Vol. 77 Thursday, 

No. 149 August 2, 2012 

Part IV 

Department of Health and Human Services 

Center for Medicare & Medicaid Services 

Medicare Program; Prospective Payment System and Consolidated Billing 

for Skilled Nursing Facilities for FY 2013; Notice 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46214 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–1432–N] 

RIN 0938–AR20 

Medicare Program; Prospective 

Payment System and Consolidated 

Billing for Skilled Nursing Facilities for 

FY 2013 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Notice. 

SUMMARY: This notice updates the 

payment rates used under the 

prospective payment system (PPS) for 

skilled nursing facilities (SNFs), for 

fiscal year (FY) 2013. 

DATES: Effective Date: This notice is 

effective on October 1, 2012. 

FOR FURTHER INFORMATION CONTACT: 

Penny Gershman, (410) 786–6643 (for 

information related to clinical issues). 

John Kane, (410) 786–0557 (for 

information related to the development 

of the payment rates and case-mix 

indexes). 

Kia Sidbury, (410) 786–7816 (for 

information related to the wage index). 

Bill Ullman, (410) 786–5667 (for 

information related to level of care 

determinations, consolidated billing, 

and general information). 

SUPPLEMENTARY INFORMATION: To assist 

readers in referencing sections 

contained in this document, we are 

providing the following Table of 

Contents. 

Table of Contents 

I. Executive Summary 

II. Background 

A. Current System for Payment of SNF 

Services Under Part A of the Medicare 

Program 

B. Requirements of the Balanced Budget 

Act of 1997 (BBA) for Updating the 

Prospective Payment System for Skilled 

Nursing Facilities 

C. The Medicare, Medicaid, and SCHIP 

Balanced Budget Refinement Act of 1999 

(BBRA) 

D. The Medicare, Medicaid, and SCHIP 

Benefits Improvement and Protection 

Act of 2000 (BIPA) 

E. The Medicare Prescription Drug, 

Improvement, and Modernization Act of 

2003 (MMA) 

F. The Affordable Care Act 

G. Skilled Nursing Facility Prospective 

Payment—General Overview 

1. Payment Provisions—Federal Rate 

2. FY 2013 Rate Updates Using the Skilled 

Nursing Facility Market Basket Index 

III. FY 2013 Annual Update of Payment Rates 

Under the Prospective Payment System 

for Skilled Nursing Facilities 

A. Federal Prospective Payment System 

1. Costs and Services Covered by the 

Federal Rates 

2. Methodology Used for the Calculation of 

the Federal Rates 

B. Case-Mix Adjustments 

C. Wage Index Adjustment to Federal Rates 

D. Updates to Federal Rates 

E. Relationship of Case-Mix Classification 

System to Existing Skilled Nursing 

Facility Level-of-Care Criteria 

F. Example of Computation of Adjusted 

PPS Rates and SNF Payment 

IV. Monitoring Impact of FY 2012 Policy 

Changes and Certain SNF Practices 

A. RUG Distributions 

B. Group Therapy Allocation 

C. MDS 3.0 Changes 

V. The Skilled Nursing Facility Market 

Basket Index 

A. Use of the Skilled Nursing Facility 

Market Basket Percentage 

B. Market Basket Forecast Error 

Adjustment 

C. Multifactor Productivity Adjustment 

D. Federal Rate Update Factor 

VI. Consolidated Billing 

VII. Application of the SNF PPS to SNF 

Services Furnished by Swing-Bed 

Hospitals 

VIII. Collection of Information Requirements 

IX. Waiver of Proposed Rulemaking 

X. Economic Analyses 

Acronyms 

In addition, because of the many 

terms to which we refer by acronym in 

this notice, we are listing these 

abbreviations and their corresponding 

terms in alphabetical order below: 

AIDS Acquired Immune Deficiency 

Syndrome 

ARD Assessment Reference Date 

BBA Balanced Budget Act of 1997, Public 

Law 105–33 

BBRA Medicare, Medicaid, and SCHIP 

Balanced Budget Refinement Act of 1999, 

Public Law 106–113 

BIPA Medicare, Medicaid, and SCHIP 

Benefits Improvement and Protection Act 

of 2000, Public Law 106–554 

CAH Critical Access Hospital 

CBSA Core-Based Statistical Area 

CFR Code of Federal Regulations 

CMI Case-Mix Index 

CMS Centers for Medicare & Medicaid 

Services 

COT Change of Therapy 

EOT End of Therapy 

EOT–R End of Therapy—Resumption 

FQHC Federally Qualified Health Center 

FR Federal Register 

FY Fiscal Year 

GAO Government Accountability Office 

HCPCS Healthcare Common Procedure 

Coding System 

HR–III Hybrid Resource Utilization Groups, 

Version 3 

IHS IGI (Information Handling Services) 

Global Insight, Inc. 

MDS Minimum Data Set 

MFP Multifactor Productivity 

MIPPA Medicare Improvements for Patients 

and Providers Act of 2008, Public Law 

110–275 

MMA Medicare Prescription Drug, 

Improvement, and Modernization Act of 

2003, Public Law 108–173 

MMSEA Medicare, Medicaid, and SCHIP 

Extension Act of 2007, Public Law 110–173 

MPAF Medicare PPS Assessment Form 

MSA Metropolitan Statistical Area 

OCN OMB Control Number 

OMB Office of Management and Budget 

OMRA Other Medicare-Required 

Assessment 

PPS Prospective Payment System 

RAI Resident Assessment Instrument 

RAVEN Resident Assessment Validation 

Entry 

RFA Regulatory Flexibility Act, Public Law 

96–354 

RHC Rural Health Clinic 

RIA Regulatory Impact Analysis 

RUG–III Resource Utilization Groups, 

Version 3 

RUG–IV Resource Utilization Groups, 

Version 4 

RUG–53 Refined 53–Group RUG–III CaseMix Classification System 

SCHIP State Children’s Health Insurance 

Program 

SNF Skilled Nursing Facility 

STM Staff Time Measurement 

STRIVE Staff Time and Resource Intensity 

Verification 

UMRA Unfunded Mandates Reform Act, 

Public Law 104–4 

I. Executive Summary 

A. Purpose 

This notice updates the SNF 

prospective payment rates for FY 2013 

as required under section 1888(e)(4)(E) 

of the Act. It also responds to section 

1888(e)(4)(H) of the Act, which requires 

the Secretary to ‘‘provide for publication 

in the Federal Register’’ before the 

August 1 that precedes the start of each 

fiscal year, the unadjusted Federal per 

diem rates, the case-mix classification 

system, and the factors to be applied in 

making the area wage adjustment used 

in computing the prospective payment 

rates for that fiscal year. 

B. Summary of Major Provisions 

This notice does not contain any 

proposals for new policies applicable to 

the SNF PPS. In accordance with 

sections 1888(e)(4)(E)(ii)(IV) and (e)(5) 

of the Act, the Federal rates in this 

notice reflect an update to the rates that 

we published in the final rule for FY 

2012 (76 FR 48486, August 8, 2011) and 

the associated correction notice (76 FR 

59265, September 26, 2011), equal to the 

full change in the SNF market basket 

index, adjusted by the forecast error 

correction, if applicable, and the 

Multifactor Productivity adjustment for 

FY 2013. 

C. Summary of Cost and Benefits 


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Provision 

description Total costs Total benefits 

FY 2013 SNF PPS payment 

rate update.

The overall economic impact of this notice is an estimated $670 million in increased payments to SNFs 

during FY 2013.

This notice accomplishes the required update of the 

SNF PPS payment rates for FY 2013 in accordance 

with the formula prescribed by law. 

II. Background 

Annual updates to the prospective 

payment system (PPS) rates for skilled 

nursing facilities (SNFs) are required by 

section 1888(e) of the Social Security 

Act (the Act), as added by section 4432 

of the Balanced Budget Act of 1997 

(BBA, Pub. L. 105–33, enacted on 

August 5, 1997), and amended by 

subsequent legislation as discussed 

elsewhere in this preamble. Our most 

recent annual update occurred in a final 

rule (76 FR 48486, August 8, 2011) that 

set forth updates to the SNF PPS 

payment rates for FY 2012. We 

subsequently published a correction 

notice (76 FR 59265, September 26, 

2011) with respect to those payment rate 

updates. 

A. Current System for Payment of 

Skilled Nursing Facility Services Under 

Part A of the Medicare Program 

Section 4432 of the BBA amended 

section 1888 of the Act to provide for 

the implementation of a per diem PPS 

for SNFs, covering all costs (routine, 

ancillary, and capital-related) of covered 

SNF services furnished to beneficiaries 

under Part A of the Medicare program, 

effective for cost reporting periods 

beginning on or after July 1, 1998. In 

this notice, we update the per diem 

payment rates for SNFs for FY 2013. 

Major elements of the SNF PPS include: 

• Rates. As discussed in section 

II.G.1. of this notice, we established per 

diem Federal rates for urban and rural 

areas using allowable costs from FY 

1995 cost reports. These rates also 

included a ‘‘Part B add-on’’ (an estimate 

of the cost of those services that, before 

July 1, 1998, were paid under Part B, but 

furnished to Medicare beneficiaries in a 

SNF during a Part A covered stay). We 

adjust the rates annually using a SNF 

market basket index, and we adjust 

them by the hospital inpatient wage 

index to account for geographic 

variation in wages. We also apply a 

case-mix adjustment to account for the 

relative resource utilization of different 

patient types. As further discussed in 

section II.G.1. of this notice, for FY 2013 

this adjustment will utilize the Resource 

Utilization Groups, version 4 (RUG–IV) 

case-mix classification system, and will 

use information obtained from the 

required resident assessments using 

version 3.0 of the Minimum Data Set 

(MDS 3.0). (The Office of Management 

and Budget (OMB) has approved the 

resident assessment under OMB Control 

Number (OCN) 0938–0739.) 

Additionally, as noted elsewhere in this 

preamble, the payment rates at various 

times have also reflected specific 

legislative provisions for certain 

temporary adjustments. 

• Transition. Under sections 

1888(e)(1)(A) and (e)(11) of the Act, the 

SNF PPS included an initial, threephase transition that blended a facilityspecific rate (reflecting the individual 

facility’s historical cost experience) with 

the Federal case-mix adjusted rate. The 

transition extended through the 

facility’s first three cost reporting 

periods under the PPS, up to and 

including the one that began in FY 

2001. Thus, the SNF PPS is no longer 

operating under the transition, as all 

facilities have been paid at the full 

Federal rate effective with cost reporting 

periods beginning in FY 2002. As we 

now base payments entirely on the 

adjusted Federal per diem rates, we no 

longer include adjustment factors 

related to facility-specific rates for the 

coming FY. 

• Coverage. The establishment of the 

SNF PPS did not change Medicare’s 

fundamental requirements for SNF 

coverage. However, because the casemix classification is based, in part, on 

the beneficiary’s need for skilled 

nursing care and therapy, we have 

attempted, where possible, to coordinate 

claims review procedures with the 

existing resident assessment process 

and case-mix classification system. As 

further discussed in section III.E. of this 

notice, in FY 2013, this approach 

includes an administrative presumption 

that utilizes a beneficiary’s initial 

classification in one of the upper 52 

RUGs of the 66-group RUG–IV case-mix 

classification system to assist in making 

certain SNF level of care 

determinations. In the July 30, 1999 

final rule (64 FR 41670), we indicated 

that we would announce any changes to 

the guidelines for Medicare level of care 

determinations related to modifications 

in the case-mix classification structure 

(see section III.E. of this notice for a 

more detailed discussion of the 

relationship between the case-mix 

classification system and SNF level of 

care determinations). 

• Consolidated Billing. The SNF PPS 

includes a consolidated billing 

provision that requires a SNF to submit 

consolidated Medicare bills to its fiscal 

intermediary or Medicare 

Administrative Contractor for almost all 

of the services that its residents receive 

during the course of a covered Part A 

stay. In addition, this provision places 

with the SNF the Medicare billing 

responsibility for physical therapy, 

occupational therapy, and speechlanguage pathology services that the 

resident receives during a noncovered 

stay. The statute excludes a small list of 

services from the consolidated billing 

provision (primarily those of physicians 

and certain other types of practitioners), 

which remain separately billable under 

Part B when furnished to a SNF’s Part 

A resident. A more detailed discussion 

of this provision appears in section VI. 

of this notice. 

• Application of the SNF PPS to SNF 

services furnished by swing-bed 

hospitals. Section 1883 of the Act 

permits certain small, rural hospitals to 

enter into a Medicare swing-bed 

agreement, under which the hospital 

can use its beds to provide either acute 

or SNF care, as needed. For critical 

access hospitals (CAHs), Part A pays on 

a reasonable cost basis for SNF services 

furnished under a swing-bed agreement. 

However, in accordance with section 

1888(e)(7) of the Act, these services 

furnished by non-CAH rural hospitals 

are paid under the SNF PPS, effective 

with cost reporting periods beginning 

on or after July 1, 2002. A more detailed 

discussion of this provision appears in 

section VII. of this notice. 

B. Requirements of the Balanced Budget 

Act of 1997 (BBA) for Updating the 

Prospective Payment System for Skilled 

Nursing Facilities 

As added by section 4432(a) of the 

BBA, section 1888(e)(4)(H) of the Act 

requires that we provide for publication 

annually in the Federal Register: 

1. The unadjusted Federal per diem 

rates to be applied to days of covered 

SNF services furnished during the 

upcoming FY. 

2. The case-mix classification system 

to be applied with respect to these 

services during the upcoming FY. 

3. The factors to be applied in making 

the area wage adjustment with respect 

to these services. 


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This notice provides these required 

annual updates to the Federal rates. 

C. The Medicare, Medicaid, and SCHIP 

Balanced Budget Refinement Act of 

1999 (BBRA) 

There were several provisions in the 

BBRA (Pub. L. 106–113, enacted on 

November 29, 1999) that resulted in 

adjustments to the SNF PPS. We 

described these provisions in detail in 

the SNF PPS final rule for FY 2001 (65 

FR 46770, July 31, 2000). In particular, 

section 101(a) of the BBRA provided for 

a temporary 20 percent increase in the 

per diem adjusted payment rates for 15 

specified groups in the original, 44- 

group Resource Utilization Groups, 

version 3 (RUG–III) case-mix 

classification system. In accordance 

with section 101(c)(2) of the BBRA, this 

temporary payment adjustment expired 

on January 1, 2006, upon the 

implementation of a refined, 53-group 

version of the RUG–III system, RUG–53 

(see section II.G.1. of this notice). We 

included further information on BBRA 

provisions that affected the SNF PPS in 

Program Memoranda A–99–53 and 

A–99–61 (December 1999). 

Also, section 103 of the BBRA 

designated certain additional services 

for exclusion from the consolidated 

billing requirement, as discussed in 

section VI. of this notice. Further, for 

swing-bed hospitals with more than 49 

(but less than 100) beds, section 408 of 

the BBRA provided for the repeal of 

certain statutory restrictions on length 

of stay and aggregate payment for 

patient days, effective with the end of 

the SNF PPS transition period described 

in section 1888(e)(2)(E) of the Act. In the 

final rule for FY 2002 (66 FR 39562, July 

31, 2001), we made conforming changes 

to the regulations at § 413.114(d), 

effective for services furnished in cost 

reporting periods beginning on or after 

July 1, 2002, to reflect section 408 of the 

BBRA. 

D. The Medicare, Medicaid, and SCHIP 

Benefits Improvement and Protection 

Act of 2000 (BIPA) 

The BIPA (Pub. L. 106–554, enacted 

December 21, 2000) also included 

several provisions that resulted in 

adjustments to the SNF PPS. We 

described these provisions in detail in 

the final rule for FY 2002 (66 FR 39562, 

July 31, 2001). In particular: 

• Section 203 of the BIPA exempted 

CAH swing beds from the SNF PPS. We 

included further information on this 

provision in Program Memorandum 

A–01–09 (Change Request #1509), 

issued January 16, 2001, which is 

available online at www.cms.gov/ 

transmittals/downloads/a0109.pdf. 

• Section 311 of the BIPA revised the 

statutory update formula for the SNF 

market basket, and also directed us to 

conduct a study of alternative case-mix 

classification systems for the SNF PPS. 

In 2006, we submitted a report to the 

Congress on this study, which is 

available online at www.cms.gov/ 

SNFPPS/Downloads/RC_2006_PCPPSSNF.pdf. 

• Section 312 of the BIPA provided 

for a temporary increase of 16.66 

percent in the nursing component of the 

case-mix adjusted Federal rate for 

services furnished on or after April 1, 

2001, and before October 1, 2002; 

accordingly, this add-on is no longer in 

effect. This section also directed the 

Government Accountability Office 

(GAO) to conduct an audit of SNF 

nursing staff ratios and submit a report 

to the Congress on whether the 

temporary increase in the nursing 

component should be continued. The 

report (GAO–03–176), which GAO 

issued in November 2002, is available 

online at www.gao.gov/new.items/ 

d03176.pdf. 

• Section 313 of the BIPA repealed 

the consolidated billing requirement for 

services (other than physical therapy, 

occupational therapy, and speechlanguage pathology services) furnished 

to SNF residents during noncovered 

stays, effective January 1, 2001. (A more 

detailed discussion of this provision 

appears in section VI. of this notice.) 

• Section 314 of the BIPA corrected 

an anomaly involving three of the RUGs 

that section 101(a) of the BBRA had 

designated to receive the temporary 

payment adjustment discussed above in 

section I.C. of this notice. (As noted 

previously, in accordance with section 

101(c)(2) of the BBRA, this temporary 

payment adjustment expired upon the 

implementation of case-mix refinements 

on January 1, 2006.) 

• Section 315 of the BIPA authorized 

us to establish a geographic 

reclassification procedure that is 

specific to SNFs, but only after 

collecting the data necessary to establish 

a SNF wage index that is based on wage 

data from nursing homes. To date, this 

has proven to be unfeasible due to the 

volatility of existing SNF wage data and 

the significant amount of resources that 

would be required to improve the 

quality of that data. 

We included further information on 

several of the BIPA provisions in 

Program Memorandum A–01–08 

(Change Request #1510), issued January 

16, 2001, which is available online at 

www.cms.gov/transmittals/downloads/ 

a0108.pdf. 

E. The Medicare Prescription Drug, 

Improvement, and Modernization Act of 

2003 (MMA) 

The MMA (Pub. L. 108–173, enacted 

on December 8, 2003) included a 

provision that resulted in a further 

adjustment to the SNF PPS. Specifically, 

section 511 of the MMA amended 

section 1888(e)(12) of the Act, to 

provide for a temporary increase of 128 

percent in the PPS per diem payment 

for any SNF residents with Acquired 

Immune Deficiency Syndrome (AIDS), 

effective with services furnished on or 

after October 1, 2004. This special AIDS 

add-on was to remain in effect until 

‘‘* * * the Secretary certifies that there 

is an appropriate adjustment in the case 

mix * * * to compensate for the 

increased costs associated with [such] 

residents * * *.’’ The AIDS add-on is 

also discussed in Program Transmittal 

#160 (Change Request #3291), issued on 

April 30, 2004, which is available 

online at www.cms.gov/transmittals/ 

downloads/r160cp.pdf. In the SNF PPS 

final rule for FY 2010 (74 FR 40288, 

August 11, 2009), we did not address 

the certification of the AIDS add-on in 

that final rule’s implementation of the 

case-mix refinements for RUG–IV, thus 

allowing the temporary add-on payment 

created by section 511 of the MMA to 

remain in effect. 

For the limited number of SNF 

residents that qualify for the AIDS addon, implementation of this provision 

results in a significant increase in 

payment. For example, using FY 2010 

data, we identified less than 3,800 SNF 

residents with a diagnosis code of 042 

(Human Immunodeficiency Virus (HIV) 

Infection). For FY 2013, an urban 

facility with a resident with AIDS in 

RUG–IV group ‘‘HC2’’ would have a 

case-mix adjusted payment of $408.88 

(see Table 4) before the application of 

the MMA adjustment. After an increase 

of 128 percent, this urban facility would 

receive a case-mix adjusted payment of 

approximately $932.25. 

In addition, section 410 of the MMA 

contained a provision that excluded 

from consolidated billing certain 

services furnished to SNF residents by 

rural health clinics (RHCs) and 

Federally Qualified Health Centers 

(FQHCs). (Further information on this 

provision appears in section VI. of this 

notice.) 

F. The Affordable Care Act 

On March 23, 2010, the Patient 

Protection and Affordable Care Act, 

Pub. L. 111–148, was enacted. 

Following the enactment of Public Law 

111–148, the Health Care and Education 

Reconciliation Act of 2010 (Pub. L. 111– 


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152, enacted on March 30, 2010) 

amended certain provisions of Public 

Law 111–148 and certain sections of the 

statute and, in certain instances, 

included ‘‘freestanding’’ provisions 

(Pub. L. 111–148 and Pub. L. 111–152 

are collectively referred to in this notice 

as the ‘‘Affordable Care Act’’). Section 

10325 of the Affordable Care Act 

included a provision involving the SNF 

PPS. Section 10325 of the Affordable 

Care Act postponed the implementation 

of the RUG–IV case-mix classification 

system published in the FY 2010 SNF 

PPS final rule (74 FR 40288, August 11, 

2009), requiring that the Secretary not 

implement the RUG–IV case-mix 

classification system before October 1, 

2011. Notwithstanding this 

postponement of overall RUG–IV 

implementation, section 10325 of the 

Affordable Care Act further specified 

that the Secretary implement, effective 

October 1 2010, the changes related to 

concurrent therapy and the look-back 

period that were finalized as 

components of RUG–IV (see 74 FR 

40315–19, 40322–24, August 11, 2009). 

As we noted in the FY 2011 SNF PPS 

notice with comment period (75 FR 

42889), implementing the particular 

combination of RUG–III and RUG–IV 

features specified in section 10325 of 

the Affordable Care Act would require 

developing a revised grouper, something 

that could not be accomplished by that 

provision’s effective date (October 1, 

2010) without risking serious disruption 

to providers, suppliers, and State 

agencies. Accordingly, in the FY 2011 

notice with comment period (75 FR 

42889), we announced our intention to 

proceed on an interim basis with 

implementation of the full RUG–IV 

case-mix classification system as of 

October 1, 2010, followed by a 

retroactive claims adjustment, using a 

hybrid RUG–III (HR–III) system 

reflecting the Affordable Care Act 

configuration, once we had developed a 

revised grouper that could 

accommodate it. 

However, section 202 of the Medicare 

and Medicaid Extenders Act of 2010 

(Pub. L. 111–309, enacted on December 

15, 2010) subsequently repealed section 

10325 of the Affordable Care Act. We 

have, therefore, left in place 

permanently the implementation of the 

full RUG–IV system as of FY 2011, as 

finalized in the FY 2010 SNF PPS final 

rule (74 FR 40288). In addition, we note 

that implementation of version 3.0 of 

the Minimum Data Set (MDS 3.0) 

proceeded as originally scheduled, with 

an effective date of October 1, 2010. The 

MDS 3.0 RAI Manual and MDS 3.0 Item 

Set are published on the MDS 3.0 

Training Materials Web site, at http:// 

www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/ 

MDS30RAIManual.html. Accordingly, 

as discussed above, effective October 1, 

2010, we implemented and began 

paying claims under the RUG–IV system 

that was finalized in the FY 2010 SNF 

PPS final rule. 

We note that a parity adjustment was 

applied to the RUG–53 nursing case-mix 

weights when the RUG–III system was 

initially refined in 2006, in order to 

ensure that the implementation of the 

refinements would not cause any 

change in overall payment levels (70 FR 

45031, August 4, 2005). Similarly, a 

parity adjustment was applied to the 

RUG–IV nursing case-mix weights for 

FY 2011 when the new classification 

system was implemented. A detailed 

discussion of the parity adjustment in 

the specific context of the RUG–IV 

payment rates appears in the FY 2010 

SNF PPS proposed rule (74 FR 22236– 

38, May 12, 2009) and final rule (74 FR 

40338–40339, August 11, 2009), and in 

the FY 2011 notice with comment 

period (75 FR 42892–42893). 

For FY 2012, the RUG–IV parity 

adjustment was recalibrated in order to 

restore the intended parity in overall 

payments between the RUG–IV and 

RUG–53 case mix classification systems, 

as discussed in the FY 2012 SNF PPS 

proposed rule (76 FR 26370–26373, May 

6, 2011) and final rule (76 FR 48492– 

48500, 48537–48538 August 8, 2011). 

G. Skilled Nursing Facility Prospective 

Payment—General Overview 

We implemented the Medicare SNF 

PPS effective with cost reporting 

periods beginning on or after July 1, 

1998. This methodology uses 

prospective, case-mix adjusted per diem 

payment rates applicable to all covered 

SNF services. These payment rates 

cover all costs of furnishing covered 

SNF services (routine, ancillary, and 

capital-related costs) other than costs 

associated with approved educational 

activities and bad debts. Covered SNF 

services include post-hospital services 

for which benefits are provided under 

Part A, as well as those items and 

services (other than physician and 

certain other services specifically 

excluded under the BBA) which, before 

July 1, 1998, had been paid under Part 

B but furnished to Medicare 

beneficiaries in a SNF during a covered 

Part A stay. A comprehensive 

discussion of these provisions appears 

in the May 12, 1998 interim final rule 

(63 FR 26252). 

1. Payment Provisions—Federal Rate 

The PPS uses per diem Federal 

payment rates based on mean SNF costs 

in a base year (FY 1995) updated for 

inflation to the first effective period of 

the PPS. We developed the Federal 

payment rates using allowable costs 

from hospital-based and freestanding 

SNF cost reports for reporting periods 

beginning in FY 1995. The data used in 

developing the Federal rates also 

incorporated an estimate of the amounts 

that would be payable under Part B for 

covered SNF services furnished to 

individuals during the course of a 

covered Part A stay in a SNF. 

In developing the rates for the initial 

period, we updated costs to the first 

effective year of the PPS (the 15-month 

period beginning July 1, 1998) using a 

SNF market basket index, and then 

standardized for the costs of facility 

differences in case mix and for 

geographic variations in wages. In 

compiling the database used to compute 

the Federal payment rates, we excluded 

those providers that received new 

provider exemptions from the routine 

cost limits, as well as costs related to 

payments for exceptions to the routine 

cost limits. Using the formula that the 

BBA prescribed, we set the Federal rates 

at a level equal to the weighted mean of 

freestanding costs plus 50 percent of the 

difference between the freestanding 

mean and weighted mean of all SNF 

costs (hospital-based and freestanding) 

combined. We computed and applied 

separately the payment rates for 

facilities located in urban and rural 

areas. In addition, we adjusted the 

portion of the Federal rate attributable 

to wage-related costs by a wage index. 

The Federal rate also incorporates 

adjustments to account for facility casemix, using a classification system that 

accounts for the relative resource 

utilization of different patient types. 

The RUG–IV classification system uses 

beneficiary assessment data from the 

MDS 3.0 completed by SNFs to assign 

beneficiaries to one of 66 RUG–IV 

groups. The original RUG–III case-mix 

classification system used beneficiary 

assessment data from the MDS, version 

2.0 (MDS 2.0) completed by SNFs to 

assign beneficiaries to one of 44 RUG– 

III groups. Then, under incremental 

refinements that became effective on 

January 1, 2006, we added nine new 

groups—comprising a new 

Rehabilitation plus Extensive Services 

category—at the top of the RUG–III 

hierarchy. The May 12, 1998 interim 

final rule (63 FR 26252) included a 

detailed description of the original 44- 

group RUG–III case-mix classification 

system. A comprehensive description of 


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the refined RUG–53 system appeared in 

the proposed and final rules for FY 2006 

(70 FR 29070, May 19, 2005, and 70 FR 

45026, August 4, 2005), and a detailed 

description of the current 66-group 

RUG–IV system appeared in the 

proposed and final rules for FY 2010 (74 

FR 22208, May 12, 2009, and 74 FR 

40288, August 11, 2009). 

Further, in accordance with sections 

1888(e)(4)(E)(ii)(IV) and (e)(5) of the Act, 

the Federal rates in this notice reflect an 

update to the rates that we published in 

the final rule for FY 2012 (76 FR 48486, 

August 8, 2011) and the associated 

correction notice (76 FR 59265, 

September 26, 2011), equal to the full 

change in the SNF market basket index, 

adjusted by the forecast error correction, 

if applicable, and the Multifactor 

Productivity (MFP) adjustment for FY 

2013. A more detailed discussion of the 

SNF market basket index and related 

issues appears in sections II.G.2. and V. 

of this notice. 

2. FY 2013 Rate Updates Using the 

Skilled Nursing Facility Market Basket 

Index 

Section 1888(e)(5) of the Act requires 

us to establish a SNF market basket 

index that reflects changes over time in 

the prices of an appropriate mix of 

goods and services included in covered 

SNF services. We use the SNF market 

basket index, adjusted in the manner 

described below, to update the Federal 

rates on an annual basis. In the SNF PPS 

final rule for FY 2008 (72 FR 43425 

through 43430, August 3, 2007), we 

revised and rebased the market basket, 

which included updating the base year 

from FY 1997 to FY 2004. The FY 2013 

market basket increase is 2.5 percent, 

which is based on IHS Global Insight, 

Inc. (IGI) second quarter 2012 forecast 

with historical data through first quarter 

2012. 

In addition, as explained in the final 

rule for FY 2004 (66 FR 46058, August 

4, 2003) and in section V.B. of this 

notice, the annual update of the 

payment rates includes, as appropriate, 

an adjustment to account for market 

basket forecast error. As described in the 

final rule for FY 2008, the threshold 

percentage that serves to trigger an 

adjustment to account for market basket 

forecast error is 0.5 percentage point 

effective for FY 2008 and subsequent 

years. This adjustment takes into 

account the forecast error from the most 

recently available FY for which there is 

final data, and applies whenever the 

difference between the forecasted and 

actual change in the market basket 

exceeds a 0.5 percentage point 

threshold. For FY 2011 (the most 

recently available FY for which there is 

final data), the estimated increase in the 

market basket index was 2.3 percentage 

points, while the actual increase was 2.2 

percentage points, resulting in the 

actual increase being 0.1 percentage 

point lower than the estimated increase. 

Accordingly, as the difference between 

the estimated and actual amount of 

change does not exceed the 0.5 

percentage point threshold, the payment 

rates for FY 2013 do not include a 

forecast error adjustment. As we stated 

in the final rule for FY 2004 that first 

promulgated the forecast error 

adjustment (68 FR 46058, August 4, 

2003), the adjustment will ‘‘* * * 

reflect both upward and downward 

adjustments, as appropriate.’’ Table 1 

shows the forecasted and actual market 

basket amounts for FY 2011. 

TABLE 1—DIFFERENCE BETWEEN THE FORECASTED AND ACTUAL MARKET BASKET INCREASES FOR FY 2011 

Index 

Forecasted FY 

2011 

increase * 

Actual FY 

2011 

increase ** 

FY 2011 

difference 

SNF .............................................................................................................................................. 2.3 2.2 ¥0.1 

* Published in Federal Register; based on second quarter 2010 IGI forecast (2004-based index). 

** Based on the second quarter 2012 IGI forecast, with historical data through the first quarter 2012 (2004-based index). 

Furthermore, effective FY 2012, as 

required by section 3401(b) of the 

Affordable Care Act, the market basket 

percentage is reduced by a productivity 

adjustment equal to ‘‘the 10-year 

moving average of changes in annual 

economy-wide private nonfarm business 

multi-factor productivity (as projected 

by the Secretary for the 10-year period 

ending with the applicable fiscal year, 

year, cost-reporting period or other 

annual period)’’ (the MFP adjustment). 

As discussed in greater detail in section 

V.C of this notice, the MFP adjustment 

for FY 2013 is 0.7 percent. 

III. FY 2013 Annual Update of Payment 

Rates Under the Prospective Payment 

System for Skilled Nursing Facilities 

A. Federal Prospective Payment System 

This notice sets forth a schedule of 

Federal prospective payment rates 

applicable to Medicare Part A SNF 

services beginning October 1, 2012. The 

schedule incorporates per diem Federal 

rates that provide Part A payment for 

almost all costs of services furnished to 

a beneficiary in a SNF during a Part A 

Medicare-covered stay. 

1. Costs and Services Covered by the 

Federal Rates 

In accordance with section 

1888(e)(2)(B) of the Act, the Federal 

rates apply to all costs (routine, 

ancillary, and capital-related) of covered 

SNF services other than costs associated 

with approved educational activities as 

defined in § 413.85. Under section 

1888(e)(2)(A)(i) of the Act, covered SNF 

services include post-hospital SNF 

services for which benefits are provided 

under Part A (the hospital insurance 

program), as well as all items and 

services (other than those services 

excluded by statute) that, before July 1, 

1998, were paid under Part B (the 

supplementary medical insurance 

program) but furnished to Medicare 

beneficiaries in a SNF during a Part A 

covered stay. (These excluded service 

categories are discussed in greater detail 

in section V.B.2 of the May 12, 1998 

interim final rule (63 FR 26295 through 

26297)). 

2. Methodology Used for the Calculation 

of the Federal Rates 

The FY 2013 rates reflect an update 

using the latest market basket index, 

reduced by the MFP adjustment. The FY 

2013 market basket increase factor is 2.5 

percent, which as discussed in section 

V.C of this notice, is reduced by a 0.7 

percent MFP adjustment. A complete 

description of the multi-step process 

used to calculate Federal rates initially 

appeared in the May 12, 1998 interim 

final rule (63 FR 26252), as further 

revised in subsequent rules. As 

explained above in section II.C of this 

notice, under section 101(c)(2) of the 

BBRA, the previous temporary increases 

in the per diem adjusted payment rates 

for certain designated RUGs (as 

specified in section 101(a) of the BBRA 

and section 314 of the BIPA) are no 

longer in effect due to the 

implementation of case-mix refinements 

as of January 1, 2006. However, the 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 46219 

temporary increase of 128 percent in the 

per diem adjusted payment rates for 

SNF residents with AIDS, enacted by 

section 511 of the MMA, remains in 

effect. 

We used the SNF market basket to 

adjust each per diem component of the 

Federal rates forward to reflect cost 

increases occurring between the 

midpoint of the Federal FY beginning 

October 1, 2011, and ending September 

30, 2012, and the midpoint of the 

Federal FY beginning October 1, 2012, 

and ending September 30, 2013, to 

which the payment rates apply. In 

accordance with sections 

1888(e)(4)(E)(ii)(IV) and (e)(5) of the Act, 

we update the payment rates for FY 

2013 by a factor equal to the market 

basket index percentage change, as 

discussed in sections II.G.2 and V. of 

this notice. As further explained in 

sections II.G.2 and V. of this notice, as 

applicable, we adjust the market basket 

index by the forecast error from the 

most recently available FY for which 

there is final data and apply this 

adjustment whenever the difference 

between the forecasted and actual 

change in the market basket exceeds a 

0.5 percentage point threshold. In 

addition, as further explained in 

sections II.G.2 and V. of this notice, 

effective FY 2012 and each subsequent 

fiscal year, we are required to reduce the 

market basket percentage by the MFP 

adjustment. We further adjust the rates 

by a wage index budget neutrality 

factor, described later in this section. 

Tables 2 and 3 reflect the updated 

components of the unadjusted Federal 

rates for FY 2013, prior to adjustment 

for case-mix. 

TABLE 2—FY 2013 UNADJUSTED FEDERAL RATE PER DIEM URBAN

Rate component Nursing— 

case-mix 

Therapy— 

case-mix 

Therapy— 

Non-case-mix Non-case-mix 

Per Diem Amount ............................................................................................ $163.58 $123.22 $16.23 $83.48 

TABLE 3—FY 2013 UNADJUSTED FEDERAL RATE PER DIEM RURAL

Rate component Nursing— 

case-mix 

Therapy— 

case-mix 

Therapy— 

non-case-mix Non-case-mix 

Per Diem Amount ............................................................................................ $156.28 $142.08 $17.33 $85.03 

B. Case-Mix Adjustments 

1. Background 

Section 1888(e)(4)(G)(i) of the Act 

requires the Secretary to make an 

adjustment to account for case mix. The 

statute specifies that the adjustment is 

to reflect both a resident classification 

system that the Secretary establishes to 

account for the relative resource use of 

different patient types, as well as 

resident assessment and other data that 

the Secretary considers appropriate. In 

first implementing the SNF PPS (63 FR 

26252, May 12, 1998), we developed the 

RUG–III case-mix classification system, 

which tied the amount of payment to 

resident resource use in combination 

with resident characteristic information. 

Staff time measurement (STM) studies 

conducted in 1990, 1995, and 1997 

provided information on resource use 

(time spent by staff members on 

residents) and resident characteristics 

that enabled us not only to establish 

RUG–III, but also to create case-mix 

indexes (CMIs). 

Although the establishment of the 

SNF PPS did not change Medicare’s 

fundamental requirements for SNF 

coverage, there is a correlation between 

level of care and provider payment. One 

of the elements affecting the SNF PPS 

per diem rates is the case-mix 

adjustment derived from a classification 

system based on comprehensive 

resident assessments using the MDS. 

Case-mix classification is based, in part, 

on the beneficiary’s need for skilled 

nursing care and therapy. The case-mix 

classification system uses clinical data 

from the MDS, and wage-adjusted staff 

time measurement data, to assign a casemix group to each patient record that is 

then used to calculate a per diem 

payment under the SNF PPS. Because 

the MDS is used as basis for payment as 

well as a clinical document, we have 

provided extensive training on proper 

coding and the time frames for MDS 

completion in our Resident Assessment 

Instrument (RAI) Manual. For an MDS 

to be considered valid for use in 

determining payment, the MDS 

assessment must be completed in 

compliance with the instructions in the 

RAI Manual in effect at the time the 

assessment is completed. For payment 

and quality monitoring purposes, the 

RAI Manual consists of both the Manual 

instructions and the interpretive 

guidance and policy clarifications 

posted on the appropriate MDS Web site 

at http://www.cms.gov/Medicare/ 

Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/ 

MDS30RAIManual.html. 

The original RUG–III grouper logic 

was based on clinical data collected in 

1990, 1995, and 1997. As discussed in 

the SNF PPS proposed rule for FY 2010 

(74 FR 22208, May 12, 2009), we 

subsequently conducted a multi-year 

data collection and analysis under the 

Staff Time and Resource Intensity 

Verification (STRIVE) project to update 

the case-mix classification system for 

FY 2011. The resulting RUG–IV casemix classification system reflected the 

data collected in 2006–2007 during the 

STRIVE project, and was finalized in the 

FY 2010 SNF PPS final rule (74 FR 

40288, August 11, 2009) to take effect in 

FY 2011 concurrently with an updated 

new resident assessment instrument, the 

MDS 3.0, which collects the clinical 

data used for case-mix classification 

under RUG–IV. 

Under the BBA, each update of the 

SNF PPS payment rates must include 

the case-mix classification methodology 

applicable for the coming Federal FY. 

As indicated in section II.G of this 

notice, the payment rates set forth 

herein reflect the use of the RUG–IV 

case-mix classification system from 

October 1, 2012, through September 30, 

2013. 

We list the case-mix adjusted RUG–IV 

payment rates, provided separately for 

urban and rural SNFs, in Tables 4 and 

5 with corresponding case-mix values. 

These tables do not reflect the AIDS 

add-on enacted by section 511 of the 

MMA, which we apply only after 

making all other adjustments (such as 

wage and case-mix). 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46220 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

TABLE 4—RUG–IV CASE-MIX ADJUSTED FEDERAL RATES AND ASSOCIATED INDEXES URBAN

RUG-IV category Nursing 

index 

Therapy 

index 

Nursing 

component 

Therapy 

component 

Non-case 

mix therapy 

comp 

Non-case 

mix component Total rate 

RUX .......................................................... 2.67 1.87 $436.76 $230.42 .................... $83.48 $750.66 

RUL .......................................................... 2.57 1.87 420.40 230.42 .................... 83.48 734.30 

RVX .......................................................... 2.61 1.28 426.94 157.72 .................... 83.48 668.14 

RVL .......................................................... 2.19 1.28 358.24 157.72 .................... 83.48 599.44 

RHX .......................................................... 2.55 0.85 417.13 104.74 .................... 83.48 605.35 

RHL .......................................................... 2.15 0.85 351.70 104.74 .................... 83.48 539.92 

RMX ......................................................... 2.47 0.55 404.04 67.77 .................... 83.48 555.29 

RML .......................................................... 2.19 0.55 358.24 67.77 .................... 83.48 509.49 

RLX .......................................................... 2.26 0.28 369.69 34.50 .................... 83.48 487.67 

RUC ......................................................... 1.56 1.87 255.18 230.42 .................... 83.48 569.08 

RUB .......................................................... 1.56 1.87 255.18 230.42 .................... 83.48 569.08 

RUA .......................................................... 0.99 1.87 161.94 230.42 .................... 83.48 475.84 

RVC .......................................................... 1.51 1.28 247.01 157.72 .................... 83.48 488.21 

RVB .......................................................... 1.11 1.28 181.57 157.72 .................... 83.48 422.77 

RVA .......................................................... 1.10 1.28 179.94 157.72 .................... 83.48 421.14 

RHC ......................................................... 1.45 0.85 237.19 104.74 .................... 83.48 425.41 

RHB .......................................................... 1.19 0.85 194.66 104.74 .................... 83.48 382.88 

RHA .......................................................... 0.91 0.85 148.86 104.74 .................... 83.48 337.08 

RMC ......................................................... 1.36 0.55 222.47 67.77 .................... 83.48 373.72 

RMB ......................................................... 1.22 0.55 199.57 67.77 .................... 83.48 350.82 

RMA ......................................................... 0.84 0.55 137.41 67.77 .................... 83.48 288.66 

RLB .......................................................... 1.50 0.28 245.37 34.50 .................... 83.48 363.35 

RLA .......................................................... 0.71 0.28 116.14 34.50 .................... 83.48 234.12 

ES3 .......................................................... 3.58 .................... 585.62 .................... 16.23 83.48 685.33 

ES2 .......................................................... 2.67 .................... 436.76 .................... 16.23 83.48 536.47 

ES1 .......................................................... 2.32 .................... 379.51 .................... 16.23 83.48 479.22 

HE2 .......................................................... 2.22 .................... 363.15 .................... 16.23 83.48 462.86 

HE1 .......................................................... 1.74 .................... 284.63 .................... 16.23 83.48 384.34 

HD2 .......................................................... 2.04 .................... 333.70 .................... 16.23 83.48 433.41 

HD1 .......................................................... 1.60 .................... 261.73 .................... 16.23 83.48 361.44 

HC2 .......................................................... 1.89 .................... 309.17 .................... 16.23 83.48 408.88 

HC1 .......................................................... 1.48 .................... 242.10 .................... 16.23 83.48 341.81 

HB2 .......................................................... 1.86 .................... 304.26 .................... 16.23 83.48 403.97 

HB1 .......................................................... 1.46 .................... 238.83 .................... 16.23 83.48 338.54 

LE2 ........................................................... 1.96 .................... 320.62 .................... 16.23 83.48 420.33 

LE1 ........................................................... 1.54 .................... 251.91 .................... 16.23 83.48 351.62 

LD2 ........................................................... 1.86 .................... 304.26 .................... 16.23 83.48 403.97 

LD1 ........................................................... 1.46 .................... 238.83 .................... 16.23 83.48 338.54 

LC2 ........................................................... 1.56 .................... 255.18 .................... 16.23 83.48 354.89 

LC1 ........................................................... 1.22 .................... 199.57 .................... 16.23 83.48 299.28 

LB2 ........................................................... 1.45 .................... 237.19 .................... 16.23 83.48 336.90 

LB1 ........................................................... 1.14 .................... 186.48 .................... 16.23 83.48 286.19 

CE2 .......................................................... 1.68 .................... 274.81 .................... 16.23 83.48 374.52 

CE1 .......................................................... 1.50 .................... 245.37 .................... 16.23 83.48 345.08 

CD2 .......................................................... 1.56 .................... 255.18 .................... 16.23 83.48 354.89 

CD1 .......................................................... 1.38 .................... 225.74 .................... 16.23 83.48 325.45 

CC2 .......................................................... 1.29 .................... 211.02 .................... 16.23 83.48 310.73 

CC1 .......................................................... 1.15 .................... 188.12 .................... 16.23 83.48 287.83 

CB2 .......................................................... 1.15 .................... 188.12 .................... 16.23 83.48 287.83 

CB1 .......................................................... 1.02 .................... 166.85 .................... 16.23 83.48 266.56 

CA2 .......................................................... 0.88 .................... 143.95 .................... 16.23 83.48 243.66 

CA1 .......................................................... 0.78 .................... 127.59 .................... 16.23 83.48 227.30 

BB2 .......................................................... 0.97 .................... 158.67 .................... 16.23 83.48 258.38 

BB1 .......................................................... 0.90 .................... 147.22 .................... 16.23 83.48 246.93 

BA2 .......................................................... 0.70 .................... 114.51 .................... 16.23 83.48 214.22 

BA1 .......................................................... 0.64 .................... 104.69 .................... 16.23 83.48 204.40 

PE2 .......................................................... 1.50 .................... 245.37 .................... 16.23 83.48 345.08 

PE1 .......................................................... 1.40 .................... 229.01 .................... 16.23 83.48 328.72 

PD2 .......................................................... 1.38 .................... 225.74 .................... 16.23 83.48 325.45 

PD1 .......................................................... 1.28 .................... 209.38 .................... 16.23 83.48 309.09 

PC2 .......................................................... 1.10 .................... 179.94 .................... 16.23 83.48 279.65 

PC1 .......................................................... 1.02 .................... 166.85 .................... 16.23 83.48 266.56 

PB2 .......................................................... 0.84 .................... 137.41 .................... 16.23 83.48 237.12 

PB1 .......................................................... 0.78 .................... 127.59 .................... 16.23 83.48 227.30 

PA2 .......................................................... 0.59 .................... 96.51 .................... 16.23 83.48 196.22 

PA1 .......................................................... 0.54 .................... 88.33 .................... 16.23 83.48 188.04 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 46221 

TABLE 5—RUG–IV CASE-MIX ADJUSTED FEDERAL RATES AND ASSOCIATED INDEXES RURAL

RUG–IV category Nursing 

index 

Therapy 

index 

Nursing 

component 

Therapy 

component 

Non-case 

mix therapy 

comp 

Non-case 

mix component Total rate 

RUX .......................................................... 2.67 1.87 $417.27 $265.69 .................... $85.03 $767.99 

RUL .......................................................... 2.57 1.87 401.64 265.69 .................... 85.03 752.36 

RVX .......................................................... 2.61 1.28 407.89 181.86 .................... 85.03 674.78 

RVL .......................................................... 2.19 1.28 342.25 181.86 .................... 85.03 609.14 

RHX .......................................................... 2.55 0.85 398.51 120.77 .................... 85.03 604.31 

RHL .......................................................... 2.15 0.85 336.00 120.77 .................... 85.03 541.80 

RMX ......................................................... 2.47 0.55 386.01 78.14 .................... 85.03 549.18 

RML .......................................................... 2.19 0.55 342.25 78.14 .................... 85.03 505.42 

RLX .......................................................... 2.26 0.28 353.19 39.78 .................... 85.03 478.00 

RUC ......................................................... 1.56 1.87 243.80 265.69 .................... 85.03 594.52 

RUB .......................................................... 1.56 1.87 243.80 265.69 .................... 85.03 594.52 

RUA .......................................................... 0.99 1.87 154.72 265.69 .................... 85.03 505.44 

RVC .......................................................... 1.51 1.28 235.98 181.86 .................... 85.03 502.87 

RVB .......................................................... 1.11 1.28 173.47 181.86 .................... 85.03 440.36 

RVA .......................................................... 1.10 1.28 171.91 181.86 .................... 85.03 438.80 

RHC ......................................................... 1.45 0.85 226.61 120.77 .................... 85.03 432.41 

RHB .......................................................... 1.19 0.85 185.97 120.77 .................... 85.03 391.77 

RHA .......................................................... 0.91 0.85 142.21 120.77 .................... 85.03 348.01 

RMC ......................................................... 1.36 0.55 212.54 78.14 .................... 85.03 375.71 

RMB ......................................................... 1.22 0.55 190.66 78.14 .................... 85.03 353.83 

RMA ......................................................... 0.84 0.55 131.28 78.14 .................... 85.03 294.45 

RLB .......................................................... 1.50 0.28 234.42 39.78 .................... 85.03 359.23 

RLA .......................................................... 0.71 0.28 110.96 39.78 .................... 85.03 235.77 

ES3 .......................................................... 3.58 .................... 559.48 .................... 17.33 85.03 661.84 

ES2 .......................................................... 2.67 .................... 417.27 .................... 17.33 85.03 519.63 

ES1 .......................................................... 2.32 .................... 362.57 .................... 17.33 85.03 464.93 

HE2 .......................................................... 2.22 .................... 346.94 .................... 17.33 85.03 449.30 

HE1 .......................................................... 1.74 .................... 271.93 .................... 17.33 85.03 374.29 

HD2 .......................................................... 2.04 .................... 318.81 .................... 17.33 85.03 421.17 

HD1 .......................................................... 1.60 .................... 250.05 .................... 17.33 85.03 352.41 

HC2 .......................................................... 1.89 .................... 295.37 .................... 17.33 85.03 397.73 

HC1 .......................................................... 1.48 .................... 231.29 .................... 17.33 85.03 333.65 

HB2 .......................................................... 1.86 .................... 290.68 .................... 17.33 85.03 393.04 

HB1 .......................................................... 1.46 .................... 228.17 .................... 17.33 85.03 330.53 

LE2 ........................................................... 1.96 .................... 306.31 .................... 17.33 85.03 408.67 

LE1 ........................................................... 1.54 .................... 240.67 .................... 17.33 85.03 343.03 

LD2 ........................................................... 1.86 .................... 290.68 .................... 17.33 85.03 393.04 

LD1 ........................................................... 1.46 .................... 228.17 .................... 17.33 85.03 330.53 

LC2 ........................................................... 1.56 .................... 243.80 .................... 17.33 85.03 346.16 

LC1 ........................................................... 1.22 .................... 190.66 .................... 17.33 85.03 293.02 

LB2 ........................................................... 1.45 .................... 226.61 .................... 17.33 85.03 328.97 

LB1 ........................................................... 1.14 .................... 178.16 .................... 17.33 85.03 280.52 

CE2 .......................................................... 1.68 .................... 262.55 .................... 17.33 85.03 364.91 

CE1 .......................................................... 1.50 .................... 234.42 .................... 17.33 85.03 336.78 

CD2 .......................................................... 1.56 .................... 243.80 .................... 17.33 85.03 346.16 

CD1 .......................................................... 1.38 .................... 215.67 .................... 17.33 85.03 318.03 

CC2 .......................................................... 1.29 .................... 201.60 .................... 17.33 85.03 303.96 

CC1 .......................................................... 1.15 .................... 179.72 .................... 17.33 85.03 282.08 

CB2 .......................................................... 1.15 .................... 179.72 .................... 17.33 85.03 282.08 

CB1 .......................................................... 1.02 .................... 159.41 .................... 17.33 85.03 261.77 

CA2 .......................................................... 0.88 .................... 137.53 .................... 17.33 85.03 239.89 

CA1 .......................................................... 0.78 .................... 121.90 .................... 17.33 85.03 224.26 

BB2 .......................................................... 0.97 .................... 151.59 .................... 17.33 85.03 253.95 

BB1 .......................................................... 0.90 .................... 140.65 .................... 17.33 85.03 243.01 

BA2 .......................................................... 0.70 .................... 109.40 .................... 17.33 85.03 211.76 

BA1 .......................................................... 0.64 .................... 100.02 .................... 17.33 85.03 202.38 

PE2 .......................................................... 1.50 .................... 234.42 .................... 17.33 85.03 336.78 

PE1 .......................................................... 1.40 .................... 218.79 .................... 17.33 85.03 321.15 

PD2 .......................................................... 1.38 .................... 215.67 .................... 17.33 85.03 318.03 

PD1 .......................................................... 1.28 .................... 200.04 .................... 17.33 85.03 302.40 

PC2 .......................................................... 1.10 .................... 171.91 .................... 17.33 85.03 274.27 

PC1 .......................................................... 1.02 .................... 159.41 .................... 17.33 85.03 261.77 

PB2 .......................................................... 0.84 .................... 131.28 .................... 17.33 85.03 233.64 

PB1 .......................................................... 0.78 .................... 121.90 .................... 17.33 85.03 224.26 

PA2 .......................................................... 0.59 .................... 92.21 .................... 17.33 85.03 194.57 

PA1 .......................................................... 0.54 .................... 84.39 .................... 17.33 85.03 186.75 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46222 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

C. Wage Index Adjustment to Federal 

Rates 

Section 1888(e)(4)(G)(ii) of the Act 

requires that we adjust the Federal rates 

to account for differences in area wage 

levels, using a wage index that we find 

appropriate. Since the inception of a 

PPS for SNFs, we have used hospital 

wage data in developing a wage index 

to be applied to SNFs. We are 

maintaining that practice for FY 2013, 

as we continue to believe that in the 

absence of SNF-specific wage data, 

using the hospital inpatient wage index 

is appropriate and reasonable for the 

SNF PPS. As explained in the update 

notice for FY 2005 (69 FR 45786, July 

30, 2004), the SNF PPS does not use the 

hospital area wage index’s occupational 

mix adjustment, as this adjustment 

serves specifically to define the 

occupational categories more clearly in 

a hospital setting; moreover, the 

collection of the occupational wage data 

also excludes any wage data related to 

SNFs. Therefore, we believe that using 

the updated wage data exclusive of the 

occupational mix adjustment continues 

to be appropriate for SNF payments. 

Finally, we continue to use the same 

methodology discussed in the SNF PPS 

final rule for FY 2008 (72 FR 43423) to 

address those geographic areas in which 

there are no hospitals and, thus, no 

hospital wage index data on which to 

base the calculation of the FY 2013 SNF 

PPS wage index. For rural geographic 

areas that do not have hospitals and, 

therefore, lack hospital wage data on 

which to base an area wage adjustment, 

we use the average wage index from all 

contiguous Core-Based Statistical Areas 

(CBSAs) as a reasonable proxy. For FY 

2013, there are no rural geographic areas 

that do not have hospitals, and thus this 

methodology will not be applied. For 

rural Puerto Rico, we do not apply this 

methodology due to the distinct 

economic circumstances that exist there, 

but instead continue using the most 

recent wage index previously available 

for that area. For urban areas without 

specific hospital wage index data, we 

use the average wage indexes of all of 

the urban areas within the State to serve 

as a reasonable proxy for the wage index 

of that urban CBSA. For FY 2013, the 

only urban area without wage index 

data available is CBSA 25980, 

Hinesville-Fort Stewart, GA. 

To calculate the SNF PPS wage index 

adjustment, we apply the wage index 

adjustment to the labor-related portion 

of the Federal rate, which is 68.383 

percent of the total rate. This percentage 

reflects the labor-related relative 

importance for FY 2013, using the 

revised and rebased FY 2004-based 

market basket. The labor-related relative 

importance for FY 2012 was 68.693, as 

shown in Table 13. We calculate the 

labor-related relative importance from 

the SNF market basket, and it 

approximates the labor-related portion 

of the total costs after taking into 

account historical and projected price 

changes between the base year and FY 

2013. The price proxies that move the 

different cost categories in the market 

basket do not necessarily change at the 

same rate, and the relative importance 

captures these changes. Accordingly, 

the relative importance figure more 

closely reflects the cost share weights 

for FY 2013 than the base year weights 

from the SNF market basket. 

We calculate the labor-related relative 

importance for FY 2013 in four steps. 

First, we compute the FY 2013 price 

index level for the total market basket 

and each cost category of the market 

basket. Second, we calculate a ratio for 

each cost category by dividing the FY 

2013 price index level for that cost 

category by the total market basket price 

index level. Third, we determine the FY 

2013 relative importance for each cost 

category by multiplying this ratio by the 

base year (FY 2004) weight. Finally, we 

add the FY 2013 relative importance for 

each of the labor-related cost categories 

(wages and salaries, employee benefits, 

non-medical professional fees, laborintensive services, and a portion of 

capital-related expenses) to produce the 

FY 2013 labor-related relative 

importance. Tables 6 and 7 below show 

the RUG–IV case-mix adjusted Federal 

rates by labor-related and non-laborrelated components. 

TABLE 6—RUG–IV CASE-MIX ADJUSTED FEDERAL RATES FOR URBAN

SNFS BY LABOR AND NON-LABOR

COMPONENT

RUG–IV 

category 

Total 

rate 

Labor 

portion 

Nonlabor 

portion 

RUX ............ $750.66 $513.32 $237.34 

RUL ............. 734.30 502.14 232.16 

RVX ............ 668.14 456.89 211.25 

RVL ............. 599.44 409.92 189.52 

RHX ............ 605.35 413.96 191.39 

RHL ............. 539.92 369.21 170.71 

RMX ............ 555.29 379.72 175.57 

RML ............ 509.49 348.40 161.09 

RLX ............. 487.67 333.48 154.19 

RUC ............ 569.08 389.15 179.93 

RUB ............ 569.08 389.15 179.93 

RUA ............ 475.84 325.39 150.45 

RVC ............ 488.21 333.85 154.36 

RVB ............ 422.77 289.10 133.67 

RVA ............ 421.14 287.99 133.15 

RHC ............ 425.41 290.91 134.50 

RHB ............ 382.88 261.82 121.06 

RHA ............ 337.08 230.51 106.57 

RMC ............ 373.72 255.56 118.16 

TABLE 6—RUG–IV CASE-MIX ADJUSTED FEDERAL RATES FOR URBAN

SNFS BY LABOR AND NON-LABOR

COMPONENT—Continued 

RUG–IV 

category 

Total 

rate 

Labor 

portion 

Nonlabor 

portion 

RMB ............ 350.82 239.90 110.92 

RMA ............ 288.66 197.39 91.27 

RLB ............. 363.35 248.47 114.88 

RLA ............. 234.12 160.10 74.02 

ES3 ............. 685.33 468.65 216.68 

ES2 ............. 536.47 366.85 169.62 

ES1 ............. 479.22 327.71 151.51 

HE2 ............. 462.86 316.52 146.34 

HE1 ............. 384.34 262.82 121.52 

HD2 ............. 433.41 296.38 137.03 

HD1 ............. 361.44 247.16 114.28 

HC2 ............. 408.88 279.60 129.28 

HC1 ............. 341.81 233.74 108.07 

HB2 ............. 403.97 276.25 127.72 

HB1 ............. 338.54 231.50 107.04 

LE2 ............. 420.33 287.43 132.90 

LE1 ............. 351.62 240.45 111.17 

LD2 ............. 403.97 276.25 127.72 

LD1 ............. 338.54 231.50 107.04 

LC2 ............. 354.89 242.68 112.21 

LC1 ............. 299.28 204.66 94.62 

LB2 ............. 336.90 230.38 106.52 

LB1 ............. 286.19 195.71 90.48 

CE2 ............. 374.52 256.11 118.41 

CE1 ............. 345.08 235.98 109.10 

CD2 ............. 354.89 242.68 112.21 

CD1 ............. 325.45 222.55 102.90 

CC2 ............. 310.73 212.49 98.24 

CC1 ............. 287.83 196.83 91.00 

CB2 ............. 287.83 196.83 91.00 

CB1 ............. 266.56 182.28 84.28 

CA2 ............. 243.66 166.62 77.04 

CA1 ............. 227.30 155.43 71.87 

BB2 ............. 258.38 176.69 81.69 

BB1 ............. 246.93 168.86 78.07 

BA2 ............. 214.22 146.49 67.73 

BA1 ............. 204.40 139.77 64.63 

PE2 ............. 345.08 235.98 109.10 

PE1 ............. 328.72 224.79 103.93 

PD2 ............. 325.45 222.55 102.90 

PD1 ............. 309.09 211.37 97.72 

PC2 ............. 279.65 191.23 88.42 

PC1 ............. 266.56 182.28 84.28 

PB2 ............. 237.12 162.15 74.97 

PB1 ............. 227.30 155.43 71.87 

PA2 ............. 196.22 134.18 62.04 

PA1 ............. 188.04 128.59 59.45 

TABLE 7—RUG–IV CASE-MIX ADJUSTED FEDERAL RATES FOR RURAL

SNFS BY LABOR AND NON-LABOR

COMPONENT

RUG–IV 

category 

Total 

rate 

Labor 

portion 

Nonlabor 

portion 

RUX ............ $767.99 $525.17 $242.82 

RUL ............. 752.36 514.49 237.87 

RVX ............ 674.78 461.43 213.35 

RVL ............. 609.14 416.55 192.59 

RHX ............ 604.31 413.25 191.06 

RHL ............. 541.80 370.50 171.30 

RMX ............ 549.18 375.55 173.63 

RML ............ 505.42 345.62 159.80 


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TABLE 7—RUG–IV CASE-MIX ADJUSTED FEDERAL RATES FOR RURAL

SNFS BY LABOR AND NON-LABOR

COMPONENT—Continued 

RUG–IV 

category 

Total 

rate 

Labor 

portion 

Nonlabor 

portion 

RLX ............. 478.00 326.87 151.13 

RUC ............ 594.52 406.55 187.97 

RUB ............ 594.52 406.55 187.97 

RUA ............ 505.44 345.64 159.80 

RVC ............ 502.87 343.88 158.99 

RVB ............ 440.36 301.13 139.23 

RVA ............ 438.80 300.06 138.74 

RHC ............ 432.41 295.69 136.72 

RHB ............ 391.77 267.90 123.87 

RHA ............ 348.01 237.98 110.03 

RMC ............ 375.71 256.92 118.79 

RMB ............ 353.83 241.96 111.87 

RMA ............ 294.45 201.35 93.10 

RLB ............. 359.23 245.65 113.58 

RLA ............. 235.77 161.23 74.54 

ES3 ............. 661.84 452.59 209.25 

ES2 ............. 519.63 355.34 164.29 

ES1 ............. 464.93 317.93 147.00 

HE2 ............. 449.30 307.24 142.06 

HE1 ............. 374.29 255.95 118.34 

HD2 ............. 421.17 288.01 133.16 

HD1 ............. 352.41 240.99 111.42 

HC2 ............. 397.73 271.98 125.75 

HC1 ............. 333.65 228.16 105.49 

HB2 ............. 393.04 268.77 124.27 

HB1 ............. 330.53 226.03 104.50 

LE2 ............. 408.67 279.46 129.21 

LE1 ............. 343.03 234.57 108.46 

LD2 ............. 393.04 268.77 124.27 

LD1 ............. 330.53 226.03 104.50 

LC2 ............. 346.16 236.71 109.45 

LC1 ............. 293.02 200.38 92.64 

LB2 ............. 328.97 224.96 104.01 

LB1 ............. 280.52 191.83 88.69 

CE2 ............. 364.91 249.54 115.37 

CE1 ............. 336.78 230.30 106.48 

CD2 ............. 346.16 236.71 109.45 

CD1 ............. 318.03 217.48 100.55 

CC2 ............. 303.96 207.86 96.10 

CC1 ............. 282.08 192.89 89.19 

CB2 ............. 282.08 192.89 89.19 

CB1 ............. 261.77 179.01 82.76 

CA2 ............. 239.89 164.04 75.85 

CA1 ............. 224.26 153.36 70.90 

BB2 ............. 253.95 173.66 80.29 

BB1 ............. 243.01 166.18 76.83 

BA2 ............. 211.76 144.81 66.95 

BA1 ............. 202.38 138.39 63.99 

PE2 ............. 336.78 230.30 106.48 

PE1 ............. 321.15 219.61 101.54 

PD2 ............. 318.03 217.48 100.55 

PD1 ............. 302.40 206.79 95.61 

PC2 ............. 274.27 187.55 86.72 

PC1 ............. 261.77 179.01 82.76 

PB2 ............. 233.64 159.77 73.87 

PB1 ............. 224.26 153.36 70.90 

PA2 ............. 194.57 133.05 61.52 

PA1 ............. 186.75 127.71 59.04 

Section 1888(e)(4)(G)(ii) of the Act 

also requires that we apply this wage 

index in a manner that does not result 

in aggregate payments that are greater or 

less than would otherwise be made in 

the absence of the wage adjustment. For 

FY 2013 (Federal rates effective October 

1, 2012), we apply an adjustment to 

fulfill the budget neutrality requirement. 

We meet this requirement by 

multiplying each of the components of 

the unadjusted Federal rates by a budget 

neutrality factor equal to the ratio of the 

weighted average wage adjustment 

factor for FY 2012 to the weighted 

average wage adjustment factor for FY 

2013. For this calculation, we use the 

same 2011 claims utilization data for 

both the numerator and denominator of 

this ratio. We define the wage 

adjustment factor used in this 

calculation as the labor share of the rate 

component multiplied by the wage 

index plus the non-labor share of the 

rate component. The budget neutrality 

factor for this year is 1.0004. The wage 

index applicable to FY 2013 is set forth 

in Tables A and B, which appear in the 

Addendum of this notice, and is also 

available on the CMS Web site at http:// 

cms.gov/Medicare/Medicare-Fee-forService-Payment/SNFPPS/ 

WageIndex.html. 

In the SNF PPS final rule for FY 2006 

(70 FR 45026, August 4, 2005), we 

adopted the changes discussed in the 

OMB Bulletin No. 03–04 (June 6, 2003), 

available online at 

www.whitehouse.gov/omb/bulletins/ 

b03-04.html, which announced revised 

definitions for Metropolitan Statistical 

Areas (MSAs), and the creation of 

Micropolitan Statistical Areas and 

Combined Statistical Areas. In addition, 

OMB published subsequent bulletins 

regarding CBSA changes, including 

changes in CBSA numbers and titles. As 

indicated in the FY 2008 SNF PPS final 

rule (72 FR 43423, August 3, 2007), this 

and all subsequent SNF PPS rules and 

notices are considered to incorporate 

the CBSA changes published in the 

most recent OMB bulletin that applies 

to the hospital wage data used to 

determine the current SNF PPS wage 

index. The OMB bulletins are available 

online at http://www.whitehouse.gov/ 

omb/bulletins/index.html. 

In adopting the OMB CBSA 

geographic designations, we provided 

for a 1-year transition with a blended 

wage index for all providers. For FY 

2006, the wage index for each provider 

consisted of a blend of 50 percent of the 

FY 2006 MSA-based wage index and 50 

percent of the FY 2006 CBSA-based 

wage index (both using FY 2002 

hospital data). We referred to the 

blended wage index as the FY 2006 SNF 

PPS transition wage index. As discussed 

in the SNF PPS final rule for FY 2006 

(70 FR 45041), subsequent to the 

expiration of this 1-year transition on 

September 30, 2006, we used the full 

CBSA-based wage index values, as now 

presented in Tables A and B in the 

Addendum of this notice. 

D. Updates to the Federal Rates 

In accordance with section 

1888(e)(4)(E) of the Act as amended by 

section 311 of the BIPA, and section 

1888(e)(5)(B) of the Act as amended by 

section 3401(b) of the Affordable Care 

Act, the payment rates in this notice 

reflect an update equal to the full SNF 

market basket, estimated at 2.5 

percentage points, reduced by the MFP 

adjustment. As discussed in sections 

II.G.2 and V.C of this notice, the annual 

update for FY 2013 includes a 0.7 

percentage point reduction to account 

for the MFP adjustment described in the 

latter section, for a net update of 1.8 

percent. 

E. Relationship of Case-Mix 

Classification System to Existing Skilled 

Nursing Facility Level-of-Care Criteria 

As discussed in § 413.345, we include 

in each update of the Federal payment 

rates in the Federal Register the 

designation of those specific RUGs 

under the classification system that 

represent the required SNF level of care, 

as provided in § 409.30. As set forth in 

the FY 2011 SNF PPS update notice (75 

FR 42910, July 22, 2010), this 

designation reflects an administrative 

presumption under the 66-group RUG– 

IV system that beneficiaries who are 

correctly assigned to one of the upper 52 

RUG–IV groups on the initial 5-day, 

Medicare-required assessment are 

automatically classified as meeting the 

SNF level of care definition up to and 

including the assessment reference date 

on the 5-day Medicare-required 

assessment. 

A beneficiary assigned to any of the 

lower 14 RUG–IV groups is not 

automatically classified as either 

meeting or not meeting the definition, 

but instead receives an individual level 

of care determination using the existing 

administrative criteria. This 

presumption recognizes the strong 

likelihood that beneficiaries assigned to 

one of the upper 52 RUG–IV groups 

during the immediate post-hospital 

period require a covered level of care, 

which would be less likely for those 

beneficiaries assigned to one of the 

lower 14 RUG–IV groups. 

In this notice, we continue to 

designate the upper 52 RUG–IV groups 

for purposes of this administrative 

presumption, consisting of all groups 

encompassed by the following RUG–IV 

categories: 

• Rehabilitation plus Extensive 

Services; 

• Ultra High Rehabilitation; 

• Very High Rehabilitation; 


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• High Rehabilitation; 

• Medium Rehabilitation; 

• Low Rehabilitation; 

• Extensive Services; 

• Special Care High; 

• Special Care Low; and, 

• Clinically Complex. 

However, we note that this 

administrative presumption policy does 

not supersede the SNF’s responsibility 

to ensure that its decisions relating to 

level of care are appropriate and timely, 

including a review to confirm that the 

services prompting the beneficiary’s 

assignment to one of the upper 52 RUG– 

IV groups (which, in turn, serves to 

trigger the administrative presumption) 

are themselves medically necessary. As 

we explained in the FY 2000 SNF PPS 

final rule (64 FR 41667, July 30, 1999), 

the administrative presumption: 

* * * is itself rebuttable in those individual 

cases in which the services actually received 

by the resident do not meet the basic 

statutory criterion of being reasonable and 

necessary to diagnose or treat a beneficiary’s 

condition (according to section 1862(a)(1) of 

the Act). Accordingly, the presumption 

would not apply, for example, in those 

situations in which a resident’s assignment to 

one of the upper * * * groups is itself based 

on the receipt of services that are 

subsequently determined to be not 

reasonable and necessary. 

Moreover, we want to stress the 

importance of careful monitoring for 

changes in each patient’s condition to 

determine the continuing need for Part 

A SNF benefits after the assessment 

reference date of the 5-day assessment. 

F. Example of Computation of Adjusted 

PPS Rates and SNF Payment 

Using the hypothetical SNF XYZ 

described below, Table 8 shows the 

adjustments made to the Federal per 

diem rates to compute the provider’s 

actual per diem PPS payment under the 

described scenario. SNF XYZ’s 12- 

month cost reporting period begins 

October 1, 2012. As illustrated in Table 

8, SNF XYZ’s total PPS payment would 

equal $41,149.70. We derive the Labor 

and Non-labor columns from Table 6. 

TABLE 8—RUG–IV SNF XYZ: LOCATED IN CEDAR RAPIDS, IA (URBAN CBSA 16300) WAGE INDEX: 0.8944 

RUG–IV group Labor Wage index Adjusted 

labor Non-labor Adjusted rate 

Percent 

adjustment 

Medicare 

days Payment 

RVX .................................. $456.89 0.8944 $408.64 $211.25 $619.89 $619.89 14 $8,678.46 

ES2 .................................. 366.85 0.8944 328.11 169.62 497.73 497.73 30 14,931.90 

RHA .................................. 230.51 0.8944 206.17 106.57 312.74 312.74 16 5,003.84 

CC2 * ................................ 212.49 0.8944 190.05 98.24 288.29 657.30 10 6,573.00 

BA2 .................................. 146.49 0.8944 131.02 67.73 198.75 198.75 30 5,962.50 

100 41,149.70 

* Reflects a 128 percent adjustment from section 511 of the MMA. 

IV. Monitoring Impact of FY 2012 

Policy Changes and Certain SNF 

Practices 

In the FY 2012 SNF PPS final rule, we 

stated we would monitor the impact of 

certain FY 2012 policy changes on 

various aspects of the SNF PPS (76 FR 

48498, August 8, 2011). Specifically, we 

have been monitoring the impact of the 

following FY 2012 policy changes: 

• Recalibration of the FY 2011 SNF 

parity adjustment to align overall 

payments under RUG–IV with those 

under RUG–III. 

• Allocation of group therapy time to 

pay more appropriately for group 

therapy services based on resource 

utilization and cost. 

• Implementation of changes to the 

MDS 3.0 patient assessment instrument, 

most notably the introduction of the 

Change-of-Therapy (COT) Other 

Medicare Required Assessment 

(OMRA). 

We have posted quarterly memos to 

the SNF PPS Web site which highlight 

some of the trends we have observed 

over a given time period. These memos 

may be accessed through the SNF PPS 

Web site at the following address: 

http://www.cms.gov/Medicare/ 

Medicare-Fee-for-Service-Payment/ 

SNFPPS/Downloads/ 

SNF_Monitoring.zip. 

Below, we provide a summary of the 

initial results derived from this 

monitoring effort. 

A. RUG Distributions 

As stated in the FY 2012 SNF PPS 

final rule (76 FR 48493), the 

recalibration of the FY 2011 parity 

adjustment used 8 months of FY 2011 

data as the basis for the recalibration. 

We observed that case-mix utilization 

patterns continued to be consistent over 

the final 4 months of FY 2011 and 

would not have resulted in a significant 

difference in the calculated amount of 

the recalibrated parity adjustment. We 

have posted data illustrating the RUG– 

IV distribution of days for the entirety 

of FY 2011, as compared to the days 

distribution used to calculate the parity 

adjustment in the FY 2012 final rule, 

and the distribution of days for the first 

half of FY 2012, all of which may be 

found at http://www.cms.gov/Medicare/ 

Medicare-Fee-for-Service-Payment/ 

SNFPPS/Downloads/ 

SNF_Monitoring.zip. 

Additionally, case-mix utilization 

observed during FY 2012 has not shown 

unanticipated changes in patient 

classification. Overall patient case mix 

is not significantly different from that 

observed in FY 2011. Table 9 below 

illustrates a breakdown of the SNF casemix distribution of service days by the 

major RUG classification categories for 

the full year of FY 2011 and for the first 

half of FY 2012. 

TABLE 9—SNF CASE-MIX DISTRIBUTIONS BY MAJOR RUG–IV CATEGORY

FY 2011 

(percent) 

Q1 & Q2 

FY 2012 

(percent) 

Rehabilitation Plus Extensive Services ........................................................................................................... 2.5 1.8 

Rehabilitation ................................................................................................................................................... 87.9 88.5 

Extensive Services .......................................................................................................................................... 0.6 0.7 

Special Care .................................................................................................................................................... 4.6 5.0 

Clinically Complex ........................................................................................................................................... 2.5 2.3 


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TABLE 9—SNF CASE-MIX DISTRIBUTIONS BY MAJOR RUG–IV CATEGORY—Continued 

FY 2011 

(percent) 

Q1 & Q2 

FY 2012 

(percent) 

Behavioral Symptoms and Cognitive Performance ......................................................................................... 0.4 0.3 

Reduced Physical Function ............................................................................................................................. 1.5 1.5 

As illustrated in Table 9, there have 

been small decreases in both the 

Rehabilitation Plus Extensive Services 

category and in the overall percentage of 

service days in a rehabilitation group, 

and increases in some of the medicallybased RUG categories, most notably 

Special Care. 

It should be noted that the 

recalibration of the parity adjustment 

applied only to those RUG–IV groups 

connected to therapy (Rehabilitation 

Plus Extensive Services and 

Rehabilitation). This caused a shift in 

the hierarchy of nursing case-mix 

weights among the various RUG–IV 

groups. Since SNFs are permitted to 

‘‘index maximize’’ when determining a 

resident’s RUG classification (i.e., of 

those RUGs for which the resident 

qualifies, SNFs are permitted to choose 

the one with the highest per diem 

payment), it is possible that the 

aforementioned case-mix distribution 

shifts reflect residents that had 

previously been classified into therapy 

groups but now index maximize into 

nursing groups instead. 

While the overall percentage of 

resident days that classify into therapy 

groups has decreased slightly during the 

first half of FY 2012 (possibly due in 

part to index maximization), the data 

show an increase in the percentage of 

service days at the highest therapy level 

(Ultra High Rehabilitation) in the first 

half of FY 2012. This is illustrated in 

Table 10 below. 

TABLE 10—SNF CASE-MIX DISTRIBUTION FOR THERAPY RUG–IV GROUPS, BY MINOR RUG–IV THERAPY CATEGORIES

FY 2011 

(percent) 

Q1 & 

Q2 FY 2012 

(percent) 

Ultra-High Rehabilitation (≥ 720 minutes of therapy per week) ...................................................................... 44.9 46.2 

Very-High Rehabilitation (500–719 minutes of therapy per week) ................................................................. 26.9 26.7 

High Rehabilitation (325–499 minutes of therapy per week) .......................................................................... 10.8 10.7 

Medium Rehabilitation (150–324 minutes of therapy per week) .................................................................... 7.6 6.6 

Low Rehabilitation (45–149 minutes of therapy per week) ............................................................................. 0.1 0.1 

≤Although there have been decreases in 

the percentage of service days which 

classify into the Very High, High and 

Medium therapy RUG–IV categories, 

some of the decrease may be due to 

index maximization into the Special 

Care category. 

B. Group Therapy Allocation 

To account more accurately for 

resource utilization and cost and to 

equalize the payment incentives across 

therapy modes, we allocated group 

therapy time beginning in FY 2012. We 

anticipated that this policy would result 

in some change to the type of therapy 

mode used for SNF residents. As noted 

in the section above, we have not 

observed any significant difference in 

patient case mix. However, as illustrated 

below in Table 11, providers have 

significantly changed the mode of 

therapy since our STRIVE study (2006– 

2007). 

TABLE 11—MODE OF THERAPY PROVISION

STRIVE 

(percent) 

FY 2011 

(percent) 

Q1 

& 

Q2 

FY 

2012 

(percent) 

Individual .............................................................................................................................................. 74 91.8 99.5 

Concurrent ........................................................................................................................................... 25 0.8 0.4 

Group ................................................................................................................................................... <1 7.4 0.1 

During FY 2011, we implemented the 

allocation of concurrent therapy without 

the allocation of group therapy and 

providers shifted from concurrent 

therapy to group therapy. During FY 

2012, we implemented the allocation of 

group therapy, and data from the first 

and second quarters of FY 2012 indicate 

that facilities are providing individual 

therapy almost exclusively. 

C. COT OMRA 

In FY 2012, we introduced a new 

assessment called the COT OMRA to 

capture more accurately the therapy 

services provided to SNF residents. 

Effective for services provided on or 

after October 1, 2011, SNFs are required 

to complete a COT OMRA for patients 

classified into a RUG–IV therapy 

category (and for patients receiving 

therapy services who are classified into 

a nursing RUG because of index 

maximization), whenever the intensity 

of therapy changes to such a degree that 

it would no longer reflect the RUG–IV 

classification and payment assigned for 

the patient based on the most recent 

assessment used for Medicare payment 

(76 FR 48525). An evaluation of the 


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necessity for a COT OMRA must be 

completed at the end of each COT 

observation period, which is a 

successive 7-day window beginning on 

the day following the ARD set for the 

most recent scheduled or unscheduled 

PPS assessment (or beginning the day 

therapy resumes in cases where an 

EOT–R OMRA is completed), and 

ending every seven calendar days 

thereafter. In cases where the resident’s 

therapy has changed to such a degree 

that it is no longer consistent with the 

resident’s current RUG–IV 

classification, then the SNF must 

complete a COT OMRA to reclassify the 

resident into the appropriate RUG–IV 

category. The new RUG–IV group 

resulting from the COT OMRA is billed 

starting the first day of the 7-day COT 

observation period for which the COT 

OMRA was completed and remains at 

this level until a new assessment is 

done that changes the patient’s RUG–IV 

classification. 

Table 12 below shows the distribution 

of all MDS assessment types as a 

percentage of all MDS assessments. We 

note that the first half of FY 2012 

included a transition period for the new 

policies and, therefore, may not be 

entirely representative of all of FY 2012. 

TABLE 12—DISTRIBUTION OF MDS ASSESSMENT TYPES

FY 2011 

(percent) 

Q1 & 

Q2 FY 2012 

(percent) 

Scheduled PPS assessment ........................................................................................................................... 95 84 

Start-of-Therapy (SOT) OMRA ........................................................................................................................ 2 2 

End-of-Therapy (EOT) OMRA (w/o Resumption) ........................................................................................... 3 3 

Combined SOT/EOT OMRA ............................................................................................................................ 0 0 

End-of-Therapy OMRA (w/Resumption) (EOT–R OMRA) .............................................................................. N/A 0 

Combined SOT/EOT–R OMRA ....................................................................................................................... N/A 0 

Change-of-Therapy (COT) OMRA ................................................................................................................... N/A 11 

Prior to the implementation of the COT 

OMRA, scheduled PPS assessments 

comprised the vast majority of 

completed assessments. With the 

implementation of the COT OMRA for 

FY 2012, scheduled PPS assessments 

still comprise the vast majority of 

completed MDS assessments, though 

the COT OMRA is the most frequently 

completed OMRA. Information related 

to our continuing monitoring activities 

will be posted on the SNF PPS Web site 

at the following address: http:// 

www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/SNFPPS/ 

Downloads/SNF_Monitoring.zip. 

Finally, while not related to the 

above-cited FY 2012 policy changes, our 

ongoing monitoring of the quality of 

care in SNFs also causes us to have 

concerns that some SNFs are using the 

practice of asking patients to sign 

binding arbitration agreements that 

require as a condition of admission that 

a patient resolve disputes with the 

facility through binding arbitration. We 

plan to monitor this closely and take 

action consistent with current rules and 

guidelines (including CMS Survey & 

Certification Letter S&C–03–10 dated 

January 9, 2003, available online at 

www.cms.gov/Medicare/ProviderEnrollment-and-Certification/ 

SurveyCertificationGenInfo/Downloads/ 

SCletter03–10.pdf), and consider 

rulemaking or any additional steps that 

may be appropriate. 

V. The Skilled Nursing Facility Market 

Basket Index 

Section 1888(e)(5)(A) of the Act 

requires us to establish a SNF market 

basket index (input price index), that 

reflects changes over time in the prices 

of an appropriate mix of goods and 

services included in the SNF PPS. This 

notice incorporates the latest available 

projections of the SNF market basket 

index. Accordingly, we have developed 

a SNF market basket index that 

encompasses the most commonly used 

cost categories for SNF routine services, 

ancillary services, and capital-related 

expenses. 

Each year, we calculate a revised 

labor-related share based on the relative 

importance of labor-related cost 

categories in the input price index. 

Table 13 summarizes the updated laborrelated share for FY 2013. 

TABLE 13—LABOR-RELATED RELATIVE IMPORTANCE, FY 2012 AND FY 2013 

Relative importance, 

labor-related, 

FY 2012 

11:2 forecast * 

Relative importance, 

labor-related, 

FY 2013 

12:2 forecast ** 

Wages and salaries ................................................................................................................. 50.129 49.847 

Employee benefits ................................................................................................................... 11.502 11.532 

Nonmedical professional fees ................................................................................................. 1.31 1.307 

Labor-intensive services .......................................................................................................... 3.394 3.364 

Capital-related (.391) ............................................................................................................... 2.358 2.333 

Total .................................................................................................................................. 68.693 68.383 

* Published in the Federal Register; based on the second-quarter 2011 IHS Global Insight Inc. forecast. 

** Based on the second-quarter 2012 IHS Global Insight forecast, with historical data through the first-quarter 2012. 

A. Use of the Skilled Nursing Facility 

Market Basket Percentage 

Section 1888(e)(5)(B) of the Act 

defines the SNF market basket 

percentage as the percentage change in 

the SNF market basket index from the 

midpoint of the previous FY to the 

midpoint of the current FY. For the 

Federal rates established in this notice, 

we use the percentage change in the 

SNF market basket index to compute the 

update factor for FY 2013. This is based 


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on the IGI (formerly DRI–WEFA) second 

quarter 2012 forecast (with historical 

data through the first quarter 2012) of 

the FY 2013 percentage increase in the 

FY 2004-based SNF market basket index 

for routine, ancillary, and capital-related 

expenses, which is used to compute the 

update factor in this notice. As 

discussed in section V.C of this notice, 

this market basket percentage change is 

reduced by the MFP adjustment as 

required by section 1888(e)(5)(B)(ii) of 

the Act. Finally, as discussed in section 

II.A of this notice, we no longer 

compute update factors to adjust a 

facility-specific portion of the SNF PPS 

rates, because the initial 3-phase 

transition period from facility-specific 

to full Federal rates that started with 

cost reporting periods beginning in July 

1998 has expired. 

B. Market Basket Forecast Error 

Adjustment 

As discussed in the June 10, 2003, 

supplemental proposed rule (68 FR 

34768) and finalized in the August 4, 

2003, final rule (68 FR 46057 through 

46059), the regulations at 

§ 413.337(d)(2) provide for an 

adjustment to account for market basket 

forecast error. The initial adjustment 

applied to the update of the FY 2003 

rate for FY 2004, and took into account 

the cumulative forecast error for the 

period from FY 2000 through FY 2002, 

resulting in an increase of 3.26 percent. 

Subsequent adjustments in succeeding 

FYs take into account the forecast error 

from the most recently available FY for 

which there is final data, and apply 

whenever the difference between the 

forecasted and actual change in the 

market basket exceeds a specified 

threshold. We originally used a 0.25 

percentage point threshold for this 

purpose; however, for the reasons 

specified in the FY 2008 SNF PPS final 

rule (72 FR 43425, August 3, 2007), we 

adopted a 0.5 percentage point 

threshold effective with FY 2008. As 

discussed previously in section II.G.2 of 

this notice, as the difference between 

the estimated and actual amounts of 

increase in the market basket index for 

FY 2011 (the most recently available FY 

for which there is final data) does not 

exceed the 0.5 percentage point 

threshold, the payment rates for FY 

2013 do not include a forecast error 

adjustment. 

C. Multifactor Productivity Adjustment 

Section 3401(b) of the Affordable Care 

Act requires that, in FY 2012 (and in 

subsequent FYs), the market basket 

percentage under the SNF payment 

system as described in section 

1888(e)(5)(B)(i) is to be reduced 

annually by the productivity adjustment 

described in section 1886(b)(3)(B)(xi)(II) 

of the Act. Specifically, section 3401(a) 

of the Affordable Care Act amends 

section 1886(b)(3)(B) of the Act to add 

clause (xi)(II), which sets forth the 

definition of this productivity 

adjustment. The statute defines the 

productivity adjustment to be equal to 

the 10-year moving average of changes 

in annual economy-wide private 

nonfarm business multi-factor 

productivity (MFP) (as projected by the 

Secretary for the 10-year period ending 

with the applicable fiscal year, year, 

cost reporting period, or other annual 

period) (the ‘‘MFP adjustment’’). The 

Bureau of Labor Statistics (BLS) is the 

agency that publishes the official 

measure of private nonfarm business 

MFP. Please see http://www.bls.gov/mfp 

to obtain the BLS historical published 

MFP data. 

The projection of MFP is currently 

produced by IGI, an economic 

forecasting firm. In order to generate a 

forecast of MFP, IGI replicated the MFP 

measure calculated by the BLS, using a 

series of proxy variables derived from 

IGI’s U.S. macroeconomic models. This 

process is described in greater detail in 

section III.F.3 of the FY 2012 SNF PPS 

final rule (76 FR 48527–48529, August 

8, 2011). 

1. Incorporating the Multifactor 

Productivity Adjustment Into the 

Market Basket Update 

According to section 1888(e)(5)(A) of 

the Act, the Secretary ‘‘shall establish a 

skilled nursing facility market basket 

index that reflects changes over time in 

the prices of an appropriate mix of 

goods and services included in covered 

skilled nursing facility services.’’ As 

described in section II.G.2 of this notice, 

we estimate the SNF PPS market basket 

percentage for FY 2013 under section 

1888(e)(5)(B)(i) of the Act based on the 

FY 2004-based SNF market basket. 

Section 3401(b) of the Affordable Care 

Act amends section 1888(e)(5)(B) of the 

Act, in part, by adding a new clause (ii), 

which requires that for FY 2012 and 

each subsequent FY, after determining 

the market basket percentage described 

in section 1888(e)(5)(B)(i) of the Act, 

‘‘the Secretary shall reduce such 

percentage by the productivity 

adjustment described in section 

1886(b)(3)(B)(xi)(II)’’ (which we refer to 

as the MFP adjustment). Section 

1888(e)(5)(B)(ii) of the Act further states 

that the reduction of the market basket 

percentage by the MFP adjustment may 

result in the market basket percentage 

being less than zero for a FY, and may 

result in payment rates under section 

1888(e) of the Act for a FY being less 

than such payment rates for the 

preceding FY. Thus, if the application of 

the MFP adjustment to the market 

basket percentage calculated under 

section 1888(e)(5)(B)(i) results in an 

MFP-adjusted market basket percentage 

that is less than zero, then the annual 

update to the unadjusted Federal per 

diem rates under section 

1888(e)(4)(E)(ii) would be negative, and 

such rates would decrease relative to the 

prior FY. 

For the FY 2013 update, the MFP 

adjustment is calculated as the 10-year 

moving average of changes in MFP for 

the period ending September 30, 2013. 

In accordance with section 

1888(e)(5)(B)(i) of the Act, the market 

basket percentage for FY 2013 for the 

SNF PPS is based on IGI’s second 

quarter 2012 forecast of the FY 2004- 

based SNF market basket update, which 

is estimated to be 2.5 percent. In 

accordance with section 1888(e)(5)(B)(ii) 

of the Act (as added by section 3401(b) 

of the Affordable Care Act), this market 

basket percentage is then reduced by the 

MFP adjustment (the 10-year moving 

average of changes in MFP for the 

period ending September 30, 2013) of 

0.7 percent, which is calculated as 

described above and based on IGI’s 

second quarter 2012 forecast. The 

resulting MFP-adjusted market basket 

update is equal to 1.8 percent, or 2.5 

percent less 0.7 percentage point. 

D. Federal Rate Update Factor 

Section 1888(e)(4)(E)(ii)(IV) of the Act 

requires that the update factor used to 

establish the FY 2013 unadjusted 

Federal rates be at a level equal to the 

market basket percentage change. 

Accordingly, to establish the update 

factor, we determined the total growth 

from the average market basket level for 

the period of October 1, 2011 through 

September 30, 2012 to the average 

market basket level for the period of 

October 1, 2012 through September 30, 

2013. Using this process, the market 

basket update factor for FY 2013 SNF 

PPS unadjusted Federal rates is 2.5 

percent. As required by section 

1888(e)(5)(B) of the Act, this market 

basket percentage is then reduced by the 

MFP adjustment (the 10-year moving 

average of changes in MFP for the 

period ending September 30, 2013) of 

0.7 percent as described in section V.C. 

The resulting MFP-adjusted market 

basket update is equal to 1.8 percent, or 

2.5 percent less 0.7 percentage point. 

We used this MFP-adjusted market 

basket update factor to compute the SNF 

PPS rate shown in Tables 2 and 3. 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46228 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

VI. Consolidated Billing 

Section 4432(b) of the BBA 

established a consolidated billing 

requirement that places with the SNF 

the Medicare billing responsibility for 

virtually all of the services that the 

SNF’s residents receive, except for a 

small number of services that the statute 

specifically identifies as being excluded 

from this provision. As noted previously 

in section II of this notice, subsequent 

legislation enacted a number of 

modifications in the consolidated 

billing provision. 

Specifically, section 103 of the BBRA 

amended this provision by further 

excluding a number of individual ‘‘highcost, low-probability’’ services, 

identified by Healthcare Common 

Procedure Coding System (HCPCS) 

codes, within several broader categories 

(chemotherapy and its administration, 

radioisotope services, and customized 

prosthetic devices) that otherwise 

remained subject to the provision. We 

discuss this BBRA amendment in 

greater detail in the proposed and final 

rules for FY 2001 (65 FR 19231 through 

19232, April 10, 2000, and 65 FR 46790 

through 46795, July 31, 2000), as well as 

in Program Memorandum AB–00–18 

(Change Request #1070), issued March 

2000, which is available online at 

www.cms.gov/transmittals/downloads/ 

ab001860.pdf. 

Section 313 of the BIPA further 

amended this provision by repealing its 

Part B aspect; that is, its applicability to 

services furnished to a resident during 

a SNF stay that Medicare Part A does 

not cover. (However, physical therapy, 

occupational therapy, and speechlanguage pathology services remain 

subject to consolidated billing, 

regardless of whether the resident who 

receives these services is in a covered 

Part A stay.) We discuss this BIPA 

amendment in greater detail in the 

proposed and final rules for FY 2002 (66 

FR 24020 through 24021, May 10, 2001, 

and 66 FR 39587 through 39588, July 

31, 2001). 

In addition, section 410 of the MMA 

amended this provision by excluding 

certain practitioner and other services 

furnished to SNF residents by RHCs and 

FQHCs. We discuss this MMA 

amendment in greater detail in the 

update notice for FY 2005 (69 FR 45818 

through 45819, July 30, 2004), as well as 

in Medicare Learning Network (MLN) 

Matters article #MM3575, which is 

available online at http://www.cms.gov/ 

MLNMattersArticles/downloads/ 

MM3575.pdf. 

Further, while not substantively 

revising the consolidated billing 

requirement itself, a related provision 

was enacted in the Medicare 

Improvements for Patients and 

Providers Act of 2008 (MIPPA, Pub. L. 

110–275). Specifically, section 149 of 

MIPPA amended section 

1834(m)(4)(C)(ii) of the Act to add 

subclause (VII), which adds SNFs (as 

defined in section 1819(a) of the Act) to 

the list of entities that can serve as a 

telehealth ‘‘originating site’’ (that is, the 

location at which an eligible individual 

can receive, through a 

telecommunications system, services of 

a physician or other practitioner who is 

located elsewhere at a ‘‘distant site’’). 

As explained in the Medicare 

Physician Fee Schedule (PFS) final rule 

for calendar year (CY) 2009 (73 FR 

69726, 69879, November 19, 2008), a 

telehealth originating site receives a 

facility fee which is always separately 

payable under Part B outside of any 

other payment methodology. Section 

149(b) of MIPPA amended section 

1888(e)(2)(A)(ii) of the Act to exclude 

telehealth services furnished under 

section 1834(m)(4)(C)(ii)(VII) of the Act 

from the definition of ‘‘covered skilled 

nursing facility services’’ that are paid 

under the SNF PPS. Thus, a SNF ‘‘ 

* * * can receive separate payment for 

a telehealth originating site facility fee 

even in those instances where it also 

receives a bundled per diem payment 

under the SNF PPS for a resident’s 

covered Part A stay’’ (73 FR 69881). By 

contrast, under section 1834(m)(2)(A) of 

the Act, a telehealth distant site service 

is payable under Part B to an eligible 

physician or practitioner only to the 

same extent that it would have been so 

payable if furnished without the use of 

a telecommunications system. Thus, as 

explained in the CY 2009 Physician Fee 

Schedule final rule (73 FR 69726, 

69880), eligible distant site physicians 

or practitioners can receive payment for 

a telehealth service that they furnish 

* * * only if the service is separately 

payable under the PFS when furnished in a 

face-to-face encounter at that location. For 

example, we pay distant site physicians or 

practitioners for furnishing services via 

telehealth only if such services are not 

included in a bundled payment to the facility 

that serves as the originating site (73 FR 

69880). 

This means that in those situations 

where a SNF serves as the telehealth 

originating site, the distant site 

professional services would be 

separately payable under Part B only to 

the extent that they are not already 

included in the SNF PPS bundled per 

diem payment and subject to 

consolidated billing. Thus, for a type of 

practitioner whose services are not 

otherwise excluded from consolidated 

billing when furnished during a face-toface encounter, the use of a telehealth 

distant site would not serve to unbundle 

those services. In fact, consolidated 

billing does exclude the professional 

services of physicians, along with those 

of most of the other types of telehealth 

practitioners that the law specifies at 

section 1842(b)(18)(C) of the Act; that is, 

physician assistants, nurse practitioners, 

clinical nurse specialists, certified 

registered nurse anesthetists, certified 

nurse midwives, and clinical 

psychologists (see section 

1888(e)(2)(A)(ii) of the Act and 42 CFR 

411.15(p)(2)). However, the services of 

clinical social workers, registered 

dietitians and nutrition professionals 

remain subject to consolidated billing 

when furnished to a SNF’s Part A 

resident and, thus, cannot qualify for 

separate Part B payment as telehealth 

distant site services in this situation. 

Additional information on this 

provision appears in MLN Matters 

article #MM6215, which is available 

online at http://www.cms.gov/

MLNMattersArticles/downloads/

MM6215.pdf. To date, the Congress has 

enacted no further legislation affecting 

the consolidated billing provision. 

VII. Application of the SNF PPS to SNF 

Services Furnished by Swing-Bed 

Hospitals 

In accordance with section 1888(e)(7) 

of the Act, as amended by section 203 

of the BIPA, Part A pays critical access 

hospitals (CAHs) on a reasonable cost 

basis for SNF services furnished under 

a swing-bed agreement. However, 

effective with cost reporting periods 

beginning on or after July 1, 2002, the 

swing-bed services of non-CAH rural 

hospitals are paid under the SNF PPS. 

As explained in the final rule for FY 

2002 (66 FR 39562, July 31, 2001), we 

selected this effective date consistent 

with the statutory provision to integrate 

swing-bed rural hospitals into the SNF 

PPS by the end of the SNF transition 

period, June 30, 2002. 

Accordingly, all non-CAH swing-bed 

rural hospitals have come under the 

SNF PPS as of June 30, 2003. Therefore, 

all rates and wage indexes outlined in 

earlier sections of this notice for the 

SNF PPS also apply to all non-CAH 

swing-bed rural hospitals. A complete 

discussion of assessment schedules, the 

MDS and the transmission software 

(RAVEN–SB for Swing Beds) appears in 

the final rule for FY 2002 (66 FR 39562, 

July 31, 2001) and in the final rule for 

FY 2010 (74 FR 40288, August 11, 

2009). As finalized in the FY 2010 SNF 

PPS final rule (74 FR 40356–57), 

effective October 1, 2010, non-CAH 

swing-bed rural hospitals are required to 

complete an MDS 3.0 swing-bed 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
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assessment which is limited to the 

required demographic, payment, and 

quality items. The latest changes in the 

MDS for swing-bed rural hospitals 

appear on the SNF PPS Web site, http:// 

www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/SNFPPS/index.

html. 

VIII. Collection of Information 

Requirements 

This notice does not impose any new 

or revised information collection or 

recordkeeping requirements. The 

information collection requirements 

referenced in this notice with regard to 

resident assessment information used to 

determine facility payments are 

currently approved under OCN 0938– 

0739 (which relates to the Medicare PPS 

Assessment Form (MPAF) information 

collection) and OCN 0938–0872 (which 

relates to the Minimum Data Set for 

Swing-Bed Hospitals), neither of which 

is affected by this notice. This notice, 

OCN: 0938–0739, and OCN: 0938–0872 

do not impose any burden requiring 

additional Office of Management and 

Budget review under the authority of 

the Paperwork Reduction Act of 1995 

(44 U.S.C. 3501 et seq.). 

IX. Waiver of Notice and Comment 

We would ordinarily publish a notice 

of proposed rulemaking in the Federal 

Register to provide a period for public 

comment, followed by a final rule. 

However, we can waive this procedure 

if we find good cause that a notice and 

comment procedure is impracticable, 

unnecessary, or contrary to the public 

interest and incorporate a statement of 

the finding and its reasons in the notice 

issued. In this instance, we have found 

good cause to waive notice and 

comment rulemaking and are issuing 

this update notice. 

We believe it is unnecessary to 

undertake notice and comment 

rulemaking in this instance, as the 

statute requires annual updates to the 

SNF PPS rates, the methodologies used 

to update the rates in this notice have 

been previously subject to public 

comment and finalized, and this notice 

initiates no policy changes with regard 

to the SNF PPS, but simply reflects 

application of previously established 

methodologies. Therefore, we find good 

cause to waive notice and comment 

procedures. 

X. Economic Analyses 

A. Regulatory Impact Analysis 

1. Introduction 

We have examined the impacts of this 

notice as required by Executive Order 

12866 on Regulatory Planning and 

Review (September 30, 1993), Executive 

Order 13563 on Improving Regulation 

and Regulatory Review (January 18, 

2011), the Regulatory Flexibility Act 

(RFA) (September 19, 1980, Pub. L. 96– 

354), section 1102(b) of the Act, section 

202 of the Unfunded Mandates Reform 

Act of 1995 (UMRA, March 22, 1995; 

Pub. L. 104–4), Executive Order 13132 

on Federalism (August 4, 1999), and the 

Congressional Review Act (5 U.S.C. 

804(2)). 

Executive Orders 12866 and 13563 

direct agencies to assess all costs and 

benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, distributive impacts, and 

equity). Executive Order 13563 

emphasizes the importance of 

quantifying both costs and benefits, of 

reducing costs, of harmonizing rules, 

and of promoting flexibility. This notice 

has been designated an economically 

significant rule, under section 3(f)(1) of 

Executive Order 12866. Accordingly, we 

have prepared a regulatory impact 

analysis (RIA) as further discussed 

below. Also, the rule has been reviewed 

by the Office of Management and 

Budget. 

2. Statement of Need 

This notice updates the SNF 

prospective payment rates for FY 2013 

as required under section 1888(e)(4)(E) 

of the Act. It also responds to section 

1888(e)(4)(H) of the Act, which requires 

the Secretary to ‘‘provide for publication 

in the Federal Register’’ before August 

1 that precedes the start of each fiscal 

year, the unadjusted Federal per diem 

rates, the case-mix classification system, 

and the factors to be applied in making 

the area wage adjustment. As these 

statutory provisions prescribe a detailed 

methodology for calculating and 

disseminating payment rates under the 

SNF PPS, we do not have the discretion 

to adopt an alternative approach. 

3. Overall Impacts 

This notice sets forth updates of the 

SNF PPS rates contained in the final 

rule for FY 2012 (76 FR 48486, August 

8, 2011). Based on the above, we 

estimate that the aggregate impact 

would be an increase of $670 million in 

payments to SNFs, resulting from the 

MFP-adjusted market basket update to 

the payment rates. The impact analysis 

of this notice represents the projected 

effects of the changes in the SNF PPS 

from FY 2012 to FY 2013. Although the 

best data available are utilized, there is 

no attempt to predict behavioral 

responses to these changes, or to make 

adjustments for future changes in such 

variables as days or case-mix. 

Certain events may occur to limit the 

scope or accuracy of our impact 

analysis, as this analysis is futureoriented and, thus, very susceptible to 

forecasting errors due to certain events 

that may occur within the assessed 

impact time period. Some examples of 

possible events may include newlylegislated general Medicare program 

funding changes by the Congress, or 

changes specifically related to SNFs. In 

addition, changes to the Medicare 

program may continue to be made as a 

result of previously-enacted legislation, 

or new statutory provisions. Although 

these changes may not be specific to the 

SNF PPS, the nature of the Medicare 

program is such that the changes may 

interact and, thus, the complexity of the 

interaction of these changes could make 

it difficult to predict accurately the full 

scope of the impact upon SNFs. 

In accordance with section 

1888(e)(4)(E) and (e)(5) of the Act, we 

update the FY 2012 payment rates by a 

factor equal to the market basket index 

percentage change adjusted by the FY 

2011 forecast error adjustment (if 

applicable) and the MFP adjustment to 

determine the payment rates for FY 

2013. As discussed previously, for FY 

2012 and each subsequent FY, as 

required by section 1888(e)(5)(B) of the 

Act as amended by section 3401(b) of 

the Affordable Care Act, the market 

basket percentage is reduced by the 

MFP adjustment. The special AIDS addon established by section 511 of the 

MMA remains in effect until ‘‘* * * 

such date as the Secretary certifies that 

there is an appropriate adjustment in 

the case mix * * * .’’ We have not 

provided a separate impact analysis for 

the MMA provision. Our latest estimates 

indicate that there are fewer than 3,800 

beneficiaries who qualify for the AIDS 

add-on payment. The impact to 

Medicare is included in the ‘‘total’’ 

column of Table 14. In updating the 

rates for FY 2013, we made a number of 

standard annual revisions and 

clarifications mentioned elsewhere in 

this notice (for example, the update to 

the wage and market basket indexes 

used for adjusting the Federal rates). 

The update set forth in this notice 

applies to payments in FY 2013. 

Accordingly, the analysis that follows 

only describes the impact of this single 

year. In accordance with the 

requirements of the Act, we will publish 

a notice or rule for each subsequent FY 

that will provide for an update to the 

payment rates and include an associated 

impact analysis. 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46230 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

4. Detailed Economic Analysis 

The FY 2013 impacts appear in Table 

14. The breakdown of the various 

categories of data in the table follows. 

The first column shows the 

breakdown of all SNFs by urban or rural 

status, hospital-based or freestanding 

status, census region, and ownership. 

The first row of figures describes the 

estimated effects of the various changes 

on all facilities. The next six rows show 

the effects on facilities split by hospitalbased, freestanding, urban, and rural 

categories. The urban and rural 

designations are based on the location of 

the facility under the CBSA designation. 

The next nineteen rows show the effects 

on facilities by urban versus rural status 

by census region. The last three rows 

show the effects on facilities by 

ownership (i.e., government, profit, and 

non-profit status). 

The second column in the table shows 

the number of facilities in the impact 

database. 

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. The total impact of this 

change is zero percent; however, there 

are distributional effects of the change. 

The fourth column shows the effect of 

all of the changes on the FY 2013 

payments. The update of 1.8 percent 

(consisting of the market basket increase 

of 2.5 percentage points, reduced by the 

0.7 percentage point MFP adjustment) is 

constant for all providers and, though 

not shown individually, is included in 

the total column. It is projected that 

aggregate payments will increase by 1.8 

percent, assuming facilities do not 

change their care delivery and billing 

practices in response. 

As can be seen from Table 14, the 

combined effects of all of the changes 

vary by specific types of providers and 

by location. Though all facilities would 

experience payment increases, the 

amount of the overall increase varies 

due to the impact of the wage index 

update. The wage index change can 

adjust the overall impact of the 1.8 

percent update upward or downward. 

For example, providers in the urban 

New England region would experience 

a 2.6 percent increase in FY 2013 total 

payments. The increase for this region 

differs from the aggregate 1.8 percent 

update due to the distributional effect of 

the wage index update as shown in the 

third column. 

TABLE 14—RUG–IV PROJECTED IMPACT TO THE SNF PPS FOR FY 2013 

Number of 

facilities 

FY 2013 

Update wage 

data 

(percent) 

Total FY 2013 

change 

(percent) 

Group: 

Total ...................................................................................................................................... 15,407 0.0 1.8 

Urban .................................................................................................................................... 10,568 0.1 1.9 

Rural ..................................................................................................................................... 4,839 ¥0.3 1.5 

Hospital based urban ........................................................................................................... 761 ¥0.1 1.7 

Freestanding urban .............................................................................................................. 9,807 0.1 1.9 

Hospital based rural ............................................................................................................. 428 ¥0.1 1.7 

Freestanding rural ................................................................................................................ 4,411 ¥0.3 1.5 

Urban by region: 

New England ........................................................................................................................ 811 0.8 2.6 

Middle Atlantic ...................................................................................................................... 1,456 0.0 1.8 

South Atlantic ....................................................................................................................... 1,747 ¥0.3 1.5 

East North Central ................................................................................................................ 2,043 0.2 2.0 

East South Central ............................................................................................................... 518 ¥1.0 0.8 

West North Central ............................................................................................................... 870 0.5 2.3 

West South Central .............................................................................................................. 1,224 ¥0.3 1.5 

Mountain ............................................................................................................................... 482 ¥0.9 0.9 

Pacific ................................................................................................................................... 1,411 0.9 2.7 

Outlying ................................................................................................................................. 6 0.2 2.0 

Rural by region: 

New England ........................................................................................................................ 152 ¥0.9 0.9 

Middle Atlantic ...................................................................................................................... 262 ¥0.1 1.7 

South Atlantic ....................................................................................................................... 611 ¥0.7 1.1 

East North Central ................................................................................................................ 935 0.3 2.1 

East South Central ............................................................................................................... 558 ¥0.4 1.4 

West North Central ............................................................................................................... 1,120 ¥0.9 0.9 

West South Central .............................................................................................................. 822 0.3 2.1 

Mountain ............................................................................................................................... 250 0.3 2.1 

Pacific ................................................................................................................................... 129 ¥1.4 0.3 

Ownership: 

Government .......................................................................................................................... 805 0.1 1.9 

Profit ..................................................................................................................................... 10,742 0.0 1.8 

Non-profit .............................................................................................................................. 3,860 0.1 1.9 

Note: The Total column includes the 2.5 percent market basket increase, reduced by the 0.7 percentage point MFP adjustment. Additionally, 

we found no SNFs in rural outlying areas. 

5. Alternatives Considered 

As described above, we estimate that 

the aggregate impact for FY 2013 would 

be an increase of $670 million in 

payments to SNFs, resulting from the 

MFP-adjusted market basket update to 

the payment rates. 

Section 1888(e) of the Act establishes 

the SNF PPS for the payment of 

Medicare SNF services for cost reporting 

periods beginning on or after July 1, 

1998. This section of the statute 

prescribes a detailed formula for 

calculating payment rates under the 

SNF PPS, and does not provide for the 

use of any alternative methodology. It 

specifies that the base year cost data to 


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Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 46231 

be used for computing the SNF PPS 

payment rates must be from FY 1995 

(October 1, 1994, through September 30, 

1995). In accordance with the statute, 

we also incorporated a number of 

elements into the SNF PPS (for example, 

case-mix classification methodology, a 

market basket index, a wage index, and 

the urban and rural distinction used in 

the development or adjustment of the 

Federal rates). Further, section 

1888(e)(4)(H) of the Act specifically 

requires us to disseminate the payment 

rates for each new FY through the 

Federal Register, and to do so before the 

August 1 that precedes the start of the 

new FY. Accordingly, we are not 

pursuing alternatives with respect to the 

payment methodology as discussed 

above. 

6. Accounting Statement 

As required by OMB Circular A–4 

(available online at 

www.whitehouse.gov/sites/default/files/ 

omb/assets/regulatory_matters_pdf/a4.pdf), in Table 15, we have prepared an 

accounting statement showing the 

classification of the expenditures 

associated with the provisions of this 

notice. Table 15 provides our best 

estimate of the possible changes in 

Medicare payments under the SNF PPS 

as a result of the policies in this notice, 

based on the data for 15,407 SNFs in our 

database. All expenditures are classified 

as transfers to Medicare providers (that 

is, SNFs). 

TABLE 15—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED EXPENDITURES, FROM THE 2012 SNF PPS 

FISCAL YEAR TO THE 2013 SNF PPS FISCAL YEAR

Category Transfers 

Annualized Monetized Transfers ....................................... 670 million.* 

From Whom To Whom? .................................................... Federal Government to SNF Medicare Providers. 

* The net increase of $670 million in transfer payments is a result of the MFP-adjusted market basket increase of $670 million. 

7. Conclusion 

This notice sets forth updates of the 

SNF PPS rates contained in the final 

rule for FY 2012 (76 FR 48486, August 

8, 2011). Based on the above, we 

estimate the overall estimated payments 

for SNFs in FY 2013 are projected to 

increase by $670 million, or 1.8 percent, 

compared with those in FY 2012. We 

estimate that in FY 2013 under RUG–IV, 

SNFs in urban and rural areas would 

experience, on average, a 1.9 and 1.5 

percent increase, respectively, in 

estimated payments compared with FY 

2012. Providers in the urban Pacific 

region would experience the largest 

estimated increase in payments of 

approximately 2.7 percent. Rural Pacific 

providers would experience the smallest 

estimated increase in payments of 0.3 

percent. 

B. Regulatory Flexibility Act Analysis 

The RFA requires agencies to analyze 

options for regulatory relief of small 

entities, if a rule has a significant impact 

on a substantial number of small 

entities. For purposes of the RFA, small 

entities include small businesses, nonprofit organizations, and small 

governmental jurisdictions. Most SNFs 

and most other providers and suppliers 

are small entities, either by their nonprofit status or by having revenues of 

$13.5 million or less in any 1 year. For 

purposes of the RFA, approximately 91 

percent of SNFs are considered small 

businesses according to the Small 

Business Administration’s latest size 

standards, with total revenues of $13.5 

million or less in any 1 year. (For 

details, see the Small Business 

Administration’s Web site at http:// 

www.sba.gov/category/navigationstructure/contracting/contractingofficials/eligibility-size-standards). 

Individuals and States are not included 

in the definition of a small entity. In 

addition, approximately 25 percent of 

SNFs classified as small entities are 

non-profit organizations. Finally, the 

estimated number of small business 

entities does not distinguish provider 

establishments that are within a single 

firm and, therefore, the number of SNFs 

classified as small entities may be 

higher than the estimate above. 

This notice sets forth updates of the 

SNF PPS rates contained in the final 

rule for FY 2012 (76 FR 48486, August 

8, 2011). Based on the above, we 

estimate that the aggregate impact 

would be an increase of $670 million in 

payments to SNFs, resulting from the 

MFP-adjusted market basket update to 

the payment rates. While it is projected 

in Table 14 that all providers would 

experience a net increase in payments, 

we note that some individual providers 

may experience larger increases in 

payments than others due to the 

distributional impact of the FY 2013 

wage indexes and the degree of 

Medicare utilization. 

Guidance issued by the Department of 

Health and Human Services on the 

proper assessment of the impact on 

small entities in rulemakings, utilizes a 

cost or revenue impact of 3 to 5 percent 

as a significance threshold under the 

RFA. According to MedPAC, Medicare 

covers approximately 12 percent of total 

patient days in freestanding facilities 

and 23 percent of facility revenue 

(March 2012). However, it is worth 

noting that the distribution of days and 

payments is highly variable. That is, the 

majority of SNFs have significantly 

lower Medicare utilization. As a result, 

for most facilities, when all payers are 

included in the revenue stream, the 

overall impact on total revenues should 

be substantially less than those impacts 

presented in Table 14. As indicated in 

Table 14, the effect on facilities is 

projected to be an aggregate positive 

impact of 1.8 percent. Additionally, as 

discussed in the FY 2012 final rule (76 

FR 48539), given the high proportion of 

SNFs that constitute small entities, any 

discussion of the impacts on the SNF 

industry as a whole may be directly 

characterized as an analysis of the 

impact of this notice on small entities. 

As the overall impact on the industry as 

a whole, and thus on small entities 

specifically, is less than the 3 to 5 

percent threshold discussed above, the 

Secretary has determined that this 

notice would not have a significant 

impact on a substantial number of small 

entities. 

In addition, section 1102(b) of the Act 

requires us to prepare a regulatory 

impact analysis if a rule may have a 

significant impact on the operations of 

a substantial number of small rural 

hospitals. This analysis must conform to 

the provisions of section 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. This notice would 

affect small rural hospitals that (a) 

furnish SNF services under a swing-bed 

agreement or (b) have a hospital-based 

SNF. We anticipate that the impact on 

small rural hospitals would be similar to 

the impact on SNF providers overall. 

Moreover, as noted in the FY 2012 final 

rule (76 FR 48539), the category of small 

rural hospitals would be included 

within the analysis of the impact of this 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46232 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

notice on small entities in general. As 

indicated in Table 14, the effect on 

facilities is projected to be an aggregate 

positive impact of 1.8 percent. As a 

result, the Secretary has determined that 

this notice would not have a significant 

impact on a substantial number of small 

rural hospitals. 

C. Unfunded Mandates Reform Act 

Analysis 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 (UMRA) 

also requires that agencies assess 

anticipated costs and benefits before 

issuing any rule whose mandates 

require spending in any 1 year of $100 

million in 1995 dollars, updated 

annually for inflation. In 2012, that 

threshold is approximately $139 

million. This notice would not impose 

spending costs on State, local, or tribal 

governments in the aggregate, or by the 

private sector, of $139 million. 

D. Federalism Analysis 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed rule (and subsequent final 

rule) that impose substantial direct 

requirement costs on State and local 

governments, preempts State law, or 

otherwise has Federalism implications. 

This notice would have no substantial 

direct effect on State and local 

governments, preempt State law, or 

otherwise have Federalism implications. 

Authority: Catalog of Federal Domestic 

Assistance Program No. 93.773, Medicare— 

Hospital Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program. 

Dated: April 17, 2012. 

Marilyn Tavenner, 

Acting Administrator, Centers for Medicare 

& Medicaid Services. 

Approved: July 24, 2012. 

Kathleen Sebelius, 

Secretary. 

Addendum—FY 2013 CBSA Wage 

Index Tables 

In this addendum, we provide the 

wage index tables referred to in the 

preamble to this notice. Tables A and B 

display the CBSA-based wage index 

values for urban and rural providers. 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS

CBSA code Urban area 

(constituent counties) Wage index 

10180 .......................... Abilene, TX ................................................................................................................................................ 0.8324 

Callahan County, TX 

Jones County, TX 

Taylor County, TX 

10380 .......................... Aguadilla-Isabela-San Sebastia ́n, PR ........................................................................................................ 0.3532 

Aguada Municipio, PR 

Aguadilla Municipio, PR 

An ̃asco Municipio, PR 

Isabela Municipio, PR 

Lares Municipio, PR 

Moca Municipio, PR 

Rinco ́n Municipio, PR 

San Sebastia ́n Municipio, PR 

10420 .......................... Akron, OH .................................................................................................................................................. 0.8729 

Portage County, OH 

Summit County, OH 

10500 .......................... Albany, GA ................................................................................................................................................. 0.8435 

Baker County, GA 

Dougherty County, GA 

Lee County, GA 

Terrell County, GA 

Worth County, GA 

10580 .......................... Albany-Schenectady-Troy, NY ................................................................................................................... 0.8647 

Albany County, NY 

Rensselaer County, NY 

Saratoga County, NY 

Schenectady County, NY 

Schoharie County, NY 

10740 .......................... Albuquerque, NM ....................................................................................................................................... 0.9542 

Bernalillo County, NM 

Sandoval County, NM 

Torrance County, NM 

Valencia County, NM 

10780 .......................... Alexandria, LA ........................................................................................................................................... 0.7857 

Grant Parish, LA 

Rapides Parish, LA 

10900 .......................... Allentown-Bethlehem-Easton, PA-NJ ........................................................................................................ 0.9084 

Warren County, NJ 

Carbon County, PA 

Lehigh County, PA 

Northampton County, PA 

11020 .......................... Altoona, PA ................................................................................................................................................ 0.8898 

Blair County, PA 

11100 .......................... Amarillo, TX ............................................................................................................................................... 0.8506 

Armstrong County, TX 

Carson County, TX 

Potter County, TX 

Randall County, TX 


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TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

11180 .......................... Ames, IA .................................................................................................................................................... 0.9595 

Story County, IA 

11260 .......................... Anchorage, AK ........................................................................................................................................... 1.2147 

Anchorage Municipality, AK 

Matanuska-Susitna Borough, AK 

11300 .......................... Anderson, IN .............................................................................................................................................. 0.9547 

Madison County, IN 

11340 .......................... Anderson, SC ............................................................................................................................................ 0.8929 

Anderson County, SC 

11460 .......................... Ann Arbor, MI ............................................................................................................................................. 1.0115 

Washtenaw County, MI 

11500 .......................... Anniston-Oxford, AL ................................................................................................................................... 0.7539 

Calhoun County, AL 

11540 .......................... Appleton, WI .............................................................................................................................................. 0.9268 

Calumet County, WI 

Outagamie County, WI 

11700 .......................... Asheville, NC ............................................................................................................................................. 0.8555 

Buncombe County, NC 

Haywood County, NC 

Henderson County, NC 

Madison County, NC 

12020 .......................... Athens-Clarke County, GA ........................................................................................................................ 0.9488 

Clarke County, GA 

Madison County, GA 

Oconee County, GA 

Oglethorpe County, GA 

12060 .......................... Atlanta-Sandy Springs-Marietta, GA .......................................................................................................... 0.9517 

Barrow County, GA 

Bartow County, GA 

Butts County, GA 

Carroll County, GA 

Cherokee County, GA 

Clayton County, GA 

Cobb County, GA 

Coweta County, GA 

Dawson County, GA 

DeKalb County, GA 

Douglas County, GA 

Fayette County, GA 

Forsyth County, GA 

Fulton County, GA 

Gwinnett County, GA 

Haralson County, GA 

Heard County, GA 

Henry County, GA 

Jasper County, GA 

Lamar County, GA 

Meriwether County, GA 

Newton County, GA 

Paulding County, GA 

Pickens County, GA 

Pike County, GA 

Rockdale County, GA 

Spalding County, GA 

Walton County, GA 

12100 .......................... Atlantic City-Hammonton, NJ ..................................................................................................................... 1.1977 

Atlantic County, NJ 

12220 .......................... Auburn-Opelika, AL ................................................................................................................................... 0.7437 

Lee County, AL 

12260 .......................... Augusta-Richmond County, GA-SC .......................................................................................................... 0.9373 

Burke County, GA 

Columbia County, GA 

McDuffie County, GA 

Richmond County, GA 

Aiken County, SC 

Edgefield County, SC 

12420 .......................... Austin-Round Rock, TX ............................................................................................................................. 0.9746 

Bastrop County, TX 

Caldwell County, TX 

Hays County, TX 

Travis County, TX 


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TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Williamson County, TX 

12540 .......................... Bakersfield, CA .......................................................................................................................................... 1.1611 

Kern County, CA 

12580 .......................... Baltimore-Towson, MD .............................................................................................................................. 1.0147 

Anne Arundel County, MD 

Baltimore County, MD 

Carroll County, MD 

Harford County, MD 

Howard County, MD 

Queen Anne’s County, MD 

Baltimore City, MD 

12620 .......................... Bangor, ME ................................................................................................................................................ 1.0184 

Penobscot County, ME 

12700 .......................... Barnstable Town, MA ................................................................................................................................ 1.2843 

Barnstable County, MA 

12940 .......................... Baton Rouge, LA ....................................................................................................................................... 0.8147 

Ascension Parish, LA 

East Baton Rouge Parish, LA 

East Feliciana Parish, LA 

Iberville Parish, LA 

Livingston Parish, LA 

Pointe Coupee Parish, LA 

St. Helena Parish, LA 

West Baton Rouge Parish, LA 

West Feliciana Parish, LA 

12980 .......................... Battle Creek, MI ......................................................................................................................................... 0.9912 

Calhoun County, MI 

13020 .......................... Bay City, MI ............................................................................................................................................... 0.9181 

Bay County, MI 

13140 .......................... Beaumont-Port Arthur, TX ......................................................................................................................... 0.8533 

Hardin County, TX 

Jefferson County, TX 

Orange County, TX 

13380 .......................... Bellingham, WA ......................................................................................................................................... 1.1415 

Whatcom County, WA 

13460 .......................... Bend, OR ................................................................................................................................................... 1.1119 

Deschutes County, OR 

13644 .......................... Bethesda-Frederick-Gaithersburg, MD ...................................................................................................... 1.0374 

Frederick County, MD 

Montgomery County, MD 

13740 .......................... Billings, MT ................................................................................................................................................ 0.8737 

Carbon County, MT 

Yellowstone County, MT 

13780 .......................... Binghamton, NY ......................................................................................................................................... 0.8707 

Broome County, NY 

Tioga County, NY 

13820 .......................... Birmingham-Hoover, AL ............................................................................................................................. 0.8516 

Bibb County, AL 

Blount County, AL 

Chilton County, AL 

Jefferson County, AL 

St. Clair County, AL 

Shelby County, AL 

Walker County, AL 

13900 .......................... Bismarck, ND ............................................................................................................................................. 0.7261 

Burleigh County, ND 

Morton County, ND 

13980 .......................... Blacksburg-Christiansburg-Radford, VA .................................................................................................... 0.8348 

Giles County, VA 

Montgomery County, VA 

Pulaski County, VA 

Radford City, VA 

14020 .......................... Bloomington, IN ......................................................................................................................................... 0.8752 

Greene County, IN 

Monroe County, IN 

Owen County, IN 

14060 .......................... Bloomington-Normal, IL ............................................................................................................................. 0.9502 

McLean County, IL 

14260 .......................... Boise City-Nampa, ID ................................................................................................................................ 0.8897 

Ada County, ID 

Boise County, ID 


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TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Canyon County, ID 

Gem County, ID 

Owyhee County, ID 

14484 .......................... Boston-Quincy, MA .................................................................................................................................... 1.2378 

Norfolk County, MA 

Plymouth County, MA 

Suffolk County, MA 

14500 .......................... Boulder, CO ............................................................................................................................................... 1.0574 

Boulder County, CO 

14540 .......................... Bowling Green, KY .................................................................................................................................... 0.8665 

Edmonson County, KY 

Warren County, KY 

14740 .......................... Bremerton-Silverdale, WA ......................................................................................................................... 1.0829 

Kitsap County, WA 

14860 .......................... Bridgeport-Stamford-Norwalk, CT .............................................................................................................. 1.3170 

Fairfield County, CT 

15180 .......................... Brownsville-Harlingen, TX .......................................................................................................................... 0.8612 

Cameron County, TX 

15260 .......................... Brunswick, GA ........................................................................................................................................... 0.8792 

Brantley County, GA 

Glynn County, GA 

McIntosh County, GA 

15380 .......................... Buffalo-Niagara Falls, NY .......................................................................................................................... 0.9999 

Erie County, NY 

Niagara County, NY 

15500 .......................... Burlington, NC ............................................................................................................................................ 0.8485 

Alamance County, NC 

15540 .......................... Burlington-South Burlington, VT ................................................................................................................ 0.9997 

Chittenden County, VT 

Franklin County, VT 

Grand Isle County, VT 

15764 .......................... Cambridge-Newton-Framingham, MA ....................................................................................................... 1.1262 

Middlesex County, MA 

15804 .......................... Camden, NJ ............................................................................................................................................... 1.0474 

Burlington County, NJ 

Camden County, NJ 

Gloucester County, NJ 

15940 .......................... Canton-Massillon, OH ................................................................................................................................ 0.8834 

Carroll County, OH 

Stark County, OH 

15980 .......................... Cape Coral-Fort Myers, FL ........................................................................................................................ 0.9153 

Lee County, FL 

16020 .......................... Cape Girardeau-Jackson, MO-IL ............................................................................................................... 0.8860 

Alexander County, IL 

Bollinger County, MO 

Cape Girardeau County, MO 

16180 .......................... Carson City, NV ......................................................................................................................................... 1.0559 

Carson City, NV 

16220 .......................... Casper, WY ...............................................................................................................................................

Natrona County, WY 

1.0143 

16300 .......................... Cedar Rapids, IA .......................................................................................................................................

Benton County, IA 

Jones County, IA 

Linn County, IA 

0.8944 

16580 .......................... Champaign-Urbana, IL ..............................................................................................................................

Champaign County, IL 

Ford County, IL 

Piatt County, IL 

0.9907 

16620 .......................... Charleston, WV ..........................................................................................................................................

Boone County, WV 

Clay County, WV 

Kanawha County, WV 

Lincoln County, WV 

Putnam County, WV 

0.8050 

16700 .......................... Charleston-North Charleston-Summerville, SC .........................................................................................

Berkeley County, SC 

Charleston County, SC 

Dorchester County, SC 

0.8820 


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TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

16740 .......................... Charlotte-Gastonia-Concord, NC-SC .........................................................................................................

Anson County, NC 

Cabarrus County, NC 

Gaston County, NC 

Mecklenburg County, NC 

Union County, NC 

York County, SC 

0.9215 

16820 .......................... Charlottesville, VA ......................................................................................................................................

Albemarle County, VA 

Fluvanna County, VA 

Greene County, VA 

Nelson County, VA 

Charlottesville City, VA 

0.9195 

16860 .......................... Chattanooga, TN-GA .................................................................................................................................

Catoosa County, GA 

Dade County, GA 

Walker County, GA 

Hamilton County, TN 

Marion County, TN 

Sequatchie County, TN 

0.8678 

16940 .......................... Cheyenne, WY ...........................................................................................................................................

Laramie County, WY 

0.9730 

16974 .......................... Chicago-Naperville-Joliet, IL ......................................................................................................................

Cook County, IL 

DeKalb County, IL 

DuPage County, IL 

Grundy County, IL 

Kane County, IL 

Kendall County, IL 

McHenry County, IL 

Will County, IL 

1.0600 

17020 .......................... Chico, CA ...................................................................................................................................................

Butte County, CA 

1.1197 

17140 .......................... Cincinnati-Middletown, OH-KY-IN ..............................................................................................................

Dearborn County, IN 

Franklin County, IN 

Ohio County, IN 

Boone County, KY 

Bracken County, KY 

Campbell County, KY 

Gallatin County, KY 

Grant County, KY 

Kenton County, KY 

Pendleton County, KY 

Brown County, OH 

Butler County, OH 

Clermont County, OH 

Hamilton County, OH 

Warren County, OH 

0.9508 

17300 .......................... Clarksville, TN-KY ......................................................................................................................................

Christian County, KY 

Trigg County, KY 

Montgomery County, TN 

Stewart County, TN 

0.8082 

17420 .......................... Cleveland, TN ............................................................................................................................................

Bradley County, TN 

Polk County, TN 

0.7592 

17460 .......................... Cleveland-Elyria-Mentor, OH .....................................................................................................................

Cuyahoga County, OH 

Geauga County, OH 

Lake County, OH 

Lorain County, OH 

Medina County, OH 

0.9082 

17660 .......................... Coeur d’Alene, ID ......................................................................................................................................

Kootenai County, ID 

0.9218 

17780 .......................... College Station-Bryan, TX .........................................................................................................................

Brazos County, TX 

Burleson County, TX 

Robertson County, TX 

0.9584 


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TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

17820 .......................... Colorado Springs, CO ................................................................................................................................

El Paso County, CO 

Teller County, CO 

0.9364 

17860 .......................... Columbia, MO ............................................................................................................................................

Boone County, MO 

Howard County, MO 

0.8339 

17900 .......................... Columbia, SC .............................................................................................................................................

Calhoun County, SC 

Fairfield County, SC 

Kershaw County, SC 

Lexington County, SC 

Richland County, SC 

Saluda County, SC 

0.8560 

17980 .......................... Columbus, GA-AL ......................................................................................................................................

Russell County, AL 

Chattahoochee County, GA 

Harris County, GA 

Marion County, GA 

Muscogee County, GA 

0.8857 

18020 .......................... Columbus, IN .............................................................................................................................................

Bartholomew County, IN 

0.9564 

18140 .......................... Columbus, OH ...........................................................................................................................................

Delaware County, OH 

Fairfield County, OH 

Franklin County, OH 

Licking County, OH 

Madison County, OH 

Morrow County, OH 

Pickaway County, OH 

Union County, OH 

0.9763 

18580 .......................... Corpus Christi, TX .....................................................................................................................................

Aransas County, TX 

Nueces County, TX 

San Patricio County, TX 

0.8591 

18700 .......................... Corvallis, OR ..............................................................................................................................................

Benton County, OR 

1.0715 

18880 .......................... Crestview-Fort Walton Beach-Destin, FL ..................................................................................................

Okaloosa County, FL 

0.8916 

19060 .......................... Cumberland, MD-WV .................................................................................................................................

Allegany County, MD 

Mineral County, WV 

0.8836 

19124 .......................... Dallas-Plano-Irving, TX ..............................................................................................................................

Collin County, TX 

Dallas County, TX 

Delta County, TX 

Denton County, TX 

Ellis County, TX 

Hunt County, TX 

Kaufman County, TX 

Rockwall County, TX 

0.9835 

19140 .......................... Dalton, GA .................................................................................................................................................

Murray County, GA 

Whitfield County, GA 

0.8828 

19180 .......................... Danville, IL .................................................................................................................................................

Vermilion County, IL 

0.9977 

19260 .......................... Danville, VA ...............................................................................................................................................

Pittsylvania County, VA 

Danville City, VA 

0.8218 

19340 .......................... Davenport-Moline-Rock Island, IA-IL .........................................................................................................

Henry County, IL 

Mercer County, IL 

Rock Island County, IL 

Scott County, IA 

0.9145 

19380 .......................... Dayton, OH ................................................................................................................................................

Greene County, OH 

Miami County, OH 

Montgomery County, OH 

Preble County, OH 

0.9136 


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TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

19460 .......................... Decatur, AL ................................................................................................................................................

Lawrence County, AL 

Morgan County, AL 

0.7261 

19500 .......................... Decatur, IL .................................................................................................................................................

Macon County, IL 

0.7993 

19660 .......................... Deltona-Daytona Beach-Ormond Beach, FL .............................................................................................

Volusia County, FL 

0.8716 

19740 .......................... Denver-Aurora-Broomfield, CO ..................................................................................................................

Adams County, CO 

Arapahoe County, CO 

Broomfield County, CO 

Clear Creek County, CO 

Denver County, CO 

Douglas County, CO 

Elbert County, CO 

Gilpin County, CO 

Jefferson County, CO 

Park County, CO 

1.0469 

19780 .......................... Des Moines-West Des Moines, IA .............................................................................................................

Dallas County, IA 

Guthrie County, IA 

Madison County, IA 

Polk County, IA 

Warren County, IA 

0.9616 

19804 .......................... Detroit-Livonia-Dearborn, MI ......................................................................................................................

Wayne County, MI 

0.9361 

20020 .......................... Dothan, AL .................................................................................................................................................

Geneva County, AL 

Henry County, AL 

Houston County, AL 

0.7398 

20100 .......................... Dover, DE ..................................................................................................................................................

Kent County, DE 

0.9893 

20220 .......................... Dubuque, IA ...............................................................................................................................................

Dubuque County, IA 

0.8662 

20260 .......................... Duluth, MN-WI ...........................................................................................................................................

Carlton County, MN 

St. Louis County, MN 

Douglas County, WI 

1.0741 

20500 .......................... Durham-Chapel Hill, NC ............................................................................................................................

Chatham County, NC 

Durham County, NC 

Orange County, NC 

Person County, NC 

0.9525 

20740 .......................... Eau Claire, WI ............................................................................................................................................

Chippewa County, WI 

Eau Claire County, WI 

0.9705 

20764 .......................... Edison-New Brunswick, NJ ........................................................................................................................

Middlesex County, NJ 

Monmouth County, NJ 

Ocean County, NJ 

Somerset County, NJ 

1.0806 

20940 .......................... El Centro, CA .............................................................................................................................................

Imperial County, CA 

0.8602 

21060 .......................... Elizabethtown, KY ......................................................................................................................................

Hardin County, KY 

Larue County, KY 

0.8294 

21140 .......................... Elkhart-Goshen, IN ....................................................................................................................................

Elkhart County, IN 

0.9097 

21300 .......................... Elmira, NY ..................................................................................................................................................

Chemung County, NY 

0.8205 

21340 .......................... El Paso, TX ................................................................................................................................................

El Paso County, TX 

0.8426 

21500 .......................... Erie, PA ......................................................................................................................................................

Erie County, PA 

0.7823 

21660 .......................... Eugene-Springfield, OR .............................................................................................................................

Lane County, OR 

1.1454 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 46239 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

21780 .......................... Evansville, IN-KY .......................................................................................................................................

Gibson County, IN 

Posey County, IN 

Vanderburgh County, IN 

Warrick County, IN 

Henderson County, KY 

Webster County, KY 

0.8401 

21820 .......................... Fairbanks, AK ............................................................................................................................................

Fairbanks North Star Borough, AK 

1.0816 

21940 .......................... Fajardo, PR ................................................................................................................................................

Ceiba Municipio, PR 

Fajardo Municipio, PR 

Luquillo Municipio, PR 

0.3663 

22020 .......................... Fargo, ND-MN ............................................................................................................................................

Cass County, ND 

Clay County, MN 

0.8108 

22140 .......................... Farmington, NM .........................................................................................................................................

San Juan County, NM 

0.9323 

22180 .......................... Fayetteville, NC ..........................................................................................................................................

Cumberland County, NC 

Hoke County, NC 

0.8971 

22220 .......................... Fayetteville-Springdale-Rogers, AR-MO ....................................................................................................

Benton County, AR 

Madison County, AR 

Washington County, AR 

McDonald County, MO 

0.9288 

22380 .......................... Flagstaff, AZ ..............................................................................................................................................

Coconino County, AZ 

1.2369 

22420 .......................... Flint, MI ......................................................................................................................................................

Genesee County, MI 

1.1257 

22500 .......................... Florence, SC ..............................................................................................................................................

Darlington County, SC 

Florence County, SC 

0.8087 

22520 .......................... Florence-Muscle Shoals, AL ......................................................................................................................

Colbert County, AL 

Lauderdale County, AL 

0.7679 

22540 .......................... Fond du Lac, WI ........................................................................................................................................

Fond du Lac County, WI 

0.9158 

22660 .......................... Fort Collins-Loveland, CO .........................................................................................................................

Larimer County, CO 

0.9833 

22744 .......................... Fort Lauderdale-Pompano Beach-Deerfield Beach, FL ............................................................................

Broward County, FL 

1.0363 

22900 .......................... Fort Smith, AR-OK .....................................................................................................................................

Crawford County, AR 

Franklin County, AR 

Sebastian County, AR 

Le Flore County, OK 

Sequoyah County, OK 

0.7848 

23060 .......................... Fort Wayne, IN ...........................................................................................................................................

Allen County, IN 

Wells County, IN 

Whitley County, IN 

0.9633 

23104 .......................... Fort Worth-Arlington, TX ............................................................................................................................

Johnson County, TX 

Parker County, TX 

Tarrant County, TX 

Wise County, TX 

0.9516 

23420 .......................... Fresno, CA .................................................................................................................................................

Fresno County, CA 

1.1593 

23460 .......................... Gadsden, AL ..............................................................................................................................................

Etowah County, AL 

0.7697 

23540 .......................... Gainesville, FL ...........................................................................................................................................

Alachua County, FL 

Gilchrist County, FL 

0.9631 

23580 .......................... Gainesville, GA ..........................................................................................................................................

Hall County, GA 

0.9327 

23844 .......................... Gary, IN .....................................................................................................................................................

Jasper County, IN 

Lake County, IN 

Newton County, IN 

Porter County, IN 

0.9259 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46240 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

24020 .......................... Glens Falls, NY ..........................................................................................................................................

Warren County, NY 

Washington County, NY 

0.8340 

24140 .......................... Goldsboro, NC ...........................................................................................................................................

Wayne County, NC 

0.8560 

24220 .......................... Grand Forks, ND-MN .................................................................................................................................

Polk County, MN 

Grand Forks County, ND 

0.7250 

24300 .......................... Grand Junction, CO ...................................................................................................................................

Mesa County, CO 

0.9415 

24340 .......................... Grand Rapids-Wyoming, MI ......................................................................................................................

Barry County, MI 

Ionia County, MI 

Kent County, MI 

Newaygo County, MI 

0.9125 

24500 .......................... Great Falls, MT ..........................................................................................................................................

Cascade County, MT 

0.7927 

24540 .......................... Greeley, CO ...............................................................................................................................................

Weld County, CO 

0.9593 

24580 .......................... Green Bay, WI ...........................................................................................................................................

Brown County, WI 

Kewaunee County, WI 

Oconto County, WI 

0.9793 

24660 .......................... Greensboro-High Point, NC .......................................................................................................................

Guilford County, NC 

Randolph County, NC 

Rockingham County, NC 

0.8638 

24780 .......................... Greenville, NC ............................................................................................................................................

Greene County, NC 

Pitt County, NC 

0.9694 

24860 .......................... Greenville-Mauldin-Easley, SC ..................................................................................................................

Greenville County, SC 

Laurens County, SC 

Pickens County, SC 

0.9737 

25020 .......................... Guayama, PR ............................................................................................................................................

Arroyo Municipio, PR 

Guayama Municipio, PR 

Patillas Municipio, PR 

0.3696 

25060 .......................... Gulfport-Biloxi, MS .....................................................................................................................................

Hancock County, MS 

Harrison County, MS 

Stone County, MS 

0.8544 

25180 .......................... Hagerstown-Martinsburg, MD-WV .............................................................................................................

Washington County, MD 

Berkeley County, WV 

Morgan County, WV 

0.9422 

25260 .......................... Hanford-Corcoran, CA ...............................................................................................................................

Kings County, CA 

1.0992 

25420 .......................... Harrisburg-Carlisle, PA ..............................................................................................................................

Cumberland County, PA 

Dauphin County, PA 

Perry County, PA 

0.9525 

25500 .......................... Harrisonburg, VA .......................................................................................................................................

Rockingham County, VA 

Harrisonburg City, VA 

0.9087 

25540 .......................... Hartford-West Hartford-East Hartford, CT .................................................................................................

Hartford County, CT 

Middlesex County, CT 

Tolland County, CT 

1.0869 

25620 .......................... Hattiesburg, MS .........................................................................................................................................

Forrest County, MS 

Lamar County, MS 

Perry County, MS 

0.8035 

25860 .......................... Hickory-Lenoir-Morganton, NC ..................................................................................................................

Alexander County, NC 

Burke County, NC 

Caldwell County, NC 

Catawba County, NC 

0.8677 

25980 .......................... Hinesville-Fort Stewart, GA1 ......................................................................................................................

Liberty County, GA 

Long County, GA 

0.8843 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 46241 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

26100 .......................... Holland-Grand Haven, MI ..........................................................................................................................

Ottawa County, MI 

0.8024 

26180 .......................... Honolulu, HI ...............................................................................................................................................

Honolulu County, HI 

1.2156 

26300 .......................... Hot Springs, AR .........................................................................................................................................

Garland County, AR 

0.8944 

26380 .......................... Houma-Bayou Cane-Thibodaux, LA ..........................................................................................................

Lafourche Parish, LA 

Terrebonne Parish, LA 

0.7928 

26420 .......................... Houston-Sugar Land-Baytown, TX ............................................................................................................

Austin County, TX 

Brazoria County, TX 

Chambers County, TX 

Fort Bend County, TX 

Galveston County, TX 

Harris County, TX 

Liberty County, TX 

Montgomery County, TX 

San Jacinto County, TX 

Waller County, TX 

0.9933 

26580 .......................... Huntington-Ashland, WV-KY-OH ...............................................................................................................

Boyd County, KY 

Greenup County, KY 

Lawrence County, OH 

Cabell County, WV 

Wayne County, WV 

0.8635 

26620 .......................... Huntsville, AL .............................................................................................................................................

Limestone County, AL 

Madison County, AL 

0.8667 

26820 .......................... Idaho Falls, ID ............................................................................................................................................

Bonneville County, ID 

Jefferson County, ID 

0.9114 

26900 .......................... Indianapolis-Carmel, IN .............................................................................................................................

Boone County, IN 

Brown County, IN 

Hamilton County, IN 

Hancock County, IN 

Hendricks County, IN 

Johnson County, IN 

Marion County, IN 

Morgan County, IN 

Putnam County, IN 

Shelby County, IN 

0.9870 

26980 .......................... Iowa City, IA ..............................................................................................................................................

Johnson County, IA 

Washington County, IA 

1.0120 

27060 .......................... Ithaca, NY ..................................................................................................................................................

Tompkins County, NY 

0.9249 

27100 .......................... Jackson, MI ................................................................................................................................................

Jackson County, MI 

0.8511 

27140 .......................... Jackson, MS ..............................................................................................................................................

Copiah County, MS 

Hinds County, MS 

Madison County, MS 

Rankin County, MS 

Simpson County, MS 

0.8177 

27180 .......................... Jackson, TN ...............................................................................................................................................

Chester County, TN 

Madison County, TN 

0.7672 

27260 .......................... Jacksonville, FL .........................................................................................................................................

Baker County, FL 

Clay County, FL 

Duval County, FL 

Nassau County, FL 

St. Johns County, FL 

0.8883 

27340 .......................... Jacksonville, NC ........................................................................................................................................

Onslow County, NC 

0.7957 

27500 .......................... Janesville, WI .............................................................................................................................................

Rock County, WI 

0.9458 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46242 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

27620 .......................... Jefferson City, MO .....................................................................................................................................

Callaway County, MO 

Cole County, MO 

Moniteau County, MO 

Osage County, MO 

0.8263 

27740 .......................... Johnson City, TN .......................................................................................................................................

Carter County, TN 

Unicoi County, TN 

Washington County, TN 

0.7359 

27780 .......................... Johnstown, PA ...........................................................................................................................................

Cambria County, PA 

0.8116 

27860 .......................... Jonesboro, AR ...........................................................................................................................................

Craighead County, AR 

Poinsett County, AR 

0.8084 

27900 .......................... Joplin, MO ..................................................................................................................................................

Jasper County, MO 

Newton County, MO 

0.7828 

28020 .......................... Kalamazoo-Portage, MI .............................................................................................................................

Kalamazoo County, MI 

Van Buren County, MI 

0.9834 

28100 .......................... Kankakee-Bradley, IL ................................................................................................................................

Kankakee County, IL 

1.0127 

28140 .......................... Kansas City, MO-KS ..................................................................................................................................

Franklin County, KS 

Johnson County, KS 

Leavenworth County, KS 

Linn County, KS 

Miami County, KS 

Wyandotte County, KS 

Bates County, MO 

Caldwell County, MO 

Cass County, MO 

Clay County, MO 

Clinton County, MO 

Jackson County, MO 

Lafayette County, MO 

Platte County, MO 

Ray County, MO 

0.9614 

28420 .......................... Kennewick-Pasco-Richland, WA ...............................................................................................................

Benton County, WA 

Franklin County, WA 

0.9708 

28660 .......................... Killeen-Temple-Fort Hood, TX ...................................................................................................................

Bell County, TX 

Coryell County, TX 

Lampasas County, TX 

0.9102 

28700 .......................... Kingsport-Bristol-Bristol, TN-VA .................................................................................................................

Hawkins County, TN 

Sullivan County, TN 

Bristol City, VA 

Scott County, VA 

Washington County, VA 

0.7325 

28740 .......................... Kingston, NY ..............................................................................................................................................

Ulster County, NY 

0.8953 

28940 .......................... Knoxville, TN ..............................................................................................................................................

Anderson County, TN 

Blount County, TN 

Knox County, TN 

Loudon County, TN 

Union County, TN 

0.7575 

29020 .......................... Kokomo, IN ................................................................................................................................................

Howard County, IN 

Tipton County, IN 

0.8756 

29100 .......................... La Crosse, WI-MN .....................................................................................................................................

Houston County, MN 

La Crosse County, WI 

1.0070 

29140 .......................... Lafayette, IN ..............................................................................................................................................

Benton County, IN 

Carroll County, IN 

Tippecanoe County, IN 

0.9316 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 46243 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

29180 .......................... Lafayette, LA ..............................................................................................................................................

Lafayette Parish, LA 

St. Martin Parish, LA 

0.8565 

29340 .......................... Lake Charles, LA .......................................................................................................................................

Calcasieu Parish, LA 

Cameron Parish, LA 

0.7813 

29404 .......................... Lake County-Kenosha County, IL-WI ........................................................................................................

Lake County, IL 

Kenosha County, WI 

1.0558 

29420 .......................... Lake Havasu City-Kingman, AZ ................................................................................................................

Mohave County, AZ 

0.9760 

29460 .......................... Lakeland-Winter Haven, FL .......................................................................................................................

Polk County, FL 

0.8262 

29540 .......................... Lancaster, PA ............................................................................................................................................

Lancaster County, PA 

0.9452 

29620 .......................... Lansing-East Lansing, MI ..........................................................................................................................

Clinton County, MI 

Eaton County, MI 

Ingham County, MI 

1.0065 

29700 .......................... Laredo, TX .................................................................................................................................................

Webb County, TX 

0.7486 

29740 .......................... Las Cruces, NM .........................................................................................................................................

Dona Ana County, NM 

0.9044 

29820 .......................... Las Vegas-Paradise, NV ...........................................................................................................................

Clark County, NV 

1.2076 

29940 .......................... Lawrence, KS ............................................................................................................................................

Douglas County, KS 

0.8676 

30020 .......................... Lawton, OK ................................................................................................................................................

Comanche County, OK 

0.8351 

30140 .......................... Lebanon, PA ..............................................................................................................................................

Lebanon County, PA 

0.7994 

30300 .......................... Lewiston, ID-WA ........................................................................................................................................

Nez Perce County, ID 

Asotin County, WA 

0.9326 

30340 .......................... Lewiston-Auburn, ME .................................................................................................................................

Androscoggin County, ME 

0.9178 

30460 .......................... Lexington-Fayette, KY ...............................................................................................................................

Bourbon County, KY 

Clark County, KY 

Fayette County, KY 

Jessamine County, KY 

Scott County, KY 

Woodford County, KY 

0.9023 

30620 .......................... Lima, OH ....................................................................................................................................................

Allen County, OH 

0.9226 

30700 .......................... Lincoln, NE ................................................................................................................................................

Lancaster County, NE 

Seward County, NE 

0.9726 

30780 .......................... Little Rock-North Little Rock-Conway, AR .................................................................................................

Faulkner County, AR 

Grant County, AR 

Lonoke County, AR 

Perry County, AR 

Pulaski County, AR 

Saline County, AR 

0.8595 

30860 .......................... Logan, UT-ID .............................................................................................................................................

Franklin County, ID 

Cache County, UT 

0.8456 

30980 .......................... Longview, TX .............................................................................................................................................

Gregg County, TX 

Rusk County, TX 

Upshur County, TX 

0.8550 

31020 .......................... Longview, WA ............................................................................................................................................

Cowlitz County, WA 

1.0081 

31084 .......................... Los Angeles-Long Beach-Glendale, CA ....................................................................................................

Los Angeles County, CA 

1.2293 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46244 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

31140 .......................... Louisville-Jefferson County, KY-IN ............................................................................................................

Clark County, IN 

Floyd County, IN 

Harrison County, IN 

Washington County, IN 

Bullitt County, KY 

Henry County, KY 

Meade County, KY 

Nelson County, KY 

Oldham County, KY 

Shelby County, KY 

Spencer County, KY 

Trimble County, KY 

0.8862 

31180 .......................... Lubbock, TX ...............................................................................................................................................

Crosby County, TX 

Lubbock County, TX 

0.8870 

31340 .......................... Lynchburg, VA ...........................................................................................................................................

Amherst County, VA 

Appomattox County, VA 

Bedford County, VA 

Campbell County, VA 

Bedford City, VA 

Lynchburg City, VA 

0.8615 

31420 .......................... Macon, GA .................................................................................................................................................

Bibb County, GA 

Crawford County, GA 

Jones County, GA 

Monroe County, GA 

Twiggs County, GA 

0.8584 

31460 .......................... Madera-Chowchilla, CA .............................................................................................................................

Madera County, CA 

0.8050 

31540 .......................... Madison, WI ...............................................................................................................................................

Columbia County, WI 

Dane County, WI 

Iowa County, WI 

1.1264 

31700 .......................... Manchester-Nashua, NH ...........................................................................................................................

Hillsborough County, NH 

1.0042 

31740 .......................... Manhattan, KS ...........................................................................................................................................

Geary County, KS 

Pottawatomie County, KS 

Riley County, KS 

0.7839 

31860 .......................... Mankato-North Mankato, MN .....................................................................................................................

Blue Earth County, MN 

Nicollet County, MN 

0.9413 

31900 .......................... Mansfield, OH ............................................................................................................................................

Richland County, OH 

0.8993 

32420 .......................... Mayagu ̈ez, PR ...........................................................................................................................................

Hormigueros Municipio, PR 

Mayagu ̈ez Municipio, PR 

0.3586 

32580 .......................... McAllen-Edinburg-Mission, TX ...................................................................................................................

Hidalgo County, TX 

0.8603 

32780 .......................... Medford, OR ..............................................................................................................................................

Jackson County, OR 

1.0400 

32820 .......................... Memphis, TN-MS-AR .................................................................................................................................

Crittenden County, AR 

DeSoto County, MS 

Marshall County, MS 

Tate County, MS 

Tunica County, MS 

Fayette County, TN 

Shelby County, TN 

Tipton County, TN 

0.9049 

32900 .......................... Merced, CA ................................................................................................................................................

Merced County, CA 

1.2996 

33124 .......................... Miami-Miami Beach-Kendall, FL ................................................................................................................

Miami-Dade County, FL 

1.0130 

33140 .......................... Michigan City-La Porte, IN .........................................................................................................................

LaPorte County, IN 

0.9694 

33260 .......................... Midland, TX ................................................................................................................................................

Midland County, TX 

1.0640 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 46245 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

33340 .......................... Milwaukee-Waukesha-West Allis, WI ........................................................................................................

Milwaukee County, WI 

Ozaukee County, WI 

Washington County, WI 

Waukesha County, WI 

0.9931 

33460 .......................... Minneapolis-St. Paul-Bloomington, MN-WI ...............................................................................................

Anoka County, MN 

Carver County, MN 

Chisago County, MN 

Dakota County, MN 

Hennepin County, MN 

Isanti County, MN 

Ramsey County, MN 

Scott County, MN 

Sherburne County, MN 

Washington County, MN 

Wright County, MN 

Pierce County, WI 

St. Croix County, WI 

1.1336 

33540 .......................... Missoula, MT .............................................................................................................................................

Missoula County, MT 

0.9001 

33660 .......................... Mobile, AL ..................................................................................................................................................

Mobile County, AL 

0.7467 

33700 .......................... Modesto, CA ..............................................................................................................................................

Stanislaus County, CA 

1.2841 

33740 .......................... Monroe, LA ................................................................................................................................................

Ouachita Parish, LA 

Union Parish, LA 

0.7717 

33780 .......................... Monroe, MI .................................................................................................................................................

Monroe County, MI 

0.8472 

33860 .......................... Montgomery, AL ........................................................................................................................................

Autauga County, AL 

Elmore County, AL 

Lowndes County, AL 

Montgomery County, AL 

0.7858 

34060 .......................... Morgantown, WV .......................................................................................................................................

Monongalia County, WV 

Preston County, WV 

0.8284 

34100 .......................... Morristown, TN ...........................................................................................................................................

Grainger County, TN 

Hamblen County, TN 

Jefferson County, TN 

0.6768 

34580 .......................... Mount Vernon-Anacortes, WA ...................................................................................................................

Skagit County, WA 

1.0340 

34620 .......................... Muncie, IN ..................................................................................................................................................

Delaware County, IN 

0.8734 

34740 .......................... Muskegon-Norton Shores, MI ....................................................................................................................

Muskegon County, MI 

1.1007 

34820 .......................... Myrtle Beach-North Myrtle Beach-Conway, SC ........................................................................................

Horry County, SC 

0.8717 

34900 .......................... Napa, CA ...................................................................................................................................................

Napa County, CA 

1.6045 

34940 .......................... Naples-Marco Island, FL ............................................................................................................................

Collier County, FL 

0.9265 

34980 .......................... Nashville-Davidson—Murfreesboro-Franklin, TN ......................................................................................

Cannon County, TN 

Cheatham County, TN 

Davidson County, TN 

Dickson County, TN 

Hickman County, TN 

Macon County, TN 

Robertson County, TN 

Rutherford County, TN 

Smith County, TN 

Sumner County, TN 

Trousdale County, TN 

Williamson County, TN 

Wilson County, TN 

0.9061 

35004 .......................... Nassau-Suffolk, NY ...................................................................................................................................

Nassau County, NY 

Suffolk County, NY 

1.2698 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46246 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

35084 .......................... Newark-Union, NJ-PA ................................................................................................................................

Essex County, NJ 

Hunterdon County, NJ 

Morris County, NJ 

Sussex County, NJ 

Union County, NJ 

Pike County, PA 

1.1223 

35300 .......................... New Haven-Milford, CT .............................................................................................................................

New Haven County, CT 

1.2061 

35380 .......................... New Orleans-Metairie-Kenner, LA .............................................................................................................

Jefferson Parish, LA 

Orleans Parish, LA 

Plaquemines Parish, LA 

St. Bernard Parish, LA 

St. Charles Parish, LA 

St. John the Baptist Parish, LA 

St. Tammany Parish, LA 

0.8932 

35644 .......................... New York-White Plains-Wayne, NY-NJ .....................................................................................................

Bergen County, NJ 

Hudson County, NJ 

Passaic County, NJ 

Bronx County, NY 

Kings County, NY 

New York County, NY 

Putnam County, NY 

Queens County, NY 

Richmond County, NY 

Rockland County, NY 

Westchester County, NY 

1.2914 

35660 .......................... Niles-Benton Harbor, MI ............................................................................................................................

Berrien County, MI 

0.8237 

35840 .......................... North Port-Bradenton-Sarasota-Venice, FL ...............................................................................................

Manatee County, FL 

Sarasota County, FL 

0.9375 

35980 .......................... Norwich-New London, CT ..........................................................................................................................

New London County, CT 

1.1376 

36084 .......................... Oakland-Fremont-Hayward, CA .................................................................................................................

Alameda County, CA 

Contra Costa County, CA 

1.6654 

36100 .......................... Ocala, FL ...................................................................................................................................................

Marion County, FL 

0.8455 

36140 .......................... Ocean City, NJ ...........................................................................................................................................

Cape May County, NJ 

1.0307 

36220 .......................... Odessa, TX ................................................................................................................................................

Ector County, TX 

0.9741 

36260 .......................... Ogden-Clearfield, UT .................................................................................................................................

Davis County, UT 

Morgan County, UT 

Weber County, UT 

0.9031 

36420 .......................... Oklahoma City, OK ....................................................................................................................................

Canadian County, OK 

Cleveland County, OK 

Grady County, OK 

Lincoln County, OK 

Logan County, OK 

McClain County, OK 

Oklahoma County, OK 

0.8810 

36500 .......................... Olympia, WA ..............................................................................................................................................

Thurston County, WA 

1.1397 

36540 .......................... Omaha-Council Bluffs, NE-IA ....................................................................................................................

Harrison County, IA 

Mills County, IA 

Pottawattamie County, IA 

Cass County, NE 

Douglas County, NE 

Sarpy County, NE 

Saunders County, NE 

Washington County, NE 

1.0037 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 46247 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

36740 .......................... Orlando-Kissimmee, FL .............................................................................................................................

Lake County, FL 

Orange County, FL 

Osceola County, FL 

Seminole County, FL 

0.9082 

36780 .......................... Oshkosh-Neenah, WI .................................................................................................................................

Winnebago County, WI 

0.9433 

36980 .......................... Owensboro, KY ..........................................................................................................................................

Daviess County, KY 

Hancock County, KY 

McLean County, KY 

0.8117 

37100 .......................... Oxnard-Thousand Oaks-Ventura, CA ........................................................................................................

Ventura County, CA 

1.3079 

37340 .......................... Palm Bay-Melbourne-Titusville, FL ............................................................................................................

Brevard County, FL 

0.8838 

37380 .......................... Palm Coast, FL ..........................................................................................................................................

Flagler County, FL 

0.9880 

37460 .......................... Panama City-Lynn Haven-Panama City Beach, FL ..................................................................................

Bay County, FL 

0.7976 

37620 .......................... Parkersburg-Marietta-Vienna, WV-OH ......................................................................................................

Washington County, OH 

Pleasants County, WV 

Wirt County, WV 

Wood County, WV 

0.7487 

37700 .......................... Pascagoula, MS .........................................................................................................................................

George County, MS 

Jackson County, MS 

0.7662 

37764 .......................... Peabody, MA .............................................................................................................................................

Essex County, MA 

1.0551 

37860 .......................... Pensacola-Ferry Pass-Brent, FL ...............................................................................................................

Escambia County, FL 

Santa Rosa County, FL 

0.7819 

37900 .......................... Peoria, IL ...................................................................................................................................................

Marshall County, IL 

Peoria County, IL 

Stark County, IL 

Tazewell County, IL 

Woodford County, IL 

0.8882 

37964 .......................... Philadelphia, PA ........................................................................................................................................

Bucks County, PA 

Chester County, PA 

Delaware County, PA 

Montgomery County, PA 

Philadelphia County, PA 

1.0806 

38060 .......................... Phoenix-Mesa-Scottsdale, AZ ...................................................................................................................

Maricopa County, AZ 

Pinal County, AZ 

1.0477 

38220 .......................... Pine Bluff, AR ............................................................................................................................................

Cleveland County, AR 

Jefferson County, AR 

Lincoln County, AR 

0.7847 

38300 .......................... Pittsburgh, PA ............................................................................................................................................

Allegheny County, PA 

Armstrong County, PA 

Beaver County, PA 

Butler County, PA 

Fayette County, PA 

Washington County, PA 

Westmoreland County, PA 

0.8585 

38340 .......................... Pittsfield, MA ..............................................................................................................................................

Berkshire County, MA 

1.0721 

38540 .......................... Pocatello, ID ..............................................................................................................................................

Bannock County, ID 

Power County, ID 

0.9555 

38660 .......................... Ponce, PR ..................................................................................................................................................

Juana Dı ́az Municipio, PR 

Ponce Municipio, PR 

Villalba Municipio, PR 

0.4314 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46248 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

38860 .......................... Portland-South Portland-Biddeford, ME ....................................................................................................

Cumberland County, ME 

Sagadahoc County, ME 

York County, ME 

0.9975 

38900 .......................... Portland-Vancouver-Beaverton, OR-WA ...................................................................................................

Clackamas County, OR 

Columbia County, OR 

Multnomah County, OR 

Washington County, OR 

Yamhill County, OR 

Clark County, WA 

Skamania County, WA 

1.1673 

38940 .......................... Port St. Lucie, FL .......................................................................................................................................

Martin County, FL 

St. Lucie County, FL 

0.9577 

39100 .......................... Poughkeepsie-Newburgh-Middletown, NY ................................................................................................

Dutchess County, NY 

Orange County, NY 

1.1325 

39140 .......................... Prescott, AZ ...............................................................................................................................................

Yavapai County, AZ 

1.2009 

39300 .......................... Providence-New Bedford-Fall River, RI-MA ..............................................................................................

Bristol County, MA 

Bristol County, RI 

Kent County, RI 

Newport County, RI 

Providence County, RI 

Washington County, RI 

1.0699 

39340 .......................... Provo-Orem, UT .........................................................................................................................................

Juab County, UT 

Utah County, UT 

0.9133 

39380 .......................... Pueblo, CO ................................................................................................................................................

Pueblo County, CO 

0.8518 

39460 .......................... Punta Gorda, FL ........................................................................................................................................

Charlotte County, FL 

0.8590 

39540 .......................... Racine, WI .................................................................................................................................................

Racine County, WI 

0.9158 

39580 .......................... Raleigh-Cary, NC .......................................................................................................................................

Franklin County, NC 

Johnston County, NC 

Wake County, NC 

0.9488 

39660 .......................... Rapid City, SD ...........................................................................................................................................

Meade County, SD 

Pennington County, SD 

0.9823 

39740 .......................... Reading, PA ...............................................................................................................................................

Berks County, PA 

0.9072 

39820 .......................... Redding, CA ..............................................................................................................................................

Shasta County, CA 

1.4555 

39900 .......................... Reno-Sparks, NV .......................................................................................................................................

Storey County, NV 

Washoe County, NV 

1.0328 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 46249 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

40060 .......................... Richmond, VA ............................................................................................................................................

Amelia County, VA 

Caroline County, VA 

Charles City County, VA 

Chesterfield County, VA 

Cumberland County, VA 

Dinwiddie County, VA 

Goochland County, VA 

Hanover County, VA 

Henrico County, VA 

King and Queen County, VA 

King William County, VA 

Louisa County, VA 

New Kent County, VA 

Powhatan County, VA 

Prince George County, VA 

Sussex County, VA 

Colonial Heights City, VA 

Hopewell City, VA 

Petersburg City, VA 

Richmond City, VA 

0.9695 

40140 .......................... Riverside-San Bernardino-Ontario, CA ......................................................................................................

Riverside County, CA 

San Bernardino County, CA 

1.1396 

40220 .......................... Roanoke, VA ..............................................................................................................................................

Botetourt County, VA 

Craig County, VA 

Franklin County, VA 

Roanoke County, VA 

Roanoke City, VA 

Salem City, VA 

0.9088 

40340 .......................... Rochester, MN ...........................................................................................................................................

Dodge County, MN 

Olmsted County, MN 

Wabasha County, MN 

1.0708 

40380 .......................... Rochester, NY ............................................................................................................................................

Livingston County, NY 

Monroe County, NY 

Ontario County, NY 

Orleans County, NY 

Wayne County, NY 

0.8704 

40420 .......................... Rockford, IL ...............................................................................................................................................

Boone County, IL 

Winnebago County, IL 

0.9935 

40484 .......................... Rockingham County-Strafford County, NH ................................................................................................

Rockingham County, NH 

Strafford County, NH 

1.0234 

40580 .......................... Rocky Mount, NC .......................................................................................................................................

Edgecombe County, NC 

Nash County, NC 

0.8898 

40660 .......................... Rome, GA ..................................................................................................................................................

Floyd County, GA 

0.8844 

40900 .......................... Sacramento-Arden-Arcade-Roseville, CA .................................................................................................

El Dorado County, CA 

Placer County, CA 

Sacramento County, CA 

Yolo County, CA 

1.4752 

40980 .......................... Saginaw-Saginaw Township North, MI ......................................................................................................

Saginaw County, MI 

0.8820 

41060 .......................... St. Cloud, MN ............................................................................................................................................

Benton County, MN 

Stearns County, MN 

1.1010 

41100 .......................... St. George, UT ..........................................................................................................................................

Washington County, UT 

0.8870 

41140 .......................... St. Joseph, MO-KS ....................................................................................................................................

Doniphan County, KS 

Andrew County, MO 

Buchanan County, MO 

DeKalb County, MO 

0.9856 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46250 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

41180 .......................... St. Louis, MO-IL .........................................................................................................................................

Bond County, IL 

Calhoun County, IL 

Clinton County, IL 

Jersey County, IL 

Macoupin County, IL 

Madison County, IL 

Monroe County, IL 

St. Clair County, IL 

Crawford County, MO 

Franklin County, MO 

Jefferson County, MO 

Lincoln County, MO 

St. Charles County, MO 

St. Louis County, MO 

Warren County, MO 

Washington County, MO 

St. Louis City, MO 

0.9420 

41420 .......................... Salem, OR .................................................................................................................................................

Marion County, OR 

Polk County, OR 

1.1069 

41500 .......................... Salinas, CA ................................................................................................................................................

Monterey County, CA 

1.6074 

41540 .......................... Salisbury, MD .............................................................................................................................................

Somerset County, MD 

Wicomico County, MD 

0.9260 

41620 .......................... Salt Lake City, UT ......................................................................................................................................

Salt Lake County, UT 

Summit County, UT 

Tooele County, UT 

0.9063 

41660 .......................... San Angelo, TX .........................................................................................................................................

Irion County, TX 

Tom Green County, TX 

0.8221 

41700 .......................... San Antonio, TX ........................................................................................................................................

Atascosa County, TX 

Bandera County, TX 

Bexar County, TX 

Comal County, TX 

Guadalupe County, TX 

Kendall County, TX 

Medina County, TX 

Wilson County, TX 

0.8936 

41740 .......................... San Diego-Carlsbad-San Marcos, CA .......................................................................................................

San Diego County, CA 

1.1922 

41780 .......................... Sandusky, OH ............................................................................................................................................

Erie County, OH 

0.8347 

41884 .......................... San Francisco-San Mateo-Redwood City, CA ..........................................................................................

Marin County, CA 

San Francisco County, CA 

San Mateo County, CA 

1.6327 

41900 .......................... San Germa ́n-Cabo Rojo, PR .....................................................................................................................

Cabo Rojo Municipio, PR 

Lajas Municipio, PR 

Sabana Grande Municipio, PR 

San Germa ́n Municipio, PR 

0.4804 

41940 .......................... San Jose-Sunnyvale-Santa Clara, CA ......................................................................................................

San Benito County, CA 

Santa Clara County, CA 

1.7396 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 46251 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

41980 .......................... San Juan-Caguas-Guaynabo, PR .............................................................................................................

Aguas Buenas Municipio, PR 

Aibonito Municipio, PR 

Arecibo Municipio, PR 

Barceloneta Municipio, PR 

Barranquitas Municipio, PR 

Bayamo ́n Municipio, PR 

Caguas Municipio, PR 

Camuy Municipio, PR 

Cano ́vanas Municipio, PR 

Carolina Municipio, PR 

Catan ̃o Municipio, PR 

Cayey Municipio, PR 

Ciales Municipio, PR 

Cidra Municipio, PR 

Comerı ́o Municipio, PR 

Corozal Municipio, PR 

Dorado Municipio, PR 

Florida Municipio, PR 

Guaynabo Municipio, PR 

Gurabo Municipio, PR 

Hatillo Municipio, PR 

Humacao Municipio, PR 

Juncos Municipio, PR 

Las Piedras Municipio, PR 

Loı ́za Municipio, PR 

Manatı ́ Municipio, PR 

Maunabo Municipio, PR 

Morovis Municipio, PR 

Naguabo Municipio, PR 

Naranjito Municipio, PR 

Orocovis Municipio, PR 

Quebradillas Municipio, PR 

Rı ́o Grande Municipio, PR 

San Juan Municipio, PR 

San Lorenzo Municipio, PR 

Toa Alta Municipio, PR 

Toa Baja Municipio, PR 

Trujillo Alto Municipio, PR 

Vega Alta Municipio, PR 

Vega Baja Municipio, PR 

Yabucoa Municipio, PR 

0.4318 

42020 .......................... San Luis Obispo-Paso Robles, CA ...........................................................................................................

San Luis Obispo County, CA 

1.3081 

42044 .......................... Santa Ana-Anaheim-Irvine, CA ..................................................................................................................

Orange County, CA 

1.2038 

42060 .......................... Santa Barbara-Santa Maria-Goleta, CA ....................................................................................................

Santa Barbara County, CA 

1.2670 

42100 .......................... Santa Cruz-Watsonville, CA ......................................................................................................................

Santa Cruz County, CA 

1.8062 

42140 .......................... Santa Fe, NM .............................................................................................................................................

Santa Fe County, NM 

1.0400 

42220 .......................... Santa Rosa-Petaluma, CA .........................................................................................................................

Sonoma County, CA 

1.6440 

42340 .......................... Savannah, GA ...........................................................................................................................................

Bryan County, GA 

Chatham County, GA 

Effingham County, GA 

0.8968 

42540 .......................... Scranton—Wilkes-Barre, PA ......................................................................................................................

Lackawanna County, PA 

Luzerne County, PA 

Wyoming County, PA 

0.8260 

42644 .......................... Seattle-Bellevue-Everett, WA ....................................................................................................................

King County, WA 

Snohomish County, WA 

1.1771 

42680 .......................... Sebastian-Vero Beach, FL .........................................................................................................................

Indian River County, FL 

0.8850 

43100 .......................... Sheboygan, WI ..........................................................................................................................................

Sheboygan County, WI 

0.9515 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46252 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

43300 .......................... Sherman-Denison, TX ...............................................................................................................................

Grayson County, TX 

0.8544 

43340 .......................... Shreveport-Bossier City, LA ......................................................................................................................

Bossier Parish, LA 

Caddo Parish, LA 

De Soto Parish, LA 

0.8412 

43580 .......................... Sioux City, IA-NE-SD .................................................................................................................................

Woodbury County, IA 

Dakota County, NE 

Dixon County, NE 

Union County, SD 

0.9010 

43620 .......................... Sioux Falls, SD ..........................................................................................................................................

Lincoln County, SD 

McCook County, SD 

Minnehaha County, SD 

Turner County, SD 

0.8338 

43780 .......................... South Bend-Mishawaka, IN-MI ..................................................................................................................

St. Joseph County, IN 

Cass County, MI 

0.9531 

43900 .......................... Spartanburg, SC ........................................................................................................................................

Spartanburg County, SC 

0.9186 

44060 .......................... Spokane, WA .............................................................................................................................................

Spokane County, WA 

1.0824 

44100 .......................... Springfield, IL .............................................................................................................................................

Menard County, IL 

Sangamon County, IL 

0.9179 

44140 .......................... Springfield, MA ..........................................................................................................................................

Franklin County, MA 

Hampden County, MA 

Hampshire County, MA 

1.0377 

44180 .......................... Springfield, MO ..........................................................................................................................................

Christian County, MO 

Dallas County, MO 

Greene County, MO 

Polk County, MO 

Webster County, MO 

0.8581 

44220 .......................... Springfield, OH ..........................................................................................................................................

Clark County, OH 

0.9236 

44300 .......................... State College, PA ......................................................................................................................................

Centre County, PA 

0.9510 

44600 .......................... Steubenville-Weirton, OH-WV ...................................................................................................................

Jefferson County, OH 

Brooke County, WV 

Hancock County, WV 

0.7640 

44700 .......................... Stockton, CA ..............................................................................................................................................

San Joaquin County, CA 

1.3356 

44940 .......................... Sumter, SC ................................................................................................................................................

Sumter County, SC 

0.7454 

45060 .......................... Syracuse, NY .............................................................................................................................................

Madison County, NY 

Onondaga County, NY 

Oswego County, NY 

0.9829 

45104 .......................... Tacoma, WA ..............................................................................................................................................

Pierce County, WA 

1.1741 

45220 .......................... Tallahassee, FL .........................................................................................................................................

Gadsden County, FL 

Jefferson County, FL 

Leon County, FL 

Wakulla County, FL 

0.8521 

45300 .......................... Tampa-St. Petersburg-Clearwater, FL .......................................................................................................

Hernando County, FL 

Hillsborough County, FL 

Pasco County, FL 

Pinellas County, FL 

0.9032 

45460 .......................... Terre Haute, IN ..........................................................................................................................................

Clay County, IN 

Sullivan County, IN 

Vermillion County, IN 

Vigo County, IN 

0.9113 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 46253 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

45500 .......................... Texarkana, TX-Texarkana, AR ..................................................................................................................

Miller County, AR 

Bowie County, TX 

0.7967 

45780 .......................... Toledo, OH ................................................................................................................................................

Fulton County, OH 

Lucas County, OH 

Ottawa County, OH 

Wood County, OH 

0.9034 

45820 .......................... Topeka, KS ................................................................................................................................................

Jackson County, KS 

Jefferson County, KS 

Osage County, KS 

Shawnee County, KS 

Wabaunsee County, KS 

0.8969 

45940 .......................... Trenton-Ewing, NJ .....................................................................................................................................

Mercer County, NJ 

1.0360 

46060 .......................... Tucson, AZ ................................................................................................................................................

Pima County, AZ 

0.9065 

46140 .......................... Tulsa, OK ...................................................................................................................................................

Creek County, OK 

Okmulgee County, OK 

Osage County, OK 

Pawnee County, OK 

Rogers County, OK 

Tulsa County, OK 

Wagoner County, OK 

0.8139 

46220 .......................... Tuscaloosa, AL ..........................................................................................................................................

Greene County, AL 

Hale County, AL 

Tuscaloosa County, AL 

0.8533 

46340 .......................... Tyler, TX ....................................................................................................................................................

Smith County, TX 

0.8361 

46540 .......................... Utica-Rome, NY .........................................................................................................................................

Herkimer County, NY 

Oneida County, NY 

0.8653 

46660 .......................... Valdosta, GA ..............................................................................................................................................

Brooks County, GA 

Echols County, GA 

Lanier County, GA 

Lowndes County, GA 

0.7918 

46700 .......................... Vallejo-Fairfield, CA ...................................................................................................................................

Solano County, CA 

1.5844 

47020 .......................... Victoria, TX ................................................................................................................................................

Calhoun County, TX 

Goliad County, TX 

Victoria County, TX 

0.8992 

47220 .......................... Vineland-Millville-Bridgeton, NJ .................................................................................................................

Cumberland County, NJ 

1.0596 

47260 .......................... Virginia Beach-Norfolk-Newport News, VA-NC .........................................................................................

Currituck County, NC 

Gloucester County, VA 

Isle of Wight County, VA 

James City County, VA 

Mathews County, VA 

Surry County, VA 

York County, VA 

Chesapeake City, VA 

Hampton City, VA 

Newport News City, VA 

Norfolk City, VA 

Poquoson City, VA 

Portsmouth City, VA 

Suffolk City, VA 

Virginia Beach City, VA 

Williamsburg City, VA 

0.9208 

47300 .......................... Visalia-Porterville, CA ................................................................................................................................

Tulare County, CA 

1.0349 

47380 .......................... Waco, TX ...................................................................................................................................................

McLennan County, TX 

0.8458 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
46254 Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

47580 .......................... Warner Robins, GA ....................................................................................................................................

Houston County, GA 

0.8197 

47644 .......................... Warren-Troy-Farmington Hills, MI .............................................................................................................

Lapeer County, MI 

Livingston County, MI 

Macomb County, MI 

Oakland County, MI 

St. Clair County, MI 

0.9543 

47894 .......................... Washington-Arlington-Alexandria, DC-VA-MD-WV ...................................................................................

District of Columbia, DC 

Calvert County, MD 

Charles County, MD 

Prince George’s County, MD 

Arlington County, VA 

Clarke County, VA 

Fairfax County, VA 

Fauquier County, VA 

Loudoun County, VA 

Prince William County, VA 

Spotsylvania County, VA 

Stafford County, VA 

Warren County, VA 

Alexandria City, VA 

Fairfax City, VA 

Falls Church City, VA 

Fredericksburg City, VA 

Manassas City, VA 

Manassas Park City, VA 

Jefferson County, WV 

1.0659 

47940 .......................... Waterloo-Cedar Falls, IA ...........................................................................................................................

Black Hawk County, IA 

Bremer County, IA 

Grundy County, IA 

0.8422 

48140 .......................... Wausau, WI ...............................................................................................................................................

Marathon County, WI 

0.8921 

48300 .......................... Wenatchee-East Wenatchee, WA .............................................................................................................

Chelan County, WA 

Douglas County, WA 

1.0037 

48424 .......................... West Palm Beach-Boca Raton-Boynton Beach, FL ..................................................................................

Palm Beach County, FL 

0.9661 

48540 .......................... Wheeling, WV-OH ......................................................................................................................................

Belmont County, OH 

Marshall County, WV 

Ohio County, WV 

0.6863 

48620 .......................... Wichita, KS ................................................................................................................................................

Butler County, KS 

Harvey County, KS 

Sedgwick County, KS 

Sumner County, KS 

0.8681 

48660 .......................... Wichita Falls, TX ........................................................................................................................................

Archer County, TX 

Clay County, TX 

Wichita County, TX 

0.9048 

48700 .......................... Williamsport, PA .........................................................................................................................................

Lycoming County, PA 

0.8230 

48864 .......................... Wilmington, DE-MD-NJ ..............................................................................................................................

New Castle County, DE 

Cecil County, MD 

Salem County, NJ 

1.0687 

48900 .......................... Wilmington, NC ..........................................................................................................................................

Brunswick County, NC 

New Hanover County, NC 

Pender County, NC 

0.9155 

49020 .......................... Winchester, VA-WV ...................................................................................................................................

Frederick County, VA 

Winchester City, VA 

Hampshire County, WV 

0.9249 


TKELLEY on DSK3SPTVN1PROD with NOTICES3
Federal Register / Vol. 77, No. 149 / Thursday, August 2, 2012 / Notices 46255 

TABLE A—FY 2013 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

49180 .......................... Winston-Salem, NC ...................................................................................................................................

Davie County, NC 

Forsyth County, NC 

Stokes County, NC 

Yadkin County, NC 

0.8660 

49340 .......................... Worcester, MA ...........................................................................................................................................

Worcester County, MA 

1.1205 

49420 .......................... Yakima, WA ...............................................................................................................................................

Yakima County, WA 

1.0097 

49500 .......................... Yauco, PR ..................................................................................................................................................

Gua ́nica Municipio, PR 

Guayanilla Municipio, PR 

Pen ̃uelas Municipio, PR 

Yauco Municipio, PR 

0.4059 

49620 .......................... York-Hanover, PA ......................................................................................................................................

York County, PA 

0.9557 

49660 .......................... Youngstown-Warren-Boardman, OH-PA ...................................................................................................

Mahoning County, OH 

Trumbull County, OH 

Mercer County, PA 

0.8283 

49700 .......................... Yuba City, CA1 ..........................................................................................................................................

Sutter County, CA 

Yuba County, CA 

1.2004 

49740 .......................... Yuma, AZ ...................................................................................................................................................

Yuma County, AZ 

0.9517 

1At this time, there are no hospitals located in this urban area on which to base a wage index. 

TABLE B—FY 2013 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS

State 

code 

Nonurban 

area 

Wage 

index 

1 ............. Alabama ............. 0.7121 

2 ............. Alaska ................. 1.2807 

3 ............. Arizona ............... 0.9182 

4 ............. Arkansas ............. 0.7350 

5 ............. California ............ 1.2567 

6 ............. Colorado ............. 1.0208 

7 ............. Connecticut ......... 1.1128 

8 ............. Delaware ............ 1.0171 

10 ............. Florida ................. 0.8062 

11 ............. Georgia ............... 0.7421 

12 ............. Hawaii ................. 1.0728 

13 ............. Idaho ................... 0.7583 

14 ............. Illinois .................. 0.8438 

15 ............. Indiana ................ 0.8472 

16 ............. Iowa .................... 0.8351 

17 ............. Kansas ................ 0.7997 

18 ............. Kentucky ............. 0.7877 

19 ............. Louisiana ............ 0.7718 

20 ............. Maine .................. 0.8300 

21 ............. Maryland ............. 0.8797 

22 ............. Massachusetts .... 1.3540 

23 ............. Michigan ............. 0.8387 

TABLE B—FY 2013 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS—Continued 

State 

code 

Nonurban 

area 

Wage 

index 

24 ............. Minnesota ........... 0.9053 

25 ............. Mississippi .......... 0.7537 

26 ............. Missouri .............. 0.7622 

27 ............. Montana .............. 0.8600 

28 ............. Nebraska ............ 0.8733 

29 ............. Nevada ............... 0.9739 

30 ............. New Hampshire .. 1.0372 

31 ............. New Jersey 1 ...... ....................

32 ............. New Mexico ........ 0.8879 

33 ............. New York ............ 0.8199 

34 ............. North Carolina .... 0.8271 

35 ............. North Dakota ...... 0.6891 

36 ............. Ohio .................... 0.8470 

37 ............. Oklahoma ........... 0.7783 

38 ............. Oregon ................ 0.9500 

39 ............. Pennsylvania ...... 0.8380 

40 ............. Puerto Rico 1 ...... 0.4047 

41 ............. Rhode Island 1 .... ....................

42 ............. South Carolina .... 0.8338 

43 ............. South Dakota ...... 0.8124 

44 ............. Tennessee .......... 0.7559 

TABLE B—FY 2013 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS—Continued 

State 

code 

Nonurban 

area 

Wage 

index 

45 ............. Texas .................. 0.7978 

46 ............. Utah .................... 0.8516 

47 ............. Vermont .............. 0.9725 

48 ............. Virgin Islands ...... 0.7185 

49 ............. Virginia ................ 0.7728 

50 ............. Washington ......... 1.0092 

51 ............. West Virginia ...... 0.7333 

52 ............. Wisconsin ........... 0.9142 

53 ............. Wyoming ............. 0.9238 

65 ............. Guam .................. 0.9611 

1All counties within the State are classified 

as urban, with the exception of Puerto Rico. 

Puerto Rico has areas designated as rural; 

however, no short-term, acute care hospitals 

are located in the area(s) for FY 2013. The 

Puerto Rico wage index is the same as FY 

2012. 

[FR Doc. 2012–18719 Filed 7–27–12; 4:15 pm] 

BILLING CODE P 


TKELLEY on DSK3SPTVN1PROD with NOTICES3