, S Dakota
99943
0.8556
0.8480
−0.8943480
Miner County, S Dakota
99943
0.8556
0.8480
−0.8943490
Minnehaha County, S Dakota
43620
0.9635
0.9559
−0.7943500
Moody County, S Dakota
99943
0.8556
0.8480
−0.8943510
Pennington County, S Dakota
39660
0.8987
0.8833
−1.7143520
Perkins County, S Dakota
99943
0.8556
0.8480
−0.8943530
Potter County, S Dakota
99943
0.8556
0.8480
−0.8943540
Roberts County, S Dakota
99943
0.8556
0.8480
−0.8943550
Sanborn County, S Dakota
99943
0.8556
0.8480
−0.8943560
Shannon County, S Dakota
99943
0.8556
0.8480
−0.8943570
Spink County, S Dakota
99943
0.8556
0.8480
−0.8943580
Stanley County, S Dakota
99943
0.8556
0.8480
−0.8943590
Sully County, S Dakota
99943
0.8556
0.8480
−0.8943600
Todd County, S Dakota
99943
0.8556
0.8480
−0.8943610
Tripp County, S Dakota
99943
0.8556
0.8480
−0.8943620
Turner County, S Dakota
43620
0.9093
0.9559
5.1243630
Union County, S Dakota
43580
0.8966
0.9200
2.6143640
Walworth County, S Dakota
99943
0.8556
0.8480
−0.8943650
Washabaugh County, S Dakota
99943
0.8556
0.8480
−0.8943670
Yankton County, S Dakota
99943
0.8556
0.8480
−0.8943680
Ziebach County, S Dakota
99943
0.8556
0.8480
−0.8944000
Anderson County, Tennessee
28940
0.8419
0.8249
−2.0244010
Bedford County, Tennessee
99944
0.7915
0.7827
−1.1144020
Benton County, Tennessee
99944
0.7915
0.7827
−1.1144030
Bledsoe County, Tennessee
99944
0.7915
0.7827
−1.1144040
Blount County, Tennessee
28940
0.8419
0.8249
−2.0244050
Bradley County, Tennessee
17420
0.8037
0.8109
0.9044060
Campbell County, Tennessee
99944
0.7915
0.7827
−1.1144070
Cannon County, Tennessee
34980
0.8838
0.9847
11.4244080
Carroll County, Tennessee
99944
0.7915
0.7827
−1.1144090
Carter County, Tennessee
27740
0.7972
0.8043
0.8944100
Cheatham County, Tennessee
34980
0.9751
0.9847
0.9844110
Chester County, Tennessee
27180
0.8964
0.8853
−1.2444120
Claiborne County, Tennessee
99944
0.7915
0.7827
−1.1144130
Clay County, Tennessee
99944
0.7915
0.7827
−1.11( print page 65996)44140
Cocke County, Tennessee
99944
0.7915
0.7827
−1.1144150
Coffee County, Tennessee
99944
0.7915
0.7827
−1.1144160
Crockett County, Tennessee
99944
0.7915
0.7827
−1.1144170
Cumberland County, Tennessee
99944
0.7915
0.7827
−1.1144180
Davidson County, Tennessee
34980
0.9751
0.9847
0.9844190
Decatur County, Tennessee
99944
0.7915
0.7827
−1.1144200
De Kalb County, Tennessee
99944
0.7915
0.7827
−1.1144210
Dickson County, Tennessee
34980
0.9751
0.9847
0.9844220
Dyer County, Tennessee
99944
0.7915
0.7827
−1.1144230
Fayette County, Tennessee
32820
0.9407
0.9373
−0.3644240
Fentress County, Tennessee
99944
0.7915
0.7827
−1.1144250
Franklin County, Tennessee
99944
0.7915
0.7827
−1.1144260
Gibson County, Tennessee
99944
0.7915
0.7827
−1.1144270
Giles County, Tennessee
99944
0.7915
0.7827
−1.1144280
Grainger County, Tennessee
34100
0.7948
0.7933
−0.1944290
Greene County, Tennessee
99944
0.7915
0.7827
−1.1144300
Grundy County, Tennessee
99944
0.7915
0.7827
−1.1144310
Hamblen County, Tennessee
34100
0.7948
0.7933
−0.1944320
Hamilton County, Tennessee
16860
0.9088
0.8948
−1.5444330
Hancock County, Tennessee
99944
0.7915
0.7827
−1.1144340
Hardeman County, Tennessee
99944
0.7915
0.7827
−1.1144350
Hardin County, Tennessee
99944
0.7915
0.7827
−1.1144360
Hawkins County, Tennessee
28700
0.8031
0.7985
−0.5744370
Haywood County, Tennessee
99944
0.7915
0.7827
−1.1144380
Henderson County, Tennessee
99944
0.7915
0.7827
−1.1144390
Henry County, Tennessee
99944
0.7915
0.7827
−1.1144400
Hickman County, Tennessee
34980
0.8838
0.9847
11.4244410
Houston County, Tennessee
99944
0.7915
0.7827
−1.1144420
Humphreys County, Tennessee
99944
0.7915
0.7827
−1.1144430
Jackson County, Tennessee
99944
0.7915
0.7827
−1.1144440
Jefferson County, Tennessee
34100
0.7948
0.7933
−0.1944450
Johnson County, Tennessee
99944
0.7915
0.7827
−1.1144460
Knox County, Tennessee
28940
0.8419
0.8249
−2.0244470
Lake County, Tennessee
99944
0.7915
0.7827
−1.1144480
Lauderdale County, Tennessee
99944
0.7915
0.7827
−1.1144490
Lawrence County, Tennessee
99944
0.7915
0.7827
−1.1144500
Lewis County, Tennessee
99944
0.7915
0.7827
−1.1144510
Lincoln County, Tennessee
99944
0.7915
0.7827
−1.1144520
Loudon County, Tennessee
28940
0.8419
0.8249
−2.0244530
Mc Minn County, Tennessee
99944
0.7915
0.7827
−1.1144540
Mc Nairy County, Tennessee
99944
0.7915
0.7827
−1.1144550
Macon County, Tennessee
34980
0.8838
0.9847
11.4244560
Madison County, Tennessee
27180
0.8964
0.8853
−1.2444570
Marion County, Tennessee
16860
0.9088
0.8948
−1.5444580
Marshall County, Tennessee
99944
0.7915
0.7827
−1.1144590
Maury County, Tennessee
99944
0.7915
0.7827
−1.1144600
Meigs County, Tennessee
99944
0.7915
0.7827
−1.1144610
Monroe County, Tennessee
99944
0.7915
0.7827
−1.1144620
Montgomery County, Tennessee
17300
0.8284
0.8436
1.8344630
Moore County, Tennessee
99944
0.7915
0.7827
−1.1144640
Morgan County, Tennessee
99944
0.7915
0.7827
−1.1144650
Obion County, Tennessee
99944
0.7915
0.7827
−1.1144660
Overton County, Tennessee
99944
0.7915
0.7827
−1.1144670
Perry County, Tennessee
99944
0.7915
0.7827
−1.1144680
Pickett County, Tennessee
99944
0.7915
0.7827
−1.1144690
Polk County, Tennessee
17420
0.8037
0.8109
0.9044700
Putnam County, Tennessee
99944
0.7915
0.7827
−1.1144710
Rhea County, Tennessee
99944
0.7915
0.7827
−1.1144720
Roane County, Tennessee
99944
0.7915
0.7827
−1.1144730
Robertson County, Tennessee
34980
0.9751
0.9847
0.9844740
Rutherford County, Tennessee
34980
0.9751
0.9847
0.9844750
Scott County, Tennessee
99944
0.7915
0.7827
−1.1144760
Sequatchie County, Tennessee
16860
0.8512
0.8948
5.1244770
Sevier County, Tennessee
99944
0.8146
0.7827
−3.9244780
Shelby County, Tennessee
32820
0.9407
0.9373
−0.3644790
Smith County, Tennessee
34980
0.8838
0.9847
11.4244800
Stewart County, Tennessee
17300
0.8110
0.8436
4.0244810
Sullivan County, Tennessee
28700
0.8031
0.7985
−0.57( print page 65997)44820
Sumner County, Tennessee
34980
0.9751
0.9847
0.9844830
Tipton County, Tennessee
32820
0.9407
0.9373
−0.3644840
Trousdale County, Tennessee
34980
0.8838
0.9847
11.4244850
Unicoi County, Tennessee
27740
0.7972
0.8043
0.8944860
Union County, Tennessee
28940
0.8419
0.8249
−2.0244870
Van Buren County, Tennessee
99944
0.7915
0.7827
−1.1144880
Warren County, Tennessee
99944
0.7915
0.7827
−1.1144890
Washington County, Tennessee
27740
0.7972
0.8043
0.8944900
Wayne County, Tennessee
99944
0.7915
0.7827
−1.1144910
Weakley County, Tennessee
99944
0.7915
0.7827
−1.1144920
White County, Tennessee
99944
0.7915
0.7827
−1.1144930
Williamson County, Tennessee
34980
0.9751
0.9847
0.9844940
Wilson County, Tennessee
34980
0.9751
0.9847
0.9845000
Anderson County, Texas
99945
0.7967
0.7965
−0.0345010
Andrews County, Texas
99945
0.7967
0.7965
−0.0345020
Angelina County, Texas
99945
0.7967
0.7965
−0.0345030
Aransas County, Texas
18580
0.8241
0.8564
3.9245040
Archer County, Texas
48660
0.8325
0.8311
−0.1745050
Armstrong County, Texas
11100
0.8544
0.9169
7.3245060
Atascosa County, Texas
41700
0.8456
0.8844
4.5945070
Austin County, Texas
26420
0.8962
1.0008
11.6745080
Bailey County, Texas
99945
0.7967
0.7965
−0.0345090
Bandera County, Texas
41700
0.8456
0.8844
4.5945100
Bastrop County, Texas
12420
0.9437
0.9344
−0.9945110
Baylor County, Texas
99945
0.7967
0.7965
−0.0345113
Bee County, Texas
99945
0.7967
0.7965
−0.0345120
Bell County, Texas
28660
0.8526
0.8901
4.4045130
Bexar County, Texas
41700
0.8982
0.8844
−1.5445140
Blanco County, Texas
99945
0.7967
0.7965
−0.0345150
Borden County, Texas
99945
0.7967
0.7965
−0.0345160
Bosque County, Texas
99945
0.7967
0.7965
−0.0345170
Bowie County, Texas
45500
0.8283
0.8104
−2.1645180
Brazoria County, Texas
26420
0.9278
1.0008
7.8745190
Brazos County, Texas
17780
0.8900
0.9045
1.6345200
Brewster County, Texas
99945
0.7967
0.7965
−0.0345201
Briscoe County, Texas
99945
0.7967
0.7965
−0.0345210
Brooks County, Texas
99945
0.7967
0.7965
−0.0345220
Brown County, Texas
99945
0.7967
0.7965
−0.0345221
Burleson County, Texas
17780
0.8416
0.9045
7.4745222
Burnet County, Texas
99945
0.7967
0.7965
−0.0345223
Caldwell County, Texas
12420
0.9437
0.9344
−0.9945224
Calhoun County, Texas
47020
0.8046
0.8560
6.3945230
Callahan County, Texas
10180
0.7914
0.8000
1.0945240
Cameron County, Texas
15180
0.9804
0.9430
−3.8145250
Camp County, Texas
99945
0.7967
0.7965
−0.0345251
Carson County, Texas
11100
0.8544
0.9169
7.3245260
Cass County, Texas
99945
0.7967
0.7965
−0.0345270
Castro County, Texas
99945
0.7967
0.7965
−0.0345280
Chambers County, Texas
26420
1.0040
1.0008
−0.3245281
Cherokee County, Texas
99945
0.7967
0.7965
−0.0345290
Childress County, Texas
99945
0.7967
0.7965
−0.0345291
Clay County, Texas
48660
0.8108
0.8311
2.5045292
Cochran County, Texas
99945
0.7967
0.7965
−0.0345300
Coke County, Texas
99945
0.7967
0.7965
−0.0345301
Coleman County, Texas
99945
0.7967
0.7965
−0.0345310
Collin County, Texas
19124
1.0217
1.0075
−1.3945311
Collingsworth County, Texas
99945
0.7967
0.7965
−0.0345312
Colorado County, Texas
99945
0.7967
0.7965
−0.0345320
Comal County, Texas
41700
0.8982
0.8844
−1.5445321
Comanche County, Texas
99945
0.7967
0.7965
−0.0345330
Concho County, Texas
99945
0.7967
0.7965
−0.0345340
Cooke County, Texas
99945
0.7967
0.7965
−0.0345341
Coryell County, Texas
28660
0.8526
0.8901
4.4045350
Cottle County, Texas
99945
0.7967
0.7965
−0.0345360
Crane County, Texas
99945
0.7967
0.7965
−0.0345361
Crockett County, Texas
99945
0.7967
0.7965
−0.0345362
Crosby County, Texas
31180
0.8357
0.8613
3.0645370
Culberson County, Texas
99945
0.7967
0.7965
−0.03( print page 65998)45380
Dallam County, Texas
99945
0.7967
0.7965
−0.0345390
Dallas County, Texas
19124
1.0217
1.0075
−1.3945391
Dawson County, Texas
99945
0.7967
0.7965
−0.0345392
Deaf Smith County, Texas
99945
0.7967
0.7965
−0.0345400
Delta County, Texas
19124
0.9080
1.0075
10.9645410
Denton County, Texas
19124
1.0217
1.0075
−1.3945420
De Witt County, Texas
99945
0.7967
0.7965
−0.0345421
Dickens County, Texas
99945
0.7967
0.7965
−0.0345430
Dimmit County, Texas
99945
0.7967
0.7965
−0.0345431
Donley County, Texas
99945
0.7967
0.7965
−0.0345440
Duval County, Texas
99945
0.7967
0.7965
−0.0345450
Eastland County, Texas
99945
0.7967
0.7965
−0.0345451
Ector County, Texas
36220
0.9813
1.0073
2.6545460
Edwards County, Texas
99945
0.7967
0.7965
−0.0345470
Ellis County, Texas
19124
1.0217
1.0075
−1.3945480
El Paso County, Texas
21340
0.8977
0.9053
0.8545490
Erath County, Texas
99945
0.7967
0.7965
−0.0345500
Falls County, Texas
99945
0.7967
0.7965
−0.0345510
Fannin County, Texas
99945
0.7967
0.7965
−0.0345511
Fayette County, Texas
99945
0.7967
0.7965
−0.0345520
Fisher County, Texas
99945
0.7967
0.7965
−0.0345521
Floyd County, Texas
99945
0.7967
0.7965
−0.0345522
Foard County, Texas
99945
0.7967
0.7965
−0.0345530
Fort Bend County, Texas
26420
1.0040
1.0008
−0.3245531
Franklin County, Texas
99945
0.7967
0.7965
−0.0345540
Freestone County, Texas
99945
0.7967
0.7965
−0.0345541
Frio County, Texas
99945
0.7967
0.7965
−0.0345542
Gaines County, Texas
99945
0.7967
0.7965
−0.0345550
Galveston County, Texas
26420
0.9814
1.0008
1.9845551
Garza County, Texas
99945
0.7967
0.7965
−0.0345552
Gillespie County, Texas
99945
0.7967
0.7965
−0.0345560
Glasscock County, Texas
99945
0.7967
0.7965
−0.0345561
Goliad County, Texas
47020
0.8046
0.8560
6.3945562
Gonzales County, Texas
99945
0.7967
0.7965
−0.0345563
Gray County, Texas
99945
0.7967
0.7965
−0.0345564
Grayson County, Texas
43300
0.9507
0.8502
−10.5745570
Gregg County, Texas
30980
0.8809
0.8788
−0.2445580
Grimes County, Texas
99945
0.7967
0.7965
−0.0345581
Guadaloupe County, Texas
41700
0.8982
0.8844
−1.5445582
Hale County, Texas
99945
0.7967
0.7965
−0.0345583
Hall County, Texas
99945
0.7967
0.7965
−0.0345590
Hamilton County, Texas
99945
0.7967
0.7965
−0.0345591
Hansford County, Texas
99945
0.7967
0.7965
−0.0345592
Hardeman County, Texas
99945
0.7967
0.7965
−0.0345600
Hardin County, Texas
13140
0.8412
0.8595
2.1845610
Harris County, Texas
26420
1.0040
1.0008
−0.3245620
Harrison County, Texas
99945
0.8446
0.7965
−5.7045621
Hartley County, Texas
99945
0.7967
0.7965
−0.0345630
Haskell County, Texas
99945
0.7967
0.7965
−0.0345631
Hays County, Texas
12420
0.9437
0.9344
−0.9945632
Hemphill County, Texas
99945
0.7967
0.7965
−0.0345640
Henderson County, Texas
99945
0.9104
0.7965
−12.5145650
Hidalgo County, Texas
32580
0.8934
0.8773
−1.8045651
Hill County, Texas
99945
0.7967
0.7965
−0.0345652
Hockley County, Texas
99945
0.7967
0.7965
−0.0345653
Hood County, Texas
99945
0.8763
0.7965
−9.1145654
Hopkins County, Texas
99945
0.7967
0.7965
−0.0345660
Houston County, Texas
99945
0.7967
0.7965
−0.0345661
Howard County, Texas
99945
0.7967
0.7965
−0.0345662
Hudspeth County, Texas
99945
0.7967
0.7965
−0.0345670
Hunt County, Texas
19124
1.0217
1.0075
−1.3945671
Hutchinson County, Texas
99945
0.7967
0.7965
−0.0345672
Irion County, Texas
41660
0.8101
0.8362
3.2245680
Jack County, Texas
99945
0.7967
0.7965
−0.0345681
Jackson County, Texas
99945
0.7967
0.7965
−0.0345690
Jasper County, Texas
99945
0.7967
0.7965
−0.0345691
Jeff Davis County, Texas
99945
0.7967
0.7965
−0.0345700
Jefferson County, Texas
13140
0.8412
0.8595
2.18( print page 65999)45710
Jim Hogg County, Texas
99945
0.7967
0.7965
−0.0345711
Jim Wells County, Texas
99945
0.7967
0.7965
−0.0345720
Johnson County, Texas
23104
0.9504
0.9569
0.6845721
Jones County, Texas
10180
0.7914
0.8000
1.0945722
Karnes County, Texas
99945
0.7967
0.7965
−0.0345730
Kaufman County, Texas
19124
1.0217
1.0075
−1.3945731
Kendall County, Texas
41700
0.8456
0.8844
4.5945732
Kenedy County, Texas
99945
0.7967
0.7965
−0.0345733
Kent County, Texas
99945
0.7967
0.7965
−0.0345734
Kerr County, Texas
99945
0.7967
0.7965
−0.0345740
Kimble County, Texas
99945
0.7967
0.7965
−0.0345741
King County, Texas
99945
0.7967
0.7965
−0.0345742
Kinney County, Texas
99945
0.7967
0.7965
−0.0345743
Kleberg County, Texas
99945
0.7967
0.7965
−0.0345744
Knox County, Texas
99945
0.7967
0.7965
−0.0345750
Lamar County, Texas
99945
0.7967
0.7965
−0.0345751
Lamb County, Texas
99945
0.7967
0.7965
−0.0345752
Lampasas County, Texas
28660
0.8229
0.8901
8.1745753
La Salle County, Texas
99945
0.7967
0.7965
−0.0345754
Lavaca County, Texas
99945
0.7967
0.7965
−0.0345755
Lee County, Texas
99945
0.7967
0.7965
−0.0345756
Leon County, Texas
99945
0.7967
0.7965
−0.0345757
Liberty County, Texas
26420
1.0040
1.0008
−0.3245758
Limestone County, Texas
99945
0.7967
0.7965
−0.0345759
Lipscomb County, Texas
99945
0.7967
0.7965
−0.0345760
Live Oak County, Texas
99945
0.7967
0.7965
−0.0345761
Llano County, Texas
99945
0.7967
0.7965
−0.0345762
Loving County, Texas
99945
0.7967
0.7965
−0.0345770
Lubbock County, Texas
31180
0.8783
0.8613
−1.9445771
Lynn County, Texas
99945
0.7967
0.7965
−0.0345772
Mc Culloch County, Texas
99945
0.7967
0.7965
−0.0345780
Mc Lennan County, Texas
47380
0.8518
0.8633
1.3545781
Mc Mullen County, Texas
99945
0.7967
0.7965
−0.0345782
Madison County, Texas
99945
0.7967
0.7965
−0.0345783
Marion County, Texas
99945
0.7967
0.7965
−0.0345784
Martin County, Texas
99945
0.7967
0.7965
−0.0345785
Mason County, Texas
99945
0.7967
0.7965
−0.0345790
Matagorda County, Texas
99945
0.7967
0.7965
−0.0345791
Maverick County, Texas
99945
0.7967
0.7965
−0.0345792
Medina County, Texas
41700
0.8456
0.8844
4.5945793
Menard County, Texas
99945
0.7967
0.7965
−0.0345794
Midland County, Texas
33260
0.9628
0.9786
1.6445795
Milam County, Texas
99945
0.7967
0.7965
−0.0345796
Mills County, Texas
99945
0.7967
0.7965
−0.0345797
Mitchell County, Texas
99945
0.7967
0.7965
−0.0345800
Montague County, Texas
99945
0.7967
0.7965
−0.0345801
Montgomery County, Texas
26420
1.0040
1.0008
−0.3245802
Moore County, Texas
99945
0.7967
0.7965
−0.0345803
Morris County, Texas
99945
0.7967
0.7965
−0.0345804
Motley County, Texas
99945
0.7967
0.7965
−0.0345810
Nacogdoches County, Texas
99945
0.7967
0.7965
−0.0345820
Navarro County, Texas
99945
0.7967
0.7965
−0.0345821
Newton County, Texas
99945
0.7967
0.7965
−0.0345822
Nolan County, Texas
99945
0.7967
0.7965
−0.0345830
Nueces County, Texas
18580
0.8550
0.8564
0.1645831
Ochiltree County, Texas
99945
0.7967
0.7965
−0.0345832
Oldham County, Texas
99945
0.7967
0.7965
−0.0345840
Orange County, Texas
13140
0.8412
0.8595
2.1845841
Palo Pinto County, Texas
99945
0.7967
0.7965
−0.0345842
Panola County, Texas
99945
0.7967
0.7965
−0.0345843
Parker County, Texas
23104
0.9504
0.9569
0.6845844
Parmer County, Texas
99945
0.7967
0.7965
−0.0345845
Pecos County, Texas
99945
0.7967
0.7965
−0.0345850
Polk County, Texas
99945
0.7967
0.7965
−0.0345860
Potter County, Texas
11100
0.9156
0.9169
0.1445861
Presidio County, Texas
99945
0.7967
0.7965
−0.0345870
Rains County, Texas
99945
0.7967
0.7965
−0.0345871
Randall County, Texas
11100
0.9156
0.9169
0.14( print page 66000)45872
Reagan County, Texas
99945
0.7967
0.7965
−0.0345873
Real County, Texas
99945
0.7967
0.7965
−0.0345874
Red River County, Texas
99945
0.7967
0.7965
−0.0345875
Reeves County, Texas
99945
0.7967
0.7965
−0.0345876
Refugio County, Texas
99945
0.7967
0.7965
−0.0345877
Roberts County, Texas
99945
0.7967
0.7965
−0.0345878
Robertson County, Texas
17780
0.8416
0.9045
7.4745879
Rockwall County, Texas
19124
1.0217
1.0075
−1.3945880
Runnels County, Texas
99945
0.7967
0.7965
−0.0345881
Rusk County, Texas
30980
0.8331
0.8788
5.4945882
Sabine County, Texas
99945
0.7967
0.7965
−0.0345883
San Augustine County, Texas
99945
0.7967
0.7965
−0.0345884
San Jacinto County, Texas
26420
0.8962
1.0008
11.6745885
San Patricio County, Texas
18580
0.8550
0.8564
0.1645886
San Saba County, Texas
99945
0.7967
0.7965
−0.0345887
Schleicher County, Texas
99945
0.7967
0.7965
−0.0345888
Scurry County, Texas
99945
0.7967
0.7965
−0.0345889
Shackelford County, Texas
99945
0.7967
0.7965
−0.0345890
Shelby County, Texas
99945
0.7967
0.7965
−0.0345891
Sherman County, Texas
99945
0.7967
0.7965
−0.0345892
Smith County, Texas
46340
0.9168
0.8811
−3.8945893
Somervell County, Texas
99945
0.7967
0.7965
−0.0345900
Starr County, Texas
99945
0.7967
0.7965
−0.0345901
Stephens County, Texas
99945
0.7967
0.7965
−0.0345902
Sterling County, Texas
99945
0.7967
0.7965
−0.0345903
Stonewall County, Texas
99945
0.7967
0.7965
−0.0345904
Sutton County, Texas
99945
0.7967
0.7965
−0.0345905
Swisher County, Texas
99945
0.7967
0.7965
−0.0345910
Tarrant County, Texas
23104
0.9504
0.9569
0.6845911
Taylor County, Texas
10180
0.7975
0.8000
0.3145912
Terrell County, Texas
99945
0.7967
0.7965
−0.0345913
Terry County, Texas
99945
0.7967
0.7965
−0.0345920
Throckmorton County, Texas
99945
0.7967
0.7965
−0.0345921
Titus County, Texas
99945
0.7967
0.7965
−0.0345930
Tom Green County, Texas
41660
0.8271
0.8362
1.1045940
Travis County, Texas
12420
0.9437
0.9344
−0.9945941
Trinity County, Texas
99945
0.7967
0.7965
−0.0345942
Tyler County, Texas
99945
0.7967
0.7965
−0.0345943
Upshur County, Texas
30980
0.8809
0.8788
−0.2445944
Upton County, Texas
99945
0.7967
0.7965
−0.0345945
Uvalde County, Texas
99945
0.7967
0.7965
−0.0345946
Val Verde County, Texas
99945
0.7967
0.7965
−0.0345947
Van Zandt County, Texas
99945
0.7967
0.7965
−0.0345948
Victoria County, Texas
47020
0.8160
0.8560
4.9045949
Walker County, Texas
99945
0.7967
0.7965
−0.0345950
Waller County, Texas
26420
1.0040
1.0008
−0.3245951
Ward County, Texas
99945
0.7967
0.7965
−0.0345952
Washington County, Texas
99945
0.7967
0.7965
−0.0345953
Webb County, Texas
29700
0.8068
0.7811
−3.1945954
Wharton County, Texas
99945
0.7967
0.7965
−0.0345955
Wheeler County, Texas
99945
0.7967
0.7965
−0.0345960
Wichita County, Texas
48660
0.8325
0.8311
−0.1745961
Wilbarger County, Texas
99945
0.7967
0.7965
−0.0345962
Willacy County, Texas
99945
0.7967
0.7965
−0.0345970
Williamson County, Texas
12420
0.9437
0.9344
−0.9945971
Wilson County, Texas
41700
0.8982
0.8844
−1.5445972
Winkler County, Texas
99945
0.7967
0.7965
−0.0345973
Wise County, Texas
23104
0.8709
0.9569
9.8745974
Wood County, Texas
99945
0.7967
0.7965
−0.0345980
Yoakum County, Texas
99945
0.7967
0.7965
−0.0345981
Young County, Texas
99945
0.7967
0.7965
−0.0345982
Zapata County, Texas
99945
0.7967
0.7965
−0.0345983
Zavala County, Texas
99945
0.7967
0.7965
−0.0346000
Beaver County, Utah
99946
0.8440
0.8140
−3.5546010
Box Elder County, Utah
99946
0.8440
0.8140
−3.5546020
Cache County, Utah
30860
0.8963
0.9022
0.6646030
Carbon County, Utah
99946
0.8440
0.8140
−3.5546040
Daggett County, Utah
99946
0.8440
0.8140
−3.55( print page 66001)46050
Davis County, Utah
36260
0.9185
0.8995
−2.0746060
Duchesne County, Utah
99946
0.8440
0.8140
−3.5546070
Emery County, Utah
99946
0.8440
0.8140
−3.5546080
Garfield County, Utah
99946
0.8440
0.8140
−3.5546090
Grand County, Utah
99946
0.8440
0.8140
−3.5546100
Iron County, Utah
99946
0.8440
0.8140
−3.5546110
Juab County, Utah
39340
0.9131
0.9537
4.4546120
Kane County, Utah
99946
0.9982
0.8140
−18.4546130
Millard County, Utah
99946
0.8440
0.8140
−3.5546140
Morgan County, Utah
36260
0.8896
0.8995
1.1146150
Piute County, Utah
99946
0.8440
0.8140
−3.5546160
Rich County, Utah
99946
0.8440
0.8140
−3.5546170
Salt Lake County, Utah
41620
0.9381
0.9402
0.2246180
San Juan County, Utah
99946
0.8440
0.8140
−3.5546190
Sanpete County, Utah
99946
0.8440
0.8140
−3.5546200
Sevier County, Utah
99946
0.8440
0.8140
−3.5546210
Summit County, Utah
41620
0.9092
0.9402
3.4146220
Tooele County, Utah
41620
0.9092
0.9402
3.4146230
Uintah County, Utah
99946
0.8440
0.8140
−3.5546240
Utah County, Utah
39340
0.9500
0.9537
0.3946250
Wasatch County, Utah
99946
0.8440
0.8140
−3.5546260
Washington County, Utah
41100
0.9077
0.9265
2.0746270
Wayne County, Utah
99946
0.8440
0.8140
−3.5546280
Weber County, Utah
36260
0.9185
0.8995
−2.0747000
Addison County, Vermont
99947
0.9830
0.9744
−0.8747010
Bennington County, Vermont
99947
0.9830
0.9744
−0.8747020
Caledonia County, Vermont
99947
0.9830
0.9744
−0.8747030
Chittenden County, Vermont
15540
0.9410
0.9474
0.6847040
Essex County, Vermont
99947
0.9830
0.9744
−0.8747050
Franklin County, Vermont
15540
0.9410
0.9474
0.6847060
Grand Isle County, Vermont
15540
0.9410
0.9474
0.6847070
Lamoille County, Vermont
99947
0.9830
0.9744
−0.8747080
Orange County, Vermont
99947
0.9830
0.9744
−0.8747090
Orleans County, Vermont
99947
0.9830
0.9744
−0.8747100
Rutland County, Vermont
99947
0.9830
0.9744
−0.8747110
Washington County, Vermont
99947
0.9830
0.9744
−0.8747120
Windham County, Vermont
99947
0.9830
0.9744
−0.8747130
Windsor County, Vermont
99947
0.9830
0.9744
−0.8748010
St Croix County, Virgin Islands
99948
0.7615
0.8467
11.1948020
St Thomas-John County, Virgin  Islands
99948
0.7615
0.8467
11.1949000
Accomack County, Virginia
99949
0.8215
0.7940
−3.3549010
Albemarle County, Virginia
16820
1.0187
1.0125
−0.6149011
Alexandria City County, Virginia
47894
1.0951
1.1054
0.9449020
Alleghany County, Virginia
99949
0.8215
0.7940
−3.3549030
Amelia County, Virginia
40060
0.8873
0.9177
3.4349040
Amherst County, Virginia
31340
0.8691
0.8694
0.0349050
Appomattox County, Virginia
31340
0.8554
0.8694
1.6449060
Arlington County, Virginia
47894
1.0951
1.1054
0.9449070
Augusta County, Virginia
99949
0.8215
0.7940
−3.3549080
Bath County, Virginia
99949
0.8215
0.7940
−3.3549088
Bedford City County, Virginia
31340
0.8691
0.8694
0.0349090
Bedford County, Virginia
31340
0.8691
0.8694
0.0349100
Bland County, Virginia
99949
0.8215
0.7940
−3.3549110
Botetourt County, Virginia
40220
0.8381
0.8647
3.1749111
Bristol City County, Virginia
28700
0.8031
0.7985
−0.5749120
Brunswick County, Virginia
99949
0.8215
0.7940
−3.3549130
Buchanan County, Virginia
99949
0.8215
0.7940
−3.3549140
Buckingham County, Virginia
99949
0.8215
0.7940
−3.3549141
Buena Vista City County, Virginia
99949
0.8215
0.7940
−3.3549150
Campbell County, Virginia
31340
0.8691
0.8694
0.0349160
Caroline County, Virginia
40060
0.8873
0.9177
3.4349170
Carroll County, Virginia
99949
0.8215
0.7940
−3.3549180
Charles City County, Virginia
40060
0.9328
0.9177
−1.6249190
Charlotte County, Virginia
99949
0.8215
0.7940
−3.3549191
Charlottesville City County,  Virginia
16820
1.0187
1.0125
−0.6149194
Chesapeake County, Virginia
47260
0.8799
0.8790
−0.1049200
Chesterfield County, Virginia
40060
0.9328
0.9177
−1.6249210
Clarke County, Virginia
47894
1.0951
1.1054
0.94( print page 66002)49211
Clifton Forge City County, Virginia
99949
0.8215
0.7940
−3.3549212
Colonial Heights County, Virginia
40060
0.9328
0.9177
−1.6249213
Covington City County, Virginia
99949
0.8215
0.7940
−3.3549220
Craig County, Virginia
40220
0.8396
0.8647
2.9949230
Culpeper County, Virginia
99949
0.9495
0.7940
−16.3849240
Cumberland County, Virginia
40060
0.8873
0.9177
3.4349241
Danville City County, Virginia
19260
0.8489
0.8451
−0.4549250
Dickenson County, Virginia
99949
0.8215
0.7940
−3.3549260
Dinniddie County, Virginia
40060
0.9328
0.9177
−1.6249270
Emporia County, Virginia
99949
0.8215
0.7940
−3.3549280
Essex County, Virginia
99949
0.8215
0.7940
−3.3549288
Fairfax City County, Virginia
47894
1.0951
1.1054
0.9449290
Fairfax County, Virginia
47894
1.0951
1.1054
0.9449291
Falls Church City County, Virginia
47894
1.0951
1.1054
0.9449300
Fauquier County, Virginia
47894
1.0951
1.1054
0.9449310
Floyd County, Virginia
99949
0.8215
0.7940
−3.3549320
Fluvanna County, Virginia
16820
1.0187
1.0125
−0.6149328
Franklin City County, Virginia
99949
0.8215
0.7940
−3.3549330
Franklin County, Virginia
40220
0.8396
0.8647
2.9949340
Frederick County, Virginia
49020
0.9316
1.0091
8.3249342
Fredericksburg City County, Virginia
47894
1.0951
1.1054
0.9449343
Galax City County, Virginia
99949
0.8215
0.7940
−3.3549350
Giles County, Virginia
13980
0.8186
0.8213
0.3349360
Gloucester County, Virginia
47260
0.8799
0.8790
−0.1049370
Goochland County, Virginia
40060
0.9328
0.9177
−1.6249380
Grayson County, Virginia
99949
0.8215
0.7940
−3.3549390
Greene County, Virginia
16820
1.0187
1.0125
−0.6149400
Greensville County, Virginia
99949
0.8215
0.7940
−3.3549410
Halifax County, Virginia
99949
0.8215
0.7940
−3.3549411
Hampton City County, Virginia
47260
0.8799
0.8790
−0.1049420
Hanover County, Virginia
40060
0.9328
0.9177
−1.6249421
Harrisonburg City County, Virginia
25500
0.8753
0.9073
3.6649430
Henrico County, Virginia
40060
0.9328
0.9177
−1.6249440
Henry County, Virginia
99949
0.8215
0.7940
−3.3549450
Highland County, Virginia
99949
0.8215
0.7940
−3.3549451
Hopewell City County, Virginia
40060
0.9328
0.9177
−1.6249460
Isle Of Wight County, Virginia
47260
0.8799
0.8790
−0.1049470
James City Co County, Virginia
47260
0.8799
0.8790
−0.1049480
King And Queen County, Virginia
40060
0.8873
0.9177
3.4349490
King George County, Virginia
99949
0.9495
0.7940
−16.3849500
King William County, Virginia
40060
0.8873
0.9177
3.4349510
Lancaster County, Virginia
99949
0.8215
0.7940
−3.3549520
Lee County, Virginia
99949
0.8215
0.7940
−3.3549522
Lexington County, Virginia
99949
0.8215
0.7940
−3.3549530
Loudoun County, Virginia
47894
1.0951
1.1054
0.9449540
Louisa County, Virginia
40060
0.8873
0.9177
3.4349550
Lunenburg County, Virginia
99949
0.8215
0.7940
−3.3549551
Lynchburg City County, Virginia
31340
0.8691
0.8694
0.0349560
Madison County, Virginia
99949
0.8215
0.7940
−3.3549561
Martinsville City County, Virginia
99949
0.8215
0.7940
−3.3549563
Manassas City County, Virginia
47894
1.0951
1.1054
0.9449565
Manassas Park City County, Virginia
47894
1.0951
1.1054
0.9449570
Mathews County, Virginia
47260
0.8799
0.8790
−0.1049580
Mecklenburg County, Virginia
99949
0.8215
0.7940
−3.3549590
Middlesex County, Virginia
99949
0.8215
0.7940
−3.3549600
Montgomery County, Virginia
13980
0.8186
0.8213
0.3349610
Nansemond, Virginia
99949
0.8215
0.7940
−3.3549620
Nelson County, Virginia
16820
0.9302
1.0125
8.8549621
New Kent County, Virginia
40060
0.9328
0.9177
−1.6249622
Newport News City County, Virginia
47260
0.8799
0.8790
−0.1049641
Norfolk City County, Virginia
47260
0.8799
0.8790
−0.1049650
Northampton County, Virginia
99949
0.8215
0.7940
−3.3549660
Northumberland County, Virginia
99949
0.8215
0.7940
−3.3549661
Norton City County, Virginia
99949
0.8215
0.7940
−3.3549670
Nottoway County, Virginia
99949
0.8215
0.7940
−3.3549680
Orange County, Virginia
99949
0.8215
0.7940
−3.3549690
Page County, Virginia
99949
0.8215
0.7940
−3.3549700
Patrick County, Virginia
99949
0.8215
0.7940
−3.35( print page 66003)49701
Petersburg City County, Virginia
40060
0.9328
0.9177
−1.6249710
Pittsylvania County, Virginia
19260
0.8489
0.8451
−0.4549711
Portsmouth City County, Virginia
47260
0.8799
0.8790
−0.1049712
Poquoson City County, Virginia
47260
0.8799
0.8790
−0.1049720
Powhatan County, Virginia
40060
0.9328
0.9177
−1.6249730
Prince Edward County, Virginia
99949
0.8215
0.7940
−3.3549740
Prince George County, Virginia
40060
0.9328
0.9177
−1.6249750
Prince William County, Virginia
47894
1.0951
1.1054
0.9449770
Pulaski County, Virginia
13980
0.8186
0.8213
0.3349771
Radford City County, Virginia
13980
0.8186
0.8213
0.3349780
Rappahannock County, Virginia
99949
0.8215
0.7940
−3.3549790
Richmond County, Virginia
99949
0.8215
0.7940
−3.3549791
Richmond City County, Virginia
40060
0.9328
0.9177
−1.6249800
Roanoke County, Virginia
40220
0.8381
0.8647
3.1749801
Roanoke City County, Virginia
40220
0.8381
0.8647
3.1749810
Rockbridge County, Virginia
99949
0.8215
0.7940
−3.3549820
Rockingham County, Virginia
25500
0.8753
0.9073
3.6649830
Russell County, Virginia
99949
0.8215
0.7940
−3.3549838
Salem County, Virginia
40220
0.8381
0.8647
3.1749840
Scott County, Virginia
28700
0.8031
0.7985
−0.5749850
Shenandoah County, Virginia
99949
0.8215
0.7940
−3.3549860
Smyth County, Virginia
99949
0.8215
0.7940
−3.3549867
South Boston City County, Virginia
99949
0.8215
0.7940
−3.3549870
Southampton County, Virginia
99949
0.8215
0.7940
−3.3549880
Spotsylvania County, Virginia
47894
1.0951
1.1054
0.9449890
Stafford County, Virginia
47894
1.0951
1.1054
0.9449891
Staunton City County, Virginia
99949
0.8215
0.7940
−3.3549892
Suffolk City County, Virginia
47260
0.8799
0.8790
−0.1049900
Surry County, Virginia
47260
0.8608
0.8790
2.1149910
Sussex County, Virginia
40060
0.8873
0.9177
3.4349920
Tazewell County, Virginia
99949
0.8215
0.7940
−3.3549921
Virginia Beach City County, Virginia
47260
0.8799
0.8790
−0.1049930
Warren County, Virginia
47894
1.0951
1.1054
0.9449950
Washington County, Virginia
28700
0.8031
0.7985
−0.5749951
Waynesboro City County, Virginia
99949
0.8215
0.7940
−3.3549960
Westmoreland County, Virginia
99949
0.8215
0.7940
−3.3549961
Williamsburg City County, Virginia
47260
0.8799
0.8790
−0.1049962
Winchester City County, Virginia
49020
0.9316
1.0091
8.3249970
Wise County, Virginia
99949
0.8215
0.7940
−3.3549980
Wythe County, Virginia
99949
0.8215
0.7940
−3.3549981
York County, Virginia
47260
0.8799
0.8790
−0.1050000
Adams County, Washington
99950
1.0364
1.0263
−0.9750010
Asotin County, Washington
30300
1.0052
0.9853
−1.9850020
Benton County, Washington
28420
1.0619
1.0343
−2.6050030
Chelan County, Washington
48300
1.0144
1.0346
1.9950040
Clallam County, Washington
99950
1.0364
1.0263
−0.9750050
Clark County, Washington
38900
1.1266
1.1416
1.3350060
Columbia County, Washington
99950
1.0364
1.0263
−0.9750070
Cowlitz County, Washington
31020
0.9898
1.0011
1.1450080
Douglas County, Washington
48300
1.0144
1.0346
1.9950090
Ferry County, Washington
99950
1.0364
1.0263
−0.9750100
Franklin County, Washington
28420
1.0619
1.0343
−2.6050110
Garfield County, Washington
99950
1.0364
1.0263
−0.9750120
Grant County, Washington
99950
1.0364
1.0263
−0.9750130
Grays Harbor County, Washington
99950
1.0364
1.0263
−0.9750140
Island County, Washington
99950
1.1039
1.0263
−7.0350150
Jefferson County, Washington
99950
1.0364
1.0263
−0.9750160
King County, Washington
42644
1.1572
1.1434
−1.1950170
Kitsap County, Washington
14740
1.0675
1.0913
2.2350180
Kittitas County, Washington
99950
1.0364
1.0263
−0.9750190
Klickitat County, Washington
99950
1.0364
1.0263
−0.9750200
Lewis County, Washington
99950
1.0364
1.0263
−0.9750210
Lincoln County, Washington
99950
1.0364
1.0263
−0.9750220
Mason County, Washington
99950
1.0364
1.0263
−0.9750230
Okanogan County, Washington
99950
1.0364
1.0263
−0.9750240
Pacific County, Washington
99950
1.0364
1.0263
−0.9750250
Pend Oreille County, Washington
99950
1.0364
1.0263
−0.9750260
Pierce County, Washington
45104
1.0742
1.0789
0.44( print page 66004)50270
San Juan County, Washington
99950
1.0364
1.0263
−0.9750280
Skagit County, Washington
34580
1.0336
1.0517
1.7550290
Skamania County, Washington
38900
1.0742
1.1416
6.2750300
Snohomish County, Washington
42644
1.1572
1.1434
−1.1950310
Spokane County, Washington
44060
1.0905
1.0447
−4.2050320
Stevens County, Washington
99950
1.0364
1.0263
−0.9750330
Thurston County, Washington
36500
1.0927
1.1081
1.4150340
Wahkiakum County, Washington
99950
1.0364
1.0263
−0.9750350
Walla Walla County, Washington
99950
1.0364
1.0263
−0.9750360
Whatcom County, Washington
13380
1.1731
1.1104
−5.3450370
Whitman County, Washington
99950
1.0364
1.0263
−0.9750380
Yakima County, Washington
49420
1.0155
0.9847
−3.0351000
Barbour County, W Virginia
99951
0.7809
0.7607
−2.5951010
Berkeley County, W Virginia
25180
1.0233
0.9038
−11.6851020
Boone County, W Virginia
16620
0.8173
0.8542
4.5151030
Braxton County, W Virginia
99951
0.7809
0.7607
−2.5951040
Brooke County, W Virginia
48260
0.7819
0.8063
3.1251050
Cabell County, W Virginia
26580
0.9477
0.8997
−5.0651060
Calhoun County, W Virginia
99951
0.7809
0.7607
−2.5951070
Clay County, W Virginia
16620
0.8173
0.8542
4.5151080
Doddridge County, W Virginia
99951
0.7809
0.7607
−2.5951090
Fayette County, W Virginia
99951
0.7809
0.7607
−2.5951100
Gilmer County, W Virginia
99951
0.7809
0.7607
−2.5951110
Grant County, W Virginia
99951
0.7809
0.7607
−2.5951120
Greenbrier County, W Virginia
99951
0.7809
0.7607
−2.5951130
Hampshire County, W Virginia
49020
0.9057
1.0091
11.4251140
Hancock County, W Virginia
48260
0.7819
0.8063
3.1251150
Hardy County, W Virginia
99951
0.7809
0.7607
−2.5951160
Harrison County, W Virginia
99951
0.7809
0.7607
−2.5951170
Jackson County, W Virginia
99951
0.7809
0.7607
−2.5951180
Jefferson County, W Virginia
47894
1.0951
1.1054
0.9451190
Kanawha County, W Virginia
16620
0.8445
0.8542
1.1551200
Lewis County, W Virginia
99951
0.7809
0.7607
−2.5951210
Lincoln County, W Virginia
16620
0.8173
0.8542
4.5151220
Logan County, W Virginia
99951
0.7809
0.7607
−2.5951230
Mc Dowell County, W Virginia
99951
0.7809
0.7607
−2.5951240
Marion County, W Virginia
99951
0.7809
0.7607
−2.5951250
Marshall County, W Virginia
48540
0.7161
0.7010
−2.1151260
Mason County, W Virginia
99951
0.7809
0.7607
−2.5951270
Mercer County, W Virginia
99951
0.7809
0.7607
−2.5951280
Mineral County, W Virginia
19060
0.9317
0.8446
−9.3551290
Mingo County, W Virginia
99951
0.7809
0.7607
−2.5951300
Monongalia County, W Virginia
34060
0.8160
0.8423
3.2251310
Monroe County, W Virginia
99951
0.7809
0.7607
−2.5951320
Morgan County, W Virginia
25180
0.8695
0.9038
3.9451330
Nicholas County, W Virginia
99951
0.7809
0.7607
−2.5951340
Ohio County, W Virginia
48540
0.7161
0.7010
−2.1151350
Pendleton County, W Virginia
99951
0.7809
0.7607
−2.5951360
Pleasants County, W Virginia
37620
0.8085
0.7977
−1.3451370
Pocahontas County, W Virginia
99951
0.7809
0.7607
−2.5951380
Preston County, W Virginia
34060
0.8160
0.8423
3.2251390
Putnam County, W Virginia
16620
0.8445
0.8542
1.1551400
Raleigh County, W Virginia
99951
0.7809
0.7607
−2.5951410
Randolph County, W Virginia
99951
0.7809
0.7607
−2.5951420
Ritchie County, W Virginia
99951
0.7809
0.7607
−2.5951430
Roane County, W Virginia
99951
0.7809
0.7607
−2.5951440
Summers County, W Virginia
99951
0.7809
0.7607
−2.5951450
Taylor County, W Virginia
99951
0.7809
0.7607
−2.5951460
Tucker County, W Virginia
99951
0.7809
0.7607
−2.5951470
Tyler County, W Virginia
99951
0.7809
0.7607
−2.5951480
Upshur County, W Virginia
99951
0.7809
0.7607
−2.5951490
Wayne County, W Virginia
26580
0.9477
0.8997
−5.0651500
Webster County, W Virginia
99951
0.7809
0.7607
−2.5951510
Wetzel County, W Virginia
99951
0.7809
0.7607
−2.5951520
Wirt County, W Virginia
37620
0.8085
0.7977
−1.3451530
Wood County, W Virginia
37620
0.8270
0.7977
−3.5451540
Wyoming County, W Virginia
99951
0.7809
0.7607
−2.5952000
Adams County, Wisconsin
99952
0.9494
0.9553
0.62( print page 66005)52010
Ashland County, Wisconsin
99952
0.9494
0.9553
0.6252020
Barron County, Wisconsin
99952
0.9494
0.9553
0.6252030
Bayfield County, Wisconsin
99952
0.9494
0.9553
0.6252040
Brown County, Wisconsin
24580
0.9483
0.9787
3.2152050
Buffalo County, Wisconsin
99952
0.9494
0.9553
0.6252060
Burnett County, Wisconsin
99952
0.9494
0.9553
0.6252070
Calumet County, Wisconsin
11540
0.9264
0.9455
2.0652080
Chippewa County, Wisconsin
20740
0.9201
0.9630
4.6652090
Clark County, Wisconsin
99952
0.9494
0.9553
0.6252100
Columbia County, Wisconsin
31540
1.0069
1.0840
7.6652110
Crawford County, Wisconsin
99952
0.9494
0.9553
0.6252120
Dane County, Wisconsin
31540
1.0707
1.0840
1.2452130
Dodge County, Wisconsin
99952
0.9494
0.9553
0.6252140
Door County, Wisconsin
99952
0.9494
0.9553
0.6252150
Douglas County, Wisconsin
20260
1.0213
1.0042
−1.6752160
Dunn County, Wisconsin
99952
0.9494
0.9553
0.6252170
Eau Claire County, Wisconsin
20740
0.9201
0.9630
4.6652180
Florence County, Wisconsin
99952
0.9494
0.9553
0.6252190
Fond Du Lac County, Wisconsin
22540
0.9559
1.0063
5.2752200
Forest County, Wisconsin
99952
0.9494
0.9553
0.6252210
Grant County, Wisconsin
99952
0.9494
0.9553
0.6252220
Green County, Wisconsin
99952
0.9494
0.9553
0.6252230
Green Lake County, Wisconsin
99952
0.9494
0.9553
0.6252240
Iowa County, Wisconsin
31540
1.0069
1.0840
7.6652250
Iron County, Wisconsin
99952
0.9494
0.9553
0.6252260
Jackson County, Wisconsin
99952
0.9494
0.9553
0.6252270
Jefferson County, Wisconsin
99952
0.9494
0.9553
0.6252280
Juneau County, Wisconsin
99952
0.9494
0.9553
0.6252290
Kenosha County, Wisconsin
29404
1.0095
1.0570
4.7152300
Kewaunee County, Wisconsin
24580
0.9481
0.9787
3.2352310
La Crosse County, Wisconsin
29100
0.9564
0.9426
−1.4452320
Lafayette County, Wisconsin
99952
0.9494
0.9553
0.6252330
Langlade County, Wisconsin
99952
0.9494
0.9553
0.6252340
Lincoln County, Wisconsin
99952
0.9494
0.9553
0.6252350
Manitowoc County, Wisconsin
99952
0.9494
0.9553
0.6252360
Marathon County, Wisconsin
48140
0.9590
0.9722
1.3852370
Marinette County, Wisconsin
99952
0.9494
0.9553
0.6252380
Marquette County, Wisconsin
99952
0.9494
0.9553
0.6252381
Menominee County, Wisconsin
99952
0.9494
0.9553
0.6252390
Milwaukee County, Wisconsin
33340
1.0146
1.0218
0.7152400
Monroe County, Wisconsin
99952
0.9494
0.9553
0.6252410
Oconto County, Wisconsin
24580
0.9481
0.9787
3.2352420
Oneida County, Wisconsin
99952
0.9494
0.9553
0.6252430
Outagamie County, Wisconsin
11540
0.9264
0.9455
2.0652440
Ozaukee County, Wisconsin
33340
1.0146
1.0218
0.7152450
Pepin County, Wisconsin
99952
0.9494
0.9553
0.6252460
Pierce County, Wisconsin
33460
1.1075
1.0946
−1.1652470
Polk County, Wisconsin
99952
0.9494
0.9553
0.6252480
Portage County, Wisconsin
99952
0.9494
0.9553
0.6252490
Price County, Wisconsin
99952
0.9494
0.9553
0.6252500
Racine County, Wisconsin
39540
0.8997
0.9356
3.9952510
Richland County, Wisconsin
99952
0.9494
0.9553
0.6252520
Rock County, Wisconsin
27500
0.9538
0.9655
1.2352530
Rusk County, Wisconsin
99952
0.9494
0.9553
0.6252540
St Croix County, Wisconsin
33460
1.1075
1.0946
−1.1652550
Sauk County, Wisconsin
99952
0.9494
0.9553
0.6252560
Sawyer County, Wisconsin
99952
0.9494
0.9553
0.6252570
Shawano County, Wisconsin
99952
0.9494
0.9553
0.6252580
Sheboygan County, Wisconsin
43100
0.8911
0.9026
1.2952590
Taylor County, Wisconsin
99952
0.9494
0.9553
0.6252600
Trempealeau County, Wisconsin
99952
0.9494
0.9553
0.6252610
Vernon County, Wisconsin
99952
0.9494
0.9553
0.6252620
Vilas County, Wisconsin
99952
0.9494
0.9553
0.6252630
Walworth County, Wisconsin
99952
0.9494
0.9553
0.6252640
Washburn County, Wisconsin
99952
0.9494
0.9553
0.6252650
Washington County, Wisconsin
33340
1.0146
1.0218
0.7152660
Waukesha County, Wisconsin
33340
1.0146
1.0218
0.7152670
Waupaca County, Wisconsin
99952
0.9494
0.9553
0.62( print page 66006)52680
Waushara County, Wisconsin
99952
0.9494
0.9553
0.6252690
Winnebago County, Wisconsin
36780
0.9211
0.9315
1.1352700
Wood County, Wisconsin
99952
0.9494
0.9553
0.6253000
Albany County, Wyoming
99953
0.9257
0.9295
0.4153010
Big Horn County, Wyoming
99953
0.9257
0.9295
0.4153020
Campbell County, Wyoming
99953
0.9257
0.9295
0.4153030
Carbon County, Wyoming
99953
0.9257
0.9295
0.4153040
Converse County, Wyoming
99953
0.9257
0.9295
0.4153050
Crook County, Wyoming
99953
0.9257
0.9295
0.4153060
Fremont County, Wyoming
99953
0.9257
0.9295
0.4153070
Goshen County, Wyoming
99953
0.9257
0.9295
0.4153080
Hot Springs County, Wyoming
99953
0.9257
0.9295
0.4153090
Johnson County, Wyoming
99953
0.9257
0.9295
0.4153100
Laramie County, Wyoming
16940
0.8775
0.9060
3.2553110
Lincoln County, Wyoming
99953
0.9257
0.9295
0.4153120
Natrona County, Wyoming
16220
0.9026
0.9145
1.3253130
Niobrara County, Wyoming
99953
0.9257
0.9295
0.4153140
Park County, Wyoming
99953
0.9257
0.9295
0.4153150
Platte County, Wyoming
99953
0.9257
0.9295
0.4153160
Sheridan County, Wyoming
99953
0.9257
0.9295
0.4153170
Sublette County, Wyoming
99953
0.9257
0.9295
0.4153180
Sweetwater County, Wyoming
99953
0.9257
0.9295
0.4153190
Teton County, Wyoming
99953
0.9257
0.9295
0.4153200
Uinta County, Wyoming
99953
0.9257
0.9295
0.4153210
Washakie County, Wyoming
99953
0.9257
0.9295
0.4153220
Weston County, Wyoming
99953
0.9257
0.9295
0.4165010
Agana County, Guam
99965
0.9611
0.9611
0.0065020
Agana Heights County, Guam
99965
0.9611
0.9611
0.0065030
Agat County, Guam
99965
0.9611
0.9611
0.0065040
Asan County, Guam
99965
0.9611
0.9611
0.0065050
Barrigada County, Guam
99965
0.9611
0.9611
0.0065060
Chalan Pago County, Guam
99965
0.9611
0.9611
0.0065070
Dededo County, Guam
99965
0.9611
0.9611
0.0065080
Inarajan County, Guam
99965
0.9611
0.9611
0.0065090
Maite County, Guam
99965
0.9611
0.9611
0.0065100
Mangilao County, Guam
99965
0.9611
0.9611
0.0065110
Merizo County, Guam
99965
0.9611
0.9611
0.0065120
Mongmong County, Guam
99965
0.9611
0.9611
0.0065130
Ordot County, Guam
99965
0.9611
0.9611
0.0065140
Piti County, Guam
99965
0.9611
0.9611
0.0065150
Santa Rita County, Guam
99965
0.9611
0.9611
0.0065160
Sinajana County, Guam
99965
0.9611
0.9611
0.0065170
Talofofo County, Guam
99965
0.9611
0.9611
0.0065180
Tamuning County, Guam
99965
0.9611
0.9611
0.0065190
Toto County, Guam
99965
0.9611
0.9611
0.0065200
Umatac County, Guam
99965
0.9611
0.9611
0.0065210
Yigo County, Guam
99965
0.9611
0.9611
0.0065220
Yona County, Guam
99965
0.9611
0.9611
0.00


[FR Doc. 06-9068  Filed 11-1-06; 4:00 pm] BILLING CODE 4120-01-P