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[Federal Register: April 30, 2010 (Volume 75, Number 83)]
[Notices]               
[Page 23105-23149]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr30ap10-163]                         

[[Page 23105]]

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Part IV

Department of Health and Human Services

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Centers for Medicare & Medicaid Services

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Medicare Program; Inpatient Psychiatric Facilities Prospective Payment 
System Payment--Update for Rate Year Beginning July 1, 2010 (RY 2011); 
Notice

[[Page 23106]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-1424-N]
RIN 0938-AP83

 
Medicare Program; Inpatient Psychiatric Facilities Prospective 
Payment System Payment--Update for Rate Year Beginning July 1, 2010 (RY 
2011)

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

ACTION: Notice

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SUMMARY: This notice updates the payment rates for the Medicare 
prospective payment system (PPS) for inpatient psychiatric hospital 
services provided by inpatient psychiatric facilities (IPFs). These 
changes are applicable to IPF discharges occurring during the rate year 
beginning July 1, 2010 through June 30, 2011. We are also responding to 
comments on the IPF PPS teaching adjustment and the market basket, 
which we received in response to our May 2009 IPF PPS notice with 
request for comments.

DATES: Effective Date: The updated IPF prospective payment rates are 
effective for discharges occurring on or after July 1, 2010 through 
June 30, 2011.

FOR FURTHER INFORMATION CONTACT:

Dorothy Myrick or Jana Lindquist, (410) 786-4533 (for general 
information).
Mary Carol Barron, (410) 786-7943 (for information regarding the market 
basket and labor-related share).
Theresa Bean, (410) 786-2287 (for information regarding the regulatory 
impact analysis).

SUPPLEMENTARY INFORMATION:

Table of Contents

    To assist readers in referencing sections contained in this 
document, we are providing the following table of contents.

I. Background
    A. Annual Requirements for Updating the IPF PPS
    B. Overview of the Legislative Requirements of the IPF PPS
    C. IPF PPS--General Overview
II. Transition Period for Implementation of the IPF PPS
III. Updates to the IPF PPS for RY Beginning July 1, 2010
    A. Determining the Standardized Budget-Neutral Federal Per Diem 
Base Rate
    1. Standardization of the Federal Per Diem Base Rate and
    Electroconvulsive Therapy (ECT) Rate
    2. Calculation of the Budget Neutrality Adjustment
    a. Outlier Adjustment
    b. Stop-Loss Provision Adjustment
    c. Behavioral Offset
    B. Update of the Federal Per Diem Base Rate and 
Electroconvulsive Therapy Rate
    1. Market Basket for IPFs Reimbursed under the IPF PPS
    a. Market Basket Index for the IPF PPS
    b. Overview of the RPL Market Basket
    2. Labor-Related Share
    3. Comments on Creating a Stand-Alone IPF Market Basket
    IV. Update of the IPF PPS Adjustment Factors
    A. Overview of the IPF PPS Adjustment Factors
    B. Patient-Level Adjustments
    1. Adjustment for MS-DRG Assignment
    2. Payment for Comorbid Conditions
    3. Patient Age Adjustments
    4. Variable Per Diem Adjustments
    C. Facility-Level Adjustments
    1. Wage Index Adjustment
    a. Background
    b. Wage Index for RY 2011
    c. OMB Bulletins
    2. Adjustment for Rural Location
    3. Teaching Adjustment
    4. Cost of Living Adjustment for IPFs Located in Alaska and 
Hawaii
    5. Adjustment for IPFs With a Qualifying Emergency Department 
(ED)
    D. Other Payment Adjustments and Policies
    1. Outlier Payments
    a. Update to the Outlier Fixed Dollar Loss Threshold Amount
    b. Statistical Accuracy of Cost-to-Charge Ratios
    2. Expiration of the Stop-Loss Provision
V. Comments Beyond the Scope of the May 2009 IPF PPS Notice With 
Request for Comments
VI. Waiver of Proposed Rulemaking
VII. Collection of Information Requirements
VIII. Regulatory Impact Analysis
Addenda

Acronyms

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

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

I. Background

A. Annual Requirements for Updating the IPF PPS

    In November 2004, we implemented the inpatient psychiatric 
facilities (IPF) prospective payment system (PPS) in a final rule that 
appeared in the November 15, 2004 Federal Register (69 FR 66922). In 
developing the IPF PPS, in order to ensure that the IPF PPS is able to 
account adequately for each IPF's case-mix, we performed an extensive 
regression analysis of the relationship between the per diem costs and 
certain patient and facility characteristics to determine those 
characteristics associated with statistically significant cost 
differences on a per diem basis. For characteristics with statistically 
significant cost differences, we used the regression coefficients of 
those variables to determine the size of the corresponding payment 
adjustments.
    In that final rule, we explained that we believe it is important to 
delay updating the adjustment factors derived from the regression 
analysis until we have IPF PPS data that includes as much information 
as possible regarding the patient-level characteristics of the 
population that each IPF serves. Therefore, we indicated that we did 
not intend to update the regression analysis and recalculate the 
Federal per diem base rate and the patient- and facility-level 
adjustments until we complete that analysis. Until that analysis is 
complete, we stated our intention to publish a notice in the Federal 
Register each spring to update the IPF PPS (71 FR 27041).
    Updates to the IPF PPS as specified in 42 CFR Sec.  412.428 include 
the following:
     A description of the methodology and data used to 
calculate the updated Federal per diem base payment amount.
     The rate of increase factor as described in Sec.  
412.424(a)(2)(iii), which is based on the excluded hospital with 
capital market basket under the update methodology of section 
1886(b)(3)(B)(ii) of the Social Security Act (the Act) for each year 
(effective from the implementation period until June 30, 2006).
     For discharges occurring on or after July 1, 2006, the 
rate of increase factor for the Federal portion of the IPF's payment, 
which is based on the rehabilitation, psychiatric, and long-term care 
(RPL) market basket.
     The best available hospital wage index and information 
regarding whether an adjustment to the Federal

[[Page 23107]]

per diem base rate is needed to maintain budget neutrality.
     Updates to the fixed dollar loss threshold amount in order 
to maintain the appropriate outlier percentage.
     Description of the International Classification of 
Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding and 
diagnosis-related groups (DRGs) classification changes discussed in the 
annual update to the hospital inpatient prospective payment system 
(IPPS) regulations.
     Update to the electroconvulsive therapy (ECT) payment by a 
factor specified by CMS.
     Update to the national urban and rural cost-to-charge 
ratio medians and ceilings.
     Update to the cost of living adjustment factors for IPFs 
located in Alaska and Hawaii, if appropriate.
    Our most recent annual update occurred in the May 2009 IPF PPS 
notice with request for comments (74 FR 20362) (hereinafter referred to 
as the May 2009 IPF PPS notice) that set forth updates to the IPF PPS 
payment rates for RY 2010. This notice updates the IPF per diem payment 
rates that were published in the May 2009 IPF PPS notice in accordance 
with our established policies.

B. Overview of the Legislative Requirements of the IPF PPS

    Section 124 of the Medicare, Medicaid, and SCHIP (State Children's 
Health Insurance Program) Balanced Budget Refinement Act of 1999, (Pub. 
L. 106-113) (BBRA) required implementation of the IPF PPS. 
Specifically, section 124 of the BBRA mandated that the Secretary 
develop a per diem PPS for inpatient hospital services furnished in 
psychiatric hospitals and psychiatric units that includes an adequate 
patient classification system that reflects the differences in patient 
resource use and costs among psychiatric hospitals and psychiatric 
units.
    Section 405(g)(2) of the Medicare Prescription Drug, Improvement, 
and Modernization Act of 2003 (MMA) (Pub. L. 108-173) extended the IPF 
PPS to distinct part psychiatric units of critical access hospitals 
(CAHs).
    To implement these provisions, we published various proposed and 
final rules in the Federal Register. For more information regarding 
these rules, see the CMS Web sites http://www.cms.hhs.gov/InpatientPsychFacilPPS/andhttp://www.cms.hhs.gov/InpatientpsychfacilPPS/02_regulations.asp.
    Section 1886(s)(3)(A) of the Act, which was added by Section 
3401(f) of the Patient Protection and Affordable Care Act (Pub. L. 111-
148) as amended by Section 10319(e) of that Act and by Section 1105 of 
the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-
152), requires the application of an ``Other Adjustment'' that reduces 
any update to the IPF PPS base rate by 0.25 percentage point for the 
rate year beginning in 2010. We are implementing that provision for RY 
2011 in this notice.

C. IPF PPS--General Overview

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

II. Transition Period for Implementation of the IPF PPS

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

III. Updates to the IPF PPS for RY Beginning July 1, 2010

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

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

    Section 124(a)(1) of the BBRA requires that we implement the IPF 
PPS in a budget neutral manner. In other words, the amount of total 
payments

[[Page 23108]]

under the IPF PPS, including any payment adjustments, must be projected 
to be equal to the amount of total payments that would have been made 
if the IPF PPS were not implemented. Therefore, we calculated the 
budget-neutrality factor by setting the total estimated IPF PPS 
payments to be equal to the total estimated payments that would have 
been made under the Tax Equity and Fiscal Responsibility Act of 1982 
(TEFRA) (Pub. L. 97-248) methodology had the IPF PPS not been 
implemented.
    Under the IPF PPS methodology, we calculated the final Federal per 
diem base rate to be budget neutral during the IPF PPS implementation 
period (that is, the 18-month period from January 1, 2005 through June 
30, 2006) using a July 1 update cycle. We updated the average cost per 
day to the midpoint of the IPF PPS implementation period (that is, 
October 1, 2005), and this amount was used in the payment model to 
establish the budget-neutrality adjustment.
    A step-by-step description of the methodology used to estimate 
payments under the TEFRA payment system appears in the November 2004 
IPF PPS final rule (69 FR 66926).
1. Standardization of the Federal Per Diem Base Rate and 
Electroconvulsive Therapy (ECT) Rate
    In the November 2004 IPF PPS final rule, we describe how we 
standardized the IPF PPS Federal per diem base rate in order to account 
for the overall positive effects of the IPF PPS payment adjustment 
factors. To standardize the IPF PPS payments, we compared the IPF PPS 
payment amounts calculated from the FY 2002 Medicare Provider Analysis 
and Review (MedPAR) file to the projected TEFRA payments from the FY 
2002 cost report file updated to the midpoint of the IPF PPS 
implementation period (that is, October 2005). The standardization 
factor was calculated by dividing total estimated payments under the 
TEFRA payment system by estimated payments under the IPF PPS. The 
standardization factor was calculated to be 0.8367.
    As described in detail in the May 2006 IPF PPS final rule (71 FR 
27045), in reviewing the methodology used to simulate the IPF PPS 
payments used for the November 2004 IPF PPS final rule, we discovered 
that due to a computer code error, total IPF PPS payments were 
underestimated by about 1.36 percent. Since the IPF PPS payment total 
should have been larger than the estimated figure, the standardization 
factor should have been smaller (0.8254 vs. 0.8367). In turn, the 
Federal per diem base rate and the ECT rate should have been reduced by 
0.8254 instead of 0.8367.
    To resolve this issue, in RY 2007, we amended the Federal per diem 
base rate and the ECT payment rate prospectively. Using the 
standardization factor of 0.8254, the average cost per day was 
effectively reduced by 17.46 percent (100 percent minus 82.54 percent = 
17.46 percent).
2. Calculation of the Budget Neutrality Adjustment
    To compute the budget neutrality adjustment for the IPF PPS, we 
separately identified each component of the adjustment, that is, the 
outlier adjustment, stop-loss adjustment, and behavioral offset.
    A complete discussion of how we calculate each component of the 
budget neutrality adjustment appears in the November 2004 IPF PPS final 
rule (69 FR 66932 through 66933) and in the May 2006 IPF PPS final rule 
(71 FR 27044 through 27046).
a. Outlier Adjustment
    Since the IPF PPS payment amount for each IPF includes applicable 
outlier amounts, we reduced the standardized Federal per diem base rate 
to account for aggregate IPF PPS payments estimated to be made as 
outlier payments. The outlier adjustment was calculated to be 2 
percent. As a result, the standardized Federal per diem base rate was 
reduced by 2 percent to account for projected outlier payments.
b. Stop-Loss Provision Adjustment
    As explained in the November 2004 IPF PPS final rule, we provided a 
stop-loss payment during the transition from cost-based reimbursement 
to the per diem payment system to ensure that an IPF's total PPS 
payments were no less than a minimum percentage of their TEFRA payment, 
had the IPF PPS not been implemented. We reduced the standardized 
Federal per diem base rate by the percentage of aggregate IPF PPS 
payments estimated to be made for stop-loss payments. As a result, the 
standardized Federal per diem base rate was reduced by 0.39 percent to 
account for stop-loss payments. Since the transition was completed in 
RY 2009, the stop-loss provision is no longer applicable, and for cost 
reporting periods beginning on or after January 1, 2008, IPFs were paid 
100 percent PPS.
c. Behavioral Offset
    As explained in the November 2004 IPF PPS final rule, 
implementation of the IPF PPS may result in certain changes in IPF 
practices, especially with respect to coding for comorbid medical 
conditions. As a result, Medicare may make higher payments than assumed 
in our calculations. Accounting for these effects through an adjustment 
is commonly known as a behavioral offset.
    Based on accepted actuarial practices and consistent with the 
assumptions made in other PPSs, we assumed in determining the 
behavioral offset that IPFs would regain 15 percent of potential 
``losses'' and augment payment increases by 5 percent. We applied this 
actuarial assumption, which is based on our historical experience with 
new payment systems, to the estimated ``losses'' and ``gains'' among 
the IPFs. The behavioral offset for the IPF PPS was calculated to be 
2.66 percent. As a result, we reduced the standardized Federal per diem 
base rate by 2.66 percent to account for behavioral changes. As 
indicated in the November 2004 IPF PPS final rule, we do not plan to 
change adjustment factors or projections until we analyze IPF PPS data.
    If we find that an adjustment is warranted, the percent difference 
may be applied prospectively to the established PPS rates to ensure the 
rates accurately reflect the payment level intended by the statute. In 
conducting this analysis, we will be interested in the extent to which 
improved coding of patients' principal and other diagnoses, which may 
not reflect real increases in underlying resource demands, has occurred 
under the PPS.

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

1. Market Basket for IPFs Reimbursed under the IPF PPS
    As described in the November 2004 IPF PPS final rule (69 FR 66931), 
the average per diem cost was updated to the midpoint of the 
implementation year. This updated average per diem cost of $724.43 was 
reduced by 17.46 percent to account for standardization to projected 
TEFRA payments for the implementation period, by 2 percent to account 
for outlier payments, by 0.39 percent to account for stop-loss 
payments, and by 2.66 percent to account for the behavioral offset. The 
Federal per diem base rate in the implementation year was $575.95. The 
increase in the per diem base rate for RY 2009 included the 0.39 
percent increase due to the removal of the stop-loss provision. We 
indicated in the November 2004 IPF PPS final rule (69 FR 66932) that we 
would remove this 0.39 percent reduction to the Federal per diem base 
rate after the transition. For RY 2009 and beyond, the stop-loss

[[Page 23109]]

provision has ended and is therefore no longer a part of budget 
neutrality.
    Due to new section 1886(s)(3)(A) of the Act, which requires the 
application of an ``Other Adjustment'' that reduces the update to the 
IPF PPS base rate for the rate year beginning in CY 2010, we reduced 
the update to the IPF PPS base rate by 0.25 percent for rate year 2011. 
Applying the market basket increase of 2.4 percent, with the ``Other 
Adjustment'' of -0.25%, and the wage index budget neutrality factor of 
0.9999 to the RY 2010 Federal per diem base rate of $651.76 yields a 
Federal per diem base rate of $665.71 for RY 2011. Similarly, applying 
the market basket increase with the ``Other Adjustment'', and the wage 
index budget neutrality factor to the RY 2010 ECT rate yields an ECT 
rate of $286.60 for RY 2011.
a. Market Basket Index for the IPF PPS
    The market basket index that was used to develop the IPF PPS was 
the excluded hospital with capital market basket. This market basket 
was based on 1997 Medicare cost report data and included data for 
Medicare-participating IPFs, inpatient rehabilitation facilities 
(IRFs), long-term care hospitals (LTCHs), cancer, and children's 
hospitals.
    Beginning with the May 2006 IPF PPS final rule (71 FR 27046 through 
27054), IPF PPS payments were updated using a 2002-based market basket 
reflecting the operating and capital cost structures for IRFs, IPFs, 
and LTCHs (hereafter referred to as the rehabilitation, psychiatric, 
long-term care (RPL) market basket).
    We excluded cancer and children's hospitals from the RPL market 
basket because their payments are based entirely on reasonable costs 
subject to rate-of-increase limits established under the authority of 
section 1886(b) of the Act, which are implemented in regulations at 
Sec.  413.40. They are not reimbursed through a PPS. Also, the FY 2002 
cost structures for cancer and children's hospitals are noticeably 
different than the cost structures of the IRFs, IPFs, and LTCHs. A 
complete discussion of the RPL market basket appears in the May 2006 
IPF PPS final rule (71 FR 27046 through 27054).
    In the May 2009 IPF PPS notice (74 FR 20362), we requested public 
comment on the possibility of creating a stand-alone IPF market basket. 
In this notice, we are responding to those comments in the ``Comments 
on Creating a Stand-Alone IPF Market Basket'' section.
b. Overview of the RPL Market Basket
    The RPL market basket is a fixed weight, Laspeyres-type price 
index. A market basket is described as a fixed-weight index because it 
answers the question of how much it would cost, at another time, to 
purchase the same mix (quantity and intensity) of goods and services 
needed to provide services in a base period. The effects on total 
expenditures resulting from changes in the mix of goods and services 
purchased subsequent to the base period are not measured. In this 
manner, the market basket measures pure price change only. Only when 
the index is rebased would changes in the quantity and intensity be 
captured in the cost weights. Therefore, we rebase the market basket 
periodically so that cost weights reflect recent changes in the mix of 
goods and services that hospitals purchase to furnish patient care 
between base periods.
    The terms ``rebasing'' and ``revising,'' while often used 
interchangeably, actually denote different activities. Rebasing means 
moving the base year for the structure of costs of an input price index 
(for example, shifting the base year cost structure from FY 1997 to FY 
2002). Revising means changing data sources, methodology, or price 
proxies used in the input price index. In 2006, we rebased and revised 
the market basket used to update the IPF PPS. Table 1 below sets forth 
the completed FY 2002-based RPL market basket including the cost 
categories, weights, and price proxies.

 Table 1--FY 2002-Based RPL Market Basket Cost Categories, Weights, and
                              Price Proxies
------------------------------------------------------------------------
                                  FY 2002-based
                                   RPL market       FY 2002-based RPL
        Cost categories            basket cost     market basket price
                                     weight              proxies
------------------------------------------------------------------------
TOTAL..........................         100.000  .......................
Compensation...................          65.877  .......................
    Wages and Salaries*........          52.895  ECI--Wages and
                                                  Salaries, Civilian
                                                  Hospital Workers.
    Employee Benefits*.........          12.982  ECI--Benefits, Civilian
                                                  Hospital Workers.
Professional Fees, Non-Medical*           2.892  ECI--Compensation for
                                                  Professional & Related
                                                  occupations.
Utilities......................           0.656  .......................
    Electricity................           0.351  PPI--Commercial
                                                  Electric Power.
    Fuel Oil, Coal, etc........           0.108  PPI--Commercial Natural
                                                  Gas.
    Water and Sewage...........           0.197  CPI--U--Water & Sewage
                                                  Maintenance.
Professional Liability                    1.161  CMS Professional
 Insurance.                                       Liability Premium
                                                  Index.
All Other Products and Services          19.265  .......................
All Other Products.............          13.323  .......................
    Pharmaceuticals............           5.103  PPI Prescription Drugs.
    Food: Direct Purchase......           0.873  PPI Processed Foods &
                                                  Feeds.
    Food: Contract Service.....           0.620  CPI--U Food Away From
                                                  Home.
    Chemicals..................           1.100  PPI Industrial
                                                  Chemicals.
    Medical Instruments........           1.014  PPI Medical Instruments
                                                  & Equipment.
    Photographic Supplies......           0.096  PPI Photographic
                                                  Supplies.
    Rubber and Plastics........           1.052  PPI Rubber & Plastic
                                                  Products.
    Paper Products.............           1.000  PPI Converted Paper &
                                                  Paperboard Products.
    Apparel....................           0.207  PPI Apparel.
    Machinery and Equipment....           0.297  PPI Machinery &
                                                  Equipment.
    Miscellaneous Products**...           1.963  PPI Finished Goods less
                                                  Food & Energy.
All Other Services.............           5.942  .......................
    Telephone..................           0.240  CPI--U Telephone
                                                  Services.
    Postage....................           0.682  CPI--U Postage.
    All Other: Labor Intensive*           2.219  ECI--Compensation for
                                                  Private Service
                                                  Occupations.
    All Other: Non-labor                  2.800  CPI--U All Items.
     Intensive.
Capital-Related Costs***.......          10.149  .......................

[[Page 23110]]

Depreciation...................           6.186  .......................
    Fixed Assets...............           4.250  Boeckh Institutional
                                                  Construction 23-year
                                                  useful life.
    Movable Equipment..........           1.937  PPI Machinery &
                                                  Equipment 11-year
                                                  useful life.
Interest Costs.................           2.775  .......................
    Nonprofit..................           2.081  Average yield on
                                                  domestic municipal
                                                  bonds (Bond Buyer 20
                                                  bonds) vintage-
                                                  weighted (23 years).
    For Profit.................           0.694  Average yield on
                                                  Moody's Aaa bond
                                                  vintage-weighted (23
                                                  years).
Other Capital-Related Costs....           1.187  CPI--U Residential
                                                  Rent.
------------------------------------------------------------------------
* Labor-related.
** Blood and blood-related products is included in miscellaneous
  products.
*** A portion of capital costs (0.46) are labor-related.

    Note: Due to rounding, weights may not sum to total.

    We evaluated the price proxies using the criteria of reliability, 
timeliness, availability, and relevance. Reliability indicates that the 
index is based on valid statistical methods and has low sampling 
variability. Timeliness implies that the proxy is published regularly 
(preferably at least once a quarter). Availability means that the proxy 
is publicly available. Finally, relevance means that the proxy is 
applicable and representative of the cost category weight to which it 
is applied. The Consumer Price Indexes (CPIs), Producer Price Indexes 
(PPIs), and Employment Cost Indexes (ECIs) used as proxies in this 
market basket meet these criteria.
    We note that the proxies are the same as those used for the FY 
1997-based excluded hospital with capital market basket. Because these 
proxies meet our criteria of reliability, timeliness, availability, and 
relevance, we believe they continue to be the best measure of price 
changes for the cost categories. For further discussion on the FY 1997-
based excluded hospital with capital market basket, see the August 1, 
2002 hospital inpatient prospective payment system (IPPS) final rule 
(67 FR at 50042).
    The RY 2011 (that is, beginning July 1, 2010) update for the IPF 
PPS using the FY 2002-based RPL market basket and Information Handling 
Services (IHS) Global Insight's 1st quarter 2010 forecast for the 
market basket components is 2.4 percent. This includes increases in 
both the operating section and the capital section for the 12-month RY 
period (that is, July 1, 2010 through June 30, 2011). IHS Global 
Insight, Inc. is a nationally recognized economic and financial 
forecasting firm that contracts with CMS to forecast the components of 
the market baskets.
2. Labor-Related Share
    Due to the variations in costs and geographic wage levels, we 
believe that payment rates under the IPF PPS should continue to be 
adjusted by a geographic wage index. This wage index applies to the 
labor-related portion of the Federal per diem base rate, hereafter 
referred to as the labor-related share.
    The labor-related share is determined by identifying the national 
average proportion of operating costs that are related to, influenced 
by, or vary with the local labor market. Using our current definition 
of labor-related, the labor-related share is the sum of the relative 
importance of wages and salaries, fringe benefits, professional fees, 
labor-intensive services, and a portion of the capital share from an 
appropriate market basket. We used the FY 2002-based RPL market basket 
cost weights relative importance to determine the labor-related share 
for the IPF PPS.
    The labor-related share for RY 2011 is the sum of the RY 2011 
relative importance of each labor-related cost category, and reflects 
the different rates of price change for these cost categories between 
the base year (FY 2002) and RY 2011. The sum of the relative importance 
for the RY 2011 operating costs (wages and salaries, employee benefits, 
professional fees, and labor-intensive services) is 71.506 percent, as 
shown in Table 2 below. The portion of capital that is influenced by 
the local labor market is estimated to be 46 percent, which is the same 
percentage used in the FY 1997-based IRF and IPF payment systems.
    Since the relative importance for capital is 8.466 percent of the 
FY 2002-based RPL market basket in RY 2011, we are taking 46 percent of 
8.466 percent to determine the labor-related share of capital for RY 
2011. The result is 3.894 percent, which we added to 71.506 percent for 
the operating cost amount to determine the total labor-related share 
for RY 2011. Thus, the labor-related share that we are using for IPF 
PPS in RY 2011 is 75.400 percent. Table 2 below shows the RY 2011 
labor-related share using the FY 2002-based RPL market basket. We note 
that this labor-related share is determined by using the same 
methodology as employed in calculating all previous IPF labor-related 
shares.
    A complete discussion of the IPF labor-related share methodology 
appears in the November 2004 IPF PPS final rule (69 FR 66952 through 
66954).

   Table 2--Total Labor-Related Share--Relative Importance for RY 2011
------------------------------------------------------------------------
                                                               FY
                                    FY 2002-based RPL   2002[dash]based
                                      market basket    RPL market basket
                                      labor-related      labor-related
           Cost category              share relative     share relative
                                        importance         importance
                                    (percent) RY 2010  (percent) RY 2011
                                            *                  **
------------------------------------------------------------------------
Wages and salaries................             53.062             52.600
Employee benefits.................             13.852             13.935
Professional fees.................              2.895              2.853

[[Page 23111]]

All other labor-intensive services              2.126              2.118
                                   -------------------------------------
    Subtotal......................             71.935             71.506
------------------------------------------------------------------------
Labor-related share of capital                  3.954              3.894
 costs (0.46).....................
                                   -------------------------------------
    Total.........................             75.889             75.400
------------------------------------------------------------------------
* Based on 2009 1st Quarter forecast.
** Based on 2010 1st Quarter forecast.

3. Comments on Creating a Stand-Alone IPF Market Basket
    In the May 2009 IPF PPS notice (74 FR 20362), we expressed our 
interest in exploring the possibility of creating a stand-alone IPF 
market basket that reflects the cost structures of only IPF providers. 
Of the available options, one would be to join the Medicare cost report 
data from freestanding IPF providers (presently incorporated into the 
RPL market basket) with data from hospital-based IPF providers. An 
examination of the Medicare cost report data comparing freestanding and 
hospital-based IPFs reveals considerable differences between the two 
with respect to cost levels and cost structures.
    In order to better understand the observed cost differences between 
freestanding and hospital-based IPFs, we reviewed, in detail, several 
explanatory variables such as geographic variation, case mix (including 
DRG, comorbidity, and age), urban or rural status, length of stay, 
teaching status, and the presence of a qualifying emergency department. 
Despite this analysis, we were unable to sufficiently explain the 
differences in costs between these two types of IPF providers. As a 
result, we felt that further research was required and solicited public 
comment on additional information that would help us to better 
understand the reasons for the variations in costs and cost structures, 
as reported by cost report data, between freestanding and hospital-
based IPFs (74 FR 20376).
    We received several timely comments from the public on this issue. 
A summary of the comments and our responses to those comments are 
below.
    Comment: Several commenters recommended that CMS consider creating 
an IPF-specific market basket. These commenters stated that including 
hospital-based IPF data in the market basket and pursuing a greater 
understanding of the differences between freestanding and hospital-
based IPFs are both worthy undertakings. The commenters cited that from 
2005 through 2007, the number of hospital-based IPFs has decreased by 
1.4 percent while the number of freestanding IPFs has increased by 1.0 
percent. The commenters expressed concern that these trends will 
continue, and likely accelerate. Furthermore, the commenters stated 
that in 2007, hospital-based IPFs experienced negative margins while 
freestanding IPF margins were positive. Given that more than 60 percent 
of IPF discharges are from hospital-based units, the commenters believe 
that preserving access to care for these patients (especially those who 
have coexisting physical conditions or experience a crisis and enter 
the emergency department for treatment) is vital. One commenter stated 
that including hospital-based IPF data in the market basket would 
increase transparency and highlight the differences between 
freestanding and hospital-based providers.
    Response: We are actively examining the technical merits of 
creating a stand-alone IPF market basket. Since publication of the May 
2009 IPF PPS notice, we have been reviewing the Medicare cost report 
and claims data for both hospital-based and freestanding IPFs to better 
understand the differences in total Medicare costs per day. Parts of 
our analysis were based on comments received by the public, which we 
address in more detail below. Based on our research to date, which has 
not adequately explained the cost-per-day differences between 
freestanding and hospital-based providers, we do not believe it is 
technically appropriate to move from the RPL market basket to update 
IPF payments at this time.
    Comment: Several commenters supported the ongoing application of 
the RPL market basket to update inpatient psychiatric facility payment 
rates. One commenter recommended we continue this method in order to 
maintain a reasonable population size of facilities to ensure stability 
in the calculation of the market basket. The commenter asserted that if 
the RPL market basket was split into separate market baskets for IRFs, 
IPFs, and LTCHs, there would be much more volatility in the year-to-
year changes, especially for LTCHs.
    Response: We appreciate the comments regarding the continued 
support for using the RPL market basket to update inpatient psychiatric 
facility payment rates. Likewise, we appreciate the comment regarding 
sample size considerations with respect to splitting the RPL market 
basket into its respective pieces. Indeed, sample size and its impact 
on the volatility of the estimates will be extensively scrutinized 
before we would propose to change the mechanism used to update payments 
to inpatient psychiatric facilities, inpatient rehabilitation 
facilities, and long-term care hospitals.
    Comment: One commenter supported the investigation of the 
differences in cost structures between hospital-based and freestanding 
IPFs. Besides determining the source of these differences, the 
commenter also stated it is important for CMS to determine whether the 
differences should be recognized (for example, are higher costs in IPF 
hospital-based facilities due to allocation of overhead to the unit or 
to differences in case mix or patient severity that is not measurable 
using available administrative data). This commenter also acknowledged 
that seeking outside input regarding differences in cost structures 
between hospital-based and freestanding IPFs is appropriate. However, 
the commenter

[[Page 23112]]

recommended that CMS proceed with caution as it may be difficult for 
CMS to confirm that the methods used to collect outside data are sound 
and that the data are representative of the industry as a whole. The 
commenter also stated that CMS should ultimately determine whether the 
market basket should in fact be based on the cost structure of 
hospital-based and freestanding IPFs (instead of just one type of 
facility) if the higher costs cannot be explained by differences in 
case mix and other patient characteristics.
    Response: Although we asked for outside information to help us 
better understand these differences, we agree with the commenter that 
any outside information should be carefully examined.
    As we have stated, we currently do not feel it is appropriate to 
incorporate data from hospital-based IPFs with that of freestanding 
IPFs to create a stand-alone IPF market basket given the observed and 
unexplained differences in cost structures.
    Comment: Several commenters stated that creating a stand-alone IPF 
market basket could be a more accurate index for the costs of 
delivering care incurred by IPFs. However, the commenters stated that 
they did not have any independent data to help CMS in developing a 
stand-alone market basket at this time. The commenters suggested that 
the issue of a stand-alone IPF market basket continue to be analyzed by 
CMS.
    Response: We agree with the commenters and plan to continue to 
analyze costs and Medicare claims data for hospital-based and 
freestanding providers.
    Comment: One commenter supports the development of a stand-alone 
IPF market basket. However, the commenter encourages CMS to avoid 
mixing data from hospital-based and freestanding IPFs. The commenter 
claims that hospital-based IPFs incur higher costs than freestanding 
IPFs in treating Medicare patients for the following reasons:
     The acuity levels and medical needs of psychiatric 
patients that present in a hospital's qualified emergency room will 
result in higher treatment costs and lengths of stay.
     Hospitals provide a greater range of ancillary services.
     Some hospitals operate approved psychiatric residency 
teaching programs.
    Therefore, the commenter is reluctant to support a combined 
hospital-based, freestanding IPF market basket at this time. The 
commenter also offered to assist CMS with any information he or she can 
provide.
    Response: We appreciate the commenter's input on possible reasons 
why hospital-based IPFs have higher costs than freestanding IPFs. As 
stated above, we compared the medical needs of the patients, as 
measured by the adjustments for DRG, comorbidities, and age. Our 
analysis did show that hospital-based providers, on average, treat more 
complex patients; however, the differences in the complexity of the 
patients, as well as other facility-based adjustments, did not 
adequately explain the differences in total Medicare costs per day 
between hospital-based and freestanding providers. In addition, using 
both Medicare cost report and claims data, we found that hospital-based 
providers, on average, had shorter lengths of stay than freestanding 
providers.
    Per the commenter's suggestion, and using MCR data, we also 
compared the Medicare ancillary costs per day of hospital-based and 
freestanding providers. We found that hospital-based facilities, on 
average, tend to have higher Medicare ancillary costs per day than 
freestanding facilities. The differences were mostly attributable to 
higher emergency room and laboratory costs. These higher ancillary 
costs accounted for about ten percent of the overall difference between 
hospital-based and freestanding providers' total Medicare costs per 
day.
    In addition, we compared the average approved teaching costs for 
hospital-based and freestanding providers. We found that hospital-based 
providers have higher teaching-related costs associated with Medicare 
approved programs relative to free standing providers; however, the 
difference accounted for only three percent of the total difference in 
Medicare costs per day for hospital-based and freestanding providers.
    Comment: One commenter simply agreed with CMS that before 
implementation of a new market basket method, the method should be 
fully evaluated and the projected impact known.
    Response: We agree with the commenter's suggestion. Before any 
implementation, CMS will fully evaluate our methodology to ensure that 
any proposed market basket most accurately reflects the cost structures 
associated with providing psychiatric care to Medicare patients.
    Comment: One commenter does not support the adoption of a stand-
alone IPF market basket at this time, pending further study, as the 
commenter is not convinced that CMS has the appropriate level of 
psychiatric cost data available to compile an accurate market basket 
for IPFs alone. These conclusions were based on the following reasons:
     There are a small number of facilities and often limited 
data (for example, only 4 percent of IPFs reported contract labor costs 
for FY 2002).
     Benefits, contract labor, and blood cost weights were 
developed using the FY 2002-based IPPS market basket.
     Other detailed cost categories were derived from the FY 
2002-based IPPS market basket.
     No cost data specific to psychiatry (that is, Wages and 
Salaries--based on Civilian Hospital Workers).
    The commenter stated that without release of both relevant internal 
data available only to CMS on the previously mentioned IPF market 
basket issues, as well as specific data on the types of cost 
differences between the various cost categories of IRF, IPF, and LTCH 
facilities, they are unable to comment on an independent IPF market 
basket at this time. The commenter believes that more detailed analysis 
needs to be conducted and released before they could consider 
supporting any change to the current RPL-based market basket update 
process.
    Response: We are in the process of evaluating multiple years of 
data in order to determine whether a stand-alone IPF market basket 
would be a more appropriate index for updating IPF PPS payments. We 
agree with the commenter that there is a lack of IPF-specific benefit 
and contract labor cost data. Currently, benefit and contract labor 
cost data are collected on Worksheet S-3, part II of the Medicare cost 
report (MCR), but are only required of IPPS hospitals. We proposed 
under separate cover to modify the present-day hospital MCR in order to 
collect benefit and contract labor data on a separate worksheet 
(proposed Worksheet S-3, part V) which would be completed by all 
hospitals (http://www.cms.hhs.gov/PaperworkReductionActof1995/PRAL/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=2&sortOrder=descending&itemID=CMS1224069&intNumPerPage). 
We disagree with the commenter that we are not capturing IPF-specific 
data for wages and salaries since all hospitals are required to report 
this data on the MCRs, which provides the sources of our wages and 
salaries cost weight. We believe the commenter may be referencing the 
Employment Cost Index (ECI) for wages and salaries for hospital 
civilian workers which we use to proxy price changes associated with 
the wages and salary cost weight. This proxy is used because the Bureau 
of Labor

[[Page 23113]]

Statistics does not publish a wages and salaries price index specific 
to IPFs only. However, the ECI for wages and salaries for hospital 
civilian workers does include the price changes of IPFs, as well as 
other hospital-types (including general surgical hospitals).

IV. Update of the IPF PPS Adjustment Factors

A. Overview of the IPF PPS Adjustment Factors

    The IPF PPS payment adjustments were derived from a regression 
analysis of 100 percent of the FY 2002 MedPAR data file, which 
contained 483,038 cases. For this notice, we used the same results of 
the regression analysis used to implement the November 2004 IPF PPS 
final rule. For a more detailed description of the data file used for 
the regression analysis, see the November 2004 IPF PPS final rule (69 
FR 66935 through 66936). While we have since used more recent claims 
data to set the fixed dollar loss threshold amount, we use the same 
results of this regression analysis to update the IPF PPS for RY 2010 
as well as RY 2011.
    As previously stated, we do not plan to update the regression 
analysis until we are able to analyze IPF PPS claims and cost report 
data. However, we continue to monitor claims and payment data 
independently from cost report data to assess issues, to determine 
whether changes in case-mix or payment shifts have occurred among 
freestanding governmental, non-profit and private psychiatric 
hospitals, and psychiatric units of general hospitals, and CAHs and 
other issues of importance to IPFs.

B. Patient-Level Adjustments

    In the May 2008 IPF PPS notice (73 FR 25709) and in the May 2009 
IPF PPS notice (74 FR 20362), we provided payment adjustments for the 
following patient-level characteristics: Medicare Severity diagnosis 
related groups (MS-DRGs) assignment of the patient's principal 
diagnosis, selected comorbidities, patient age, and the variable per 
diem adjustments.
1. Adjustment for MS-DRG Assignment
    The IPF PPS includes payment adjustments for the psychiatric DRG 
assigned to the claim based on each patient's principal diagnosis. The 
IPF PPS recognizes the MS-DRGs. The DRG adjustment factors were 
expressed relative to the most frequently reported psychiatric DRG in 
FY 2002, that is, DRG 430 (psychoses). The coefficient values and 
adjustment factors were derived from the regression analysis.
    In accordance with Sec.  412.27(a), payment under the IPF PPS is 
conditioned on IPFs admitting ``only patients whose admission to the 
unit is required for active treatment, of an intensity that can be 
provided appropriately only in an inpatient hospital setting, of a 
psychiatric principal diagnosis that is listed in Chapter Five 
(``Mental Disorders'') of the International Classification of Diseases, 
Ninth Revision, Clinical Modification (ICD-9-CM)'' or in the Fourth 
Edition, Text Revision of the American Psychiatric Association's 
Diagnostic and Statistical Manual, (DSM-IV-TR). IPF claims with a 
principal diagnosis included in Chapter Five of the ICD-9-CM or the 
DSM-IV-TR are paid the Federal per diem base rate under the IPF PPS and 
all other applicable adjustments, including any applicable DRG 
adjustment. Psychiatric principal diagnoses that do not group to one of 
the designated DRGs still receive the Federal per diem base rate and 
all other applicable adjustments, but the payment would not include a 
DRG adjustment.
    The Standards for Electronic Transaction final rule published in 
the Federal Register on August 17, 2000 (65 FR 50312), adopted the ICD-
9-CM as the designated code set for reporting diseases, injuries, 
impairments, other health related problems, their manifestations, and 
causes of injury, disease, impairment, or other health related 
problems. Therefore, we use the ICD-9-CM as the designated code set for 
the IPF PPS.
    We believe that it is important to maintain the same diagnostic 
coding and DRG classification for IPFs that are used under the IPPS for 
providing the psychiatric care. Therefore, when the IPF PPS was 
implemented for cost reporting periods beginning on or after January 1, 
2005, we adopted the same diagnostic code set and DRG patient 
classification system (that is, the CMS DRGs) that was utilized at the 
time under the hospital inpatient prospective payment system (IPPS). 
Since the inception of the IPF PPS, the DRGs used as the patient 
classification system under the IPF PPS have corresponded exactly with 
the CMS DRGs applicable under the IPPS for acute care hospitals.
    Every year, changes to the ICD-9-CM coding system are addressed in 
the IPPS proposed and final rules. The changes to the codes are 
effective October 1 of each year and must be used by acute care 
hospitals as well as other providers to report diagnostic and procedure 
information. The IPF PPS has always incorporated ICD-9-CM coding 
changes made in the annual IPPS update. We publish coding changes in a 
Transmittal/Change Request, similar to how coding changes are announced 
by the IPPS and LTCH PPS. Those ICD-9-CM coding changes are also 
published in the following IPF PPS RY update, in either the IPF PPS 
proposed and final rules, or in an IPF PPS update notice.
    In the May 2008 IPF PPS notice (73 FR 25714), we discussed CMS' 
effort to better recognize resource use and the severity of illness 
among patients. CMS adopted the new MS-DRGs for the IPPS in the FY 2008 
IPPS final rule with comment period (72 FR 47130). We believe by better 
accounting for patients' severity of illness in Medicare payment rates, 
the MS-DRGs encourage hospitals to improve their coding and 
documentation of patient diagnoses. The MS-DRGs, which are based on the 
CMS DRGs, represent a significant increase in the number of DRGs (from 
538 to 745, an increase of 207). For a full description of the 
development and implementation of the MS-DRGs, see the FY 2008 IPPS 
final rule with comment period (72 FR 47141 through 47175).
    All of the ICD-9-CM coding changes are reflected in the FY 2010 
GROUPER, Version 27.0, effective for IPPS discharges occurring on or 
after October 1, 2009 through September 30, 2010. The GROUPER Version 
27.0 software package assigns each case to an MS-DRG on the basis of 
the diagnosis and procedure codes and demographic information (that is, 
age, sex, and discharge status). The Medicare Code Editor (MCE) 26.0 
uses the new ICD-9-CM codes to validate coding for IPPS discharges on 
or after October 1, 2009. For additional information on the GROUPER 
Version 27.0 and MCE 26.0, see Transmittal 1816 (Change Request 6634), 
dated October 1, 2009. The IPF PPS has always used the same GROUPER and 
Code Editor as the IPPS. Therefore, the ICD-9-CM changes, which were 
reflected in the GROUPER Version 27.0 and MCE 26.0 on October 1, 2009, 
also became effective for the IPF PPS for discharges occurring on or 
after October 1, 2009.
    The impact of the new MS-DRGs on the IPF PPS was negligible. 
Mapping to the MS-DRGs resulted in the current 17 MS-DRGs, instead of 
the original 15 DRGs, for which the IPF PPS provides an adjustment. 
Although the code set is updated, the same associated adjustment 
factors apply now that have been in place since implementation of the 
IPF PPS, with one exception that is unrelated to the update to the 
codes. When DRGs 521 and 522 were consolidated into MS-DRG 895, we 
carried over the adjustment factor of 1.02 from DRG 521 to the newly

[[Page 23114]]

consolidated MS-DRG. This was done to reflect the higher claims volume 
under DRG 521, with more than eight times the number of claims than 
billed under DRG 522. The updates are reflected in Table 5. For a 
detailed description of the mapping changes from the original DRG 
adjustment categories to the current MS-DRG adjustment categories, we 
refer readers to the May 2008 IPF PPS notice (73 FR 25714).
    The official version of the ICD-9-CM is available on CD-ROM from 
the U.S. Government Printing Office. The FY 2009 version can be ordered 
by contacting the Superintendent of Documents, U.S. Government Printing 
Office, Department 50, Washington, DC 20402-9329, telephone number 
(202) 512-1800. Questions concerning the ICD-9-CM should be directed to 
Patricia E. Brooks, Co-Chairperson, ICD-9-CM Coordination and 
Maintenance Committee, CMS, Center for Medicare Management, Hospital 
and Ambulatory Policy Group, Division of Acute Care, Mailstop C4-08-06, 
7500 Security Boulevard, Baltimore, Maryland 21244-1850.
    Further information concerning the official version of the ICD-9-CM 
can be found in the IPPS final rule with comment period, ``Changes to 
Hospital Inpatient Prospective Payment System and Fiscal Year 2010 
Rates'' in the August 27, 2009 Federal Register (74 FR 43754) and at 
http://www.cms.hhs.gov/AcuteInpatientPPS/IPPS/list.asp#TopOfPage.
    Tables 3 and 4 below list the FY 2010 new and invalid ICD-9-CM 
diagnosis codes that group to one of the 17 MS-DRGs for which the IPF 
PPS provides an adjustment. These tables are only a listing of FY 2010 
changes and do not reflect all of the currently valid and applicable 
ICD-9-CM codes classified in the MS-DRGs. When coded as a principal 
code or diagnosis, these codes receive the correlating MS-DRG 
adjustment.

                  Table 3--FY 2010 New Diagnosis Codes
------------------------------------------------------------------------
       Diagnosis code                Description              MS-DRG
------------------------------------------------------------------------
438.13.....................  Late effects of                    056, 057
                              cerebrovascular disease,
                              dysarthria.
438.14.....................  Late effects of                    056, 057
                              cerebrovascular disease,
                              fluency disorder.
799.21.....................  Nervousness................             880
799.22.....................  Irritability...............             880
799.23.....................  Impulsiveness..............             882
799.24.....................  Emotional lability.........             883
799.25.....................  Demoralization and apathy..             880
799.29.....................  Other signs and symptoms                880
                              involving emotional state.
------------------------------------------------------------------------

                Table 4--FY 2010 Invalid Diagnosis Codes
------------------------------------------------------------------------
       Diagnosis code                   Description             MS-DRG
------------------------------------------------------------------------
799.2.......................  Nervousness...................         880
------------------------------------------------------------------------

    We do not plan to update the regression analysis until we are able 
to analyze IPF PPS data. The MS-DRG adjustment factors (as shown in 
Table 5 below) will continue to be paid for discharges occurring in RY 
2011.

 Table 5--RY 2011 Current MS-DRGs Applicable for the Principal Diagnosis
                               Adjustment
------------------------------------------------------------------------
                                                            Adjustment
           MS-DRG                MS-DRG descriptions          factor
------------------------------------------------------------------------
056........................  Degenerative nervous system            1.05
                              disorders w MCC.
057........................  Degenerative nervous system            1.05
                              disorders w/o MCC.
080........................  Nontraumatic stupor & coma             1.07
                              w MCC.
081........................  Nontraumatic stupor & coma             1.07
                              w/o MCC.
876........................  O.R. procedure w principal             1.22
                              diagnoses of mental
                              illness.
880........................  Acute adjustment reaction &            1.05
                              psychosocial dysfunction.
881........................  Depressive neuroses........            0.99
882........................  Neuroses except depressive.            1.02
883........................  Disorders of personality &             1.02
                              impulse control.
884........................  Organic disturbances &                 1.03
                              mental retardation.
885........................  Psychoses..................            1.00
886........................  Behavioral & developmental             0.99
                              disorders.
887........................  Other mental disorder                  0.92
                              diagnoses.
894........................  Alcohol/drug abuse or                  0.97
                              dependence, left AMA.
895........................  Alcohol/drug abuse or                  1.02
                              dependence w
                              rehabilitation therapy.
896........................  Alcohol/drug abuse or                  0.88
                              dependence w/o
                              rehabilitation therapy w
                              MCC.
897........................  Alcohol/drug abuse or                  0.88
                              dependence w/o
                              rehabilitation therapy w/o
                              MCC.
------------------------------------------------------------------------

2. Payment for Comorbid Conditions
    The intent of the comorbidity adjustments is to recognize the 
increased costs associated with comorbid conditions by providing 
additional payments for certain concurrent medical or psychiatric 
conditions that are expensive to treat. In the May 2009 IPF PPS notice 
(74 FR 20362), we explained that the IPF PPS includes 17 comorbidity 
categories and identified the new, revised, and deleted ICD-9-CM 
diagnosis codes that generate a comorbid condition payment adjustment 
under the IPF PPS for RY 2010 (77 FR 20372).
    Comorbidities are specific patient conditions that are secondary to 
the patient's principal diagnosis and that require treatment during the 
stay.

[[Page 23115]]

Diagnoses that relate to an earlier episode of care and have no bearing 
on the current hospital stay are excluded and must not be reported on 
IPF claims. Comorbid conditions must exist at the time of admission or 
develop subsequently, and affect the treatment received, length of stay 
(LOS), or both treatment and LOS.
    For each claim, an IPF may receive only one comorbidity adjustment 
per comorbidity category, but it may receive an adjustment for more 
than one comorbidity category. Billing instructions require that IPFs 
must enter the full ICD-9-CM codes for up to 8 additional diagnoses if 
they co-exist at the time of admission or develop subsequently and 
impact the treatment provided.
    The comorbidity adjustments were determined based on the regression 
analysis using the diagnoses reported by IPFs in FY 2002. The principal 
diagnoses were used to establish the DRG adjustments and were not 
accounted for in establishing the comorbidity category adjustments, 
except where ICD-9-CM ``code first'' instructions apply. As we 
explained in the May 2008 IPF PPS notice (73 FR 25716), the code first 
rule applies when a condition has both an underlying etiology and a 
manifestation due to the underlying etiology. For these conditions, the 
ICD-9-CM has a coding convention that requires the underlying 
conditions to be sequenced first followed by the manifestation. 
Whenever a combination exists, there is a ``use additional code'' note 
at the etiology code and a code first note at the manifestation code.
    As discussed in the MS-DRG section, it is our policy to maintain 
the same diagnostic coding set for IPFs that is used under the IPPS for 
providing the same psychiatric care. Although the ICD-9-CM code set has 
been updated, the same adjustment factors have been in place since the 
implementation of the IPF PPS. Table 6 below lists the FY 2010 new ICD 
diagnosis codes that impact the comorbidity adjustments under the IPF 
PPS. Table 6 is not a list of all currently valid ICD codes applicable 
for the IPF PPS comorbidity adjustments.

Table 6--FY 2010 New ICD Codes Applicable for the Comorbidity Adjustment
------------------------------------------------------------------------
    Diagnosis code        Description          Comorbidity category
------------------------------------------------------------------------
209.31...............  Merkel cell       Oncology Treatment.
                        carcinoma of
                        the face.
209.32...............  Merkel cell       Oncology Treatment.
                        carcinoma of
                        the scalp and
                        neck.
209.33...............  Merkel cell       Oncology Treatment.
                        carcinoma of
                        the upper limb.
209.34...............  Merkel cell       Oncology Treatment.
                        carcinoma of
                        the lower limb.
209.35...............  Merkel cell       Oncology Treatment.
                        carcinoma of
                        the trunk.
209.36...............  Merkel cell       Oncology Treatment.
                        carcinoma of
                        other sites.
209.70...............  Secondary         Oncology Treatment.
                        neuroendocrine
                        tumor,
                        unspecified
                        site.
209.71...............  Secondary         Oncology Treatment.
                        neuroendocrine
                        tumor of
                        distant lymph
                        nodes.
209.72...............  Secondary         Oncology Treatment.
                        neuroendocrine
                        tumor of liver.
209.73...............  Secondary         Oncology Treatment.
                        neuroendocrine
                        tumor of bone.
209.74...............  Secondary         Oncology Treatment.
                        neuroendocrine
                        tumor of
                        peritoneum.
209.75...............  Secondary Merkel  Oncology Treatment.
                        cell carcinoma.
209.79...............  Secondary         Oncology Treatment.
                        neuroendocrine
                        tumor of other
                        sites.
239.81...............  Neoplasms of      Oncology Treatment.
                        unspecified
                        nature, retina
                        and choroid.
239.89...............  Neoplasms of      Oncology Treatment.
                        unspecified
                        nature, other
                        specified sites.
969.00...............  Poisoning by      Poisoning.
                        antidepressant,
                        unspecified.
969.01...............  Poisoning by      Poisoning.
                        monoamine
                        oxidase
                        inhibitors.
969.02...............  Poisoning by      Poisoning.
                        selective
                        serotonin and
                        norepinephrine
                        reuptake
                        inhibitors.
969.03...............  Poisoning by      Poisoning.
                        selective
                        serotonin
                        reuptake
                        inhibitors.
969.04...............  Poisoning by      Poisoning.
                        tetracyclic
                        antidepressants.
969.05...............  Poisoning by      Poisoning.
                        tricyclic
                        antidepressants.
969.09...............  Poisoning by      Poisoning.
                        other
                        antidepressants.
969.70...............  Poisoning by      Poisoning.
                        psychostimulant
                        , unspecified.
969.71...............  Poisoning by      Poisoning.
                        caffeine.
969.72...............  Poisoning by      Poisoning.
                        amphetamines.
969.73...............  Poisoning by      Poisoning.
                        methylphenidate.
969.79...............  Poisoning by      Poisoning.
                        other
                        psychostimulant
                        s.
------------------------------------------------------------------------

    Table 7 below lists the FY 2010 revised ICD diagnosis codes that 
are applicable for the comorbidity adjustment.

    Table 7--FY 2010 Revised ICD Codes Applicable for the Comorbidity
                               Adjustment
------------------------------------------------------------------------
    Diagnosis code        Description          Comorbidity category
------------------------------------------------------------------------
584.5................  Acute kidney      Renal Failure, Acute.
                        failure with
                        lesion of
                        tubular
                        necrosis.
584.6................  Acute kidney      Renal Failure, Acute.
                        failure with
                        lesion of renal
                        cortical
                        necrosis.
584.7................  Acute kidney      Renal Failure, Acute.
                        failure with
                        lesion of renal
                        medullary
                        [papillary]
                        necrosis.
584.8................  Acute kidney      Renal Failure, Acute.
                        failure with
                        other specified
                        pathological
                        lesion in
                        kidney.
584.9................  Acute kidney      Renal Failure, Acute.
                        failure,
                        unspecified.
639.3................  Kidney failure    Renal Failure, Acute.
                        following
                        abortion and
                        ectopic and
                        molar
                        pregnancies.
669.32...............  Acute kidney      Renal Failure, Acute.
                        failure
                        following labor
                        and delivery,
                        delivered, with
                        mention of
                        postpartum
                        complication.
669.34...............  Acute kidney      Renal Failure, Acute.
                        failure
                        following labor
                        and delivery,
                        postpartum
                        condition or
                        complication.
------------------------------------------------------------------------

[[Page 23116]]

    Table 8 below lists the invalid FY 2010 ICD-9-CM codes no longer 
applicable for the comorbidity adjustment.

     Table 8--FY 2010 Invalid ICD Codes No Longer Applicable for the
                         Comorbidity Adjustment
------------------------------------------------------------------------
    Diagnosis code        Description          Comorbidity category
------------------------------------------------------------------------
239.8................  Neoplasm of       Oncology Treatment.
                        unspecified
                        nature of other
                        specified sites.
969.0................  Poisoning by      Poisoning.
                        antidepressants.
969.7................  Poisoning by      Poisoning.
                        psychostimulant
                        s.
------------------------------------------------------------------------

    For RY 2011, we are applying the seventeen comorbidity categories 
for which we are providing an adjustment, their respective codes, 
including the new FY 2010 ICD-9-CM codes, and their respective 
adjustment factors in Table 9 below.

 Table 9--RY 2011 Diagnosis Codes and Adjustment Factors for Comorbidity
                               Categories
------------------------------------------------------------------------
                                                            Adjustment
   Description of comorbidity          ICD-9CM code           factor
------------------------------------------------------------------------
Developmental Disabilities.....  317, 3180, 3181, 3182,             1.04
                                  and 319.
Coagulation Factor Deficits....  2860 through 2864......            1.13
Tracheostomy...................  51900 through 51909 and            1.06
                                  V440.
Renal Failure, Acute...........  5845 through 5849,                 1.11
                                  63630, 63631, 63632,
                                  63730, 63731, 63732,
                                  6383, 6393, 66932,
                                  66934, 9585.
Renal Failure, Chronic.........  40301, 40311, 40391,               1.11
                                  40402, 40412, 40413,
                                  40492, 40493, 5853,
                                  5854, 5855, 5856,
                                  5859, 586, V4511,
                                  V4512, V560, V561, and
                                  V562.
Oncology Treatment.............  1400 through 2399 with             1.07
                                  a radiation therapy
                                  code 92.21-92.29 or
                                  chemotherapy code
                                  99.25.
Uncontrolled Diabetes-Mellitus   25002, 25003, 25012,               1.05
 with or without complications.   25013, 25022, 25023,
                                  25032, 25033, 25042,
                                  25043, 25052, 25053,
                                  25062, 25063, 25072,
                                  25073, 25082, 25083,
                                  25092, and 25093.
Severe Protein Calorie           260 through 262........            1.13
 Malnutrition.
Eating and Conduct Disorders...  3071, 30750, 31203,                1.12
                                  31233, and 31234.
Infectious Disease.............  01000 through 04110,               1.07
                                  042, 04500 through
                                  05319, 05440 through
                                  05449, 0550 through
                                  0770, 0782 through
                                  07889, and 07950
                                  through 07959.
Drug and/or Alcohol Induced      2910, 2920, 29212,                 1.03
 Mental Disorders.                2922, 30300, and 30400.
Cardiac Conditions.............  3910, 3911, 3912,                  1.11
                                  40201, 40403, 4160,
                                  4210, 4211, and 4219.
Gangrene.......................  44024 and 7854.........            1.10
Chronic Obstructive Pulmonary    49121, 4941, 5100,                 1.12
 Disease.                         51883, 51884, V4611,
                                  V4612, V4613 and V4614.
Artificial Openings--Digestive   56960 through 56969,               1.08
 and Urinary.                     9975, and V441 through
                                  V446.
Severe Musculoskeletal and       6960, 7100, 73000                  1.09
 Connective Tissue Diseases.      through 73009, 73010
                                  through 73019, and
                                  73020 through 73029.
Poisoning......................  96500 through 96509,               1.11
                                  9654, 9670 through
                                  9699, 9770, 9800
                                  through 9809, 9830
                                  through 9839, 986,
                                  9890 through 9897.
------------------------------------------------------------------------

3. Patient Age Adjustments
    As explained in the November 2004 IPF PPS final rule (69 FR 66922), 
we analyzed the impact of age on per diem cost by examining the age 
variable (that is, the range of ages) for payment adjustments.
    In general, we found that the cost per day increases with age. The 
older age groups are more costly than the under 45 age group, the 
differences in per diem cost increase for each successive age group, 
and the differences are statistically significant.
    For RY 2011, we are continuing to use the patient age adjustments 
currently in effect as shown in Table 10 below.

             Table 10--Age Groupings and Adjustment Factors
------------------------------------------------------------------------
                                                             Adjustment
                            Age                                factor
------------------------------------------------------------------------
Under 45..................................................          1.00
45 and under 50...........................................          1.01
50 and under 55...........................................          1.02
55 and under 60...........................................          1.04
60 and under 65...........................................          1.07
65 and under 70...........................................          1.10
70 and under 75...........................................          1.13
75 and under 80...........................................          1.15
80 and over...............................................          1.17
------------------------------------------------------------------------

4. Variable Per Diem Adjustments
    We explained in the November 2004 IPF PPS final rule (69 FR 66946) 
that the regression analysis indicated that per diem cost declines as 
the LOS increases. The variable per diem adjustments to the Federal per 
diem base rate account for ancillary and administrative costs that 
occur disproportionately in the first days after admission to an IPF.
    We used a regression analysis to estimate the average differences 
in per diem cost among stays of different lengths. As a result of this 
analysis, we established variable per diem adjustments that begin on 
day 1 and decline gradually until day 21 of a patient's stay. For day 
22 and thereafter, the variable per diem adjustment remains the same 
each day for the remainder of the stay. However, the adjustment applied 
to day 1 depends upon whether the IPF has a qualifying ED. If an IPF 
has a qualifying ED, it receives a 1.31 adjustment factor for day 1 of 
each stay. If an IPF does not have a qualifying ED, it receives a 1.19 
adjustment factor for day 1 of the stay. The ED adjustment is explained 
in more detail in section IV.C.5 of this notice.

[[Page 23117]]

    For RY 2011, we are continuing to use the variable per diem 
adjustment factors currently in effect as shown in Table 11 below. A 
complete discussion of the variable per diem adjustments appears in the 
November 2004 IPF PPS final rule (69 FR 66946).

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

C. Facility-Level Adjustments

    The IPF PPS includes facility-level adjustments for the wage index, 
IPFs located in rural areas, teaching IPFs, cost of living adjustments 
for IPFs located in Alaska and Hawaii, and IPFs with a qualifying ED.
1. Wage Index Adjustment
a. Background
    As discussed in the May 2006 IPF PPS final rule and in the May 2008 
and May 2009 update notices, in providing an adjustment for geographic 
wage levels, the labor-related portion of an IPF's payment is adjusted 
using an appropriate wage index. Currently, an IPF's geographic wage 
index value is determined based on the actual location of the IPF in an 
urban or rural area as defined in Sec.  412.64(b)(1)(ii)(A) through 
Sec.  412.64(C).
b. Wage Index for RY 2011
    Since the inception of the IPF PPS, we have used hospital wage data 
in developing a wage index to be applied to IPFs. We are continuing 
that practice for RY 2011. We apply the wage index adjustment to the 
labor-related portion of the Federal rate, which is 75.400 percent. 
This percentage reflects the labor-related relative importance of the 
RPL market basket for RY 2011 (see section III.B.2 of this notice). The 
IPF PPS uses the pre-floor, pre-reclassified hospital wage index. 
Changes to the wage index are made in a budget neutral manner so that 
updates do not increase expenditures.
    For RY 2011, we are applying the most recent hospital wage index 
(that is, the FY 2010 pre-floor, pre-reclassified hospital wage index 
because this is the most appropriate index as it best reflects the 
variation in local labor costs of IPFs in the various geographic areas) 
using the most recent hospital wage data (that is, data from hospital 
cost reports for the cost reporting period beginning during FY 2006), 
and applying an adjustment in accordance with our budget neutrality 
policy. This policy requires us to estimate the total amount of IPF PPS 
payments in RY 2010 using the applicable wage index value divided by 
the total estimated IPF PPS payments in RY 2011 using the most recent 
wage index. The estimated payments are based on FY 2008 IPF claims, 
inflated to the appropriate RY. This quotient is the wage index budget 
neutrality factor, and it is applied in the update of the Federal per 
diem base rate for RY 2011 in addition to the market basket described 
in section III.B.1 of this notice. The wage index budget neutrality 
factor for RY 2011 is 0.9999.
    The wage index applicable for RY 2011 appears in Table 1 and Table 
2 in Addendum B of this notice. As explained in the May 2006 IPF PPS 
final rule for RY 2007 (71 FR 27061), the IPF PPS applies the hospital 
wage index without a hold-harmless policy, and without an out-commuting 
adjustment or out-migration adjustment because the statutory authority 
for these policies applies only to the IPPS.
    Also in the May 2006 IPF PPS final rule for RY 2007 (71 FR 27061), 
we adopted the changes discussed in the Office of Management and Budget 
(OMB) Bulletin No. 03-04 (June 6, 2003), which announced revised 
definitions for Metropolitan Statistical Areas (MSAs), and the creation 
of Micropolitan Statistical Areas and Combined Statistical Areas. In 
adopting the OMB Core-Based Statistical Area (CBSA) geographic 
designations, since the IPF PPS was already in a transition period from 
TEFRA payments to PPS payments, we did not provide a separate 
transition for the CBSA-based wage index.
    As was the case in RY 2010, for RY 2011 we will continue to use the 
CBSA-based wage index values as presented in Tables 1 and 2 in Addendum 
B of this notice. A complete discussion of the CBSA labor market 
definitions appears in the May 2006 IPF PPS final rule (71 FR 27061 
through 27067).
    In summary, for RY 2011 we will use the FY 2010 wage index data 
(collected from cost reports submitted by hospitals for cost reporting 
periods beginning during FY 2006) to adjust IPF PPS payments beginning 
July 1,2010.
c. OMB Bulletins
    The Office of Management and Budget (OMB) publishes bulletins 
regarding CBSA changes, including changes to CBSA numbers and titles. 
In the May 2008 IPF PPS notice, we incorporated the CBSA nomenclature 
changes published in the most recent OMB bulletin that applies to the 
hospital wage data used to determine the current IPF PPS wage index (73 
FR 25721). We will continue to do the same for all such OMB CBSA 
nomenclature changes in future IPF PPS rules and notices, as necessary. 
The OMB bulletins may be accessed online at http://www.whitehouse.gov/omb/bulletins/index.html.
2. Adjustment for Rural Location
    In the November 2004 IPF PPS final rule, we provided a 17 percent 
payment adjustment for IPFs located in a rural area. This adjustment 
was based on the regression analysis, which indicated that the per diem 
cost of rural facilities was 17 percent higher than that of urban 
facilities after accounting for the influence of the other variables 
included in the regression. For RY 2011, we are applying a 17 percent 
payment adjustment for IPFs located in a rural area as defined at Sec.  
412.64(b)(1)(ii)(C). As stated in the November 2004 IPF PPS final rule, 
we do not intend to update the adjustment factors derived from the 
regression analysis until we are able to analyze IPF PPS data. A 
complete discussion of the adjustment for rural locations appears in 
the November 2004 IPF PPS final rule (69 FR 66954).
3. Teaching Adjustment
    In the November 2004 IPF PPS final rule, we implemented regulations 
at Sec.  412.424(d)(1)(iii) to establish a facility-level adjustment 
for IPFs that are, or are part of, teaching hospitals. The teaching 
adjustment accounts for the higher indirect operating costs experienced 
by hospitals that participate in graduate medical education (GME) 
programs. The payment adjustments are made based on the number of full-
time equivalent (FTE) interns and residents training in the IPF and the 
IPF's average daily census.
    Medicare makes direct GME payments (for direct costs such as 
resident and

[[Page 23118]]

teaching physician salaries, and other direct teaching costs) to all 
teaching hospitals including those paid under the IPPS, and those that 
were once paid under the TEFRA rate-of-increase limits but are now paid 
under other PPSs. These direct GME payments are made separately from 
payments for hospital operating costs and are not part of the PPSs. The 
direct GME payments do not address the estimated higher indirect 
operating costs teaching hospitals may face.
    For teaching hospitals paid under the TEFRA rate-of-increase 
limits, Medicare did not make separate payments for indirect medical 
education costs because payments to these hospitals were based on the 
hospitals' reasonable costs which already included these higher 
indirect costs that may be associated with teaching programs.
    The results of the regression analysis of FY 2002 IPF data 
established the basis for the payment adjustments included in the 
November 2004 IPF PPS final rule. The results showed that the indirect 
teaching cost variable is significant in explaining the higher costs of 
IPFs that have teaching programs. We calculated the teaching adjustment 
based on the IPF's ``teaching variable,'' which is one plus the ratio 
of the number of FTE residents training in the IPF (subject to 
limitations described below) to the IPF's average daily census (ADC).
    We established the teaching adjustment in a manner that limited the 
incentives for IPFs to add FTE residents for the purpose of increasing 
their teaching adjustment. We imposed a cap on the number of FTE 
residents that may be counted for purposes of calculating the teaching 
adjustment. We emphasize that the cap limits the number of FTE 
residents that teaching IPFs may count for the purposes of calculating 
the IPF PPS teaching adjustment, not the number of residents teaching 
institutions can hire or train. We calculated the number of FTE 
residents that trained in the IPF during a ``base year'' and used that 
FTE resident number as the cap. An IPF's FTE resident cap is ultimately 
determined based on the final settlement of the IPF's most recent cost 
report filed before November 15, 2004 (that is, the publication date of 
the IPF PPS final rule).
    In the regression analysis, the logarithm of the teaching variable 
had a coefficient value of 0.5150. We converted this cost effect to a 
teaching payment adjustment by treating the regression coefficient as 
an exponent and raising the teaching variable to a power equal to the 
coefficient value. We note that the coefficient value of 0.5150 was 
based on the regression analysis holding all other components of the 
payment system constant.
    As with other adjustment factors derived through the regression 
analysis, we do not plan to rerun the regression analysis until we 
analyze IPF PPS data. Therefore, for RY 2011, we are retaining the 
coefficient value of 0.5150 for the teaching adjustment to the Federal 
per diem base rate.
    A complete discussion of how the teaching adjustment was calculated 
appears in the November 2004 IPF PPS final rule (69 FR 66954 through 
66957) and the May 2008 IPF PPS notice (73 FR 25721).
FTE Intern and Resident Cap Adjustment
    CMS has been asked to reconsider the current policy on the FTE 
intern and resident cap adjustment and to permit an increase in the FTE 
resident cap when the IPF increases the number of FTE residents it 
trains due to the acceptance of relocated residents when another IPF 
closes or closes its psychiatry residency program. To help us assess 
how many IPFs have been, or expect to be adversely affected by their 
inability to adjust their caps under Sec.  412.424(d)(1) and under 
these situations, we specifically requested public comment from IPFs in 
the May 2009 IPF PPS notice (74 FR 20362). A summary of the comments 
and our response to those comments are below.
    Comment: We received several comments on the FTE Intern and 
Resident Cap Adjustment. All of the commenters recommended that CMS 
modify the IPF PPS resident cap policy, supporting a policy change that 
would permit the IPF PPS residency cap to be increased when residents 
in a psychiatry residency program must be relocated from one IPF to 
another due to closure of an IPF or an IPF's psychiatry residency 
training program. Many commenters expressed concern that a cap on the 
number of FTE residents used to calculate the teaching adjustment is 
based on a snapshot of activity essentially ``freezing'' the status of 
residency education at a random point in time, CY 2004. Commenters 
stated that it is time to substantially modify the resident cap policy 
for the IPF PPS. Several commenters stated that this change in 
residency policy could help address the psychiatrist shortage, and help 
ensure access to care for beneficiaries who suffer from mental health 
and substance use disorders. Other commenters pointed out that the 
demand for health care services will continue to rise with the growing 
needs of the 78 million ``baby boomers'' who will retire in 2010 and 
with the recent passage of Paul Wellstone and Pete Domenici Mental 
Health Parity and Addiction Equality Act of 2008. The commenters 
further stated that the U.S. already faces a shortage of psychiatrists, 
and these factors could potentially elevate what is now a problem to 
what could be a crisis.
    Several commenters stated that in FY 2000, CMS instituted a 
temporary adjustment to the IPPS FTE cap policy when a hospital 
increases the number of FTE residents it trains due to the acceptance 
of relocated residents when another hospital closes (64 FR 41552). The 
commenters further stated that in FY 2002, CMS also implemented a 
similar policy for acute care hospitals that accept relocated residents 
from a closed program (66 FR 39899). The commenters indicated that the 
same need exists for IPFs that accept displaced residents when an IPF 
closes or when an IPF or acute care hospital closes its psychiatric 
residency program. The commenters recommended that CMS implement a 
temporary resident cap increase policy to the current FTE resident cap 
when an IPF increases the number of FTE residents it trains due to the 
acceptance of relocated residents. The commenters believe this change 
is necessary in order to promote consistency among payment systems and 
to ensure that residents training in psychiatry can continue their 
training when their original residency training program closes.
    Several commenters suggested that although the extent of the 
problem of displaced psychiatry residents is not clear at this time, 
the number of inpatient psychiatric units is declining. Therefore, they 
agreed that a temporary increase in the resident cap, similar to that 
allowed for acute care hospitals, would provide an incentive for IPFs 
to accept those psychiatry residents who are displaced by the closure 
of residency training programs. Some commenters expressed concern that 
inpatient psychiatric programs are closing in different parts of the 
country and believe the cap issue could become more of a problem in the 
future.
    One association surveyed IPFs and concluded that the cap does 
impact IPF training of psychiatric residents. Specifically, they stated 
that certain IPFs reported that they trained additional residents from 
a closed residency program and have exceeded their caps because of 
those residents. Other IPFs in the survey reported that they had been 
asked to train additional residents but had not agreed because

[[Page 23119]]

these additional residents would have caused them to exceed their cap.
    Another commenter believes the cap limits the flexibility of health 
systems to become more efficient by consolidating programs and 
residency training. This commenter indicated that while they have not 
heard of many facilities that have experienced a problem exceeding the 
cap, they were aware of specific cases where it has created problems 
and prevented some changes in the training of residents from one IPF to 
another. The example cited was a facility in the northwest that is part 
of a large health system, wanted to close down their training program 
in their outpatient department and shift the residents to an IPF owned 
by the health system. However, they indicated that the cap prevented 
the system from moving the residents from the outpatient program to the 
IPF.
    Another commenter believes this change is necessary and has 
personally encountered this situation when a local IPF was closed and 
their residents had to be relocated, some of which came to the 
commenter's facility. The commenter stated that a change in this policy 
would help keep needed residency slots in the local communities.
    One commenter indicated that they trained 24.56 FTE(s), which 
included 1.60 FTE(s) from a closed IPF. The commenter's cap is 18.18. 
The commenter indicated training of the closed IPF's residents did not 
give them relief from the cap.
    Response: We appreciate all comments received on the FTE intern and 
resident cap adjustment. We will take all comments into consideration 
as we assess the IPF PPS regulations with respect to developing the 
policy for the teaching cap adjustment in the future.
4. Cost of Living Adjustment for IPFs Located in Alaska and Hawaii
    The IPF PPS includes a payment adjustment for IPFs located in 
Alaska and Hawaii based upon the county in which the IPF is located. As 
we explained in the November 2004 IPF PPS final rule, the FY 2002 data 
demonstrated that IPFs in Alaska and Hawaii had per diem costs that 
were disproportionately higher than other IPFs. Other Medicare PPSs 
(for example, the IPPS and LTCH PPS) have adopted a cost of living 
adjustment (COLA) to account for the cost differential of care 
furnished in Alaska and Hawaii.
    We analyzed the effect of applying a COLA to payments for IPFs 
located in Alaska and Hawaii. The results of our analysis demonstrated 
that a COLA for IPFs located in Alaska and Hawaii would improve payment 
equity for these facilities. As a result of this analysis, we provided 
a COLA in the November 2004 IPF PPS final rule.
    A COLA adjustment for IPFs located in Alaska and Hawaii is made by 
multiplying the non-labor share of the Federal per diem base rate by 
the applicable COLA factor based on the COLA area in which the IPF is 
located.
    As previously stated in the November 2004 IPF PPS final rule, we 
will update the COLA factors according to updates established by the 
U.S. Office of Personnel Management (OPM), which issued a final rule, 
May 28, 2008 to change COLA rates.
    The COLA factors are published on the OPM Web site at (http://www.opm.gov/oca/cola/rates.asp).
    We note that the COLA areas for Alaska are not defined by county as 
are the COLA areas for Hawaii. In 5 CFR 591.207, the OPM established 
the following COLA areas:
    (a) City of Anchorage, and 80-kilometer (50-mile) radius by road, 
as measured from the Federal courthouse;
    (b) City of Fairbanks, and 80-kilometer (50-mile) radius by road, 
as measured from the Federal courthouse;
    (c) City of Juneau, and 80-kilometer (50-mile) radius by road, as 
measured from the Federal courthouse;
    (d) Rest of the State of Alaska.
    For RY 2011, IPFs located in Alaska and Hawaii will continue to 
receive the updated COLA factors based on the COLA area in which the 
IPF is located as shown in Table 12 below.

            Table 12--COLA Factors for Alaska and Hawaii IPFs
------------------------------------------------------------------------
                            Location                               COLA
------------------------------------------------------------------------
Alaska:
  Anchorage....................................................     1.23
  Fairbanks....................................................     1.23
  Juneau.......................................................     1.23
  Rest of Alaska...............................................     1.25
Hawaii:
  Honolulu County..............................................     1.25
  Hawaii County................................................     1.18
  Kauai County.................................................     1.25
  Maui County..................................................     1.25
  Kalawao County...............................................     1.25
------------------------------------------------------------------------

5. Adjustment for IPFs With a Qualifying Emergency Department (ED)
    Currently, the IPF PPS includes a facility-level adjustment for 
IPFs with qualifying EDs. We provide an adjustment to the Federal per 
diem base rate to account for the costs associated with maintaining a 
full-service ED. The adjustment is intended to account for ED costs 
incurred by a freestanding psychiatric hospital with a qualifying ED or 
a distinct part psychiatric unit of an acute hospital or a CAH for 
preadmission services otherwise payable under the Medicare Outpatient 
Prospective Payment System (OPPS) furnished to a beneficiary during the 
day immediately preceding the date of admission to the IPF (see Sec.  
413.40(c)(2)) and the overhead cost of maintaining the ED. This payment 
is a facility-level adjustment that applies to all IPF admissions (with 
one exception described below), regardless of whether a particular 
patient receives preadmission services in the hospital's ED.
    The ED adjustment is incorporated into the variable per diem 
adjustment for the first day of each stay for IPFs with a qualifying 
ED. That is, IPFs with a qualifying ED receive an adjustment factor of 
1.31 as the variable per diem adjustment for day 1 of each stay. If an 
IPF does not have a qualifying ED, it receives an adjustment factor of 
1.19 as the variable per diem adjustment for day 1 of each patient 
stay.
    The ED adjustment is made on every qualifying claim except as 
described below. As specified in Sec.  412.424(d)(1)(v)(B), the ED 
adjustment is not made where a patient is discharged from an acute care 
hospital or critical access hospital (CAH) and admitted to the same 
hospital's or CAH's psychiatric unit. An ED adjustment is not made in 
this case because the costs associated with ED services are reflected 
in the DRG payment to the acute care hospital or through the reasonable 
cost payment made to the CAH. If we provided the ED adjustment in these 
cases, the hospital would be paid twice for the overhead costs of the 
ED, as stated in the November 2004 IPF PPS final rule (69 FR 66960).
    Therefore, when patients are discharged from an acute care hospital 
or CAH and admitted to the same hospital's or CAH's psychiatric unit, 
the IPF receives the 1.19 adjustment factor as the variable per diem 
adjustment for the first day of the patient's stay in the IPF.
    For RY 2011, we are retaining the 1.31 adjustment factor for IPFs 
with qualifying EDs. A complete discussion of the steps involved in the 
calculation of the ED adjustment factor appears in the November 2004 
IPF PPS final rule (69 FR 66959 through 66960) and the May 2006 IPF PPS 
final rule (71 FR 27070 through 27072).

D. Other Payment Adjustments and Policies

    For RY 2011, the IPF PPS includes: An outlier adjustment to promote 
access

[[Page 23120]]

to IPF care for those patients who require expensive care and to limit 
the financial risk of IPFs treating unusually costly patients. In this 
section, we also explain the reason for ending the stop-loss provision 
that was applicable during the transition period.
1. Outlier Payments
    In the November 2004 IPF PPS final rule, we implemented regulations 
at Sec.  412.424(d)(3)(i) to provide a per-case payment for IPF stays 
that are extraordinarily costly. Providing additional payments to IPFs 
for extremely costly cases strongly improves the accuracy of the IPF 
PPS in determining resource costs at the patient and facility level. 
These additional payments reduce the financial losses that would 
otherwise be incurred in treating patients who require more costly care 
and, therefore, reduce the incentives for IPFs to under-serve these 
patients.
    We make outlier payments for discharges in which an IPF's estimated 
total cost for a case exceeds a fixed dollar loss threshold amount 
(multiplied by the IPF's facility-level adjustments) plus the Federal 
per diem payment amount for the case.
    In instances when the case qualifies for an outlier payment, we pay 
80 percent of the difference between the estimated cost for the case 
and the adjusted threshold amount for days 1 through 9 of the stay 
(consistent with the median LOS for IPFs in FY 2002), and 60 percent of 
the difference for day 10 and thereafter. We established the 80 percent 
and 60 percent loss sharing ratios because we were concerned that a 
single ratio established at 80 percent (like other Medicare PPSs) might 
provide an incentive under the IPF per diem payment system to increase 
LOS in order to receive additional payments. After establishing the 
loss sharing ratios, we determined the current fixed dollar loss 
threshold amount of $6,565 through payment simulations designed to 
compute a dollar loss beyond which payments are estimated to meet the 2 
percent outlier spending target.
a. Update to the Outlier Fixed Dollar Loss Threshold Amount
    In accordance with the update methodology described in Sec.  
412.428(d), we are updating the fixed dollar loss threshold amount used 
under the IPF PPS outlier policy. Based on the regression analysis and 
payment simulations used to develop the IPF PPS, we established a 2 
percent outlier policy which strikes an appropriate balance between 
protecting IPFs from extraordinarily costly cases while ensuring the 
adequacy of the Federal per diem base rate for all other cases that are 
not outlier cases.
    We believe it is necessary to update the fixed dollar loss 
threshold amount because analysis of the latest available data (that 
is, FY 2008 IPF claims) and rate increases indicates adjusting the 
fixed dollar loss amount is necessary in order to maintain an outlier 
percentage that equals 2 percent of total estimated IPF PPS payments.
    In the May 2006 IPF PPS final rule (71 FR 27072), we describe the 
process by which we calculate the outlier fixed dollar loss threshold 
amount. We continue to use this process for RY 2011. We begin by 
simulating aggregate payments with and without an outlier policy, and 
applying an iterative process to determine an outlier fixed dollar loss 
threshold amount that will result in outlier payments being equal to 2 
percent of total estimated payments under the simulation. Based on this 
process, we are updating the outlier fixed dollar loss threshold amount 
to $6,372 to maintain estimated outlier payments at 2 percent of total 
estimated IPF payments for RY 2011.
b. Statistical Accuracy of Cost-to-Charge Ratios
    As previously stated, under the IPF PPS, an outlier payment is made 
if an IPF's cost for a stay exceeds a fixed dollar loss threshold 
amount. In order to establish an IPF's cost for a particular case, we 
multiply the IPF's reported charges on the discharge bill by its 
overall cost-to-charge ratio (CCR). This approach to determining an 
IPF's cost is consistent with the approach used under the IPPS and 
other PPSs. In FY 2004, we implemented changes to the IPPS outlier 
policy used to determine CCRs for acute care hospitals because we 
became aware that payment vulnerabilities resulted in inappropriate 
outlier payments. Under the IPPS, we established a statistical measure 
of accuracy for CCRs in order to ensure that aberrant CCR data did not 
result in inappropriate outlier payments.
    As we indicated in the November 2004 IPF PPS final rule, because we 
believe that the IPF outlier policy is susceptible to the same payment 
vulnerabilities as the IPPS, we adopted an approach to ensure the 
statistical accuracy of CCRs under the IPF PPS (69 FR 66961). 
Therefore, we adopted the following procedure in the November 2004 IPF 
PPS final rule:
     We calculated two national ceilings, one for IPFs located 
in rural areas and one for IPFs located in urban areas. We computed the 
ceilings by first calculating the national average and the standard 
deviation of the CCR for both urban and rural IPFs.
    To determine the rural and urban ceilings, we multiplied each of 
the standard deviations by 3 and added the result to the appropriate 
national CCR average (either rural or urban). The upper threshold CCR 
for IPFs in RY 2011 is 1.7383 for rural IPFs, and 1.7377 for urban 
IPFs, based on CBSA-based geographic designations. If an IPF's CCR is 
above the applicable ceiling, the ratio is considered statistically 
inaccurate and we assign the appropriate national (either rural or 
urban) median CCR to the IPF.
    We are applying the national CCRs to the following situations:
    ++ New IPFs that have not yet submitted their first Medicare cost 
report.
    ++ IPFs whose overall CCR is in excess of 3 standard deviations 
above the corresponding national geometric mean (that is, above the 
ceiling).
    ++ Other IPFs for which the Medicare contractor obtains inaccurate 
or incomplete data with which to calculate a CCR.
    For new IPFs, we are using these national CCRs until the facility's 
actual CCR can be computed using the first tentatively or final settled 
cost report.
    We are not making any changes to the procedures for ensuring the 
statistical accuracy of CCRs in RY 2011. However, we are updating the 
national urban and rural CCRs (ceilings and medians) for IPFs for RY 
2011 based on the CCRs entered in the latest available IPF PPS Provider 
Specific File.
    The national CCRs for RY 2011 are 0.6480 for rural IPFs and 0.5170 
for urban IPFs and will be used in each of the three situations listed 
above. These calculations are based on the IPF's location (either urban 
or rural) using the CBSA-based geographic designations.
    A complete discussion regarding the national median CCRs appears in 
the November 2004 IPF PPS final rule (69 FR 66961 through 66964).
2. Expiration of the Stop-Loss Provision
    In the November 2004 IPF PPS final rule, we implemented a stop-loss 
policy that reduced financial risk to IPFs projected to experience 
substantial reductions in Medicare payments during the period of 
transition to the IPF PPS. This stop-loss policy guaranteed that each 
facility received total IPF PPS payments that were no less than 70 
percent of its TEFRA payments had the IPF PPS not been implemented. 
This policy was applied to the IPF PPS portion of Medicare payments 
during the 3-year transition.

[[Page 23121]]

    In the implementation year, the 70 percent of TEFRA payment stop-
loss policy required a reduction in the standardized Federal per diem 
and ECT base rates of 0.39 percent in order to make the stop-loss 
payments budget neutral. As described in the May 2008 IPF PPS notice 
for RY 2009, we increased the Federal per diem base rate and ECT rate 
by 0.39 percent because these rates were reduced by 0.39 percent in the 
implementation year to ensure stop-loss payments were budget neutral.
    The stop-loss provision ended during RY 2009 (that is for 
discharges occurring on or after July 1, 2008 through June 30, 2009). 
The stop-loss policy is no longer applicable under the IPF PPS.

V. Comments Beyond the Scope of the May 2009 IPF PPS Notice With 
Request for Comments

    In the May 2009 IPF PPS notice, which specifically solicited 
comments on the IPF PPS teaching adjustment and the market basket, we 
received several public comments which were outside the scope of that 
notice. Below, we are providing a summary of the comments and our 
response.
    Comment: Two commenters recommended that CMS continue its study of 
the wage index in favor of future changes that create a more equitable 
system and adequately reimburse hospitals for providing quality care to 
beneficiaries. The commenters recommend that the Bureau of Labor 
Statistics (BLS) data approach be used to construct a hospital 
compensation index. They support the elimination of the separate 
Occupational Mix Survey documents and the large additional reporting 
burden it creates for hospitals.
    One commenter expressed concern that a large increase in the fixed 
dollar threshold amount will significantly reduce the number of 
inpatient cases eligible for outlier payments and consequently, further 
reduce the ability of psychiatric facilities to provide necessary 
psychiatric care to Medicare beneficiaries. The commenter recommends 
that CMS continue examining its data to determine more specifically the 
causes for the increase and if further analysis suggests that the 
threshold increase is still valid, CMS should publish these reasons as 
part of the final rule.
    One commenter recommended that CMS revisit the Variable Per Diem 
Adjustments that have been established in the November 2004 IPF PPS 
final rule (69 FR 66946) and to validate these adjustments based on 
current claim information. The commenter believes the current system 
does not reflect all factors affecting cost. The example cited was that 
inpatient prospective payment system facilities receive a special 
payment treatment for servicing a disproportionate share of low-income 
patients, which is intended to reimburse a facility for additional cost 
incurred for handling such patients. The commenter stated that the 
current IPF PPS payment system does not consider this type of patient 
in its payment mechanism.
    Response: We are not addressing these comments in this notice 
because they are beyond the scope of the May 2009 notice. However, we 
will consider the comments and decide whether to take actions based on 
the information or recommendations of the commenters in future 
rulemaking.

VI. Waiver of Proposed Rulemaking

    We ordinarily publish a notice of proposed rulemaking in the 
Federal Register to provide a period for public comment before the 
provisions of a rule take effect. We can waive this procedure, however, 
if we find good cause that notice and comment procedures are 
impracticable, unnecessary, or contrary to the public interest and we 
incorporate a statement of finding and its reasons in the notice. We 
find it is unnecessary to undertake notice and comment rulemaking for 
the update in this notice because the update does not make any 
substantive changes in policy, but merely reflects the application of 
previously established methodologies. In addition, new section 
1886(s)(3)(A) of the Act requires the application of an ``Other 
Adjustment'' to the update to the IPF PPS base rate in RY 2011. We 
applied the statutorily-required adjustment in this notice. We find 
that notice and comment rulemaking is unnecessary to implement that 
statutory provision because it is a self-implementing provision of law, 
not requiring the exercise of any discretion on the part of CMS. 
Therefore, under 5 U.S.C. 553(b)(3)(B), for good cause, we waive notice 
and comment procedures.

VII. Collection of Information Requirements

    This document does not impose any information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 35).

VIII. Regulatory Impact Analysis

A. Overall Impact

    We have examined the impacts of this notice as required by 
Executive Order 12866 (September 1993, Regulatory Planning and Review), 
the September 19, 1980 Regulatory Flexibility Act (RFA) (Pub. L. 96-
354), section 1102(b) of the Act, the Unfunded Mandates Reform Act of 
1995 (Pub. L. 104-4), Executive Order 13132 on Federalism, and the 
Congressional Review Act (5 U.S.C. 804(2)).
    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). A regulatory impact 
analysis (RIA) must be prepared for major rules with economically 
significant effects ($100 million or more in any 1 year). Although this 
notice does not meet the $100 million threshold established by 
Executive Order 12866, we are considering this notice to be 
``economically significant'' because the redistributive effects are 
estimated to be close to constituting a shift of $100 million. For 
purposes of Title 5, United States Code, section 804(2), we estimate 
that this rulemaking is ``economically significant'', and is also a 
major rule under the Congressional Review Act. Accordingly, we have 
prepared a Regulatory Impact Analysis that to the best of our ability 
presents the costs and benefits of the rulemaking on the 1,679 IPFs.
    The updates to the IPF labor-related share and wage indices are 
made in a budget neutral manner and thus have no effect on estimated 
costs to the Medicare program. Therefore, the estimated increased cost 
to the Medicare program is due to the update to the IPF payment rates, 
which results in an approximate $91 million increase in payments (due 
to the 2.4% market basket increase with the 0.25% ``Other Adjustment'' 
reduction, as required by new section 1886(a)(3)(A) of the Act, and the 
update to the outlier fixed dollar loss threshold amount, which results 
in about a $4 million increase in payments). The distribution of these 
impacts is summarized in Table 13. The net effect of the updates 
described in this notice results in an overall estimated $95 million 
increase in payments from RY 2010 to RY 2011.
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses, if a rule has a significant impact on a 
substantial number of small entities. For purposes of the RFA, we 
estimate that the great majority of IPFs are small entities as that 
term is used in the RFA (include small businesses, nonprofit 
organizations, and small

[[Page 23122]]

governmental jurisdictions). The majority of hospitals and most other 
health care providers and suppliers are small entities, either by being 
nonprofit organizations or by meeting the SBA definition of a small 
business (having revenues of $7 million to $34.5 million in any 1 
year). (For details, see the Small Business Administration's Interim 
final rule that set forth size standards at 70 FR 72577, December 6, 
2005.) Because we lack data on individual hospital receipts, we cannot 
determine the number of small proprietary IPFs or the proportion of 
IPFs' revenue that is derived from Medicare payments. Therefore, we 
assume that all IPFs are considered small entities. The Department of 
Health and Human Services (HHS) generally uses a revenue impact of 3 to 
5 percent as a significance threshold under the RFA. As shown in Table 
13, we estimate that the net revenue impact of this notice on all IPFs 
is to increase estimated payments by about 2.26 percent. Since the 
estimated impact of this notice is a net increase in revenue across all 
categories of IPFs, we believe that this notice would not impose a 
significant burden on small entities. Medicare fiscal intermediaries 
and carriers are not considered to be small entities. Individuals and 
States are not included in the definition of a small entity.
    Although section 1102(b) of the Act applies to regulations for 
which a proposed rule is published, the HHS policy is to prepare an 
analysis of the impact on small rural hospitals for any regulation 
published. As a result, we are voluntarily determining whether this 
notice will have a significant impact on the operations of a 
substantial number of small rural hospitals. For purposes of section 
1102(b) of the Act, we define a small rural hospital as a hospital with 
fewer than 100 beds that is located outside of an MSA. As discussed in 
detail below, the rates and policies set forth in this notice will not 
have an adverse impact on the rural hospitals based on the data of the 
312 rural units and 64 rural hospitals in our database of 1,679 IPFs 
for which data were available.
    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 2010, that 
threshold is approximately $135 million. This notice will not impose 
spending costs on State, local, or Tribal governments in the aggregate, 
or by the private sector, of $135 million.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. We have reviewed this notice under the criteria set forth 
in Executive Order 13132 and have determined that the notice will not 
have any substantial direct impact on State or local governments, 
preempt State law, or otherwise have a Federalism implication.

B. Anticipated Effects

    We discuss below the historical background of the IPF PPS and the 
impact of this notice on the Federal Medicare budget and on IPFs.
1. Budgetary Impact
    As discussed in the November 2004 and May 2006 IPF PPS final rules, 
we applied a budget neutrality factor to the Federal per diem and ECT 
base rates to ensure that total estimated payments under the IPF PPS in 
the implementation period would equal the amount that would have been 
paid if the IPF PPS had not been implemented. The budget neutrality 
factor includes the following components: Outlier adjustment, stop-loss 
adjustment, and the behavioral offset. As discussed in the May 2008 IPF 
PPS notice (73 FR 25711), the stop-loss adjustment is no longer 
applicable under the IPF PPS.
    In accordance with Sec.  412.424(c)(3)(ii), we indicated that we 
would evaluate the accuracy of the budget neutrality adjustment within 
the first 5 years after implementation of the payment system. We may 
make a one-time prospective adjustment to the Federal per diem and ECT 
base rates to account for differences between the historical data on 
cost-based TEFRA payments (the basis of the budget neutrality 
adjustment) and estimates of TEFRA payments based on actual data from 
the first year of the IPF PPS. As part of that process, we will 
reassess the accuracy of all of the factors impacting budget 
neutrality.
    In addition, as discussed in section III.B.2 of this notice, we are 
using the wage index and labor market share in a budget neutral manner 
by applying a wage index budget neutrality factor to the Federal per 
diem and ECT base rates. Therefore, the budgetary impact to the 
Medicare program by this update to the IPF PPS will be due to the 
market basket update (see section III.B.2.a of this notice) with the 
``Other Adjustment,'' as required by new section 1886(s)(3)(A) of the 
Act, and the update to the outlier fixed dollar loss threshold amount.
2. Impacts on Providers
    To understand the impact of the changes to the IPF PPS on 
providers, discussed in this notice, it is necessary to compare 
estimated payments under the IPF PPS rates and factors for RY 2011 
versus those under RY 2010. The estimated payments for RY 2010 and RY 
2011 will be 100 percent of the IPF PPS payment, since the transition 
period has ended and stop-loss payments are no longer paid. We 
determined the percent change of estimated RY 2011 IPF PPS payments to 
estimated RY 2010 IPF PPS payments for each category of IPFs. In 
addition, for each category of IPFs, we have included the estimated 
percent change in payments resulting from the update to the outlier 
fixed dollar loss threshold amount, the wage index changes for the RY 
2011 IPF PPS, and the market basket update, as adjusted by the ``Other 
Adjustment''.
    To illustrate the impacts of the final RY 2011 changes in this 
notice, our analysis begins with an RY 2010 baseline simulation model 
based on FY 2008 IPF payments inflated to the midpoint of RY 2010 using 
IHS Global Insight's most recent forecast of the market basket update 
(see section III.2.b of this notice); the estimated outlier payments in 
RY 2010; the CBSA designations for IPFs based on OMB's MSA definitions 
after June 2003; the FY 2009 pre-floor, pre-reclassified hospital wage 
index; the RY 2010 labor-market share; and the RY 2010 percentage 
amount of the rural adjustment. During the simulation, the total 
estimated outlier payments are maintained at 2 percent of total 
estimated IPF PPS payments.
    Each of the following changes is added incrementally to this 
baseline model in order for us to isolate the effects of each change:
     The update to the outlier fixed dollar loss threshold 
amount.
     The FY 2010 pre-floor, pre-reclassified hospital wage 
index and RY 2011 final labor-related share.
     Our final comparison illustrates the percent change in 
payments from RY 2010 (that is, July 1, 2009 to June 30, 2010) to RY 
2011 (that is, July 1, 2010 to June 30, 2011) and includes a 2.4 
percent market basket update to the IPF PPS base rates with a -0.25% 
``Other Adjustment'' to the IPF PPS base rates, as required by new 
section 1886(s)(3)(A) of the Act.

[[Page 23123]]

                                           Table 13--Projected Impacts
----------------------------------------------------------------------------------------------------------------
                                          Projected impacts (% Change)
-----------------------------------------------------------------------------------------------------------------
                                                                                                    Total with
                                                     Number of                       CBSA wage     market basket
                Facility by type                    facilities        Outlier      index & labor      & other
                                                                                       share      adjustment \1\
(1)                                                          (2)             (3)             (4)             (5)
----------------------------------------------------------------------------------------------------------------
All Facilities..................................           1,679            0.11            0.00            2.26
Total Urban.....................................           1,303            0.11            0.02            2.28
Total Rural.....................................             376            0.09           -0.10            2.14
Urban DPU.......................................             899            0.15           -0.01            2.29
Urban CAH unit..................................              14            0.35           -0.30            2.20
Urban hospital..................................             390            0.03            0.07            2.26
Rural DPU.......................................             259            0.11           -0.13            2.13
Rural CAH unit..................................              53            0.06            0.17            2.39
Rural hospital..................................              64            0.03           -0.13            2.05
Freestanding IPF By Type of Ownership:
    Urban Psychiatric Hospitals:
        Government..............................             170            0.03            0.03            2.22
        Non-Profit..............................             115            0.03            0.16            2.35
        For-Profit..............................             105            0.03            0.02            2.20
    Rural Psychiatric Hospitals:
        Government..............................              41            0.03           -0.51            1.66
        Non-Profit..............................              10            0.04            0.20            2.40
        For-Profit..............................              13            0.01            0.88            3.06
IPF Units By Type of Ownership:
    Urban DPU:
        Government..............................             156            0.23            0.30            2.69
        Non-Profit..............................             616            0.14           -0.13            2.17
        For-Profit..............................             127            0.10            0.12            2.37
    Urban CAH:
        Government..............................               5            0.53           -1.61            1.03
        Non-Profit..............................               8            0.28            0.13            2.56
        For-Profit..............................               1            0.03            3.18            5.43
    Rural DPU:
        Government..............................              61            0.12            0.08            2.35
        Non-Profit..............................             150            0.11           -0.26            2.00
        For-Profit..............................              48            0.11           -0.03            2.24
    Rural CAH:
        Government..............................              21            0.05            0.43            2.64
        Non-Profit..............................              28            0.07           -0.01            2.21
        For-Profit..............................               4            0.07            0.09            2.32
By Teaching Status:
    Non-teaching................................           1,442            0.10           -0.03            2.22
    Less than 10% interns and residents to beds.             131            0.11            0.15            2.42
    10% to 30% interns and residents to beds....              73            0.19            0.07            2.41
    More than 30% interns and residents to beds.              33            0.27           -0.11            2.31
By Region:
    New England.................................             118            0.15            0.52            2.83
    Mid-Atlantic................................             285            0.09           -0.04            2.20
    South Atlantic..............................             234            0.09           -0.03            2.21
    East North Central..........................             284            0.14           -0.40            1.88
    East South Central..........................             167            0.08            0.01            2.24
    West North Central..........................             149            0.11            0.07            2.33
    West South Central..........................             228            0.09           -0.08            2.16
    Mountain....................................              85            0.11            0.67            2.95
    Pacific.....................................             129            0.15            0.02            2.32
By Bed Size:
    Psychiatric Hospitals:
        Under 12 beds...........................               3            0.01           -0.31            1.84
        Beds: 12-24.............................              64            0.08            0.60            2.85
        Beds: 25-49.............................              69            0.08            0.09            2.32
        Beds: 50-75.............................              74            0.04            0.58            2.78
        Over 75 beds............................             244            0.02           -0.13            2.03
    Psychiatric Units:
        Under 12 beds...........................             191            0.18           -0.09            2.24
        Beds: 12-24.............................             529            0.16           -0.16            2.14
        Beds: 25-49.............................             335            0.14            0.00            2.30
        Beds: 50-75.............................             106            0.13           -0.15            2.13

[[Page 23124]]

        Over 75 beds............................              64            0.13            0.36            2.65
----------------------------------------------------------------------------------------------------------------
\1\ This column shows changes in payments from RY 2010 to RY 2011. It reflects the impact of the RY 2011 market
  basket update with the ``Other Adjustment'' for the rate year beginning in 2010, as required by new section
  1886(s)(3)(A) of the Act. The RY 2011 market basket update is 2.4% and the ``Other Adjustment'' for the rate
  year beginning in 2010 is -0.25%. It incorporates all of the changes displayed in Columns 3 and 4. The product
  of these impacts may be different from the percentage changes shown here due to rounding effects.

3. Results
    Table 13 above displays the results of our analysis. The table 
groups IPFs into the categories listed below based on characteristics 
provided in the Provider of Services (POS) file, the IPF provider 
specific file, and cost report data from HCRIS:
     Facility Type.
     Location.
     Teaching Status Adjustment.
     Census Region.
     Size.
    The top row of the table shows the overall impact on the 1,679 IPFs 
included in the analysis.
    In column 3, we present the effects of the update to the outlier 
fixed dollar loss threshold amount. We estimate total outlier payments 
in RY 2010 to be approximately 1.9 percent of total estimated payments. 
Therefore, we are updating the threshold from $6,565 in RY 2010 to 
$6,372 in RY 2011 in order to maintain total estimated outlier payments 
equal to 2 percent of total estimated payments for RY 2011. The overall 
aggregate effect of this change (as shown in column 3 of table 13), 
across all hospital groups, is to increase total estimated payments to 
IPFs by about 0.11 percent. All categories of IPFs are projected to 
receive either an increase or no change in payments. There are 
distributional effects of this change among different categories of 
IPFs. Urban and rural, freestanding psychiatric hospitals; urban, for-
profit IPF units located in CAHs; and psychiatric hospitals with under 
12 beds and 50 or more will experience approximately a zero percent 
change in their payments. Alternatively, urban, government IPF units 
located in CAHs will receive the largest increase of 0.53 percent.
    In column 4, we present the effects of the budget-neutral update to 
the labor-related share and the wage index adjustment under the CBSA 
geographic area definitions announced by OMB in June 2003. This is a 
comparison of the simulated RY 2011 payments under the FY 2010 hospital 
wage index under CBSA classification and associated labor-related share 
to the simulated RY 2010 payments under the FY 2009 hospital wage index 
under CBSA classifications and associated labor-related share. We note 
that there is no projected change in aggregate payments to IPFs, as 
indicated in the first row of column 4. However, there would be 
distributional effects among different categories of IPFs. For example, 
urban, government IPF units located in CAHs will experience a 1.61 
percent decrease in payments. An urban, for-profit IPF CAH unit will 
receive the largest increase of 3.18 percent.
    Column 5 compares our estimates of the changes reflected in this 
notice for RY 2011, to our estimates of payments for RY 2010 (without 
these changes). This column reflects all RY 2011 changes relative to RY 
2010 (as shown in columns 3 and 4 and including the market basket 
update with the -.25% ``Other Adjustment''). The average increase for 
all IPFs is approximately 2.26 percent. This increase includes the 
effects of the market basket update (2.4%) with the ``Other 
Adjustment'' (-0.25%) resulting in a 2.15 percent increase in total RY 
2011 payments, and an approximate 0.11 percent increase in RY 2011 
payments due to the update to the outlier fixed dollar loss threshold.
    Overall, the largest payment increases ranging from 3.06 percent to 
5.43 percent are projected to be among rural, for-profit freestanding 
IPFs and urban, for-profit IPF units located in CAHs. Urban, government 
IPF units located in CAHs will receive the smallest increase of 1.03 
percent.
4. Effect on the Medicare Program
    Based on actuarial projections resulting from our experience with 
other PPSs, we estimate that Medicare spending (total Medicare program 
payments) for IPF services over the next 5 years would be as shown in 
Table 14 below.

                      Table 14--Estimated Payments
------------------------------------------------------------------------
                                                                Dollars
                          Rate year                                in
                                                                millions
------------------------------------------------------------------------
July 1, 2010 to June 30, 2011................................     $4,438
July 1, 2011 to June 30, 2012................................      4,685
July 1, 2012 to June 30, 2013................................      4,930
July 1, 2013 to June 30, 2014................................      5,178
July 1, 2014 to June 30, 2015................................      5,450
------------------------------------------------------------------------

    These estimates are based on the current forecast of the increases 
in the RPL market basket, including an adjustment for productivity, for 
which we are using a preliminary estimate, for the rate year beginning 
in 2012 and each subsequent rate year, as required by new section 
1886(s)(3)(A) of the Act, as follows:
     2.4 percent for rate years beginning in 2010 (RY 2011).
     2.9 percent for rate years beginning in 2011 (RY 2012).
     1.7 percent for rate years beginning in 2012 (RY 2013).
     1.9 percent for rate years beginning in 2013 (RY 2014).
     2.1 percent for rate years beginning in 2014 (RY 2015).
    The estimates in Table 14 also include the application of the 
``Other Adjustment,'' as required by section 1886(s)(A)(3) of the Act, 
as follows:
     -0.25 percent for rate years beginning in 2010.
     -0.25 percent for rate years beginning in 2011.
     -0.1 percent for rate years beginning in 2012.
     -0.1 percent for rate years beginning in 2013.
     -0.3 percent for rate years beginning in 2014.
    We estimate that there would be a change in fee-for-service 
Medicare beneficiary enrollment as follows:
     2.5 percent in RY 2011.
     3.2 percent in RY 2012.
     3.1 percent in RY 2013.

[[Page 23125]]

     3.1 percent in RY 2014.
     2.8 percent in RY 2015.
5. Effect on Beneficiaries
    Under the IPF PPS, IPFs will receive payment based on the average 
resources consumed by patients for each day. We do not expect changes 
in the quality of care or access to services for Medicare beneficiaries 
under the RY 2011 IPF PPS. In fact, we believe that access to IPF 
services will be enhanced due to the patient- and facility-level 
adjustment factors, all of which are intended to adequately reimburse 
IPFs for expensive cases. Finally, the outlier policy is intended to 
assist IPFs that experience high-cost cases.

C. Alternatives Considered

    The statute does not specify an update strategy for the IPF PPS and 
is broadly written to give the Secretary discretion in establishing an 
update methodology. Therefore, we are updating the IPF PPS using the 
methodology published in the November 2004 IPF PPS final rule.
    We note that this notice does not initiate any policy changes with 
regard to the IPF PPS; rather, it simply provides an update to the 
rates for RY 2011. Therefore, no options were considered.

D. Accounting Statement

    As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 15 below, we 
have prepared an accounting statement showing the classification of the 
expenditures associated with the provisions of this notice. This table 
provides our best estimate of the increase in Medicare payments under 
the IPF PPS notice, as a result of the changes presented in this 
notice, and based on the data for 1,679 IPFs in our database. All 
expenditures are classified as transfers to Medicare providers (that 
is, IPFs).

       Table 15--Accounting Statement: Classification of Estimated
      Expenditures, From the 2010 IPF PPS RY to the 2011 IPF PPS RY
                              [In millions]
------------------------------------------------------------------------
                 Category                             Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............  $95.
From Whom To Whom?                          Federal Government To IPF
                                             Medicare Providers.
------------------------------------------------------------------------

    In accordance with the provisions of Executive Order 12866, this 
notice was reviewed by OMB.

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

    Dated: March 4, 2010.
Charlene Frizzera,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Approved: April 20, 2010.
Kathleen Sebelius,
Secretary.

Addendum A--Rate and Adjustment Factors

                              Per Diem Rate
------------------------------------------------------------------------

------------------------------------------------------------------------
Federal Per Diem Base Rate....................................   $665.71
Labor Share (0.75400).........................................    501.95
Non-Labor Share (0.24600).....................................    163.76
------------------------------------------------------------------------

    Fixed Dollar Loss Threshold Amount: $6,372.
    Wage Index Budget Neutrality Factor: 0.9999.

                          Facility Adjustments
------------------------------------------------------------------------

------------------------------------------------------------------------
Rural Adjustment Factor...................  1.17.
Teaching Adjustment Factor................  0.5150.
Wage Index................................  Pre-reclass Hospital Wage
                                             Index (FY 2010).
------------------------------------------------------------------------

                   Cost of Living Adjustments (COLAs)
------------------------------------------------------------------------

------------------------------------------------------------------------
                                 Alaska
------------------------------------------------------------------------
Anchorage.....................................................      1.23
Fairbanks.....................................................      1.23
Juneau........................................................      1.23
Rest of Alaska................................................      1.25
------------------------------------------------------------------------
                                 Hawaii
------------------------------------------------------------------------
Honolulu County...............................................      1.25
Hawaii County.................................................      1.18
Kauai County..................................................      1.25
Maui County...................................................      1.25
Kalawao County................................................      1.25
------------------------------------------------------------------------

                           Patient Adjustments
------------------------------------------------------------------------

------------------------------------------------------------------------
ECT--Per Treatment............................................   $286.60
------------------------------------------------------------------------

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

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

                                                 DRG Adjustments
----------------------------------------------------------------------------------------------------------------
                                                                                                      Adjustment
                   MS-DRG                                      MS-DRG descriptions                      factor
----------------------------------------------------------------------------------------------------------------
056........................................  Degenerative nervous system disorders w MCC...........         1.05

[[Page 23126]]

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

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

Addendum B--RY 2011 CBSA Wage Index Tables

    In this addendum, we provide Tables 1 and 2 which indicate the 
CBSA-based wage index values for urban and rural providers.

 Table 1--RY 2011 Wage Index For Urban Areas Based on CBSA Labor Market
                                  Areas
------------------------------------------------------------------------
                                                                  Wage
        CBSA code           Urban area (constituent counties)     index
------------------------------------------------------------------------
10180....................  Abilene, TX........................    0.7946
                           Callahan County, TX
                           Jones County, TX
                           Taylor County, TX
10380....................  Aguadilla-Isabela-San                  0.3462
                            Sebasti[aacute]n, PR.
                           Aguada Municipio, PR
                           Aguadilla Municipio, PR
                           A[ntilde]asco Municipio, PR
                           Isabela Municipio, PR
                           Lares Municipio, PR
                           Moca Municipio, PR
                           Rinc[oacute]n Municipio, PR
                           San Sebasti[aacute]n Municipio, PR
10420....................  Akron, OH..........................    0.8850
                           Portage County, OH
                           Summit County, OH
10500....................  Albany, GA.........................    0.8899

[[Page 23127]]

                           Baker County, GA
                           Dougherty County, GA
                           Lee County, GA
                           Terrell County, GA
                           Worth County, GA
10580....................  Albany-Schenectady-Troy, NY........    0.8777
                           Albany County, NY
                           Rensselaer County, NY
                           Saratoga County, NY
                           Schenectady County, NY
                           Schoharie County, NY
10740....................  Albuquerque, NM....................    0.9399
                           Bernalillo County, NM
                           Sandoval County, NM
                           Torrance County, NM
                           Valencia County, NM
10780....................  Alexandria, LA.....................    0.8012
                           Grant Parish, LA
                           Rapides Parish, LA
10900....................  Allentown-Bethlehem-Easton, PA-NJ..    0.9611
                           Warren County, NJ
                           Carbon County, PA
                           Lehigh County, PA
                           Northampton County, PA
11020....................  Altoona, PA........................    0.8863
                           Blair County, PA
11100....................  Amarillo, TX.......................    0.8689
                           Armstrong County, TX
                           Carson County, TX
                           Potter County, TX
                           Randall County, TX
11180....................  Ames, IA...........................    0.9493
                           Story County, IA
11260....................  Anchorage, AK......................    1.2013
                           Anchorage Municipality, AK
                           Matanuska-Susitna Borough, AK
11300....................  Anderson, IN.......................    0.9052
                           Madison County, IN
11340....................  Anderson, SC.......................    0.9023
                           Anderson County, SC
11460....................  Ann Arbor, MI......................    1.0293
                           Washtenaw County, MI
11500....................  Anniston-Oxford, AL................    0.7643
                           Calhoun County, AL
11540....................  Appleton, WI.......................    0.9289
                           Calumet County, WI
                           Outagamie County, WI
11700....................  Asheville, NC......................    0.9057
                           Buncombe County, NC
                           Haywood County, NC
                           Henderson County, NC
                           Madison County, NC
12020....................  Athens-Clarke County, GA...........    0.9492
                           Clarke County, GA
                           Madison County, GA
                           Oconee County, GA
                           Oglethorpe County, GA
12060....................  Atlanta-Sandy Springs-Marietta, GA.    0.9591
                           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

[[Page 23128]]

                           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........    1.1554
                           Atlantic County, NJ
12220....................  Auburn-Opelika, AL.................    0.8138
                           Lee County, AL
12260....................  Augusta-Richmond County, GA-SC.....    0.9409
                           Burke County, GA
                           Columbia County, GA
                           McDuffie County, GA
                           Richmond County, GA
                           Aiken County, SC
                           Edgefield County, SC
12420....................  Austin-Round Rock, TX..............    0.9518
                           Bastrop County, TX
                           Caldwell County, TX
                           Hays County, TX
                           Travis County, TX
                           Williamson County, TX
12540....................  Bakersfield, CA....................    1.1232
                           Kern County, CA
12580....................  Baltimore-Towson, MD...............    1.0214
                           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.........................    1.0154
                           Penobscot County, ME
12700....................  Barnstable Town, MA................    1.2618
                           Barnstable County, MA
12940....................  Baton Rouge, LA....................    0.8180
                           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...................    1.0000
                           Calhoun County, MI
13020....................  Bay City, MI.......................    0.9267
                           Bay County, MI
13140....................  Beaumont-Port Arthur, TX...........    0.8383
                           Hardin County, TX
                           Jefferson County, TX
                           Orange County, TX
13380....................  Bellingham, WA.....................    1.1395
                           Whatcom County, WA
13460....................  Bend, OR...........................    1.1446
                           Deschutes County, OR
13644....................  Bethesda-Frederick-Gaithersburg, MD    1.0298
                           Frederick County, MD
                           Montgomery County, MD

[[Page 23129]]

13740....................  Billings, MT.......................    0.8781
                           Carbon County, MT
                           Yellowstone County, MT
13780....................  Binghamton, NY.....................    0.8780
                           Broome County, NY
                           Tioga County, NY
13820....................  Birmingham-Hoover, AL..............    0.8554
                           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.......................    0.7637
                           Burleigh County, ND
                           Morton County, ND
13980....................  Blacksburg-Christiansburg-Radford,     0.8394
                            VA.
                           Giles County, VA
                           Montgomery County, VA
                           Pulaski County, VA
                           Radford City, VA
14020....................  Bloomington, IN....................    0.9043
                           Greene County, IN
                           Monroe County, IN
                           Owen County, IN
14060....................  Bloomington-Normal, IL.............    0.9378
                           McLean County, IL
14260....................  Boise City-Nampa, ID...............    0.9318
                           Ada County, ID
                           Boise County, ID
                           Canyon County, ID
                           Gem County, ID
                           Owyhee County, ID
14484....................  Boston-Quincy, MA..................    1.2186
                           Norfolk County, MA
                           Plymouth County, MA
                           Suffolk County, MA
14500....................  Boulder, CO........................    1.0266
                           Boulder County, CO
14540....................  Bowling Green, KY..................    0.8469
                           Edmonson County, KY
                           Warren County, KY
14600....................  Bradenton-Sarasota-Venice, FL......    0.9735
                           Manatee County, FL
                           Sarasota County, FL
14740....................  Bremerton-Silverdale, WA...........    1.0755
                           Kitsap County, WA
14860....................  Bridgeport-Stamford-Norwalk, CT....    1.2792
                           Fairfield County, CT
15180....................  Brownsville-Harlingen, TX..........    0.9020
                           Cameron County, TX
15260....................  Brunswick, GA......................    0.9178
                           Brantley County, GA
                           Glynn County, GA
                           McIntosh County, GA
15380....................  Buffalo-Niagara Falls, NY..........    0.9740
                           Erie County, NY
                           Niagara County, NY
15500....................  Burlington, NC.....................    0.8749
                           Alamance County, NC
15540....................  Burlington-South Burlington, VT....    1.0106
                           Chittenden County, VT
                           Franklin County, VT
                           Grand Isle County, VT
15764....................  Cambridge-Newton-Framingham, MA....    1.1278
                           Middlesex County, MA
15804....................  Camden, NJ.........................    1.0374
                           Burlington County, NJ
                           Camden County, NJ
                           Gloucester County, NJ

[[Page 23130]]

15940....................  Canton-Massillon, OH...............    0.8813
                           Carroll County, OH
                           Stark County, OH
15980....................  Cape Coral-Fort Myers, FL..........    0.9076
                           Lee County, FL
16020....................  Cape Girardeau-Jackson, MO-IL......    0.9047
                           Alexander County, IL
                           Bollinger County, MO
                           Cape Girardeau County, MO
16180....................  Carson City, NV....................    1.0531
                           Carson City, NV
16220....................  Casper, WY.........................    0.9520
                           Natrona County, WY
16300....................  Cedar Rapids, IA...................    0.8984
                           Benton County, IA
                           Jones County, IA
                           Linn County, IA
16580....................  Champaign-Urbana, IL...............    1.0108
                           Champaign County, IL
                           Ford County, IL
                           Piatt County, IL
16620....................  Charleston, WV.....................    0.8141
                           Boone County, WV
                           Clay County, WV
                           Kanawha County, WV
                           Lincoln County, WV
                           Putnam County, WV
16700....................  Charleston-North Charleston-           0.9279
                            Summerville, SC.
                           Berkeley County, SC
                           Charleston County, SC
                           Dorchester County, SC
16740....................  Charlotte-Gastonia-Concord,            0.9474
                            NC[dash]SC.
                           Anson County, NC
                           Cabarrus County, NC
                           Gaston County, NC
                           Mecklenburg County, NC
                           Union County, NC
                           York County, SC
16820....................  Charlottesville, VA................    0.9372
                           Albemarle County, VA
                           Fluvanna County, VA
                           Greene County, VA
                           Nelson County, VA
                           Charlottesville City, VA
16860....................  Chattanooga, TN-GA.................    0.8831
                           Catoosa County, GA
                           Dade County, GA
                           Walker County, GA
                           Hamilton County, TN
                           Marion County, TN
                           Sequatchie County, TN
16940....................  Cheyenne, WY.......................    0.9344
                           Laramie County, WY
16974....................  Chicago-Naperville-Joliet, IL......    1.0471
                           Cook County, IL
                           DeKalb County, IL
                           DuPage County, IL
                           Grundy County, IL
                           Kane County, IL
                           Kendall County, IL
                           McHenry County, IL
                           Will County, IL
17020....................  Chico, CA..........................    1.1198
                           Butte County, CA
17140....................  Cincinnati-Middletown, OH-KY-IN....    0.9483
                           Dearborn County, IN
                           Franklin County, IN
                           Ohio County, IN
                           Boone County, KY
                           Bracken County, KY
                           Campbell County, KY

[[Page 23131]]

                           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
17300....................  Clarksville, TN-KY.................    0.7980
                           Christian County, KY
                           Trigg County, KY
                           Montgomery County, TN
                           Stewart County, TN
17420....................  Cleveland, TN......................    0.7564
                           Bradley County, TN
                           Polk County, TN
17460....................  Cleveland-Elyria-Mentor, OH........    0.8914
                           Cuyahoga County, OH
                           Geauga County, OH
                           Lake County, OH
                           Lorain County, OH
                           Medina County, OH
17660....................  Coeur d'Alene, ID..................    0.9235
                           Kootenai County, ID
17780....................  College Station-Bryan, TX..........    0.9498
                           Brazos County, TX
                           Burleson County, TX
                           Robertson County, TX
17820....................  Colorado Springs, CO...............    0.9821
                           El Paso County, CO
                           Teller County, CO
17860....................  Columbia, MO.......................    0.8618
                           Boone County, MO
                           Howard County, MO
17900....................  Columbia, SC.......................    0.8789
                           Calhoun County, SC
                           Fairfield County, SC
                           Kershaw County, SC
                           Lexington County, SC
                           Richland County, SC
                           Saluda County, SC
17980....................  Columbus, GA-AL....................    0.8724
                           Russell County, AL
                           Chattahoochee County, GA
                           Harris County, GA
                           Marion County, GA
                           Muscogee County, GA
18020....................  Columbus, IN.......................    0.9536
                           Bartholomew County, IN
18140....................  Columbus, OH.......................    1.0101
                           Delaware County, OH
                           Fairfield County, OH
                           Franklin County, OH
                           Licking County, OH
                           Madison County, OH
                           Morrow County, OH
                           Pickaway County, OH
                           Union County, OH
18580....................  Corpus Christi, TX.................    0.8693
                           Aransas County, TX
                           Nueces County, TX
                           San Patricio County, TX
18700....................  Corvallis, OR......................    1.1002
                           Benton County, OR
19060....................  Cumberland, MD-WV..................    0.8045
                           Allegany County, MD
                           Mineral County, WV
19124....................  Dallas-Plano-Irving, TX............    0.9853
                           Collin County, TX
                           Dallas County, TX

[[Page 23132]]

                           Delta County, TX
                           Denton County, TX
                           Ellis County, TX
                           Hunt County, TX
                           Kaufman County, TX
                           Rockwall County, TX
19140....................  Dalton, GA.........................    0.8666
                           Murray County, GA
                           Whitfield County, GA
19180....................  Danville, IL.......................    0.8738
                           Vermilion County, IL
19260....................  Danville, VA.......................    0.8323
                           Pittsylvania County, VA
                           Danville City, VA
19340....................  Davenport-Moline-Rock Island, IA-IL    0.8284
                           Henry County, IL
                           Mercer County, IL
                           Rock Island County, IL
                           Scott County, IA
19380....................  Dayton, OH.........................    0.9211
                           Greene County, OH
                           Miami County, OH
                           Montgomery County, OH
                           Preble County, OH
19460....................  Decatur, AL........................    0.7799
                           Lawrence County, AL
                           Morgan County, AL
19500....................  Decatur, IL........................    0.7995
                           Macon County, IL
19660....................  Deltona-Daytona Beach-Ormond Beach,    0.8865
                            FL.
                           Volusia County, FL
19740....................  Denver-Aurora-Broomfield, CO.......    1.0731
                           Adams County, CO
                           Arapahoe County, CO
                           Broomfield County, CO
                           Clear Creek County, CO
                           Denver County, CO
                           Douglas County, CO
                           Elbert County, CO
                           Gilpin County, CO
                           Jefferson County, CO
                           Park County, CO
19780....................  Des Moines-West Des Moines, IA.....    0.9649
                           Dallas County, IA
                           Guthrie County, IA
                           Madison County, IA
                           Polk County, IA
                           Warren County, IA
19804....................  Detroit-Livonia-Dearborn, MI.......    0.9729
                           Wayne County, MI
20020....................  Dothan, AL.........................    0.7406
                           Geneva County, AL
                           Henry County, AL
                           Houston County, AL
20100....................  Dover, DE..........................    0.9931
                           Kent County, DE
20220....................  Dubuque, IA........................    0.8869
                           Dubuque County, IA
20260....................  Duluth, MN-WI......................    1.0448
                           Carlton County, MN
                           St. Louis County, MN
                           Douglas County, WI
20500....................  Durham-Chapel Hill, NC.............    0.9618
                           Chatham County, NC
                           Durham County, NC
                           Orange County, NC
                           Person County, NC
20740....................  Eau Claire, WI.....................    0.9567
                           Chippewa County, WI
                           Eau Claire County, WI
20764....................  Edison-New Brunswick, NJ...........    1.1061

[[Page 23133]]

                           Middlesex County, NJ
                           Monmouth County, NJ
                           Ocean County, NJ
                           Somerset County, NJ
20940....................  El Centro, CA......................    0.8766
                           Imperial County, CA
21060....................  Elizabethtown, KY..................    0.8388
                           Hardin County, KY
                           Larue County, KY
21140....................  Elkhart-Goshen, IN.................    0.9489
                           Elkhart County, IN
21300....................  Elmira, NY.........................    0.8341
                           Chemung County, NY
21340....................  El Paso, TX........................    0.8541
                           El Paso County, TX
21500....................  Erie, PA...........................    0.8779
                           Erie County, PA
21660....................  Eugene-Springfield, OR.............    1.1034
                           Lane County, OR
21780....................  Evansville, IN-KY..................    0.8522
                           Gibson County, IN
                           Posey County, IN
                           Vanderburgh County, IN
                           Warrick County, IN
                           Henderson County, KY
                           Webster County, KY
21820....................  Fairbanks, AK......................    1.1114
                           Fairbanks North Star Borough, AK
21940....................  Fajardo, PR........................    0.3790
                           Ceiba Municipio, PR
                           Fajardo Municipio, PR
                           Luquillo Municipio, PR
22020....................  Fargo, ND-MN.......................    0.8172
                           Cass County, ND
                           Clay County, MN
22140....................  Farmington, NM.....................    0.7889
                           San Juan County, NM
22180....................  Fayetteville, NC...................    0.9358
                           Cumberland County, NC
                           Hoke County, NC
22220....................  Fayetteville-Springdale-Rogers, AR-    0.8775
                            MO.
                           Benton County, AR
                           Madison County, AR
                           Washington County, AR
                           McDonald County, MO
22380....................  Flagstaff, AZ......................    1.2475
                           Coconino County, AZ
22420....................  Flint, MI..........................    1.1234
                           Genesee County, MI
22500....................  Florence, SC.......................    0.8114
                           Darlington County, SC
                           Florence County, SC
22520....................  Florence-Muscle Shoals, AL.........    0.7998
                           Colbert County, AL
                           Lauderdale County, AL
22540....................  Fond du Lac, WI....................    0.9660
                           Fond du Lac County, WI
22660....................  Fort Collins-Loveland, CO..........    1.0175
                           Larimer County, CO
22744....................  Fort Lauderdale-Pompano Beach-         1.0383
                            Deerfield Beach, FL.
                           Broward County, FL
22900....................  Fort Smith, AR-OK..................    0.7861
                           Crawford County, AR
                           Franklin County, AR
                           Sebastian County, AR
                           Le Flore County, OK
                           Sequoyah County, OK
23020....................  Fort Walton Beach-Crestview-Destin,    0.8758
                            FL.
                           Okaloosa County, FL
23060....................  Fort Wayne, IN.....................    0.9012
                           Allen County, IN

[[Page 23134]]

                           Wells County, IN
                           Whitley County, IN
23104....................  Fort Worth-Arlington, TX...........    0.9499
                           Johnson County, TX
                           Parker County, TX
                           Tarrant County, TX
                           Wise County, TX
23420....................  Fresno, CA.........................    1.1267
                           Fresno County, CA
23460....................  Gadsden, AL........................    0.8266
                           Etowah County, AL
23540....................  Gainesville, FL....................    0.8978
                           Alachua County, FL
                           Gilchrist County, FL
23580....................  Gainesville, GA....................    0.9123
                           Hall County, GA
23844....................  Gary, IN...........................    0.9288
                           Jasper County, IN
                           Lake County, IN
                           Newton County, IN
                           Porter County, IN
24020....................  Glens Falls, NY....................    0.8456
                           Warren County, NY
                           Washington County, NY
24140....................  Goldsboro, NC......................    0.9056
                           Wayne County, NC
24220....................  Grand Forks, ND-MN.................    0.7775
                           Polk County, MN
                           Grand Forks County, ND
24300....................  Grand Junction, CO.................    0.9721
                           Mesa County, CO
24340....................  Grand Rapids-Wyoming, MI...........    0.9178
                           Barry County, MI
                           Ionia County, MI
                           Kent County, MI
                           Newaygo County, MI
24500....................  Great Falls, MT....................    0.8354
                           Cascade County, MT
24540....................  Greeley, CO........................    0.9578
                           Weld County, CO
24580....................  Green Bay, WI......................    0.9621
                           Brown County, WI
                           Kewaunee County, WI
                           Oconto County, WI
24660....................  Greensboro-High Point, NC..........    0.9062
                           Guilford County, NC
                           Randolph County, NC
                           Rockingham County, NC
24780....................  Greenville, NC.....................    0.9401
                           Greene County, NC
                           Pitt County, NC
24860....................  Greenville-Mauldin-Easley, SC......    0.9980
                           Greenville County, SC
                           Laurens County, SC
                           Pickens County, SC
25020....................  Guayama, PR........................    0.3537
                           Arroyo Municipio, PR
                           Guayama Municipio, PR
                           Patillas Municipio, PR
25060....................  Gulfport-Biloxi, MS................    0.8783
                           Hancock County, MS
                           Harrison County, MS
                           Stone County, MS
25180....................  Hagerstown-Martinsburg, MD-WV......    0.8965
                           Washington County, MD
                           Berkeley County, WV
                           Morgan County, WV
25260....................  Hanford-Corcoran, CA...............    1.1010
                           Kings County, CA
25420....................  Harrisburg-Carlisle, PA............    0.9286
                           Cumberland County, PA

[[Page 23135]]

                           Dauphin County, PA
                           Perry County, PA
25500....................  Harrisonburg, VA...................    0.9025
                           Rockingham County, VA
                           Harrisonburg City, VA
25540....................  Hartford-West Hartford-East            1.1194
                            Hartford, CT.
                           Hartford County, CT
                           Middlesex County, CT
                           Tolland County, CT
25620....................  Hattiesburg, MS....................    0.7664
                           Forrest County, MS
                           Lamar County, MS
                           Perry County, MS
25860....................  Hickory-Lenoir-Morganton, NC.......    0.9000
                           Alexander County, NC
                           Burke County, NC
                           Caldwell County, NC
                           Catawba County, NC
25980....................  Hinesville-Fort Stewart, GA \1\....    0.9028
                           Liberty County, GA
                           Long County, GA
26100....................  Holland-Grand Haven, MI............    0.8696
                           Ottawa County, MI
26180....................  Honolulu, HI.......................    1.1662
                           Honolulu County, HI
26300....................  Hot Springs, AR....................    0.9004
                           Garland County, AR
26380....................  Houma-Bayou Cane-Thibodaux, LA.....    0.7875
                           Lafourche Parish, LA
                           Terrebonne Parish, LA
26420....................  Houston-Sugar Land-Baytown, TX.....    0.9841
                           Austin County, TX
                           Brazoria County, TX
                           Chambers County, TX
                           Fort Bend County, TX
                           Galveston County, TX
                           Harris County, TX
                           Liberty County, TX
                           Montgomery County, TX
                           San Jacinto County, TX
                           Waller County, TX
26580....................  Huntington-Ashland, WV-KY-OH.......    0.9097
                           Boyd County, KY
                           Greenup County, KY
                           Lawrence County, OH
                           Cabell County, WV
                           Wayne County, WV
26620....................  Huntsville, AL.....................    0.9064
                           Limestone County, AL
                           Madison County, AL
26820....................  Idaho Falls, ID....................    0.9436
                           Bonneville County, ID
                           Jefferson County, ID
26900....................  Indianapolis-Carmel, IN............    0.9742
                           Boone County, IN
                           Brown County, IN
                           Hamilton County, IN
                           Hancock County, IN
                           Hendricks County, IN
                           Johnson County, IN
                           Marion County, IN
                           Morgan County, IN
                           Putnam County, IN
                           Shelby County, IN
26980....................  Iowa City, IA......................    0.9548
                           Johnson County, IA
                           Washington County, IA
27060....................  Ithaca, NY.........................    1.0112
                           Tompkins County, NY
27100....................  Jackson, MI........................    0.8720
                           Jackson County, MI

[[Page 23136]]

27140....................  Jackson, MS........................    0.8186
                           Copiah County, MS
                           Hinds County, MS
                           Madison County, MS
                           Rankin County, MS
                           Simpson County, MS
27180....................  Jackson, TN........................    0.8581
                           Chester County, TN
                           Madison County, TN
27260....................  Jacksonville, FL...................    0.9105
                           Baker County, FL
                           Clay County, FL
                           Duval County, FL
                           Nassau County, FL
                           St. Johns County, FL
27340....................  Jacksonville, NC...................    0.8026
                           Onslow County, NC
27500....................  Janesville, WI.....................    0.9201
                           Rock County, WI
27620....................  Jefferson City, MO.................    0.8709
                           Callaway County, MO
                           Cole County, MO
                           Moniteau County, MO
                           Osage County, MO
27740....................  Johnson City, TN...................    0.7722
                           Carter County, TN
                           Unicoi County, TN
                           Washington County, TN
27780....................  Johnstown, PA......................    0.8233
                           Cambria County, PA
27860....................  Jonesboro, AR......................    0.7722
                           Craighead County, AR
                           Poinsett County, AR
27900....................  Joplin, MO.........................    0.8285
                           Jasper County, MO
                           Newton County, MO
28020....................  Kalamazoo-Portage, MI..............    1.0264
                           Kalamazoo County, MI
                           Van Buren County, MI
28100....................  Kankakee-Bradley, IL...............    1.0174
                           Kankakee County, IL
28140....................  Kansas City, MO-KS.................    0.9679
                           Franklin County, KS
                           Johnson County, KS
                           Leavenworth County, KS
                           Linn County, KS
                           Miami County, KS
                           Wyandotte County, KS
                           Bates County, MO
                           Caldwell County, MO
                           Cass County, MO
                           Clay County, MO
                           Clinton County, MO
                           Jackson County, MO
                           Lafayette County, MO
                           Platte County, MO
                           Ray County, MO
28420....................  Kennewick-Pasco-Richland, WA.......    1.0448
                           Benton County, WA
                           Franklin County, WA
28660....................  Killeen-Temple-Fort Hood, TX.......    0.8702
                           Bell County, TX
                           Coryell County, TX
                           Lampasas County, TX
28700....................  Kingsport-Bristol-Bristol, TN-VA...    0.7999
                           Hawkins County, TN
                           Sullivan County, TN
                           Bristol City, VA
                           Scott County, VA
                           Washington County, VA
28740....................  Kingston, NY.......................    0.9367

[[Page 23137]]

                           Ulster County, NY
28940....................  Knoxville, TN......................    0.7881
                           Anderson County, TN
                           Blount County, TN
                           Knox County, TN
                           Loudon County, TN
                           Union County, TN
29020....................  Kokomo, IN.........................    0.9862
                           Howard County, IN
                           Tipton County, IN
29100....................  La Crosse, WI-MN...................    0.9915
                           Houston County, MN
                           La Crosse County, WI
29140....................  Lafayette, IN......................    0.9181
                           Benton County, IN
                           Carroll County, IN
                           Tippecanoe County, IN
29180....................  Lafayette, LA......................    0.8516
                           Lafayette Parish, LA
                           St. Martin Parish, LA
29340....................  Lake Charles, LA...................    0.7985
                           Calcasieu Parish, LA
                           Cameron Parish, LA
29404....................  Lake County-Kenosha County, IL-WI..    1.0475
                           Lake County, IL
                           Kenosha County, WI
29420....................  Lake Havasu City-Kingman, AZ.......    1.0567
                           Mohave County, AZ
29460....................  Lakeland-Winter Haven, FL..........    0.8390
                           Polk County, FL
29540....................  Lancaster, PA......................    0.9204
                           Lancaster County, PA
29620....................  Lansing-East Lansing, MI...........    0.9770
                           Clinton County, MI
                           Eaton County, MI
                           Ingham County, MI
29700....................  Laredo, TX.........................    0.8078
                           Webb County, TX
29740....................  Las Cruces, NM.....................    0.8939
                           Dona Ana County, NM
29820....................  Las Vegas-Paradise, NV.............    1.2130
                           Clark County, NV
29940....................  Lawrence, KS.......................    0.8580
                           Douglas County, KS
30020....................  Lawton, OK.........................    0.7847
                           Comanche County, OK
30140....................  Lebanon, PA........................    0.8119
                           Lebanon County, PA
30300....................  Lewiston, ID-WA....................    0.9570
                           Nez Perce County, ID
                           Asotin County, WA
30340....................  Lewiston-Auburn, ME................    0.9085
                           Androscoggin County, ME
30460....................  Lexington-Fayette, KY..............    0.8889
                           Bourbon County, KY
                           Clark County, KY
                           Fayette County, KY
                           Jessamine County, KY
                           Scott County, KY
                           Woodford County, KY
30620....................  Lima, OH...........................    0.9379
                           Allen County, OH
30700....................  Lincoln, NE........................    0.9563
                           Lancaster County, NE
                           Seward County, NE
30780....................  Little Rock-North Little Rock-         0.8559
                            Conway, AR.
                           Faulkner County, AR
                           Grant County, AR
                           Lonoke County, AR
                           Perry County, AR
                           Pulaski County, AR

[[Page 23138]]

                           Saline County, AR
30860....................  Logan, UT-ID.......................    0.8993
                           Franklin County, ID
                           Cache County, UT
30980....................  Longview, TX.......................    0.8049
                           Gregg County, TX
                           Rusk County, TX
                           Upshur County, TX
31020....................  Longview, WA.......................    1.0707
                           Cowlitz County, WA
31084....................  Los Angeles-Long Beach-Santa Ana,      1.2039
                            CA.
                           Los Angeles County, CA
31140....................  Louisville-Jefferson County, KY-IN.    0.8964
                           Clark County, IN
                           Floyd County, IN
                           Harrison County, IN
                           Washington County, IN
                           Bullitt County, KY
                           Henry County, KY
                           Meade County, KY
                           Nelson County, KY
                           Oldham County, KY
                           Shelby County, KY
                           Spencer County, KY
                           Trimble County, KY
31180....................  Lubbock, TX........................    0.8751
                           Crosby County, TX
                           Lubbock County, TX
31340....................  Lynchburg, VA......................    0.8521
                           Amherst County, VA
                           Appomattox County, VA
                           Bedford County, VA
                           Campbell County, VA
                           Bedford City, VA
                           Lynchburg City, VA
31420....................  Macon, GA..........................    0.9826
                           Bibb County, GA
                           Crawford County, GA
                           Jones County, GA
                           Monroe County, GA
                           Twiggs County, GA
31460....................  Madera-Chowchilla, CA..............    0.7958
                           Madera County, CA
31540....................  Madison, WI........................    1.1234
                           Columbia County, WI
                           Dane County, WI
                           Iowa County, WI
31700....................  Manchester-Nashua, NH..............    1.0171
                           Hillsborough County, NH
31740....................  Manhattan, KS......................    0.7878
                           Geary County, KS
                           Pottawatomie County, KS
                           Riley County, KS
31860....................  Mankato-North Mankato, MN..........    0.9177
                           Blue Earth County, MN
                           Nicollet County, MN
31900....................  Mansfield, OH......................    0.9100
                           Richland County, OH
32420....................  Mayag[uuml]ez, PR..................    0.3704
                           Hormigueros Municipio, PR
                           Mayag[uuml]ez Municipio, PR
32580....................  McAllen-Edinburg-Mission, TX.......    0.8852
                           Hidalgo County, TX
32780....................  Medford, OR........................    1.0070
                           Jackson County, OR
32820....................  Memphis, TN-MS-AR..................    0.9268
                           Crittenden County, AR
                           DeSoto County, MS
                           Marshall County, MS
                           Tate County, MS
                           Tunica County, MS

[[Page 23139]]

                           Fayette County, TN
                           Shelby County, TN
                           Tipton County, TN
32900....................  Merced, CA.........................    1.2123
                           Merced County, CA
33124....................  Miami-Miami Beach-Kendall, FL......    0.9954
                           Miami-Dade County, FL
33140....................  Michigan City-La Porte, IN.........    0.9311
                           LaPorte County, IN
33260....................  Midland, TX........................    0.9546
                           Midland County, TX
33340....................  Milwaukee-Waukesha-West Allis, WI..    1.0151
                           Milwaukee County, WI
                           Ozaukee County, WI
                           Washington County, WI
                           Waukesha County, WI
33460....................  Minneapolis-St. Paul-Bloomington,      1.1095
                            MN-WI.
                           Anoka County, MN
                           Carver County, MN
                           Chisago County, MN
                           Dakota County, MN
                           Hennepin County, MN
                           Isanti County, MN
                           Ramsey County, MN
                           Scott County, MN
                           Sherburne County, MN
                           Washington County, MN
                           Wright County, MN
                           Pierce County, WI
                           St. Croix County, WI
33540....................  Missoula, MT.......................    0.9206
                           Missoula County, MT
33660....................  Mobile, AL.........................    0.7785
                           Mobile County, AL
33700....................  Modesto, CA........................    1.2502
                           Stanislaus County, CA
33740....................  Monroe, LA.........................    0.7752
                           Ouachita Parish, LA
                           Union Parish, LA
33780....................  Monroe, MI.........................    0.8885
                           Monroe County, MI
33860....................  Montgomery, AL.....................    0.8304
                           Autauga County, AL
                           Elmore County, AL
                           Lowndes County, AL
                           Montgomery County, AL
34060....................  Morgantown, WV.....................    0.8459
                           Monongalia County, WV
                           Preston County, WV
34100....................  Morristown, TN.....................    0.7201
                           Grainger County, TN
                           Hamblen County, TN
                           Jefferson County, TN
34580....................  Mount Vernon-Anacortes, WA.........    1.0452
                           Skagit County, WA
34620....................  Muncie, IN.........................    0.8386
                           Delaware County, IN
34740....................  Muskegon-Norton Shores, MI.........    0.9823
                           Muskegon County, MI
34820....................  Myrtle Beach-North Myrtle Beach-       0.8730
                            Conway, SC.
                           Horry County, SC
34900....................  Napa, CA...........................    1.4453
                           Napa County, CA
34940....................  Naples-Marco Island, FL............    0.9662
                           Collier County, FL
34980....................  Nashville-Davidson--Murfreesboro--     0.9689
                            Franklin, TN.
                           Cannon County, TN
                           Cheatham County, TN
                           Davidson County, TN
                           Dickson County, TN
                           Hickman County, TN

[[Page 23140]]

                           Macon County, TN
                           Robertson County, TN
                           Rutherford County, TN
                           Smith County, TN
                           Sumner County, TN
                           Trousdale County, TN
                           Williamson County, TN
                           Wilson County, TN
35004....................  Nassau-Suffolk, NY.................    1.2477
                           Nassau County, NY
                           Suffolk County, NY
35084....................  Newark-Union, NJ-PA................    1.1419
                           Essex County, NJ
                           Hunterdon County, NJ
                           Morris County, NJ
                           Sussex County, NJ
                           Union County, NJ
                           Pike County, PA
35300....................  New Haven-Milford, CT..............    1.1545
                           New Haven County, CT
35380....................  New Orleans-Metairie-Kenner, LA....    0.9092
                           Jefferson Parish, LA
                           Orleans Parish, LA
                           Plaquemines Parish, LA
                           St. Bernard Parish, LA
                           St. Charles Parish, LA
                           St. John the Baptist Parish, LA
                           St. Tammany Parish, LA
35644....................  New York-White Plains-Wayne, NY-NJ.    1.3005
                           Bergen County, NJ
                           Hudson County, NJ
                           Passaic County, NJ
                           Bronx County, NY
                           Kings County, NY
                           New York County, NY
                           Putnam County, NY
                           Queens County, NY
                           Richmond County, NY
                           Rockland County, NY
                           Westchester County, NY
35660....................  Niles-Benton Harbor, MI............    0.8903
                           Berrien County, MI
35980....................  Norwich-New London, CT.............    1.1399
                           New London County, CT
36084....................  Oakland-Fremont-Hayward, CA........    1.6404
                           Alameda County, CA
                           Contra Costa County, CA
36100....................  Ocala, FL..........................    0.8556
                           Marion County, FL
36140....................  Ocean City, NJ.....................    1.0160
                           Cape May County, NJ
36220....................  Odessa, TX.........................    0.9862
                           Ector County, TX
36260....................  Ogden-Clearfield, UT...............    0.9361
                           Davis County, UT
                           Morgan County, UT
                           Weber County, UT
36420....................  Oklahoma City, OK..................    0.8900
                           Canadian County, OK
                           Cleveland County, OK
                           Grady County, OK
                           Lincoln County, OK
                           Logan County, OK
                           McClain County, OK
                           Oklahoma County, OK
36500....................  Olympia, WA........................    1.1531
                           Thurston County, WA
36540....................  Omaha-Council Bluffs, NE-IA........    0.9608
                           Harrison County, IA
                           Mills County, IA
                           Pottawattamie County, IA

[[Page 23141]]

                           Cass County, NE
                           Douglas County, NE
                           Sarpy County, NE
                           Saunders County, NE
                           Washington County, NE
36740....................  Orlando-Kissimmee, FL..............    0.8951
                           Lake County, FL
                           Orange County, FL
                           Osceola County, FL
                           Seminole County, FL
36780....................  Oshkosh-Neenah, WI.................    0.9152
                           Winnebago County, WI
36980....................  Owensboro, KY......................    0.8357
                           Daviess County, KY
                           Hancock County, KY
                           McLean County, KY
37100....................  Oxnard-Thousand Oaks-Ventura, CA...    1.2301
                           Ventura County, CA
37340....................  Palm Bay-Melbourne-Titusville, FL..    0.9060
                           Brevard County, FL
37380....................  Palm Coast, FL.....................    0.9603
                           Flagler County, FL
37460....................  Panama City-Lynn Haven-Panama City     0.8324
                            Beach, FL.
                           Bay County, FL
37620....................  Parkersburg-Marietta-Vienna, WV-OH.    0.7716
                           Washington County, OH
                           Pleasants County, WV
                           Wirt County, WV
                           Wood County, WV
37700....................  Pascagoula, MS.....................    0.8433
                           George County, MS
                           Jackson County, MS
37764....................  Peabody, MA........................    1.0871
                           Essex County, MA
37860....................  Pensacola-Ferry Pass-Brent, FL.....    0.8312
                           Escambia County, FL
                           Santa Rosa County, FL
37900....................  Peoria, IL.........................    0.9155
                           Marshall County, IL
                           Peoria County, IL
                           Stark County, IL
                           Tazewell County, IL
                           Woodford County, IL
37964....................  Philadelphia, PA...................    1.0739
                           Bucks County, PA
                           Chester County, PA
                           Delaware County, PA
                           Montgomery County, PA
                           Philadelphia County, PA
38060....................  Phoenix-Mesa-Scottsdale, AZ........    1.0630
                           Maricopa County, AZ
                           Pinal County, AZ
38220....................  Pine Bluff, AR.....................    0.7281
                           Cleveland County, AR
                           Jefferson County, AR
                           Lincoln County, AR
38300....................  Pittsburgh, PA.....................    0.8625
                           Allegheny County, PA
                           Armstrong County, PA
                           Beaver County, PA
                           Butler County, PA
                           Fayette County, PA
                           Washington County, PA
                           Westmoreland County, PA
38340....................  Pittsfield, MA.....................    1.0658
                           Berkshire County, MA
38540....................  Pocatello, ID......................    0.9239
                           Bannock County, ID
                           Power County, ID
38660....................  Ponce, PR..........................    0.4220
                           Juana D[iacute]az Municipio, PR

[[Page 23142]]

                           Ponce Municipio, PR
                           Villalba Municipio, PR
38860....................  Portland-South Portland-Biddeford,     1.0187
                            ME.
                           Cumberland County, ME
                           Sagadahoc County, ME
                           York County, ME
38900....................  Portland-Vancouver-Beaverton, OR-WA    1.1498
                           Clackamas County, OR
                           Columbia County, OR
                           Multnomah County, OR
                           Washington County, OR
                           Yamhill County, OR
                           Clark County, WA
                           Skamania County, WA
38940....................  Port St. Lucie, FL.................    0.9896
                           Martin County, FL
                           St. Lucie County, FL
39100....................  Poughkeepsie-Newburgh-Middletown,      1.1216
                            NY.
                           Dutchess County, NY
                           Orange County, NY
39140....................  Prescott, AZ.......................    1.0121
                           Yavapai County, AZ
39300....................  Providence-New Bedford-Fall River,     1.0782
                            RI-MA.
                           Bristol County, MA
                           Bristol County, RI
                           Kent County, RI
                           Newport County, RI
                           Providence County, RI
                           Washington County, RI
39340....................  Provo-Orem, UT.....................    0.9548
                           Juab County, UT
                           Utah County, UT
39380....................  Pueblo, CO.........................    0.8570
                           Pueblo County, CO
39460....................  Punta Gorda, FL....................    0.8774
                           Charlotte County, FL
39540....................  Racine, WI.........................    0.9373
                           Racine County, WI
39580....................  Raleigh-Cary, NC...................    0.9663
                           Franklin County, NC
                           Johnston County, NC
                           Wake County, NC
39660....................  Rapid City, SD.....................    1.0046
                           Meade County, SD
                           Pennington County, SD
39740....................  Reading, PA........................    0.9263
                           Berks County, PA
39820....................  Redding, CA........................    1.4039
                           Shasta County, CA
39900....................  Reno-Sparks, NV....................    1.0285
                           Storey County, NV
                           Washoe County, NV
40060....................  Richmond, VA.......................    0.9521
                           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

[[Page 23143]]

                           Petersburg City, VA
                           Richmond City, VA
40140....................  Riverside-San Bernardino-Ontario,      1.1285
                            CA.
                           Riverside County, CA
                           San Bernardino County, CA
40220....................  Roanoke, VA........................    0.8671
                           Botetourt County, VA
                           Craig County, VA
                           Franklin County, VA
                           Roanoke County, VA
                           Roanoke City, VA
                           Salem City, VA
40340....................  Rochester, MN......................    1.1136
                           Dodge County, MN
                           Olmsted County, MN
                           Wabasha County, MN
40380....................  Rochester, NY......................    0.8724
                           Livingston County, NY
                           Monroe County, NY
                           Ontario County, NY
                           Orleans County, NY
                           Wayne County, NY
40420....................  Rockford, IL.......................    1.0152
                           Boone County, IL
                           Winnebago County, IL
40484....................  Rockingham County, NH..............    1.0125
                           Rockingham County, NH
                           Strafford County, NH
40580....................  Rocky Mount, NC....................    0.8845
                           Edgecombe County, NC
                           Nash County, NC
40660....................  Rome, GA...........................    0.8915
                           Floyd County, GA
40900....................  Sacramento--Arden-Arcade--             1.4073
                            Roseville, CA.
                           El Dorado County, CA
                           Placer County, CA
                           Sacramento County, CA
                           Yolo County, CA
40980....................  Saginaw-Saginaw Township North, MI.    0.9122
                           Saginaw County, MI
41060....................  St. Cloud, MN......................    1.1107
                           Benton County, MN
                           Stearns County, MN
41100....................  St. George, UT.....................    0.9236
                           Washington County, UT
41140....................  St. Joseph, MO-KS..................    1.0189
                           Doniphan County, KS
                           Andrew County, MO
                           Buchanan County, MO
                           DeKalb County, MO
41180....................  St. Louis, MO-IL...................    0.9102
                           Bond County, IL
                           Calhoun County, IL
                           Clinton County, IL
                           Jersey County, IL
                           Macoupin County, IL
                           Madison County, IL
                           Monroe County, IL
                           St. Clair County, IL
                           Crawford County, MO
                           Franklin County, MO
                           Jefferson County, MO
                           Lincoln County, MO
                           St. Charles County, MO
                           St. Louis County, MO
                           Warren County, MO
                           Washington County, MO
                           St. Louis City, MO
41420....................  Salem, OR..........................    1.0974
                           Marion County, OR
                           Polk County, OR

[[Page 23144]]

41500....................  Salinas, CA........................    1.5207
                           Monterey County, CA
41540....................  Salisbury, MD......................    0.9110
                           Somerset County, MD
                           Wicomico County, MD
41620....................  Salt Lake City, UT.................    0.9378
                           Salt Lake County, UT
                           Summit County, UT
                           Tooele County, UT
41660....................  San Angelo, TX.....................    0.7914
                           Irion County, TX
                           Tom Green County, TX
41700....................  San Antonio, TX....................    0.8857
                           Atascosa County, TX
                           Bandera County, TX
                           Bexar County, TX
                           Comal County, TX
                           Guadalupe County, TX
                           Kendall County, TX
                           Medina County, TX
                           Wilson County, TX
41740....................  San Diego-Carlsbad-San Marcos, CA..    1.1752
                           San Diego County, CA
41780....................  Sandusky, OH.......................    0.8888
                           Erie County, OH
41884....................  San Francisco-San Mateo-Redwood        1.5874
                            City, CA.
                           Marin County, CA
                           San Francisco County, CA
                           San Mateo County, CA
41900....................  San Germ[aacute]n-Cabo Rojo, PR....    0.4740
                           Cabo Rojo Municipio, PR
                           Lajas Municipio, PR
                           Sabana Grande Municipio, PR
                           San Germ[aacute]n Municipio, PR
41940....................  San Jose-Sunnyvale-Santa Clara, CA.    1.6404
                           San Benito County, CA
                           Santa Clara County, CA
41980....................  San Juan-Caguas-Guaynabo, PR.......    0.4363
                           Aguas Buenas Municipio, PR
                           Aibonito Municipio, PR
                           Arecibo Municipio, PR
                           Barceloneta Municipio, PR
                           Barranquitas Municipio, PR
                           Bayam[oacute]n Municipio, PR
                           Caguas Municipio, PR
                           Camuy Municipio, PR
                           Can[oacute]vanas Municipio, PR
                           Carolina Municipio, PR
                           Cata[ntilde]o Municipio, PR
                           Cayey Municipio, PR
                           Ciales Municipio, PR
                           Cidra Municipio, PR
                           Comer[iacute]o Municipio, PR
                           Corozal Municipio, PR
                           Dorado Municipio, PR
                           Florida Municipio, PR
                           Guaynabo Municipio, PR
                           Gurabo Municipio, PR
                           Hatillo Municipio, PR
                           Humacao Municipio, PR
                           Juncos Municipio, PR
                           Las Piedras Municipio, PR
                           Lo[iacute]za Municipio, PR
                           Manat[iacute] Municipio, PR
                           Maunabo Municipio, PR
                           Morovis Municipio, PR
                           Naguabo Municipio, PR
                           Naranjito Municipio, PR
                           Orocovis Municipio, PR
                           Quebradillas Municipio, PR
                           R[iacute]o Grande Municipio, PR

[[Page 23145]]

                           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
42020....................  San Luis Obispo-Paso Robles, CA....    1.2550
                           San Luis Obispo County, CA
42044....................  Santa Ana-Anaheim-Irvine, CA.......    1.1972
                           Orange County, CA
42060....................  Santa Barbara-Santa Maria-Goleta,      1.2213
                            CA.
                           Santa Barbara County, CA
42100....................  Santa Cruz-Watsonville, CA.........    1.6735
                           Santa Cruz County, CA
42140....................  Santa Fe, NM.......................    1.0694
                           Santa Fe County, NM
42220....................  Santa Rosa-Petaluma, CA............    1.5891
                           Sonoma County, CA
42340....................  Savannah, GA.......................    0.9043
                           Bryan County, GA
                           Chatham County, GA
                           Effingham County, GA
42540....................  Scranton--Wilkes-Barre, PA.........    0.8375
                           Lackawanna County, PA
                           Luzerne County, PA
                           Wyoming County, PA
42644....................  Seattle-Bellevue-Everett, WA.......    1.1577
                           King County, WA
                           Snohomish County, WA
42680....................  Sebastian-Vero Beach, FL...........    0.9362
                           Indian River County, FL
43100....................  Sheboygan, WI......................    0.9166
                           Sheboygan County, WI
43300....................  Sherman-Denison, TX................    0.8064
                           Grayson County, TX
43340....................  Shreveport-Bossier City, LA........    0.8383
                           Bossier Parish, LA
                           Caddo Parish, LA
                           De Soto Parish, LA
43580....................  Sioux City, IA-NE-SD...............    0.9094
                           Woodbury County, IA
                           Dakota County, NE
                           Dixon County, NE
                           Union County, SD
43620....................  Sioux Falls, SD....................    0.8983
                           Lincoln County, SD
                           McCook County, SD
                           Minnehaha County, SD
                           Turner County, SD
43780....................  South Bend-Mishawaka, IN-MI........    0.9690
                           St. Joseph County, IN
                           Cass County, MI
43900....................  Spartanburg, SC....................    0.9341
                           Spartanburg County, SC
44060....................  Spokane, WA........................    1.0444
                           Spokane County, WA
44100....................  Springfield, IL....................    0.9545
                           Menard County, IL
                           Sangamon County, IL
44140....................  Springfield, MA....................    1.0373
                           Franklin County, MA
                           Hampden County, MA
                           Hampshire County, MA
44180....................  Springfield, MO....................    0.8453
                           Christian County, MO
                           Dallas County, MO
                           Greene County, MO
                           Polk County, MO
                           Webster County, MO

[[Page 23146]]

44220....................  Springfield, OH....................    0.9195
                           Clark County, OH
44300....................  State College, PA..................    0.9096
                           Centre County, PA
44700....................  Stockton, CA.......................    1.2331
                           San Joaquin County, CA
44940....................  Sumter, SC.........................    0.8152
                           Sumter County, SC
45060....................  Syracuse, NY.......................    0.9785
                           Madison County, NY
                           Onondaga County, NY
                           Oswego County, NY
45104....................  Tacoma, WA.........................    1.1195
                           Pierce County, WA
45220....................  Tallahassee, FL....................    0.8406
                           Gadsden County, FL
                           Jefferson County, FL
                           Leon County, FL
                           Wakulla County, FL
45300....................  Tampa-St. Petersburg-Clearwater, FL    0.8982
                           Hernando County, FL
                           Hillsborough County, FL
                           Pasco County, FL
                           Pinellas County, FL
45460....................  Terre Haute, IN....................    0.9061
                           Clay County, IN
                           Sullivan County, IN
                           Vermillion County, IN
                           Vigo County, IN
45500....................  Texarkana, TX--Texarkana, AR.......    0.8113
                           Miller County, AR
                           Bowie County, TX
45780....................  Toledo, OH.........................    0.9541
                           Fulton County, OH
                           Lucas County, OH
                           Ottawa County, OH
                           Wood County, OH
45820....................  Topeka, KS.........................    0.9026
                           Jackson County, KS
                           Jefferson County, KS
                           Osage County, KS
                           Shawnee County, KS
                           Wabaunsee County, KS
45940....................  Trenton-Ewing, NJ..................    1.0552
                           Mercer County, NJ
46060....................  Tucson, AZ.........................    0.9505
                           Pima County, AZ
46140....................  Tulsa, OK..........................    0.8662
                           Creek County, OK
                           Okmulgee County, OK
                           Osage County, OK
                           Pawnee County, OK
                           Rogers County, OK
                           Tulsa County, OK
                           Wagoner County, OK
46220....................  Tuscaloosa, AL.....................    0.8698
                           Greene County, AL
                           Hale County, AL
                           Tuscaloosa County, AL
46340....................  Tyler, TX..........................    0.8312
                           Smith County, TX
46540....................  Utica-Rome, NY.....................    0.8460
                           Herkimer County, NY
                           Oneida County, NY
46660....................  Valdosta, GA.......................    0.7944
                           Brooks County, GA
                           Echols County, GA
                           Lanier County, GA
                           Lowndes County, GA
46700....................  Vallejo-Fairfield, CA..............    1.4934
                           Solano County, CA

[[Page 23147]]

47020....................  Victoria, TX.......................    0.8054
                           Calhoun County, TX
                           Goliad County, TX
                           Victoria County, TX
47220....................  Vineland-Millville-Bridgeton, NJ...    1.0207
                           Cumberland County, NJ
47260....................  Virginia Beach-Norfolk-Newport         0.8960
                            News, VA-NC.
                           Currituck County, NC
                           Gloucester County, VA
                           Isle of Wight County, VA
                           James City County, VA
                           Mathews County, VA
                           Surry County, VA
                           York County, VA
                           Chesapeake City, VA
                           Hampton City, VA
                           Newport News City, VA
                           Norfolk City, VA
                           Poquoson City, VA
                           Portsmouth City, VA
                           Suffolk City, VA
                           Virginia Beach City, VA
                           Williamsburg City, VA
47300....................  Visalia-Porterville, CA............    1.0221
                           Tulare County, CA
47380....................  Waco, TX...........................    0.8377
                           McLennan County, TX
47580....................  Warner Robins, GA..................    0.8754
                           Houston County, GA
47644....................  Warren-Troy-Farmington Hills, MI...    0.9806
                           Lapeer County, MI
                           Livingston County, MI
                           Macomb County, MI
                           Oakland County, MI
                           St. Clair County, MI
47894....................  Washington-Arlington-Alexandria, DC-   1.0882
                            VA-MD-WV.
                           District of Columbia, DC
                           Calvert County, MD
                           Charles County, MD
                           Prince George's County, MD
                           Arlington County, VA
                           Clarke County, VA
                           Fairfax County, VA
                           Fauquier County, VA
                           Loudoun County, VA
                           Prince William County, VA
                           Spotsylvania County, VA
                           Stafford County, VA
                           Warren County, VA
                           Alexandria City, VA
                           Fairfax City, VA
                           Falls Church City, VA
                           Fredericksburg City, VA
                           Manassas City, VA
                           Manassas Park City, VA
                           Jefferson County, WV
47940....................  Waterloo-Cedar Falls, IA...........    0.8518
                           Black Hawk County, IA
                           Bremer County, IA
                           Grundy County, IA
48140....................  Wausau, WI.........................    0.9440
                           Marathon County, WI
48260....................  Weirton-Steubenville, WV-OH........    0.7368
                           Jefferson County, OH
                           Brooke County, WV
                           Hancock County, WV
48300....................  Wenatchee-East Wenatchee, WA.......    0.9719
                           Chelan County, WA
                           Douglas County, WA
48424....................  West Palm Beach-Boca Raton-Boynton     0.9879
                            Beach, FL.
                           Palm Beach County, FL

[[Page 23148]]

48540....................  Wheeling, WV-OH....................    0.6869
                           Belmont County, OH
                           Marshall County, WV
                           Ohio County, WV
48620....................  Wichita, KS........................    0.9018
                           Butler County, KS
                           Harvey County, KS
                           Sedgwick County, KS
                           Sumner County, KS
48660....................  Wichita Falls, TX..................    0.9197
                           Archer County, TX
                           Clay County, TX
                           Wichita County, TX
48700....................  Williamsport, PA...................    0.7877
                           Lycoming County, PA
48864....................  Wilmington, DE-MD-NJ...............    1.0555
                           New Castle County, DE
                           Cecil County, MD
                           Salem County, NJ
48900....................  Wilmington, NC.....................    0.8986
                           Brunswick County, NC
                           New Hanover County, NC
                           Pender County, NC
49020....................  Winchester, VA-WV..................    0.9777
                           Frederick County, VA
                           Winchester City, VA
                           Hampshire County, WV
49180....................  Winston-Salem, NC..................    0.8953
                           Davie County, NC
                           Forsyth County, NC
                           Stokes County, NC
                           Yadkin County, NC
49340....................  Worcester, MA......................    1.1089
                           Worcester County, MA
49420....................  Yakima, WA.........................    0.9949
                           Yakima County, WA
49500....................  Yauco, PR..........................    0.3348
                           Gu[aacute]nica Municipio, PR
                           Guayanilla Municipio, PR
                           Pe[ntilde]uelas Municipio, PR
                           Yauco Municipio, PR
49620....................  York-Hanover, PA...................    0.9299
                           York County, PA
49660....................  Youngstown-Warren-Boardman, OH-PA..    0.8679
                           Mahoning County, OH
                           Trumbull County, OH
                           Mercer County, PA
49700....................  Yuba City, CA......................    1.1265
                           Sutter County, CA
                           Yuba County, CA
49740....................  Yuma, AZ...........................    0.9143
                           Yuma County, AZ
------------------------------------------------------------------------
\1\ At this time, there are no hospitals located in this urban area on
  which to base a wage index.

 Table 2--RY 2011 Wage Index Based on CBSA Labor Market Areas for Rural
                                  Areas
------------------------------------------------------------------------
        State code                   Nonurban area            Wage index
------------------------------------------------------------------------
1.........................  Alabama........................       0.7327
2.........................  Alaska.........................       1.1669
3.........................  Arizona........................       0.8790
4.........................  Arkansas.......................       0.7332
5.........................  California.....................       1.2051
6.........................  Colorado.......................       0.9929
7.........................  Connecticut....................       1.1093
8.........................  Delaware.......................       0.9910
10........................  Florida........................       0.8566
11........................  Georgia........................       0.7623
12........................  Hawaii.........................       1.1113
13........................  Idaho..........................       0.7733
14........................  Illinois.......................       0.8312
15........................  Indiana........................       0.8529
16........................  Iowa...........................       0.8624
17........................  Kansas.........................       0.8167
18........................  Kentucky.......................       0.7813
19........................  Louisiana......................       0.7611
20........................  Maine..........................       0.8579
21........................  Maryland.......................       0.9131
22........................  Massachusetts \1\..............       1.1700
23........................  Michigan.......................       0.8778

[[Page 23149]]

24........................  Minnesota......................       0.9160
25........................  Mississippi....................       0.7638
26........................  Missouri.......................       0.7671
27........................  Montana........................       0.8399
28........................  Nebraska.......................       0.8705
29........................  Nevada.........................       0.9674
30........................  New Hampshire..................       0.9957
31........................  New Jersey \1\.................  ...........
32........................  New Mexico.....................       0.8938
33........................  New York.......................       0.8269
34........................  North Carolina.................       0.8535
35........................  North Dakota...................       0.7813
36........................  Ohio...........................       0.8506
37........................  Oklahoma.......................       0.7654
38........................  Oregon.........................       1.0236
39........................  Pennsylvania...................       0.8306
40........................  Puerto Rico \1\................       0.4047
41........................  Rhode Island \1\...............  ...........
42........................  South Carolina.................       0.8394
43........................  South Dakota...................       0.8510
44........................  Tennessee......................       0.7808
45........................  Texas..........................       0.7759
46........................  Utah...........................       0.8363
47........................  Vermont........................       0.9763
48........................  Virgin Islands.................       0.7416
49........................  Virginia.......................       0.7869
50........................  Washington.....................       1.0224
51........................  West Virginia..................       0.7396
52........................  Wisconsin......................       0.9206
53........................  Wyoming........................       0.9535
65........................  Guam...........................       0.9611
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban, with the
  exception of Massachusetts and Puerto Rico. Massachusetts and Puerto
  Rico have areas designated as rural; however, no short-term, acute
  care hospitals are located in the area(s) for FY 2010. The rural
  Massachusetts wage index is calculated as the average of all
  contiguous CBSAs. The Puerto Rico wage index is the same as FY 2009.

[FR Doc. 2010-9870 Filed 4-29-10; 8:45 am]
BILLING CODE 4120-01-P
```