Vol. 78 Thursday, 

No. 148 August 1, 2013 

Part III 

Department of Health and Human Services 

Centers for Medicare & Medicaid Services 

Medicare Program; Inpatient Psychiatric Facilities Prospective Payment 

System—Update for Fiscal Year Beginning October 1, 2013 (FY 2014); 

Notice 

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46734 Federal Register / Vol. 78, No. 148 / Thursday, August 1, 2013 / Notices 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–1447–N] 

RIN 0938–AR63 

Medicare Program; Inpatient 

Psychiatric Facilities Prospective 

Payment System—Update for Fiscal 

Year Beginning October 1, 2013 (FY 

2014) 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Notice. 

SUMMARY: This notice updates the 

prospective payment rates for Medicare 

inpatient hospital services provided by 

inpatient psychiatric facilities (IPFs). 

These changes are applicable to IPF 

discharges occurring during the fiscal 

year (FY) beginning October 1, 2013 

through September 30, 2014. 

DATES: Effective Date: The updated IPF 

prospective payment rates are effective 

for discharges occurring on or after 

October 1, 2013 through September 30, 

2014. 

FOR FURTHER INFORMATION CONTACT: 

Dorothy Myrick or Jana Lindquist, (410) 

786–4533, for general information. 

Hudson Osgood, (410) 786–7897 or 

Bridget Dickensheets, (410) 786–8670, 

for information regarding the market 

basket and labor-related share. Theresa 

Bean, (410) 786–2287, for information 

regarding the regulatory impact 

analysis. 

SUPPLEMENTARY INFORMATION: 

Table of Contents 

To assist readers in referencing 

sections contained in this document, we 

are providing the following table of 

contents. 

I. Executive Summary 

A. Purpose 

B. Summary of the Major Provisions 

C. Summary of Costs and Benefits 

II. Background 

A. Annual Requirements for Updating the 

IPF PPS 

B. Overview of the Legislative 

Requirements of the IPF PPS 

C. General Overview of the IPF PPS 

III. Transition Period for Implementation of 

the IPF PPS 

IV. Changing the IPF PPS Payment Rate 

Update Period from a Rate Year to a 

Fiscal Year 

V. Market Basket for the IPF PPS 

A. Background 

B. FY 2014 Market Basket Update 

C. Labor-Related Share 

VI. Updates to the IPF PPS for FY Beginning 

October 1, 2013 

A. Determining the Standardized BudgetNeutral Federal Per Diem Base Rate 

1. Standardization of the Federal Per Diem 

Base Rate and Electroconvulsive Therapy 

(ECT) Rate 

2. Calculation of the Budget Neutrality 

Adjustment 

a. Outlier Adjustment 

b. Stop-Loss Provision Adjustment 

c. Behavioral Offset 

B. Update of the Federal Per Diem Base 

Rate and Electroconvulsive Therapy Rate 

VII. Update of the IPF PPS Adjustment 

Factors 

A. Overview of the IPF PPS Adjustment 

Factors 

B. Patient-Level Adjustments 

1. Adjustment for MS–DRG Assignment 

2. Payment for Comorbid Conditions 

3. Patient Age Adjustments 

4. Variable Per Diem Adjustments 

C. Facility-Level Adjustments 

1. Wage Index Adjustment 

a. Background 

b. Wage Index for FY 2014 

c. OMB Bulletins 

2. Adjustment for Rural Location 

3. Teaching Adjustment 

a. FTE Intern and Resident Cap Adjustment 

b. Temporary Adjustment to the FTE Cap 

to Reflect Residents Added Due to 

Hospital Closure 

c. Temporary Adjustment to FTE Cap to 

Reflect Residents Affected By Residency 

Program Closure 

i. Receiving IPF 

ii. IPF That Closed Its Program 

4. Cost of Living Adjustment for IPFs 

Located in Alaska and Hawaii 

5. Adjustment for IPFs with a Qualifying 

Emergency Department (ED) 

D. Other Payment Adjustments and 

Policies 

1. Outlier Payments 

a. Update to the Outlier Fixed Dollar Loss 

Threshold Amount 

b. Update to IPF Cost-to-Charge Ratio 

Ceilings 

2. Expiration of the Stop-Loss Provision 

3. Future Refinements 

VIII. Secretary’s Recommendations 

IX. Waiver of Notice and Comment 

X. Collection of Information Requirements 

XI. Regulatory Impact Analysis 

Addenda 

Acronyms 

Because of the many terms to which 

we refer by acronym in this notice, we 

are listing the acronyms used and their 

corresponding meanings in alphabetical 

order below: 

BBRA Medicare, Medicaid and SCHIP 

[State Children’s Health Insurance Program] 

Balanced Budget Refinement Act of 1999, 

(Pub. L. 106–113) 

CBSA Core-Based Statistical Area 

CCR Cost-to-charge ratio 

CAH Critical access hospital 

DSM–IV–TR Diagnostic and Statistical 

Manual of Mental Disorders Fourth 

Edition—Text Revision 

DRGs Diagnosis-related groups 

FY Federal fiscal year (October 1 through 

September 30) 

ICD–9–CM International Classification of 

Diseases, 9th Revision, Clinical 

Modification 

IPFs Inpatient psychiatric facilities 

IRFs Inpatient rehabilitation facilities 

LTCHs Long-term care hospitals 

MedPAR Medicare provider analysis and 

review file 

RPL Rehabilitation, Psychiatric, and LongTerm Care 

RY Rate Year (July 1 through June 30) 

TEFRA Tax Equity and Fiscal 

Responsibility Act of 1982, (Pub. L. 97– 

248) 

I. Executive Summary 

A. Purpose 

This notice updates the prospective 

payment rates for Medicare inpatient 

hospital services provided by inpatient 

psychiatric facilitates for discharges 

occurring during the fiscal year (FY) 

beginning October 1, 2013 through 

September 30, 2014. 

B. Summary of the Major Provisions 

In this notice, we update the IPF PPS, 

as specified in 42 CFR 412.428. The 

updates include the following: 

• The FY 2008-based Rehabilitation, 

Psychiatric, and Long Term Care (RPL) 

market basket update of 2.6 percent 

adjusted by a 0.1 percentage point 

reduction as required by section 

1886(s)(2)(A)(ii) of the Social Security 

Act (the Act) and a 0.5 percentage point 

reduction for economy-wide 

productivity as required by 

1886(s)(2)(A)(i) of the Act. 

• The fixed dollar loss threshold 

amount in order to maintain the 

appropriate outlier percentage. 

• The electroconvulsive therapy 

payment by a factor specified by CMS. 

• The national urban and rural costto-charge ratio medians and ceilings. 

• The cost of living adjustment 

factors for IPFs located in Alaska and 

Hawaii, if appropriate. 

• Description of the ICD–9–CM and 

MS–DRG classification changes 

discussed in the annual update to the 

hospital inpatient PPS regulations. 

• Use of the best available hospital 

wage index and information regarding 

whether an adjustment to the Federal 

per diem base rate is needed to maintain 

budget neutrality. 

• The MS–DRG listing and 

comorbidity categories to reflect the 

ICD–9–CM revisions effective October 1, 

2013. 

• Retaining the 17 percent adjustment 

for IPFs located in rural areas, the 1.31 

adjustment factor for IPFs with a 

qualifying emergency department, the 

coefficient value of 0.5150 for the 

teaching adjustment to the Federal per 

diem rate, the MS–DRG adjustment 

factors and comorbidity adjustment 

factors currently being paid to IPFs for 

FY 2013. 

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C. Summary of Transfers 

Provision 

description Total transfers 

FY 2014 IPF 

PPS payment rate 

update.

The overall economic impact 

of this notice is an estimated $115 million in increased payments to IPFs 

during FY 2014. 

II. Background 

A. Annual Requirements for Updating 

the IPF PPS 

In November 2004, we implemented 

the inpatient psychiatric facilities (IPF) 

prospective payment system (PPS) in a 

final rule that appeared in the 

November 15, 2004 Federal Register (69 

FR 66922). In developing the IPF PPS, 

in order to ensure that the IPF PPS is 

able to account adequately for each 

IPF’s case-mix, we performed an 

extensive regression analysis of the 

relationship between the per diem costs 

and certain patient and facility 

characteristics to determine those 

characteristics associated with 

statistically significant cost differences 

on a per diem basis. For characteristics 

with statistically significant cost 

differences, we used the regression 

coefficients of those variables to 

determine the size of the corresponding 

payment adjustments. 

In that final rule, we explained that 

we believe it is important to delay 

updating the adjustment factors derived 

from the regression analysis until we 

have IPF PPS data that include as much 

information as possible regarding the 

patient-level characteristics of the 

population that each IPF serves. 

Therefore, we indicated that we did not 

intend to update the regression analysis 

and recalculate the Federal per diem 

base rate and the patient-and facilitylevel adjustments until we complete 

that analysis. Until that analysis is 

complete, we stated our intention to 

publish a notice in the Federal Register 

each spring to update the IPF PPS (71 

FR 27041). In the May 6, 2011 IPF PPS 

final rule (76 FR 26432), we changed the 

payment rate update period to a rate 

year (RY) that coincides with a fiscal 

year (FY) update. Therefore, update 

notices are now published in the 

Federal Register in the summer to be 

effective on October 1. For further 

discussion on changing the IPF PPS 

payment rate update period to a RY that 

coincides with a FY, see the IPF PPS 

final rule published in the Federal 

Register on May 6, 2011 (76 FR 26434 

through 26435). 

Updates to the IPF PPS, as specified 

in 42 CFR § 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 § 412.424(a)(2)(iii), which 

is based on the Excluded Hospital with 

Capital market basket under the update 

methodology of section 1886(b)(3)(B)(ii) 

of the Act for each year (effective from 

the implementation period until June 

30, 2006). 

• For discharges occurring on or after 

July 1, 2006, the rate of increase factor 

for the Federal portion of the IPF’s 

payment, which is based on the 

Rehabilitation, Psychiatric, and LongTerm Care (RPL) market basket. 

• The best available hospital wage 

index and information regarding 

whether an adjustment to the Federal 

per diem base rate is needed to maintain 

budget neutrality. 

• Updates to the fixed dollar loss 

threshold amount in order to maintain 

the appropriate outlier percentage. 

• Description of the International 

Classification of Diseases, 9th Revision, 

Clinical Modification (ICD–9–CM) 

coding and diagnosis-related groups 

(DRGs) classification changes discussed 

in the annual update to the hospital 

inpatient prospective payment system 

(IPPS) regulations. 

• Update to the electroconvulsive 

therapy (ECT) payment by a factor 

specified by CMS. 

• Update to the national urban and 

rural cost-to-charge ratio medians and 

ceilings. 

• Update to the cost of living 

adjustment factors for IPFs located in 

Alaska and Hawaii, if appropriate. 

Our most recent IPF PPS annual 

update occurred in the August 7, 2012 

Federal Register notice (77 FR 47224) 

(hereinafter referred to as the August 

2012 IPF PPS notice) that set forth 

updates to the IPF PPS payment rates 

for FY 2013. That notice updated the 

IPF PPS per diem payment rates that 

were published in the May 2011 IPF 

PPS final rule in accordance with our 

established policies. 

Since implementation of the IPF PPS, 

we have explained that we believe it is 

important to delay updating the 

adjustment factors derived from the 

regression analysis until we have IPF 

PPS data that include as much 

information as possible regarding the 

patient-level characteristics of the 

population that each IPF serves. 

Because we are now approximately 8 

years into the system, we believe that 

we have enough data to begin that 

process. Therefore, we have begun the 

necessary analysis to make future 

refinements. While we do not propose 

to make refinements in this notice, as 

explained in section V.D.3 below, we 

expect that in future rulemaking, for FY 

2015, we will be ready to propose 

potential refinements. 

B. Overview of the Legislative 

Requirements of the IPF PPS 

Section 124 of the Medicare, 

Medicaid, and SCHIP (State Children’s 

Health Insurance Program) Balanced 

Budget Refinement Act of 1999 (BBRA) 

(Pub. L. 106–113) required the 

establishment and implementation of an 

IPF PPS. Specifically, section 124 of the 

BBRA mandated that the Secretary 

develop a per diem PPS for inpatient 

hospital services furnished in 

psychiatric hospitals and psychiatric 

units including an adequate patient 

classification system that reflects the 

differences in patient resource use and 

costs among psychiatric hospitals and 

psychiatric units. 

Section 405(g)(2) of the Medicare 

Prescription Drug, Improvement, and 

Modernization Act of 2003 (MMA) (Pub. 

L. 108–173) extended the IPF PPS to 

distinct part psychiatric units of critical 

access hospitals (CAHs). 

Section 3401(f) of the Patient 

Protection and Affordable Care Act 

(Pub. L. 111–148) as amended by 

section 10319(e) of that Act and by 

section 1105(d) of the Health Care and 

Education Reconciliation Act of 2010 

(Pub. L. 111–152) (hereafter referred to 

as ‘‘the Affordable Care Act’’) added 

subsection (s) to section 1886 of the Act. 

Section 1886(s)(1) is titled ‘‘Reference 

to Establishment and Implementation of 

System’’ and it refers to section 124 of 

the Medicare, Medicaid, and SCHIP 

Balanced Budget Refinement Act of 

1999, which relates to the establishment 

of the IPF PPS. 

Section 1886(s)(2)(A)(i) of the Act 

requires the application of the 

productivity adjustment described in 

section 1886(b)(3)(B)(xi)(II) of the Act to 

the IPF PPS for the RY beginning in 

2012 (that is, a RY that coincides with 

a FY) and each subsequent RY. For the 

RY beginning in 2013 (that is, FY 2014), 

the productivity adjustment is equal to 

0.5 percentage point, which we are 

implementing in this notice. Section 

1886(s)(2)(A)(ii) of the Act requires the 

application of an ‘‘other adjustment’’ 

that reduces any update to an IPF PPS 

base rate by percentages specified in 

section 1886(s)(3) of the Act for the RY 

beginning in 2010 through the RY 

beginning in 2019. For the RY beginning 

in 2013 (that is, FY 2014), section 

1886(s)(3)(B) of the Act requires the 

reduction to be 0.1 percentage point. We 

are implementing that provision in this 

FY 2014 IPF PPS notice. 

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Section 1886(s)(4) of the Act requires 

the establishment of a quality data 

reporting program for the IPF PPS 

beginning in RY 2014. We proposed and 

finalized new requirements for quality 

reporting for IPFs in the ‘‘Hospital 

Inpatient Prospective Payment System 

for Acute Care Hospitals and the Long 

Term Care Hospital Prospective 

Payment System and Fiscal Year 2013 

Rates’’ proposed rule (May 11, 2012) (77 

FR 27870, 28105 through 28116) and 

final rule (August 31, 2012) (77 FR 

53258, 53644 through 53360). 

To implement and periodically 

update these provisions, we have 

published various proposed and final 

rules in the Federal Register. For more 

information regarding these rules, see 

the CMS Web site at http:// 

www.cms.hhs.gov/ 

InpatientPsychFacilPPS/. 

C. General Overview of the IPF PPS 

The November 2004 IPF PPS final 

rule (69 FR 66922) established the IPF 

PPS, as authorized under section 124 of 

the BBRA and codified at subpart N of 

part 412 of the Medicare regulations. 

The November 2004 IPF PPS final rule 

set forth the per diem Federal rates for 

the implementation year (the 18-month 

period from January 1, 2005 through 

June 30, 2006), and it provided payment 

for the inpatient operating and capital 

costs to IPFs for covered psychiatric 

services they furnish (that is, routine, 

ancillary, and capital costs, but not costs 

of approved educational activities, bad 

debts, and other services or items that 

are outside the scope of the IPF PPS). 

Covered psychiatric services include 

services for which benefits are provided 

under the fee-for-service Part A 

(Hospital Insurance Program) Medicare 

program. 

The IPF PPS established the Federal 

per diem base rate for each patient day 

in an IPF derived from the national 

average daily routine operating, 

ancillary, and capital costs in IPFs in FY 

2002. The average per diem cost was 

updated to the midpoint of the first year 

under the IPF PPS, standardized to 

account for the overall positive effects of 

the IPF PPS payment adjustments, and 

adjusted for budget neutrality. 

The Federal per diem payment under 

the IPF PPS is comprised of the Federal 

per diem base rate described above and 

certain patient- and facility-level 

payment adjustments that were found in 

the regression analysis to be associated 

with statistically significant per diem 

cost differences. 

The patient-level adjustments include 

age, DRG assignment, comorbidities, 

and variable per diem adjustments to 

reflect higher per diem costs in the early 

days of an IPF stay. Facility-level 

adjustments include adjustments for the 

IPF’s wage index, rural location, 

teaching status, a cost of living 

adjustment for IPFs located in Alaska 

and Hawaii, and presence of a 

qualifying emergency department (ED). 

The IPF PPS provides additional 

payment policies for: Outlier cases; 

stop-loss protection (which was 

applicable only during the IPF PPS 

transition period); interrupted stays; and 

a per treatment adjustment for patients 

who undergo ECT. 

A complete discussion of the 

regression analysis appears in the 

November 2004 IPF PPS final rule (69 

FR 66933 through 66936). 

Section 124 of BBRA did not specify 

an annual update rate strategy for the 

IPF PPS and was broadly written to give 

the Secretary discretion in establishing 

an update methodology. Therefore, in 

the November 2004 IPF PPS final rule, 

we implemented the IPF PPS using the 

following update strategy: 

• Calculate the final Federal per diem 

base rate to be budget neutral for the 18- 

month period of January 1, 2005 

through June 30, 2006. 

• Use a July 1 through June 30 annual 

update cycle. 

• Allow the IPF PPS first update to be 

effective for discharges on or after July 

1, 2006 through June 30, 2007. 

III. Transition Period for 

Implementation of the IPF PPS 

In the November 2004 IPF PPS final 

rule, we provided for a 3-year transition 

period. During this 3-year transition 

period, an IPF’s total payment under the 

PPS was based on an increasing 

percentage of the Federal rate with a 

corresponding decreasing percentage of 

the IPF PPS payment that was based on 

reasonable cost concepts. However, 

effective for cost reporting periods 

beginning on or after January 1, 2008, 

IPF PPS payments were based on 100 

percent of the Federal rate. 

IV. Changing the IPF PPS Payment Rate 

Update Period From a Rate Year to a 

Fiscal Year 

Prior to RY 2012, the IPF PPS was 

updated on a July 1st through June 30th 

annual update cycle. Effective with RY 

2012, we switched the IPF PPS payment 

rate update from a rate year that begins 

on July 1st ending on June 30th to a 

period that coincides with a fiscal year. 

In order to transition from a RY to a FY, 

the IPF PPS RY 2012 covered a 15 

month period from July 1st through 

September 30th. As proposed and 

finalized, after RY 2012, the rate update 

period for the IPF PPS payment rates 

and other policy changes begin on 

October 1 through September 30. 

Therefore, the update cycle for FY 2014 

will be October 1, 2013 through 

September 30, 2014. 

For further discussion of the 15- 

month market basket update for RY 

2012 and changing the payment rate 

update period from a RY to a FY, we 

refer readers to the RY 2012 IPF PPS 

proposed rule (76 FR 4998) and the RY 

2012 IPF PPS final rule (76 FR 26432). 

V. Market Basket for the IPF PPS 

A. Background 

The input price index (that is, the 

market basket) that was used to develop 

the IPF PPS was the Excluded Hospital 

with Capital market basket. This market 

basket was based on 1997 Medicare cost 

report data and included data for 

Medicare participating IPFs, inpatient 

rehabilitation facilities (IRFs), long-term 

care hospitals (LTCHs), cancer 

hospitals, and children’s hospitals. 

Although ‘‘market basket’’ technically 

describes the mix of goods and services 

used in providing hospital care, this 

term is also commonly used to denote 

the input price index (that is, cost 

category weights and price proxies 

combined) derived from that market 

basket. Accordingly, the term ‘‘market 

basket’’ as used in this document refers 

to a hospital input price index. 

Beginning with the May 2006 IPF PPS 

final rule (71 FR 27046 through 27054), 

IPF PPS payments were updated using 

a FY 2002-based market basket 

reflecting the operating and capital cost 

structures for IRFs, IPFs, and LTCHs 

(hereafter referred to as the 

Rehabilitation, Psychiatric, and LongTerm Care (RPL) market basket). 

We excluded cancer and children’s 

hospitals from the RPL market basket 

because these hospitals are not 

reimbursed through a PPS; rather, their 

payments are based entirely on 

reasonable costs subject to rate-ofincrease limits established under the 

authority of section 1886(b) of the Act, 

which are implemented in regulations at 

§ 413.40. Moreover, the FY 2002 cost 

structures for cancer and children’s 

hospitals are noticeably different than 

the cost structures of the IRFs, IPFs, and 

LTCHs. A complete discussion of the FY 

2002-based RPL market basket appears 

in the May 2006 IPF PPS final rule (71 

FR 27046 through 27054). 

In the May 1, 2009 IPF PPS notice (74 

FR 20362), we expressed our interest in 

exploring the possibility of creating a 

stand-alone IPF market basket that 

reflects the cost structures of only IPF 

providers. We noted that, of the 

available options, one would be to join 

the Medicare cost report data from 

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freestanding IPF providers (presently 

incorporated into the RPL market 

basket) with data from hospital-based 

IPF providers (not currently 

incorporated in any market basket cost 

weights). We indicated that an 

examination of the Medicare cost report 

data comparing freestanding and 

hospital-based IPFs revealed 

considerable differences between the 

two with respect to cost levels and cost 

structures. At that time, we were unable 

to fully understand the differences 

between these two types of IPF 

providers. As a result, we felt that 

further research was required; therefore 

we solicited public comment for 

additional information that might help 

us to better understand the reasons for 

the variations in costs and cost 

structures, as indicated by the cost 

report data, between freestanding and 

hospital-based IPFs (74 FR 20376). 

We summarized the public comments 

received and our responses in the April 

2010 IPF PPS notice (75 FR 23111 

through 23113). Despite receiving 

comments from the public on this issue, 

we were unable to explain the observed 

differences in costs and cost structures 

between hospital-based and 

freestanding IPFs. Therefore, we did not 

believe it was appropriate, at the time, 

to incorporate data from hospital-based 

IPFs with those of freestanding IPFs to 

create a stand-alone IPF market basket. 

In the RY 2012 IPF PPS proposed rule 

(76 FR 4998) and final rule (76 FR 

26432), we proposed and finalized the 

use of a rebased and revised FY 2008- 

based RPL market basket to update IPF 

payments. In the RY 2012 IPF PPS 

proposed rule (76 FR 5001), we also 

welcomed public comment on the 

possibility of using a rehabilitation and 

psychiatric (RP) market basket to update 

IPF payments in the future. Comments 

received and our responses are 

summarized in the RY 2012 final rule 

(76 FR 26436). 

We continue to explore the viability 

of creating separate market baskets from 

the current RPL market basket. In the FY 

2013 IPPS/LTCH final rule (77 FR 53468 

through 53476), we adopted the newly 

created FY 2009-based LTCH-specific 

market basket for use under the LTCH 

PPS beginning in FY 2013. We continue 

to investigate the use of an alternative 

market basket to update IPF PPS 

payments; however, for the FY 2014 IPF 

PPS update, we continue to use (as was 

done for the FY 2013 update) the 

percentage increase in the FY 2008- 

based RPL market basket to determine 

the IPF PPS market basket update. We 

still have concerns about cost 

differences between freestanding and 

hospital-based providers, which remain 

unexplained even when looking at more 

recent data. However, we remain 

interested in researching this topic 

further to determine if these data quality 

and representativeness concerns can be 

overcome, and have plans to conduct 

more analysis into the claims and cost 

data for IPFs. Any possible changes to 

the market basket used to update IPF 

payments would appear in a future 

rulemaking and be subject to public 

comment. 

B. FY 2014 Market Basket Update 

The FY 2014 update for the IPF PPS 

using the FY 2008-based RPL market 

basket and IHS Global Insight’s second 

quarter 2013 forecast of the market 

basket components is 2.6 percent (prior 

to the application of any statutory 

adjustments). This includes increases in 

both the operating and the capital 

components for FY 2014 (that is, 

October 1, 2013 through September 30, 

2014). IHS Global Insight, Inc. is a 

nationally recognized economic and 

financial forecasting firm that contracts 

with CMS to forecast the components of 

the market baskets. 

As previously described in section 

I.B, section 1886(s)(2)(A)(i) of the Act 

requires the application of the 

productivity adjustment described in 

section 1886(b)(3)(B)(xi)(II) of the Act to 

the IPF PPS for the RY beginning in 

2012 and each subsequent RY. The 

statute defines the productivity 

adjustment to be equal to the 10-year 

moving average of changes in annual 

economy-wide private nonfarm business 

multifactor productivity (MFP) (as 

projected by the Secretary for the 10- 

year period ending with the applicable 

FY, year, cost reporting period, or other 

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

The Bureau of Labor Statistics (BLS) 

is the agency that publishes the official 

measure of private non-farm business 

MFP. We refer readers to the BLS Web 

site at http://www.bls.gov/mfp to obtain 

the BLS historical published MFP data. 

The MFP adjustment for FY 2014 

applicable to the IPF PPS is derived 

using a projection of MFP that is 

currently produced by IHS Global 

Insight, Inc. For a detailed description 

of the model currently used by IHS 

Global Insight, Inc. to project MFP, as 

well as a description of how the MFP 

adjustment is calculated, we refer 

readers to the FY 2012 IPPS/LTCH final 

rule (76 FR 51690 through 51692). 

Based on IHS Global Insight, Inc.’s 2013 

second quarter forecast, the productivity 

adjustment for FY 2014 is 0.5 

percentage point. Section 

1886(s)(2)(A)(ii) of the Act also requires 

the application of an ‘‘other adjustment’’ 

that reduces any update to an IPF PPS 

base rate by percentages specified in 

section 1886(s)(3) of the Act for rate 

years beginning in 2010 through the RY 

beginning in 2019. For the RY beginning 

in 2013 (that is, FY 2014), the reduction 

is 0.1 percentage point. We are 

implementing the productivity 

adjustment and ‘‘other adjustment’’ in 

this FY 2014 IPF PPS notice. 

C. Labor-Related Share 

Due to variations in geographic wage 

levels and other labor-related costs, we 

believe that payment rates under the IPF 

PPS should continue to be adjusted by 

a geographic wage index, which would 

apply to the labor-related portion of the 

Federal per diem base rate (hereafter 

referred to as the labor-related share). 

The labor-related share is determined 

by identifying the national average 

proportion of total costs that are related 

to, influenced by, or vary with the local 

labor market. We classify a cost category 

as labor-related if the costs are laborintensive and vary with the local labor 

market. Based on our definition of the 

labor-related share, we include in the 

labor-related share the sum of the 

relative importance of Wages and 

Salaries, Employee Benefits, 

Professional Fees: Labor-related, 

Administrative and Business Support 

Services, All Other: Labor-related 

Services, and a portion of the CapitalRelated cost weight. 

Therefore, to determine the laborrelated share for the IPF PPS for FY 

2014, we used the FY 2008-based RPL 

market basket cost weights relative 

importance to determine the laborrelated share for the IPF PPS. This 

estimate of the FY 2014 labor-related 

share is based on IHS Global Insight 

Inc.’s second quarter 2013 forecast, 

which is the same forecast used to 

derive the FY 2014 market basket 

update. 

Table 1 below shows the FY 2014 

relative importance labor-related share 

using the FY 2008-based RPL market 

basket along with the FY 2013 relative 

importance labor-related share. 

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TABLE 1—FY 2014 RELATIVE IMPORTANCE LABOR-RELATED SHARE AND THE FY 2013 RELATIVE IMPORTANCE LABORRELATED SHARE BASED ON THE FY 2008-BASED RPL MARKET BASKET

FY 2013 

relative importance laborrelated share 1

FY 2014 

relative importance laborrelated share 2

Wages and Salaries ........................................................................................................................................ 48.796 48.394 

Employee Benefits ........................................................................................................................................... 13.021 12.963 

Professional Fees: Labor-Related ................................................................................................................... 2.070 2.065 

Administrative and Business Support Services ............................................................................................... 0.417 0.415 

All Other: Labor-Related Services ................................................................................................................... 2.077 2.080 

Subtotal ............................................................................................................................................................ 66.381 65.917 

Labor-Related Portion of Capital Costs (46%) ................................................................................................ 3.600 3.577 

Total Labor-Related Share ....................................................................................................................... 69.981 69.494 

1. Published in the FY 2013 IPF PPS notice (77 FR 47228) and based on IHS Global Insight, Inc.’s second quarter 2012 forecast of the FY 

2008-based RPL market basket. 

2. Based on IHS Global Insight, Inc.’s second quarter 2013 forecast of the FY 2008-based RPL market basket. 

The labor-related share for FY 2014 is 

the sum of the FY 2014 relative 

importance of each labor-related cost 

category, and would reflect the different 

rates of price change for these cost 

categories between the base year (FY 

2008) and FY 2014. The sum of the 

relative importance for FY 2014 for 

operating costs (Wages and Salaries, 

Employee Benefits, Professional Fees: 

Labor-Related, Administrative and 

Business Support Services, and All 

Other: Labor-related Services) is 65.917 

percent, as shown in Table 1 above. The 

portion of Capital-related cost that is 

influenced by the local labor market is 

estimated to be 46 percent. Since the 

relative importance for Capital-Related 

Costs is 7.776 percent of the FY 2008- 

based RPL market basket in FY 2014, we 

take 46 percent of 7.776 percent to 

determine the labor-related share of 

Capital-related cost for FY 2014. The 

result is 3.577 percent, which we add to 

65.917 percent for the operating cost 

amount to determine the total laborrelated share for FY 2014. Therefore, the 

labor-related share for the IPF PPS in FY 

2014 is 69.494 percent. This laborrelated share is determined using the 

same general methodology as employed 

in calculating all previous IPF laborrelated shares (see, for example, 69 FR 

66952 through 66953). The wage index 

and the labor-related share are reflected 

in budget neutrality adjustments. 

VI. Updates to the IPF PPS for FY 

Beginning October 1, 2013 

The IPF PPS is based on a 

standardized Federal per diem base rate 

calculated from the IPF average per 

diem costs and adjusted for budgetneutrality in the implementation year. 

The Federal per diem base rate is used 

as the standard payment per day under 

the IPF PPS and is adjusted by the 

patient- and facility-level adjustments 

that are applicable to the IPF stay. A 

detailed explanation of how we 

calculated the average per diem cost 

appears in the November 2004 IPF PPS 

final rule (69 FR 66926). 

A. Determining the Standardized 

Budget-Neutral Federal Per Diem Base 

Rate 

Section 124(a)(1) of the BBRA 

required that we implement the IPF PPS 

in a budget neutral manner. In other 

words, the amount of total payments 

under the IPF PPS, including any 

payment adjustments, must be projected 

to be equal to the amount of total 

payments that would have been made if 

the IPF PPS were not implemented. 

Therefore, we calculated the budgetneutrality factor by setting the total 

estimated IPF PPS payments to be equal 

to the total estimated payments that 

would have been made under the Tax 

Equity and Fiscal Responsibility Act of 

1982 (TEFRA) (Pub. L. 97–248) 

methodology had the IPF PPS not been 

implemented. 

Under the IPF PPS methodology, we 

calculated the final Federal per diem 

base rate to be budget neutral during the 

IPF PPS implementation period (that is, 

the 18-month period from January 1, 

2005 through June 30, 2006) using a July 

1 update cycle. We updated the average 

cost per day to the midpoint of the IPF 

PPS implementation period (that is, 

October 1, 2005), and this amount was 

used in the payment model to establish 

the budget-neutrality adjustment. 

A step-by-step description of the 

methodology used to estimate payments 

under the TEFRA payment system 

appears in the November 2004 IPF PPS 

final rule (69 FR 66926). 

1. Standardization of the Federal Per 

Diem Base Rate and Electroconvulsive 

Therapy (ECT) Rate 

In the November 2004 IPF PPS final 

rule, we describe how we standardized 

the IPF PPS Federal per diem base rate 

to account for the overall positive effects 

of the IPF PPS payment adjustment 

factors. To standardize the IPF PPS 

payments, we compared the IPF PPS 

payment amounts calculated from the 

FY 2002 Medicare Provider Analysis 

and Review (MedPAR) file to the 

projected TEFRA payments from the FY 

2002 cost report file updated to the 

midpoint of the IPF PPS 

implementation period (that is, October 

2005). The standardization factor was 

calculated by dividing total estimated 

payments under the TEFRA payment 

system by estimated payments under 

the IPF PPS. The standardization factor 

was calculated to be 0.8367. 

As described in detail in the May 

2006 IPF PPS final rule (71 FR 27045), 

in reviewing the methodology used to 

simulate the IPF PPS payments used for 

the November 2004 IPF PPS final rule, 

we discovered that due to a computer 

code error, total IPF PPS payments were 

underestimated by about 1.36 percent. 

Since the IPF PPS payment total should 

have been larger than the estimated 

figure, the standardization factor should 

have been smaller (0.8254 vs. 0.8367). In 

turn, the Federal per diem base rate and 

the ECT rate should have been reduced 

by 0.8254 instead of 0.8367. 

To resolve this issue, in RY 2007, we 

amended the Federal per diem base rate 

and the ECT payment rate 

prospectively. Using the standardization 

factor of 0.8254, the average cost per day 

was effectively reduced by 17.46 

percent (100 percent minus 82.54 

percent = 17.46 percent). 

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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 stoploss 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 stoploss payments. As a result, the 

standardized Federal per diem base rate 

was reduced by 0.39 percent to account 

for stop-loss payments. Since the 

transition was completed in RY 2009, 

the stop-loss provision is no longer 

applicable, and for cost reporting 

periods beginning on or after January 1, 

2008, IPFs were paid 100 percent PPS 

rates. 

c. Behavioral Offset 

As explained in the November 2004 

IPF PPS final rule, implementation of 

the IPF PPS may result in certain 

changes in IPF practices, especially with 

respect to coding for comorbid medical 

conditions. As a result, Medicare may 

make higher payments than assumed in 

our calculations. Accounting for these 

effects through an adjustment is 

commonly known as a behavioral offset. 

Based on accepted actuarial practices 

and consistent with the assumptions 

made in other PPSs, we assumed in 

determining the behavioral offset that 

IPFs would regain 15 percent of 

potential ‘‘losses’’ and augment 

payment increases by 5 percent. We 

applied this actuarial assumption, 

which is based on our historical 

experience with new payment systems, 

to the estimated ‘‘losses’’ and ‘‘gains’’ 

among the IPFs. The behavioral offset 

for the IPF PPS was calculated to be 

2.66 percent. As a result, we reduced 

the standardized Federal per diem base 

rate by 2.66 percent to account for 

behavioral changes. As indicated in the 

November 2004 IPF PPS final rule, we 

do not plan to change adjustment factors 

or projections until we analyze IPF PPS 

data. 

If we find that an adjustment is 

warranted, the percent difference may 

be applied prospectively to the 

established PPS rates to ensure the rates 

accurately reflect the payment level. In 

conducting this analysis, we will be 

interested in the extent to which 

improved coding of patients’ principal 

and other diagnoses, which may not 

reflect real increases in underlying 

resource demands, has occurred under 

the PPS. 

B. Update of the Federal Per Diem Base 

Rate and Electroconvulsive Therapy 

Rate 

As described in the November 2004 

IPF PPS final rule (69 FR 66931), the 

average per diem cost was updated to 

the midpoint of the implementation 

year. This updated average per diem 

cost of $724.43 was reduced by—(1) 

17.46 percent to account for 

standardization to projected TEFRA 

payments for the implementation 

period; (2) 2 percent to account for 

outlier payments; (3) 0.39 percent to 

account for stop-loss payments; and (4) 

2.66 percent to account for the 

behavioral offset. The Federal per diem 

base rate in the implementation year 

was $575.95. The increase in the per 

diem base rate for RY 2009 included the 

0.39 percent increase due to the removal 

of the stop-loss provision. We indicated 

in the November 2004 IPF PPS final rule 

(69 FR 66932) that we would remove 

this 0.39 percent reduction to the 

Federal per diem base rate after the 

transition. As discussed in section 

IV.D.2. of the May 2008 IPF PPS notice, 

we increased the Federal per diem base 

rate and the ECT base rate by 0.39 

percent in RY 2009. Therefore for RY 

2009 and beyond, the stop-loss 

provision has ended and is no longer a 

part of budget neutrality. 

In accordance with section 

1886(s)(2)(A)(ii) of the Act, which 

requires the application of an ‘‘other 

adjustment,’’ described in section 

1886(s)(3) of the Act (specifically, 

section 1886(s)(3)(B)) for RYs 2013 and 

2014 that reduces the update to the IPF 

PPS base rate for the FY beginning in 

Calendar Year (CY) 2013, we are 

adjusting the IPF PPS update by a 0.1 

percentage point reduction for FY 2014. 

In addition, in accordance with section 

1886(s)(2)(A)(i) of the Act, which 

requires the application of the 

productivity adjustment that reduces 

the update to the IPF PPS base rate for 

the FY beginning in CY 2013, we are 

adjusting the IPF PPS update by a 0.5 

percentage point reduction for FY 2014. 

For this notice, we are applying an 

annual update of 2.0 percent (that is the 

FY 2008-based RPL market basket 

increase for FY 2014 of 2.6 percent less 

the productivity adjustment of 0.5 

percentage point less the 0.1 percentage 

point required under 

section1886(s)(3)(B) of the Act), and the 

wage index budget neutrality factor of 

1.0010 to the FY 2013 Federal per diem 

base rate of $698.51, yielding a Federal 

per diem base rate of $713.19 for FY 

2014. Similarly, we are applying the 2.0 

percent payment update, and the 1.0010 

wage index budget neutrality factor to 

the FY 2013 ECT base rate, yielding an 

ECT base rate of $307.04 for FY 2014. 

As noted above, section 1886(s)(4) of 

the Act requires the establishment of a 

quality data reporting program for the 

IPF PPS beginning in RY 2014. We 

finalized new requirements for quality 

reporting for IPFs in the ‘‘Hospital 

Inpatient Prospective Payment System 

for Acute Care Hospitals and the Long 

Term Care Hospital Prospective 

Payment System and Fiscal Year 2013 

Rates’’ final rule (August 31, 2012) (77 

FR 53258, 53644 through 53360). 

Section 1886(s)(4)(A)(i) of the Act 

requires that, for RY 2014 and each 

subsequent rate year, the Secretary shall 

reduce any annual update to a standard 

Federal rate for discharges occurring 

during the rate year by 2.0 percentage 

points for any IPF that does not comply 

with the quality data submission 

requirements with respect to an 

applicable year. Therefore, we are 

applying a 2.0 percentage point 

reduction to the federal per diem base 

rate and the ECT base rate as follows. 

For IPFs that fail to submit quality 

reporting data under the IPFQR 

program, we are applying a 0 percent 

annual update (that is 2 percent reduced 

by 2 percentage points in accordance 

with section 1886(s)(4)(A)(ii) of the Act) 

and the wage index budget neutrality 

factor of 1.0010 to the FY 2013 Federal 

per diem base rate of $698.51, yielding 

a Federal per diem base rate of $699.21 

for FY 2014. 

Similarly, we are applying the 0 

percent annual update and the 1.0010 

wage index budget neutrality factor to 

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the FY 2013 ECT base rate of $300.72, 

yielding an ECT base rate of $301.02 for 

FY 2014. 

In the FY 2014 IPPS/LTCH PPS final 

rule (78 FR 27485), we are adopting two 

new measures for the FY 2016 payment 

determination and subsequent years for 

the IPFQR Program. We are also 

finalizing a request for voluntary 

information whereby IPFs will be asked 

to provide information on the patient 

experience of care survey they use. 

VII. Update of the IPF PPS Adjustment 

Factors 

A. Overview of the IPF PPS Adjustment 

Factors 

The IPF PPS payment adjustments 

were derived from a regression analysis 

of 100 percent of the FY 2002 MedPAR 

data file, which contained 483,038 

cases. For this notice, we used the same 

results of the regression analysis used to 

implement the November 2004 IPF PPS 

final rule. For a more detailed 

description of the data file used for the 

regression analysis, see the November 

2004 IPF PPS final rule (69 FR 66935 

through 66936). While we have since 

used more recent claims data to set the 

fixed dollar loss threshold amount, we 

used the same results of this regression 

analysis to update the IPF PPS for FY 

2013 and for FY 2014. Now that we are 

approximately 8 years into the IPF PPS, 

we believe that we have enough data to 

begin looking at the process of refining 

the IPF PPS as appropriate. We expect 

that in future rulemaking, we may 

propose potential refinements to the 

system. 

As we stated previously, we do not 

plan to update the regression analysis 

until we are able to analyze IPF PPS 

claims and cost report data. However, 

we continue to monitor claims and 

payment data independently from cost 

report data to assess issues, to determine 

whether changes in case-mix or 

payment shifts have occurred among 

freestanding governmental, non-profit 

and private psychiatric hospitals, and 

psychiatric units of general hospitals, 

and CAHs and other issues of 

importance to IPFs. 

B. Patient-Level Adjustments 

In the August 2012 IPF PPS notice (77 

FR 47230 through 47233) we announced 

payment adjustments for the following 

patient-level characteristics: Medicare 

Severity diagnosis related groups (MS– 

DRGs) assignment of the patient’s 

principal diagnosis, selected 

comorbidities, patient age, and the 

variable per diem adjustments. 

1. Adjustment for MS–DRG Assignment 

The IPF PPS includes payment 

adjustments for designated psychiatric 

DRGs assigned to the claim based on 

each patient’s principal diagnosis. As 

we did in FY 2013 (77 FR 47231), for 

FY 2014, we will make a payment 

adjustment for psychiatric diagnoses 

that group to one of the 17 MS–IPF– 

DRGs listed in Table 2. The DRG 

adjustment factors were expressed 

relative to the most frequently reported 

psychiatric DRG in FY 2002, that is, 

DRG 430 (psychoses). The coefficient 

values and adjustment factors were 

derived from the regression analysis. 

In accordance with § 412.27(a), 

payment under the IPF PPS is 

conditioned on IPFs admitting ‘‘only 

patients whose admission to the unit is 

required for active treatment, of an 

intensity that can be provided 

appropriately only in an inpatient 

hospital setting, of a psychiatric 

principal diagnosis that is listed in 

Chapter Five (‘Mental Disorders’) of the 

International Classification of Diseases, 

Ninth Revision, Clinical Modification 

(ICD–9–CM)’’ or in the Fourth Edition, 

Text Revision of the American 

Psychiatric Association’s Diagnostic and 

Statistical Manual, (DSM–IV–TR). IPF 

claims with a principal diagnosis 

included in Chapter Five of the ICD–9– 

CM or the DSM–IV–TR are paid the 

Federal per diem base rate under the IPF 

PPS and all other applicable 

adjustments, including any applicable 

DRG adjustment. Psychiatric principal 

diagnoses that do not group to one of 

the 17 designated DRGs will still receive 

the Federal per diem base rate and all 

other applicable adjustments, but the 

payment will not include a DRG 

adjustment. 

The Standards for Electronic 

Transaction final rule published in the 

Federal Register on August 17, 2000 (65 

FR 50312), adopted ICD–9–CM as the 

designated code set for reporting 

diseases, injuries, impairments, other 

health related problems, their 

manifestations, and causes of injury, 

disease, impairment, or other health 

related problems. Therefore, we use 

ICD–9–CM as the designated code set 

for the IPF PPS. 

We believe that it is important to 

maintain the same diagnostic coding 

and DRG classification for IPFs that are 

used under the IPPS for providing 

psychiatric care. Therefore, when the 

IPF PPS was implemented for cost 

reporting periods beginning on or after 

January 1, 2005, we adopted the same 

diagnostic code set and DRG patient 

classification system (that is, the CMS 

DRGs) that were utilized at the time 

under the hospital inpatient IPPS. Since 

the inception of the IPF PPS, the DRGs 

used as the patient classification system 

under the IPF PPS have corresponded 

exactly with the CMS DRGs applicable 

under the IPPS for acute care hospitals. 

Every year, changes to the ICD–9–CM 

coding system are addressed in the IPPS 

proposed and final rules. The changes to 

the codes are effective October 1 of each 

year and must be used by acute care 

hospitals as well as other providers to 

report diagnostic and procedure 

information. The IPF PPS has always 

incorporated ICD–9–CM coding changes 

made in the annual IPPS update. We 

publish coding changes in a 

Transmittal/Change Request, similar to 

how coding changes are announced by 

the IPPS and LTCH PPS. Those ICD–9– 

CM coding changes are also published 

in the following IPF PPS FY update, in 

either the IPF PPS proposed and final 

rules, or in an IPF PPS update notice. 

In the May 2008 IPF PPS notice (73 

FR 25709), we discussed CMS’ effort to 

better recognize resource use and the 

severity of illness among patients. CMS 

adopted the new MS–DRGs for the IPPS 

in the FY 2008 IPPS final rule with 

comment period (72 FR 47130). A 

crosswalk, to reflect changes that were 

made to the DRGs under the IPF PPS to 

the new MS–DRGs, was provided (73 FR 

25716). We believe by better accounting 

for patients’ severity of illness in 

Medicare payment rates, the MS–DRGs 

encourage hospitals to improve their 

coding and documentation of patient 

diagnoses. The MS–DRGs, which are 

based on the IPPS MS–DRGs, represent 

a significant increase in the number of 

DRGs (from 538 to 745, an increase of 

207). For a full description of the 

development and implementation of the 

MS–DRGs, see the FY 2008 IPPS final 

rule with comment period (72 FR 47141 

through 47175). 

All of the ICD–9–CM coding changes 

are reflected in the FY 2013 GROUPER, 

Version 31.0, effective for IPPS 

discharges occurring on or after October 

1, 2013 through September 30, 2014. 

The GROUPER Version 31.0 software 

package assigns each case to an MS– 

DRG on the basis of the diagnosis and 

procedure codes and demographic 

information (that is, age, sex, and 

discharge status). The Medicare Code 

Editor (MCE) 31.0 uses the new ICD–9– 

CM codes to validate coding for IPPS 

discharges on or after October 1, 2013. 

The complete documentation of the 

GROUPER logic is available from 3M/ 

Health Information System (HIS), 

which, under contract with CMS, is 

responsible for updating and 

maintaining the GROUPER program. 

The current MS–DRG Definitions 

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Manual, version 30.0, is available on a 

CD for $225.00. Version 31.0 of this 

manual, which will include the final FY 

2014 MS–DRG changes, will be 

available on CD for $225.00. These 

manuals may be obtained by writing to 

3M/HIS at the following address: 100 

Barnes Road, Wallingford, CT 06492; or 

by calling (203) 949–0303, or by 

obtaining an order form at the Web site: 

http://www.3MHIS.com. The IPF PPS 

has always used the same GROUPER 

and Code Editor as the IPPS. Therefore, 

the ICD–9–CM changes, which were 

reflected in the GROUPER Version 31.0 

and MCE 31.0 on October 1, 2013, also 

became effective for the IPF PPS for 

discharges occurring on or after October 

1, 2013. 

The impact of the new MS–DRGs on 

the IPF PPS was negligible. Mapping to 

the MS–DRGs resulted in the current 17 

MS–DRGs, instead of the original 15, for 

which the IPF PPS provides an 

adjustment. Although the code set is 

updated, the same associated 

adjustment factors apply now that have 

been in place since implementation of 

the IPF PPS, with one exception that is 

unrelated to the update to the codes. 

When DRGs 521 and 522 were 

consolidated into MS–DRG 895, we 

carried over the adjustment factor of 

1.02 from DRG 521 to the newly 

consolidated MS–DRG. This was done 

to reflect the higher claims volume 

under DRG 521, with more than eight 

times the number of claims than billed 

under DRG 522. For a detailed 

description of the mapping changes 

from the original DRG adjustment 

categories to the current MS–DRG 

adjustment categories, we refer readers 

to the May 2008 IPF PPS notice (73 FR 

25714). 

The official version of the ICD–9–CM 

is available on CD–ROM from the U.S. 

Government Printing Office. The FY 

2012 version can be ordered by 

contacting the Superintendent of 

Documents, U.S. Government Printing 

Office, Department 50, Washington, DC 

20402–9329, telephone number (202) 

512–1800. Questions concerning the 

ICD–9–CM should be directed to 

Patricia E. Brooks, Co-Chairperson, ICD– 

9–CM Coordination and Maintenance 

Committee, CMS, Center for Medicare 

Management, Hospital and Ambulatory 

Policy Group, Division of Acute Care, 

Mailstop C4–08–06, 7500 Security 

Boulevard, Baltimore, Maryland 21244– 

1850. The Web site for the CD–ROM 

which contains the complete official 

version of the International 

Classification of Diseases, Ninth 

Revision, Clinical Modification is 

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

Medicare/Coding/ 

ICD9ProviderDiagnosticCodes/ 

CDROM.html. 

Further information concerning the 

official version of the ICD–9–CM can be 

found on the IPPS Web site at: http:// 

cms.hhs.gov/medicare/coding/ 

icd9providerdiagnosticcodes/ 

addendum.html. 

Transition to ICD–10–CM 

We note that, in accordance with the 

requirements of the final rule published 

in the Federal Register on September 5, 

2012 (77 FR 54664), we will be 

discontinuing our current use of the 

International Classification of Diseases, 

9th revision, Clinical Modification 

(ICD–9–CM), effective with the 

compliance date for using the 

international Classification of Diseases, 

10th revision, Clinical Modifications 

(ICD–10–CM) of October 1, 2014. The 

ICD–10–CM coding guidelines are 

available through the CMS Web site at: 

www.cms.gov/Medicare/Coding/ICD10/ 

downloads/pcs_2012_guidelines.pdf 

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

Coding/ICD10/index.html?redirect=/ 

ICD10 or on the CDC’s Web site at 

www.cdc.gov/nchs/data/icd10/ 

10cmguidelines2012.pdf. 

The MS–IPF–DRG adjustment factors 

(as shown in Table 2) will continue to 

be paid for discharges occurring in FY 

2014. In FY 2015, the MS–IPF–DRG 

adjustment factors will be updated 

effective with the compliance date for 

using the ICD–10–CM of October 1, 

2014. 

TABLE 2—FY 2014 CURRENT MS–IPF–DRGS APPLICABLE FOR THE PRINCIPAL DIAGNOSIS ADJUSTMENT

MS–DRG MS–DRG descriptions Adjustment 

factor 

056 ..................... Degenerative nervous system disorders w MCC ................................................................................................... 1.05 

057 ..................... Degenerative nervous system disorders w/o MCC ................................................................................................ 1.05 

080 ..................... Nontraumatic stupor & coma w MCC ..................................................................................................................... 1.07 

081 ..................... Nontraumatic stupor & coma w/o MCC .................................................................................................................. 1.07 

876 ..................... O.R. procedure w principal diagnoses of mental illness ........................................................................................ 1.22 

880 ..................... Acute adjustment reaction & psychosocial dysfunction .......................................................................................... 1.05 

881 ..................... Depressive neuroses ............................................................................................................................................... 0.99 

882 ..................... Neuroses except depressive ................................................................................................................................... 1.02 

883 ..................... Disorders of personality & impulse control ............................................................................................................. 1.02 

884 ..................... Organic disturbances & mental retardation ............................................................................................................ 1.03 

885 ..................... Psychoses ............................................................................................................................................................... 1.00 

886 ..................... Behavioral & developmental disorders ................................................................................................................... 0.99 

887 ..................... Other mental disorder diagnoses ............................................................................................................................ 0.92 

894 ..................... Alcohol/drug abuse or dependence, left AMA ........................................................................................................ 0.97 

895 ..................... Alcohol/drug abuse or dependence w rehabilitation therapy .................................................................................. 1.02 

896 ..................... Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC ................................................................. 0.88 

897 ..................... Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC .............................................................. 0.88 

2. Payment for Comorbid Conditions 

The intent of the comorbidity 

adjustments is to recognize the 

increased costs associated with 

comorbid conditions by providing 

additional payments for certain 

concurrent medical or psychiatric 

conditions that are expensive to treat. In 

the May 2011 IPF PPS final rule (76 FR 

26451 through 26452), we explained 

that the IPF PPS includes 17 

comorbidity categories and identified 

the new, revised, and deleted ICD–9– 

CM diagnosis codes that generate a 

comorbid condition payment 

adjustment under the IPF PPS for RY 

2012 (76 FR 26451). 

Comorbidities are specific patient 

conditions that are secondary to the 

patient’s principal diagnosis and that 

require treatment during the stay. 

Diagnoses that relate to an earlier 

episode of care and have no bearing on 

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the current hospital stay are excluded 

and must not be reported on IPF claims. 

Comorbid conditions must exist at the 

time of admission or develop 

subsequently, and affect the treatment 

received, length of stay (LOS), or both 

treatment and LOS. 

For each claim, an IPF may receive 

only one comorbidity adjustment within 

a comorbidity category, but it may 

receive an adjustment for more than one 

comorbidity category. Billing 

instructions require that IPFs must enter 

the full ICD–9–CM codes for up to 24 

additional diagnoses if they co-exist at 

the time of admission or develop 

subsequently and impact the treatment 

provided. 

The comorbidity adjustments were 

determined based on the regression 

analysis using the diagnoses reported by 

IPFs in FY 2002. The principal 

diagnoses were used to establish the 

DRG adjustments and were not 

accounted for in establishing the 

comorbidity category adjustments, 

except where ICD–9–CM ‘‘code first’’ 

instructions apply. As we explained in 

the May 2011 IPF PPS final rule (76 FR 

265451), the code first rule applies 

when a condition has both an 

underlying etiology and a manifestation 

due to the underlying etiology. For these 

conditions, ICD–9–CM has a coding 

convention that requires the underlying 

conditions to be sequenced first 

followed by the manifestation. 

Whenever a combination exists, there is 

a ‘‘use additional code’’ note at the 

etiology code and a code first note at the 

manifestation code. 

As discussed in the MS–DRG section, 

it is our policy to maintain the same 

diagnostic coding set for IPFs that is 

used under the IPPS for providing the 

same psychiatric care. 

For FY 2014, we are applying the 17 

comorbidity categories for which we are 

providing an adjustment, their 

respective codes, and their respective 

adjustment factors in Table 3 below. In 

FY 2015, the diagnosis codes and 

adjustment factors for the comorbidity 

categories will be updated effective with 

the compliance date for using the ICD– 

10–CM of October 1, 2014. 

TABLE 3—FY 2014 DIAGNOSIS CODES AND ADJUSTMENT FACTORS FOR COMORBIDITY CATEGORIES

Description of comorbidity Diagnoses codes Adjustment 

factor 

Developmental Disabilities ......................... 317, 3180, 3181, 3182, and 319 .................................................................................... 1.04 

Coagulation Factor Deficits ........................ 2860 through 2864 ......................................................................................................... 1.13 

Tracheostomy ............................................. 51900 through 51909 and V440 .................................................................................... 1.06 

Renal Failure, Acute ................................... 5845 through 5849, 63630, 63631, 63632, 63730, 63731, 63732, 6383, 6393, 66932, 

66934, 9585.

1.11 

Renal Failure, Chronic ................................ 40301, 40311, 40391, 40402, 40412, 40413, 40492, 40493, 5853, 5854, 5855, 5856, 

5859, 586, V4511, V4512, V560, V561, and V562.

1.11 

Oncology Treatment ................................... 1400 through 2399 with a radiation therapy code 92.21–92.29 or chemotherapy code 

99.25.

1.07 

Uncontrolled Diabetes-Mellitus with or 

without complications.

25002, 25003, 25012, 25013, 25022, 25023, 25032, 25033, 25042, 25043, 25052, 

25053, 25062, 25063, 25072, 25073, 25082, 25083, 25092, and 25093.

1.05 

Severe Protein Calorie Malnutrition ........... 260 through 262 ............................................................................................................. 1.13 

Eating and Conduct Disorders ................... 3071, 30750, 31203, 31233, and 31234 ........................................................................ 1.12 

Infectious Disease ...................................... 01000 through 04110, 042, 04500 through 05319, 05440 through 05449, 0550 

through 0770, 0782 through 07889, and 07950 through 07959.

1.07 

Drug and/or Alcohol Induced Mental Disorders.2910, 2920, 29212, 2922, 30300, and 30400 ............................................................... 1.03 

Cardiac Conditions ..................................... 3910, 3911, 3912, 40201, 40403, 4160, 4210, 4211, and 4219 ................................... 1.11 

Gangrene .................................................... 44024 and 7854 ............................................................................................................. 1.10 

Chronic Obstructive Pulmonary Disease ... 49121, 4941, 5100, 51883, 51884, V4611, V4612, V4613 and V4614 ........................ 1.12 

Artificial Openings—Digestive and Urinary 56960 through 56969, 9975, and V441 through V446 .................................................. 1.08 

Severe Musculoskeletal and Connective 

Tissue Diseases.

6960, 7100, 73000 through 73009, 73010 through 73019, and 73020 through 73029 1.09 

Poisoning .................................................... 96500 through 96509, 9654, 9670 through 9699, 9770, 9800 through 9809, 9830 

through 9839, 986, 9890 through 9897.

1.11 

3. Patient Age Adjustments 

As explained in the November 2004 

IPF PPS final rule (69 FR 66922), we 

analyzed the impact of age on per diem 

cost by examining the age variable (that 

is, the range of ages) for payment 

adjustments. 

In general, we found that the cost per 

day increases with age. The older age 

groups are more costly than the under 

45 age group, the differences in per 

diem cost increase for each successive 

age group, and the differences are 

statistically significant. 

We do not plan to update the 

regression analysis until we are able to 

analyze IPF PPS data. Therefore, for FY 

2014, we are continuing to use the 

patient age adjustments currently in 

effect as shown in Table 4 below. 

TABLE 4—AGE GROUPINGS AND

ADJUSTMENT FACTORS

Age Adjustment 

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 

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remains the same each day for the 

remainder of the stay. However, the 

adjustment applied to day 1 depends 

upon whether the IPF has a qualifying 

ED. If an IPF has a qualifying ED, it 

receives a 1.31 adjustment factor for day 

1 of each stay. If an IPF does not have 

a qualifying ED, it receives a 1.19 

adjustment factor for day 1 of the stay. 

The ED adjustment is explained in more 

detail in section VII.C.5 of this notice. 

For FY 2014, we are continuing to use 

the variable per diem adjustment factors 

currently in effect as shown in Table 5 

below. A complete discussion of the 

variable per diem adjustments appears 

in the November 2004 IPF PPS final rule 

(69 FR 66946). 

TABLE 5—VARIABLE PER DIEM

ADJUSTMENTS

Day-of-stay Adjustment 

factor 

Day 1—IPF Without a Qualifying ED ................................ 1.19 

Day 1—IPF With a Qualifying 

ED ......................................... 1.31 

Day 2 ........................................ 1.12 

Day 3 ........................................ 1.08 

Day 4 ........................................ 1.05 

Day 5 ........................................ 1.04 

Day 6 ........................................ 1.02 

Day 7 ........................................ 1.01 

Day 8 ........................................ 1.01 

Day 9 ........................................ 1.00 

Day 10 ...................................... 1.00 

Day 11 ...................................... 0.99 

Day 12 ...................................... 0.99 

Day 13 ...................................... 0.99 

Day 14 ...................................... 0.99 

Day 15 ...................................... 0.98 

Day 16 ...................................... 0.97 

Day 17 ...................................... 0.97 

Day 18 ...................................... 0.96 

Day 19 ...................................... 0.95 

Day 20 ...................................... 0.95 

Day 21 ...................................... 0.95 

After Day 21 ............................. 0.92 

C. Facility-Level Adjustments 

The IPF PPS includes facility-level 

adjustments for the wage index, IPFs 

located in rural areas, teaching IPFs, 

cost of living adjustments for IPFs 

located in Alaska and Hawaii, and IPFs 

with a qualifying ED. 

1. Wage Index Adjustment 

a. Background 

As discussed in the May 2006 IPF PPS 

final rule (71 FR 27061) and in the May 

2008 (73 FR 25719) and May 2009 IPF 

PPS notices (74 FR 20373), in order to 

provide an adjustment for geographic 

wage levels, the labor-related portion of 

an IPF’s payment is adjusted using an 

appropriate wage index. Currently, an 

IPF’s geographic wage index value is 

determined based on the actual location 

of the IPF in an urban or rural area as 

defined in § 412.64(b)(1)(ii)(A) and (C). 

b. Wage Index for FY 2014 

Since the inception of the IPF PPS, we 

have used the pre-reclassified, pre-floor 

hospital wage index in developing a 

wage index to be applied to IPFs 

because there is not an IPF-specific 

wage index available and we believe 

that IPFs generally compete in the same 

labor market as acute care hospitals so 

the pre-reclassified, pre-floor inpatient 

acute care hospital wage index should 

be reflective of labor costs of IPFs. As 

discussed in the May 2006 IPF PPS final 

rule for FY 2007 (71 FR 27061 through 

27067), under the IPF PPS, the wage 

index is calculated using the IPPS wage 

index for the labor market area in which 

the IPF is located, without taking into 

account geographic reclassifications, 

floors, and other adjustments made to 

the wage index under the IPPS. For a 

complete description of these IPPS wage 

index adjustments, please see the CY 

2013 IPPS/IRF PPS final rule (77 FR 

53365 through 53374). We are 

continuing that practice for FY 2014. 

We apply the wage index adjustment 

to the labor-related portion of the 

Federal rate, which is 69.494 percent. 

This percentage reflects the laborrelated relative importance of the FY 

2008-based RPL market basket for FY 

2014 (see section V.C. of this notice). 

Changes to the wage index are made 

in a budget neutral manner so that 

updates do not increase expenditures. 

For FY 2014, we are applying the most 

recent hospital wage index (that is, the 

FY 2013 pre-floor, pre-reclassified 

hospital wage index because this is the 

most appropriate index as it best reflects 

the variation in local labor costs of IPFs 

in the various geographic areas) using 

the most recent hospital wage data (that 

is, data from hospital cost reports for the 

cost reporting period beginning during 

FY 2009), and applying an adjustment 

in accordance with our budget 

neutrality policy. This policy requires 

us to estimate the total amount of IPF 

PPS payments for FY 2013 using the 

labor-related share and the wage indices 

from FY 2013 divided by the total 

estimated IPF PPS payments for FY 

2014 using the labor-related share and 

wage indices from FY 2014. The 

estimated payments are based on FY 

2012 IPF claims, inflated to the 

appropriate FY. This quotient is the 

wage index budget neutrality factor, and 

it is applied in the update of the Federal 

per diem base rate for FY 2014 in 

addition to the market basket described 

in section VI.B. of this notice. The wage 

index budget neutrality factor for FY 

2014 is 1.0010. The wage index 

applicable for FY 2014 appears in Table 

1 and Table 2 in Addendum B of this 

notice. 

In the May 2006 IPF PPS final rule for 

RY 2007 (71 FR 27061–27067), we 

adopted the changes discussed in the 

Office of Management and Budget 

(OMB) Bulletin No. 03–04 (June 6, 

2003), which announced revised 

definitions for Metropolitan Statistical 

Areas (MSAs), and the creation of 

Micropolitan Statistical Areas and 

Combined Statistical Areas. In adopting 

the OMB Core-Based Statistical Area 

(CBSA) geographic designations, we did 

not provide a separate transition for the 

CBSA-based wage index since the IPF 

PPS was already in a transition period 

from TEFRA payments to PPS 

payments. 

As was the case in FY 2013, for FY 

2014, we will continue to use the CBSA 

geographic designations. The updated 

FY 2014 CBSA-based wage index values 

are presented in Tables 1 and 2 in 

Addendum B of this notice. A complete 

discussion of the CBSA labor market 

definitions appears in the May 2006 IPF 

PPS final rule (71 FR 27061 through 

27067). 

In keeping with established IPF PPS 

wage index policy, we will use the FY 

2013 pre-floor, pre-reclassified hospital 

wage index (which is based on data 

collected from hospital cost reports 

submitted by hospitals for cost reporting 

periods beginning during FY 2009) to 

adjust IPF PPS payments beginning 

October 1, 2013. 

c. OMB Bulletins 

OMB publishes bulletins regarding 

CBSA changes, including changes to 

CBSA numbers and titles. In the May 

2008 IPF PPS notice, we incorporated 

the CBSA nomenclature changes 

published in the most recent OMB 

bulletin that applies to the hospital 

wage index used to determine the 

current IPF PPS wage index and stated 

that we expect to continue to do the 

same for all the OMB CBSA 

nomenclature changes in future IPF PPS 

rules and notices, as necessary (73 FR 

25721). The OMB bulletins may be 

accessed online at http:// 

www.whitehouse.gov/omb/bullentins/ 

index.html. 

In accordance with our established 

methodology, we have historically 

adopted any CBSA changes that are 

published in the OMB bulletin that 

corresponds with the hospital wage 

index used to determine the IPF PPS 

wage index. For FY 2014, we use the FY 

2013 pre-floor, pre-reclassified hospital 

wage index to adjust the IPF PPS 

payments. On February 28, 2013, OMB 

issued OMB Bulletin No. 13–01, which 

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establishes revised delineations of 

statistical areas based on OMB 

standards published in the Federal 

Register on June 28, 2010 and 2010 

Census Bureau data. Because the FY 

2013 pre-floor, pre-reclassified hospital 

wage index was finalized prior to the 

issuance of this Bulletin, the FY 2013 

pre-floor, pre-reclassified hospital wage 

index does not reflect OMB’s new area 

delineations based on the 2010 Census 

and, thus, the FY 2014 IPF PPS wage 

index will not reflect the OMB changes. 

CMS intends to propose changes to the 

hospital wage index based on this OMB 

Bulletin in the FY 2015 IPPS/LTCH PPS 

proposed rule, as stated in the FY 2014 

IPPS/LTCH PPS proposed rule (78 FR 

27552 through 27553). Therefore, we 

anticipate that the OMB Bulletin 

changes will be reflected in the FY 2015 

hospital wage index. Because we base 

the IPF PPS wage index on the hospital 

wage index from the prior year, we 

anticipate that the OMB Bulletin 

changes would be reflected in the FY 

2016 IPPS PPS wage index. 

2. Adjustment for Rural Location 

In the November 2004 IPF PPS final 

rule, we provided a 17 percent payment 

adjustment for IPFs located in a rural 

area. This adjustment was based on the 

regression analysis, which indicated 

that the per diem cost of rural facilities 

was 17 percent higher than that of urban 

facilities after accounting for the 

influence of the other variables included 

in the regression. For FY 2014, we are 

applying a 17 percent payment 

adjustment for IPFs located in a rural 

area as defined at § 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 

§ 412.424(d)(1)(iii) to establish a facilitylevel adjustment for IPFs that are, or are 

part of, teaching hospitals. The teaching 

adjustment accounts for the higher 

indirect operating costs experienced by 

hospitals that participate in graduate 

medical education (GME) programs. The 

payment adjustments are made based on 

the number of full-time equivalent (FTE) 

interns and residents training in the IPF 

and the IPF’s average daily census. 

Medicare makes direct GME payments 

(for direct costs such as resident and 

teaching physician salaries, and other 

direct teaching costs) to all teaching 

hospitals including those paid under a 

PPS, and those paid under the TEFRA 

rate-of-increase limits. These direct 

GME payments are made separately 

from payments for hospital operating 

costs and are not part of the IPF PPS. 

The direct GME payments do not 

address the estimated higher indirect 

operating costs teaching hospitals may 

face. 

For teaching hospitals paid under the 

TEFRA rate-of-increase limits, Medicare 

does not make separate payments for 

indirect medical education costs 

because payments to these hospitals are 

based on the hospitals’ reasonable costs 

which already include these higher 

indirect costs that may be associated 

with teaching programs. 

The results of the regression analysis 

of FY 2002 IPF data established the 

basis for the payment adjustments 

included in the November 2004 IPF PPS 

final rule. The results showed that the 

indirect teaching cost variable is 

significant in explaining the higher 

costs of IPFs that have teaching 

programs. We calculated the teaching 

adjustment based on the IPF’s ‘‘teaching 

variable,’’ which is one plus the ratio of 

the number of FTE residents training in 

the IPF (subject to limitations described 

below) to the IPF’s average daily census 

(ADC). 

We established the teaching 

adjustment in a manner that limited the 

incentives for IPFs to add FTE residents 

for the purpose of increasing their 

teaching adjustment. We imposed a cap 

on the number of FTE residents that 

may be counted for purposes of 

calculating the teaching adjustment. The 

cap limits the number of FTE residents 

that teaching IPFs may count for the 

purpose of calculating the IPF PPS 

teaching adjustment, not the number of 

residents teaching institutions can hire 

or train. We calculated the number of 

FTE residents that trained in the IPF 

during a ‘‘base year’’ and used that FTE 

resident number as the cap. An IPF’s 

FTE resident cap is ultimately 

determined based on the final 

settlement of the IPF’s most recent cost 

report filed before November 15, 2004 

(that is, the publication date of the IPF 

PPS final rule). 

In the regression analysis, the 

logarithm of the teaching variable had a 

coefficient value of 0.5150. We 

converted this cost effect to a teaching 

payment adjustment by treating the 

regression coefficient as an exponent 

and raising the teaching variable to a 

power equal to the coefficient value. We 

note that the coefficient value of 0.5150 

was based on the regression analysis 

holding all other components of the 

payment system constant. 

As with other adjustment factors 

derived through the regression analysis, 

we do not plan to rerun the regression 

analysis until we analyze IPF PPS data. 

Therefore, in this notice, for FY 2014, 

we are retaining the coefficient value of 

0.5150 for the teaching adjustment to 

the Federal per diem base rate. 

A complete discussion of how the 

teaching adjustment was calculated 

appears in the November 2004 IPF PPS 

final rule (69 FR 66954 through 66957) 

and the May 2008 IPF PPS notice (73 FR 

25721). 

a. FTE Intern and Resident Cap 

Adjustment 

CMS had been asked to reconsider the 

original IPF teaching policy and permit 

a temporary increase in the FTE resident 

cap when an IPF increases the number 

of FTE residents it trains due to the 

acceptance of displaced residents 

(residents that are training in an IPF or 

a program before the IPF or program 

closed) when another IPF closes or 

closes its medical residency training 

program. 

To help us assess how many IPFs had 

been, or were expected to be adversely 

affected by their inability to adjust their 

caps under § 412.424(d)(1) and under 

these situations, we specifically 

requested public comment from IPFs in 

the May 1, 2009 IPF PPS notice (74 FR 

20376 through 20377). A summary of 

the comments and our responses can be 

reviewed in the April 30, 2010 IPF PPS 

notice (75 FR 23106 through 23117). All 

of the commenters recommended that 

CMS modify the IPF PPS teaching 

adjustment policy, supporting a policy 

change that would permit the IPF PPS 

residency cap to be temporarily adjusted 

when that IPF trains displaced residents 

due to closure of an IPF or closure of an 

IPF’s medical residency training 

program(s). The commenters 

recommended a temporary resident cap 

adjustment policy similar to the policies 

applied in similar contexts for acute 

care hospitals. 

We agreed with the commenters that, 

when a hospital temporarily takes on 

residents because another hospital 

closes or discontinues its program, a 

temporary adjustment to the cap would 

be appropriate for a rotation that occurs 

in an IPF setting (freestanding or units). 

In these situations, residents may have 

partially completed a medical residency 

training program at the hospital that has 

closed its training program and may be 

unable to complete their training at 

another hospital that is already training 

residents up to or in excess of its cap. 

We believe that it is appropriate to 

allow temporary adjustments to the FTE 

caps for an IPF that provides residency 

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training to medical residents who have 

partially completed a residency training 

program at an IPF that closes or at an 

IPF that discontinues training residents 

in a residency training program(s) (also 

referred to as a ‘‘closed’’ program 

throughout this preamble). For this 

reason, we adopted the following 

temporary resident cap adjustment 

policies, similar to the temporary 

adjustments to the FTE cap used for 

acute care hospitals. We proposed and 

finalized that the cap adjustment would 

be temporary because it is resident 

specific and would only apply to the 

displaced resident(s) until the 

resident(s) completes training in that 

specialty. As under the IPPS policy for 

displaced residents, the IPF PPS 

temporary cap adjustment would apply 

only to residents that were still training 

at the IPF at the time the IPF closed or 

at the time the IPF ceased training 

residents in the residency training 

program(s). Residents who leave the 

IPF, for whatever reason, before the 

closure of the IPF hospital or medical 

residency training program would not 

be considered displaced residents for 

purposes of the IPF temporary cap 

adjustment policy. Similarly, as under 

the IPPS policy, medical students who 

match to a program at an IPF but the IPF 

or medical residency training program 

closes before the individual begins 

training at that IPF are also not 

considered displaced residents for 

purposes of the IPF temporary cap 

adjustments. For detailed information 

on these acute care hospital GME/IME 

payment policies, we refer the reader to 

the August 1, 2001 final rule (66 FR 

39899), July 30, 1999 final rule (64 FR 

41522), and May 7, 1999 proposed rule 

(64 FR 24736). We note that although 

we adopted a policy under the IPF PPS 

that is consistent with the policy 

applicable under the IPPS, the actual 

caps under the two payment systems 

may not be commingled. 

b. Temporary Adjustment to the FTE 

Cap To Reflect Residents Added Due to 

Hospital Closure 

In the May 6, 2011 IPF PPS final rule 

(76 FR 26455), we indicated that we 

would allow an IPF to receive a 

temporary adjustment to the FTE cap to 

reflect residents added because of 

another IPF’s closure. This adjustment 

is intended to account for medical 

residents who would have partially 

completed a medical residency training 

program at the hospital that has closed 

and may be unable to complete their 

training at another hospital because that 

hospital is already training residents up 

to or in excess of its cap. We made this 

change because IPFs have indicated a 

reluctance to accept additional residents 

from a closed IPF without a temporary 

adjustment to their caps. For purposes 

of this policy on IPF closure, we 

adopted the IPPS definition of ‘‘closure 

of a hospital’’ in 42 CFR 413.79(h) to 

mean the IPF terminates its Medicare 

provider agreement as specified in 42 

CFR 489.52. Therefore, we added a new 

§ 412.424(d)(1)(iii)(F)(1) to allow a 

temporary adjustment to an IPF’s FTE 

cap to reflect residents added because of 

an IPF’s closure on or after July 1, 2011, 

to be effective for cost reporting periods 

beginning on or after July 1, 2011. 

Under this policy, we allow an 

adjustment to an IPF’s FTE cap if the 

IPF meets the following criteria: (1) The 

IPF is training displaced residents from 

an IPF that closed on or after July 1, 

2011; and (2) the IPF that is training the 

displaced residents from the closed IPF 

submits a request for a temporary 

adjustment to its FTE cap to its 

Medicare contractor no later than 60 

days after the hospital first begins 

training the displaced residents, and 

documents that the IPF is eligible for 

this temporary adjustment to its FTE 

cap by identifying the residents who 

have come from the closed IPF and have 

caused the IPF to exceed its cap, (or the 

IPF may already be over its cap), and 

specifies the length of time that the 

adjustment is needed. After the 

displaced residents leave the IPF’s 

training program or complete their 

residency program, the IPF’s cap would 

revert to its original level. This means 

that the temporary adjustment to the 

FTE cap would be available to the IPF 

only for the period of time necessary for 

the displaced residents to complete 

their training. Further, as under the 

IPPS policy, we also indicated that the 

total amount of temporary cap 

adjustment that can be distributed to all 

receiving hospitals cannot exceed the 

cap amount of the IPF that closed. 

c. Temporary Adjustment to FTE Cap To 

Reflect Residents Affected by Residency 

Program Closure 

In the May 6, 2011 final rule (76 FR 

26455), we indicated that if an IPF that 

ceases training residents in a residency 

training program(s) agrees to 

temporarily reduce its FTE cap, we 

would allow another IPF to receive a 

temporary adjustment to its FTE cap to 

reflect residents added because of the 

closure of another IPF’s residency 

training program. For purposes of this 

policy on closed residency programs, 

we adopted the IPPS definition of 

‘‘closure of a hospital residency training 

program’’ to mean that the hospital 

ceases to offer training for residents in 

a particular approved medical residency 

training program as specified in 

§ 413.79(h). The methodology for 

adjusting the caps for the ‘‘receiving 

IPF’’ and the ‘‘IPF that closed its 

program’’ is described below. 

i. Receiving IPF 

We proposed and finalized that an 

IPF(s) may receive a temporary 

adjustment to its FTE cap to reflect 

residents added because of the closure 

of another IPF’s residency training 

program for cost reporting periods 

beginning on or after July 1, 2011 if— 

• The IPF is training additional 

residents from the residency training 

program of an IPF that closed its 

program on or after July 1, 2011. 

• No later than 60 days after the IPF 

begins to train the residents, the IPF 

submits to its Medicare Contractor a 

request for a temporary adjustment to its 

FTE cap, documents that the IPF is 

eligible for this temporary adjustment 

by identifying the residents who have 

come from another IPF’s closed program 

and have caused the IPF to exceed its 

cap, (or the IPF may already be in excess 

of its cap), specifies the length of time 

the adjustment is needed, and, submits 

to its Medicare contractor a copy of the 

FTE cap reduction statement by the IPF 

closing the residency training program. 

In general, the temporary adjustment 

criteria established for closed medical 

residency training programs at IPFs is 

similar to the criteria established for 

closed IPFs. More than one IPF may be 

eligible to apply for the temporary 

adjustment because residents from one 

closed program may complete their 

training at one IPF, or at several IPFs. 

Also, an IPF would be eligible for the 

temporary adjustment only to the extent 

that the displaced residents would 

cause the IPF to exceed its FTE cap. 

Finally, we proposed and finalized 

that IPFs meeting the proposed criteria 

would be eligible to receive temporary 

adjustments to their FTE caps for cost 

reporting periods beginning on or after 

July 1, 2011. 

ii. IPF That Closed Its Program 

We indicated that an IPF that agrees 

to train residents who have been 

displaced by the closure of another IPF’s 

resident teaching program, may receive 

a temporary FTE cap adjustment only if 

the IPF that closed a program: 

• Temporarily reduces its FTE cap by 

the number of FTE residents, in each 

program year, training in the program at 

the time of the program’s closure. The 

yearly reduction would be determined 

by deducting the number of those 

residents who would have been training 

in the program during the year of the 

closure, had the program not closed. 

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• No later than 60 days after the 

residents who were in the closed 

program begin training at another IPF, 

submits to its Medicare contractor a 

statement signed and dated by its 

representative that specifies that it 

agrees to the temporary reduction in its 

FTE cap to allow the IPF training the 

displaced residents to obtain a 

temporary adjustment to its cap; 

identifies the residents who were 

training at the time of the program’s 

closure; identifies the IPFs to which the 

residents are transferring once the 

program closes; and specifies the 

reduction for the applicable program 

years. 

We proposed and finalized that the 

cap reduction for the IPF with the 

closed program would be based on the 

number of FTE residents in each 

program year who were in the program 

at the IPF at the time of the program’s 

closure, and who begin training at 

another IPF. 

A complete discussion on the 

temporary adjustment to the FTE cap to 

reflect residents added due to hospital 

closure and by residency program 

appears in the January 27, 2011 IPF PPS 

proposed rule (76 FR 5018 through 

5020) and the May 6, 2011 IPF PPS final 

rule (76 FR 26453 through 26456). 

4. Cost of Living Adjustment for IPFs 

Located in Alaska and Hawaii 

The IPF PPS includes a payment 

adjustment for IPFs located in Alaska 

and Hawaii based upon the county in 

which the IPF is located. As we 

explained in the November 2004 IPF 

PPS final rule, the FY 2002 data 

demonstrated that IPFs in Alaska and 

Hawaii had per diem costs that were 

disproportionately higher than other 

IPFs. Other Medicare PPSs (for example, 

the IPPS and LTCH PPS) have adopted 

a cost of living adjustment (COLA) to 

account for the cost differential of care 

furnished in Alaska and Hawaii. 

We analyzed the effect of applying a 

COLA to payments for IPFs located in 

Alaska and Hawaii. The results of our 

analysis demonstrated that a COLA for 

IPFs located in Alaska and Hawaii 

would improve payment equity for 

these facilities. As a result of this 

analysis, we provided a COLA in the 

November 2004 IPF PPS final rule. 

A COLA adjustment for IPFs located 

in Alaska and Hawaii is made by 

multiplying the nonlabor-related 

portion of the Federal per diem base rate 

by the applicable COLA factor based on 

the COLA area in which the IPF is 

located. 

The COLA factors are published on 

the Office of Personnel Management 

(OPM) Web site (http://www.opm.gov/ 

oca/cola/rates.asp). 

We note that the COLA areas for 

Alaska are not defined by county as are 

the COLA areas for Hawaii. In 5 CFR 

591.207, the OPM established the 

following COLA areas: 

• City of Anchorage, and 80-kilometer 

(50-mile) radius by road, as measured 

from the Federal courthouse; 

• City of Fairbanks, and 80-kilometer 

(50-mile) radius by road, as measured 

from the Federal courthouse; 

• City of Juneau, and 80-kilometer 

(50-mile) radius by road, as measured 

from the Federal courthouse; 

• Rest of the State of Alaska. 

As previously stated in the November 

2004 IPF PPS final rule, we update the 

COLA factors according to updates 

established by the OPM. Sections 1911 

through 1919 of the Nonforeign Area 

Retirement Equity Assurance Act, as 

contained in subtitle B of title XIX of the 

National Defense Authorization Act 

(NDAA) for Fiscal Year 2010 (Pub. L. 

111–84, October 28, 2009), transitions 

the Alaska and Hawaii COLAs to 

locality pay. Under section 1914 of 

Public Law 111–84, locality pay is being 

phased in over a 3-year period 

beginning in January 2010, with COLA 

rates frozen as of the date of enactment, 

October 28, 2009, and then 

proportionately reduced to reflect the 

phase-in of locality pay. 

When we published the proposed 

COLA adjustment factors in the January 

2011 IPF proposed rule (76 FR 4998), 

we inadvertently selected the FY 2010 

COLA rates. The FY 2010 COLA rates 

were reduced rates to account for the 

phase-in of locality pay. We did not 

intend to propose reduced COLA rates, 

and we do not believe it is appropriate 

to finalize the reduced COLAs that we 

showed in our January 2011 proposed 

rule. The 2009 COLA rates do not reflect 

the phase-in of locality pay. Therefore, 

we finalized the FY 2009 COLA rates, 

which are the same rates that were in 

effect for RY 2010 through RY 2012. We 

plan to address the COLA in the future 

refinement process in FY 2015. For FY 

2014, IPFs located in Alaska and Hawaii 

will continue to receive the updated 

COLA factors based on the COLA area 

in which the IPF is located as shown in 

Table 6 below. 

TABLE 6—COLA FACTORS FOR ALASKA AND HAWAII IPFS

Area 

Cost of living 

adjustment 

factor 

Alaska: 

City of Anchorage and 80-kilometer (50-mile) radius by road ................................................................................................. 1.23 

City of Fairbanks and 80-kilometer (50-mile) radius by road .................................................................................................. 1.23 

City of Juneau and 80-kilometer (50-mile) radius by road ...................................................................................................... 1.23 

Rest of Alaska .......................................................................................................................................................................... 1.25 

Hawaii: 

City and County of Honolulu .................................................................................................................................................... 1.25 

County of Hawaii ...................................................................................................................................................................... 1.18 

County of Kauai ........................................................................................................................................................................ 1.25 

County of Maui and County of Kalawao .................................................................................................................................. 1.25 

(The above factors are based on data obtained from the U.S. Office of Personnel Management Web site at: http://www.opm.gov/oca/cola/ 

rates.asp.) 

5. Adjustment for IPFs With a 

Qualifying Emergency Department (ED) 

The IPF PPS includes a facility-level 

adjustment for IPFs with qualifying EDs. 

We provide an adjustment to the 

Federal per diem base rate to account 

for the costs associated with 

maintaining a full-service ED. The 

adjustment is intended to account for 

ED costs incurred by a freestanding 

psychiatric hospital with a qualifying 

ED or a distinct part psychiatric unit of 

an acute hospital or a CAH for 

preadmission services otherwise 

payable under the Medicare Outpatient 

Prospective Payment System (OPPS) 

furnished to a beneficiary on the date of 

the beneficiary’s admission to the 

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hospital and during the day 

immediately preceding the date of 

admission to the IPF (see § 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 

§ 412.424(d)(1)(v)(B), the ED adjustment 

is not made where a patient is 

discharged from an acute care hospital 

or CAH and admitted to the same 

hospital’s or CAH’s psychiatric unit. An 

ED adjustment is not made in this case 

because the costs associated with ED 

services are reflected in the DRG 

payment to the acute care hospital or 

through the reasonable cost payment 

made to the CAH. If we provided the ED 

adjustment in these cases, the hospital 

would be paid twice for the overhead 

costs of the ED, as stated in the 

November 2004 IPF PPS final rule (69 

FR 66960). 

Therefore, when patients are 

discharged from an acute care hospital 

or CAH and admitted to the same 

hospital’s or CAH’s psychiatric unit, the 

IPF receives the 1.19 adjustment factor 

as the variable per diem adjustment for 

the first day of the patient’s stay in the 

IPF. 

For FY 2014, we are retaining the 1.31 

adjustment factor for IPFs with 

qualifying EDs. A complete discussion 

of the steps involved in the calculation 

of the ED adjustment factor appears in 

the November 2004 IPF PPS final rule 

(69 FR 66959 through 66960) and the 

May 2006 IPF PPS final rule (71 FR 

27070 through 27072). 

D. Other Payment Adjustments and 

Policies 

For FY 2014, the IPF PPS includes an 

outlier adjustment to promote access to 

IPF care for those patients who require 

expensive care and to limit the financial 

risk of IPFs treating unusually costly 

patients. In this section, we also explain 

the reason for ending the stop-loss 

provision that was applicable during the 

transition period. 

1. Outlier Payments 

In the November 2004 IPF PPS final 

rule, we implemented regulations at 

§ 412.424(d)(3)(i) to provide a per-case 

payment for IPF stays that are 

extraordinarily costly. Providing 

additional payments to IPFs for 

extremely costly cases strongly 

improves the accuracy of the IPF PPS in 

determining resource costs at the patient 

and facility level. These additional 

payments reduce the financial losses 

that would otherwise be incurred in 

treating patients who require more 

costly care and, therefore, reduce the 

incentives for IPFs to under-serve these 

patients. 

We make outlier payments for 

discharges in which an IPF’s estimated 

total cost for a case exceeds a fixed 

dollar loss threshold amount 

(multiplied by the IPF’s facility-level 

adjustments) plus the Federal per diem 

payment amount for the case. 

In instances when the case qualifies 

for an outlier payment, we pay 80 

percent of the difference between the 

estimated cost for the case and the 

adjusted threshold amount for days 1 

through 9 of the stay (consistent with 

the median LOS for IPFs in FY 2002), 

and 60 percent of the difference for day 

10 and thereafter. We established the 80 

percent and 60 percent loss sharing 

ratios because we were concerned that 

a single ratio established at 80 percent 

(like other Medicare PPSs) might 

provide an incentive under the IPF per 

diem payment system to increase LOS 

in order to receive additional payments. 

After establishing the loss sharing ratios, 

we determined the current fixed dollar 

loss threshold amount of $11,600 

through payment simulations designed 

to compute a dollar loss beyond which 

payments are estimated to meet the 2 

percent outlier spending target. 

a. Update to the Outlier Fixed Dollar 

Loss Threshold Amount 

In accordance with the update 

methodology described in § 412.428(d), 

we are updating the fixed dollar loss 

threshold amount used under the IPF 

PPS outlier policy. Based on the 

regression analysis and payment 

simulations used to develop the IPF 

PPS, we established a 2 percent outlier 

policy which strikes an appropriate 

balance between protecting IPFs from 

extraordinarily costly cases while 

ensuring the adequacy of the Federal 

per diem base rate for all other cases 

that are not outlier cases. 

We believe it is necessary to update 

the fixed dollar loss threshold amount 

because an analysis of the latest 

available data (that is, FY 2012 IPF 

claims) and rate increases indicate that 

adjusting the fixed dollar loss amount is 

necessary in order to maintain an outlier 

percentage that equals 2 percent of total 

estimated IPF PPS payments. 

In the May 2006 IPF PPS final rule (71 

FR 27072), we describe the process by 

which we calculate the outlier fixed 

dollar loss threshold amount. We will 

continue to use this process for FY 

2014. We begin by simulating aggregate 

payments with and without an outlier 

policy, and applying an iterative process 

to determine an outlier fixed dollar loss 

threshold amount that will result in 

estimated outlier payments being equal 

to 2 percent of total estimated payments 

under the simulation. Based on this 

process, using the FY 2012 claims data, 

we estimate that IPF outlier payments as 

a percentage of total estimated payments 

are approximately 1.7 percent in FY 

2013. Thus, for this notice, we are 

updating the FY 2014 IPF outlier 

threshold amount to ensure that 

estimated FY 2014 outlier payments are 

approximately 2 percent of total 

estimated IPF payments. The outlier 

fixed dollar loss threshold amount of 

$11,600 for FY 2013 will be changed to 

$10,245 for FY 2014 to increase 

estimated outlier payments and thereby 

maintain estimated outlier payments at 

2 percent of total estimated aggregate 

IPF payments for FY 2014. 

b. Update to IPF Cost-to-Charge Ratio 

Ceilings 

As previously stated, under the IPF 

PPS, an outlier payment is made if an 

IPF’s cost for a stay exceeds a fixed 

dollar loss threshold amount. In order to 

establish an IPF’s cost for a particular 

case, we multiply the IPF’s reported 

charges on the discharge bill by its 

overall cost-to-charge ratio (CCR). This 

approach to determining an IPF’s cost is 

consistent with the approach used 

under the IPPS and other PPSs. In the 

June 2003 IPPS final rule (68 FR 34494), 

we implemented changes to the IPPS 

policy used to determine CCRs for acute 

care hospitals because we became aware 

that payment vulnerabilities resulted in 

inappropriate outlier payments. Under 

the IPPS, we established a statistical 

measure of accuracy for CCRs in order 

to ensure that aberrant CCR data did not 

result in inappropriate outlier 

payments. 

As we indicated in the November 

2004 IPF PPS final rule, because we 

believe that the IPF outlier policy is 

susceptible to the same payment 

vulnerabilities as the IPPS, we adopted 

a method to ensure the statistical 

accuracy of CCRs under the IPF PPS (69 

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FR 66961). Specifically, we adopted the 

following procedure in the November 

2004 IPF PPS final rule: We calculated 

two national ceilings, one for IPFs 

located in rural areas and one for IPFs 

located in urban areas. We computed 

the ceilings by first calculating the 

national average and the standard 

deviation of the CCR for both urban and 

rural IPFs using the most recent CCRs 

entered in the CY 2013 Provider 

Specific File. 

To determine the rural and urban 

ceilings, we multiplied each of the 

standard deviations by 3 and added the 

result to the appropriate national CCR 

average (either rural or urban). The 

upper threshold CCR for IPFs in FY 

2014 is 1.8644 for rural IPFs, and 1.7066 

for urban IPFs, based on CBSA-based 

geographic designations. If an IPF’s CCR 

is above the applicable ceiling, the ratio 

is considered statistically inaccurate 

and we assign the appropriate national 

(either rural or urban) median CCR to 

the IPF. 

We apply the national CCRs to the 

following situations: 

++ New IPFs that have not yet 

submitted their first Medicare cost 

report. 

++ IPFs whose overall CCR is in 

excess of 3 standard deviations above 

the corresponding national geometric 

mean (that is, above the ceiling). 

++ Other IPFs for which the Medicare 

contractor obtains inaccurate or 

incomplete data with which to calculate 

a CCR. 

For new IPFs, we are using these 

national CCRs until the facility’s actual 

CCR can be computed using the first 

tentatively or final settled cost report. 

We are not making any changes to the 

procedures for updating the CCR 

ceilings in FY 2014. However, we are 

updating the FY 2014 national median 

and ceiling CCRs for urban and rural 

IPFs based on the CCRs entered in the 

latest available IPF PPS Provider 

Specific File. Specifically, for FY 2014, 

and to be used in each of the three 

situations listed above, using the most 

recent CCRs entered in the CY 2013 

Provider Specific File we estimate the 

national median CCR of 0.6220 for rural 

IPFs and the national median CCR of 

0.4770 for urban IPFs. These 

calculations are based on the IPF’s 

location (either urban or rural) using the 

CBSA-based geographic designations. 

A complete discussion regarding the 

national median CCRs appears in the 

November 2004 IPF PPS final rule (69 

FR 66961 through 66964). 

2. Expiration of the Stop-Loss Provision 

In the November 2004 IPF PPS final 

rule, we implemented a stop-loss policy 

that reduced financial risk to IPFs 

projected to experience substantial 

reductions in Medicare payments 

during the period of transition to the IPF 

PPS. This stop-loss policy guaranteed 

that each facility received total IPF PPS 

payments that were no less than 70 

percent of its TEFRA payments had the 

IPF PPS not been implemented. This 

policy was applied to the IPF PPS 

portion of Medicare payments during 

the 3-year transition. 

In the implementation year, the 70 

percent of TEFRA payment stop-loss 

policy required a reduction in the 

standardized Federal per diem and ECT 

base rates of 0.39 percent in order to 

make the stop-loss payments budget 

neutral. As described in the May 2008 

IPF PPS notice for RY 2009, we 

increased the Federal per diem base rate 

and ECT rate by 0.39 percent because 

these rates were reduced by 0.39 percent 

in the implementation year to ensure 

stop-loss payments were budget neutral. 

The stop-loss provision ended during 

RY 2009 (that is for discharges occurring 

on or after July 1, 2008 through June 30, 

2009). The stop-loss policy is no longer 

applicable under the IPF PPS. 

3. Future Refinements 

As we have indicated throughout this 

notice, we have delayed making 

refinements to the IPF PPS until we 

have adequate IPF PPS data on which to 

base those refinements. Specifically, we 

explained that we will delay updating 

the adjustment factors derived from the 

regression analysis until we have IPF 

PPS data that include as much 

information as possible regarding the 

patient-level characteristics of the 

population that each IPF serves. Now 

that we are approximately 8 years into 

the system, we believe that we have 

enough data to begin that process. We 

have begun the necessary analysis to 

better understand IPF industry practices 

so that we may refine the IPF PPS as 

appropriate. Using more recent data, we 

plan to re-run the regression analyses 

and recalculate the Federal per diem 

base rate and the patient-and facilitylevel adjustments. While we are not 

making these refinements in this notice, 

we expect that in the rulemaking for FY 

2015 we will be ready to present the 

results of our analysis. 

For RY 2012, we published several 

areas of concern for future refinement 

and we invited comments on these 

issues in our RY 2012 proposed and 

final rules. For further discussion of 

these issues and to review public 

comments, we refer readers to the RY 

2012 IPF PPS proposed rule (76 FR 

4998) and final rule (76 FR 26432). 

VIII. Secretary’s Recommendations 

Section 1886(e)(4)(A) of the Act 

requires the Secretary, taking into 

consideration the recommendations of 

MedPAC, to recommend update factors 

for inpatient hospital services 

(including IPFs) for each FY that take 

into account the amounts necessary for 

the efficient and effective delivery of 

medically appropriate and necessary 

care of high quality. Section 1886(e)(5) 

of the Act requires the Secretary to 

publish the recommended and final 

update factors in the Federal Register. 

In the past, the Secretary’s 

recommendations and a discussion 

about the MedPAC recommendations 

for the IPF PPS were included in the 

IPPS proposed and final rules. The 

market basket update for the IPF PPS 

was also included in the IPPS proposed 

and final rules, as well as in the IPF PPS 

annual update. 

Beginning FY 2013, however, we only 

publish the market basket update for the 

IPF PPS in the annual IPF PPS FY 

update and not in the IPPS proposed 

and final rules. Furthermore, for any 

years in which MedPAC makes 

recommendations for the IPF PPS, those 

recommendations will be noted and 

considered in the IPF PPS update. 

MedPAC did not make any 

recommendations for the IPF PPS for FY 

2014. For the update to the IPF PPS 

standard Federal rate for FY 2014, see 

section IV B. of this notice. 

IX. Waiver of Notice and Comment 

We ordinarily publish a notice of 

proposed rulemaking in the Federal 

Register to provide a period for public 

comment before the provisions of a rule 

take effect. We can waive this 

procedure, however, if we find good 

cause that notice and comment 

procedures are impracticable, 

unnecessary, or contrary to the public 

interest and we incorporate a statement 

of finding and its reasons in the notice. 

We find it is unnecessary to undertake 

notice and comment rulemaking for this 

action because the updates in this notice 

do not reflect any substantive changes 

in policy, but merely reflect the 

application of previously established 

methodologies. Therefore, under 5 

U.S.C 553(b)(3)(B), for good cause, we 

waive notice and comment procedures. 

X. Collection of Information 

Requirements 

This notice does not impose any new 

or revised information collection, 

recordkeeping, or third-party disclosure 

requirements. Consequently, it does not 

need additional Office of Management 

and Budget review under the authority 

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of the Paperwork Reduction Act of 1995 

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

XI. Regulatory Impact Analysis 

A. Statement of Need 

This notice will update the 

prospective payment rates for Medicare 

inpatient hospital services provided by 

IPF for discharges occurring during the 

FY beginning October 1, 2013 through 

September 30, 2014. We are applying 

the FY 2008-based RPL market basket 

increase of 2.6 percent, less the 0.1 

percentage point required by sections 

1886(s)(2)(A) (ii) and 1886(s)(3)(B) of the 

Act and less the productivity 

adjustment of 0.5 percentage point as 

required by 1886(s)(2)(A)(i) of the Act. 

B. Overall Impact 

We have examined the impact of this 

notice as required by Executive Order 

12866 on Regulatory Planning and 

Review (September 30, 1993), Executive 

Order 13563 on Improving Regulation 

and Regulatory Review (January 18, 

2011), the Regulatory Flexibility Act 

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

354), section 1102(b) of the Social 

Security Act, section 202 of the 

Unfunded Mandates Reform Act of 1995 

(March 22, 1995; Pub. L. 104–4), 

Executive Order 13132 on Federalism 

(August 4, 1999) and the Congressional 

Review Act (5 U.S.C. 804(2)). 

Executive Orders 12866 and 13563 

direct agencies to assess all costs and 

benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, distributive impacts, and 

equity). A regulatory impact analysis 

(RIA) must be prepared for a major 

notice with economically significant 

effects ($100 million or more in any 1 

year). This notice is designated as 

economically ‘‘significant’’ under 

section 3(f)(1) of Executive Order 12866. 

We estimate that the total impact of 

these changes for FY 2014 payments 

compared to FY 2013 payments will be 

a net increase of approximately $115 

million. This reflects a $100 million 

increase from the update to the payment 

rates, as well as, a $15 million increase 

as a result of the update to the outlier 

threshold amount. Outlier payments are 

estimated to increase from 1.7 percent 

in FY 2013 to 2.0 percent in FY 2014. 

The RFA requires agencies to analyze 

options for regulatory relief of small 

entities, if a rule has a significant impact 

on a substantial number of small 

entities. For purposes of the RFA, small 

entities include small businesses, 

nonprofit organizations, and small 

governmental jurisdictions. Most IPFs 

and most other providers and suppliers 

are small entities, either by nonprofit 

status or having revenues of $7 million 

to $34.5 million or less in any 1 year 

depending on industry classification 

(for details, refer to the SBA Small 

Business Size Standards found at 

http://www.sba.gov/sites/default/files/ 

files/Size_Standards_Table.pdf), or 

being nonprofit organizations that are 

not dominant in their markets.’’ 

Because we lack data on individual 

hospital receipts, we cannot determine 

the number of small proprietary IPFs or 

the proportion of IPFs’ revenue that is 

derived from Medicare payments. 

Therefore, we assume that all IPFs are 

considered small entities. The 

Department of Health and Human 

Services generally uses a revenue 

impact of 3 to 5 percent as a significance 

threshold under the RFA. 

As shown in Table 7, we estimate that 

the overall revenue impact of this notice 

on all IPFs is to increase Medicare 

payments by approximately 2.3 percent. 

As a result, since the estimated impact 

of this notice is a net increase in 

revenue across all categories of IPFs, the 

Secretary has determined that this 

notice will have a positive revenue 

impact on a substantial number of small 

entities. Medicare fiscal intermediaries, 

Medicare Administrative Contractors, 

and Carriers are not considered to be 

small entities. Individuals and States are 

not included in the definition of a small 

entity. 

In addition, section 1102(b) of the 

Social Security Act requires us to 

prepare a regulatory impact analysis if 

a rule may have a significant impact on 

the operations of a substantial number 

of small rural hospitals. This analysis 

must conform to the provisions of 

section 604 of the RFA. For purposes of 

section 1102(b) of the Act, we define a 

small rural hospital as a hospital that is 

located outside of a metropolitan 

statistical area and has fewer than 100 

beds. As discussed in detail below, the 

rates and policies set forth in this notice 

will not have an adverse impact on the 

rural hospitals based on the data of the 

309 rural units and 73 rural hospitals in 

our database of 1,624 IPFs for which 

data were available. Therefore, the 

Secretary has determined that this 

notice will not have a significant impact 

on the operations of a substantial 

number of small rural hospitals. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 (UMRA) 

also requires that agencies assess 

anticipated costs and benefits before 

issuing any rule whose mandates 

require spending in any 1 year of $100 

million in 1995 dollars, updated 

annually for inflation. In 2014, that 

threshold is approximately $141 

million. This notice will not impose 

spending costs on state, local, or tribal 

governments in the aggregate, or by the 

private sector, of $141 million. 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed rule (and subsequent final 

rule) that imposes substantial direct 

requirement costs on state and local 

governments, preempts state law, or 

otherwise has Federalism implications. 

As stated above, this notice would not 

have a substantial effect on state and 

local governments. 

C. Anticipated Effects 

We discuss the historical background 

of the IPF PPS and the impact of this 

notice on the Federal Medicare budget 

and on IPFs. 

1. Budgetary Impact 

As discussed in the November 2004 

and May 2006 IPF PPS final rules, we 

applied a budget neutrality factor to the 

Federal per diem and ECT base rates to 

ensure that total estimated payments 

under the IPF PPS in the 

implementation period would equal the 

amount that would have been paid if the 

IPF PPS had not been implemented. The 

budget neutrality factor includes the 

following components: outlier 

adjustment, stop-loss adjustment, and 

the behavioral offset. As discussed in 

the May 2008 IPF PPS notice (73 FR 

25711), the stop-loss adjustment is no 

longer applicable under the IPF PPS. 

In accordance with § 412.424(c)(3)(ii), 

we indicated that we will evaluate the 

accuracy of the budget neutrality 

adjustment within the first 5 years after 

implementation of the payment system. 

We may make a one-time prospective 

adjustment to the Federal per diem and 

ECT base rates to account for differences 

between the historical data on costbased TEFRA payments (the basis of the 

budget neutrality adjustment) and 

estimates of TEFRA payments based on 

actual data from the first year of the IPF 

PPS. As part of that process, we will 

reassess the accuracy of all of the factors 

impacting budget neutrality. In 

addition, as discussed in section VII.C.1 

of this notice, we are using the wage 

index and labor-related share in a 

budget neutral manner by applying a 

wage index budget neutrality factor to 

the Federal per diem and ECT base 

rates. Therefore, the budgetary impact to 

the Medicare program of this notice will 

be due to the market basket update for 

FY 2014 of 2.6 percent (see section V.B. 

of this notice) less the ‘‘other 

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adjustment’’ of 0.1 percentage point 

according to sections 1886(s)(2)(A)(ii) 

and 1886 (s)(3)(B) of the Act, less the 

productivity adjustment of 0.5 

percentage point required by section 

1886 (s)(2)(A)(i) of the Act, and the 

update to the outlier fixed dollar loss 

threshold amount. 

We estimate that the FY 2014 impact 

will be a net increase of $115 million in 

payments to IPF providers. This reflects 

an estimated $100 million increase from 

the update to the payment rates and a 

$15 million increase due to the update 

to the outlier threshold amount to 

increase outlier payments from 

approximately 1.7 percent in FY 2013 to 

2.0 percent in FY 2014. 

2. Impact on Providers 

To understand the impact of the 

changes to the IPF PPS on providers, 

discussed in this notice, it is necessary 

to compare estimated payments under 

the IPF PPS rates and factors for FY 

2014 versus those under FY 2013. The 

estimated payments for FY 2013 and FY 

2014 will be 100 percent of the IPF PPS 

payment, since the transition period has 

ended and stop-loss payments are no 

longer paid. We determined the percent 

change of estimated FY 2014 IPF PPS 

payments to FY 2013 IPF PPS payments 

for each category of IPFs. In addition, 

for each category of IPFs, we have 

included the estimated percent change 

in payments resulting from the update 

to the outlier fixed dollar loss threshold 

amount, the labor-related share and 

wage index changes for the FY 2014 IPF 

PPS, and the market basket update for 

FY 2014, as adjusted by the ‘‘other 

adjustment’’ according to sections 

1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the 

Act and the productivity adjustment 

according to section 1886(s)(2)(A)(i). 

To illustrate the impacts of the FY 

2014 changes in this notice, our analysis 

begins with a FY 2013 baseline 

simulation model based on FY 2012 IPF 

payments inflated to the midpoint of FY 

2013 using IHS Global Insight Inc.’s 

most recent forecast of the market basket 

update (see section V.B. of this notice); 

the estimated outlier payments in FY 

2013; the CBSA designations for IPFs 

based on OMB’s MSA definitions after 

June 2003; the FY 2012 pre-floor, prereclassified hospital wage index; the FY 

2013 labor-related share; and the FY 

2013 percentage amount of the rural 

adjustment. During the simulation, the 

total estimated outlier payments are 

maintained at 2 percent of total IPF PPS 

payments. 

Each of the following changes is 

added incrementally to this baseline 

model in order for us to isolate the 

effects of each change: 

• The update to the outlier fixed 

dollar loss threshold amount. 

• The FY 2013 pre-floor, prereclassified hospital wage index and FY 

2014 labor-related share. 

• The market basket update for FY 

2014 of 2.6 percent less the ‘‘other 

adjustment’’ of 0.1 percentage point in 

accordance with sections 

1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the 

Act and less the productivity 

adjustment of 0.5 percentage point 

reduction in accordance with section 

1886(s)(2)(A)(i) of the Act. 

Our final comparison illustrates the 

percent change in payments from FY 

2013 (that is, October 1, 2012 to 

September 30, 2013) to FY 2014 (that is, 

October 1, 2013 to September 30, 2014) 

including all the changes in this notice. 

TABLE 7—IPF IMPACT TABLE FOR FY 2014 

Projected Impacts (% Change In Columns 3–6) 

Facility by type Number of 

facilities Outlier 

CBSA wage 

index & 

labor share 

Adjusted 

market basket 

update 1

Total percent 

change 2

(1) (2) (3) (4) (5) (6) 

All Facilities .......................................................................... 1,624 0.3 0.0 2.0 2.3 

Total Urban .......................................................................... 1,242 0.3 0.0 2.0 2.3 

Total Rural ........................................................................... 382 0.2 ¥0.1 2.0 2.1 

Urban unit ............................................................................ 834 0.4 0.0 2.0 2.5 

Urban hospital ...................................................................... 408 0.1 0.0 2.0 2.1 

Rural unit .............................................................................. 309 0.2 ¥0.1 2.0 2.2 

Rural hospital ....................................................................... 73 0.3 ¥0.2 2.0 2.0 

By Type of Ownership: 

Freestanding IPFs: 

Urban Psychiatric Hospitals: 

Government ........................................................... 130 0.3 ¥0.1 2.0 2.2 

Non-Profit ............................................................... 99 0.1 0.2 2.0 2.2 

For-Profit ................................................................ 177 0.1 0.0 2.0 2.0 

Rural Psychiatric Hospitals: 

Government ........................................................... 36 0.5 ¥0.4 2.0 2.1 

Non-Profit ............................................................... 13 0.1 0.0 2.0 2.1 

For-Profit ................................................................ 23 0.1 ¥0.1 2.0 2.0 

IPF Units: 

Urban: 

Government ........................................................... 131 0.8 0.1 2.0 2.9 

Non-Profit ............................................................... 548 0.4 0.1 2.0 2.5 

For-Profit ................................................................ 155 0.3 ¥0.2 2.0 2.0 

Rural: 

Government ........................................................... 80 0.2 ¥0.1 2.0 2.1 

Non-Profit ............................................................... 163 0.3 0.0 2.0 2.2 

For-Profit ................................................................ 66 0.3 ¥0.1 2.0 2.2 

Unknown Ownership Type ................................................... 3 0.0 0.2 2.0 2.2 

By Teaching Status: 

Non-teaching ................................................................. 1,419 0.2 0.0 2.0 2.2 

Less than 10% interns and residents to beds .............. 109 0.5 0.0 2.0 2.5 

10% to 30% interns and residents to beds .................. 70 0.5 0.1 2.0 2.6 

More than 30% interns and residents to beds ............. 26 0.9 0.5 2.0 3.5 

By Region: 

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TABLE 7—IPF IMPACT TABLE FOR FY 2014—Continued 

Projected Impacts (% Change In Columns 3–6) 

Facility by type Number of 

facilities Outlier 

CBSA wage 

index & 

labor share 

Adjusted 

market basket 

update 1

Total percent 

change 2

(1) (2) (3) (4) (5) (6) 

New England ................................................................ 111 0.4 0.5 2.0 3.0 

Mid-Atlantic ................................................................... 256 0.4 ¥0.1 2.0 2.3 

South Atlantic ................................................................ 233 0.2 ¥0.3 2.0 1.9 

East North Central ........................................................ 258 0.3 0.1 2.0 2.4 

East South Central ....................................................... 171 0.2 ¥0.7 2.0 1.6 

West North Central ....................................................... 139 0.3 0.2 2.0 2.5 

West South Central ...................................................... 234 0.2 ¥0.2 2.0 1.9 

Mountain ....................................................................... 99 0.3 ¥0.6 2.0 1.7 

Pacific ........................................................................... 123 0.5 0.9 2.0 3.5 

By Bed Size: 

Psychiatric Hospitals: 

Beds: 0–24 ............................................................ 82 0.2 ¥0.3 2.0 1.9 

Beds: 25–49 .......................................................... 75 0.1 ¥0.1 2.0 1.9 

Beds: 50–75 .......................................................... 79 0.2 0.0 2.0 2.2 

Beds: 76 + ............................................................. 245 0.1 0.0 2.0 2.1 

Psychiatric Units: 

Beds: 0–24 ............................................................ 684 0.4 0.0 2.0 2.4 

Beds: 25–49 .......................................................... 306 0.4 0.2 2.0 2.5 

Beds: 50–75 .......................................................... 94 0.4 ¥0.1 2.0 2.2 

Beds: 76 + ............................................................. 59 0.5 0.0 2.0 2.6 

1This column reflects the payment update impact of the RPL market basket update for FY 2014 of 2.6 percent, a 0.1 percentage point reduction in accordance with sections 1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the Act, and a 0.5 percentage point reduction for the productivity adjustment as required by section 1886(s)(2)(A)(i) of the Act. 2Percent changes in estimated payments from FY 2013 to FY 2014 include all of the changes presented in this notice. Note, the products of 

these impacts may be different from the percentage changes shown here due to rounding effects. 

3. Results 

Table 7 above displays the results of 

our analysis. The table groups IPFs into 

the categories listed below based on 

characteristics provided in the Provider 

of Services (POS) file, the IPF provider 

specific file, and cost report data from 

HCRIS: 

• Facility Type 

• Location 

• Teaching Status Adjustment 

• Census Region 

• Size 

The top row of the table shows the 

overall impact on the 1,624 IPFs 

included in this analysis. 

In column 3, we present the effects of 

the update to the outlier fixed dollar 

loss threshold amount. We estimate that 

IPF outlier payments as a percentage of 

total IPF payments are 1.7 percent in FY 

2013. Thus, we are adjusting the outlier 

threshold amount in this notice to set 

total estimated outlier payments equal 

to 2 percent of total payments in FY 

2014. The estimated change in total IPF 

payments for FY 2014, therefore, 

includes an approximate 0.3 percent 

increase in payments because the outlier 

portion of total payments is expected to 

increase from approximately 1.7 percent 

to 2 percent. 

The overall impact of this outlier 

adjustment update (as shown in column 

3 of table 7), across all hospital groups, 

is to increase total estimated payments 

to IPFs by 0.3 percent. We do not 

estimate that any group of IPFs will 

experience a decrease in payments from 

this update. The largest increase in 

payments is estimated to reflect a 0.9 

percent increase in payments for IPFs 

located in teaching hospitals with an 

intern and resident ADC ratio greater 

than 30 percent. 

In column 4, we present the effects of 

the budget-neutral update to the laborrelated share and the wage index 

adjustment under the CBSA geographic 

area definitions announced by OMB in 

June 2003. This is a comparison of the 

simulated FY 2014 payments under the 

FY 2013 hospital wage index under 

CBSA classification and associated 

labor-related share to the simulated FY 

2013 payments under the FY 2012 

hospital wage index under CBSA 

classifications and associated laborrelated share. We note that there is no 

projected change in aggregate payments 

to IPFs, as indicated in the first row of 

column 4. However, there will be small 

distributional effects among different 

categories of IPFs. For example, we 

estimate the largest increase in 

payments to be a 0.9 percent increase 

for IPFs in the Pacific region and the 

largest decrease in payments to be a 0.7 

percent decrease for IPFs in the East 

South Central region. 

Column 5 shows the estimated effect 

of the update to the IPF PPS payment 

rates, which includes a 2.6 percent 

market basket update less the 0.1 

percentage point in accordance with 

section 1886(s)(2)(A)(ii) and 

1886(s)(3)(B) and less the productivity 

adjustment of 0.5 percentage point in 

accordance with section 1886(s)(2)(A)(i). 

Column 6 compares our estimates of 

the total changes reflected in this notice 

for FY 2014, to our payments for FY 

2013 (without these changes). This 

column reflects all FY 2014 changes 

relative to FY 2013. The average 

estimated increase for all IPFs is 

approximately 2.3 percent. This 

estimated net increase includes the 

effects of the 2.6 percent market basket 

update adjusted by the ‘‘other 

adjustment’’ of minus 0.1 percentage 

point, as required by sections 

1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the 

Act and the productivity adjustment of 

minus 0.5 percentage point, as required 

by section 1886(s)(2)(A)(i) of the Act. It 

also includes the overall estimated 0.3 

percent increase in estimated IPF outlier 

payments from the update to the outlier 

fixed dollar loss threshold amount. 

Since we are making the updates to the 

IPF labor-related share and wage index 

in a budget-neutral manner, they will 

not affect total estimated IPF payments 

in the aggregate. However, they will 

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46752 Federal Register / Vol. 78, No. 148 / Thursday, August 1, 2013 / Notices 

affect the estimated distribution of 

payments among providers. 

Overall, no IPFs are estimated to 

experience a net decrease in payments 

as a result of the updates in this notice. 

IPFs in urban areas will experience a 2.3 

percent increase and IPFs in rural areas 

will experience a 2.1 percent increase. 

The largest payment increase is 

estimated at 3.5 percent for IPFs located 

in teaching hospitals with an intern and 

resident ADC ratio greater than 30 

percent and IPFs in the Pacific region. 

This is due to the larger than average 

positive effect of the CBSA wage index 

and labor-related share updates and the 

higher volume of outlier payments for 

IPFs in these categories. 

4. Effect on the Medicare Program 

Based on actuarial projections 

resulting from our experience with other 

PPSs, we estimate that Medicare 

spending (total Medicare program 

payments) for IPF services over the next 

5 years would be as shown in Table 8 

below. 

TABLE 8—ESTIMATED PAYMENTS

SHOWN IN CURRENT YEAR DOLLARS

Fiscal year Dollars in 

millions 

2014 .......................................... 5,420 

2015 .......................................... 5,910 

2016 .......................................... 6,500 

2017 .......................................... 7,090 

2018 .......................................... 7,570 

These estimates are based on the 

current forecast of the increases in the 

RPL market basket, including an 

adjustment for productivity, for the FY 

beginning in 2014 and each subsequent 

RY, as required by section 

1886(s)(2)(A)(i) of the Act, as follows: 

• 2.1 percent for FY 2014. 

• 2.3 percent for FY 2015. 

• 2.6 percent for FY 2016. 

• 2.6 percent for FY 2017. 

• 2.5 percent for FY 2018. 

The estimates in Table 8 also include 

the application of the ‘‘other 

adjustment,’’ as required by sections 

1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the 

Act, as follows: 

• ¥0.3 percentage point for rate years 

beginning in 2014. 

• ¥0.2 percentage point for rate years 

beginning in 2015. 

• ¥0.2 percentage point for rate years 

beginning in 2016. 

• ¥0.75 percentage point for rate 

years beginning in 2017. 

• ¥0.75 percentage point for rate 

years beginning in 2018. 

We estimate that there would be a 

change in fee-for-service Medicare 

beneficiary enrollment as follows: 

• 2.2 percent in FY 2014. 

• 4.1 percent in FY 2015. 

• 5.0 percent in FY 2016. 

• 5.5 percent in FY 2017. 

• 4.4 percent in FY 2018. 

5. Effect on Beneficiaries 

Under the IPF PPS, IPFs will receive 

payment based on the average resources 

consumed by patients for each day. We 

do not expect changes in the quality of 

care or access to services for Medicare 

beneficiaries under the FY 2014 IPF PPS 

but we continue to expect that paying 

prospectively for IPF services would 

enhance the efficiency of the Medicare 

program. 

D. Alternatives Considered 

The statute does not specify an update 

strategy for the IPF PPS and is broadly 

written to give the Secretary discretion 

in establishing an update methodology. 

Therefore, we are updating the IPF PPS 

using the methodology published in the 

November 2004 IPF PPS final rule. 

Lastly, no alternative policy options 

were considered in this notice, since 

this notice does not initiate policy 

changes with regard to the IPF PPS. This 

notice simply provides an update to the 

rates for FY 2014. 

E. Accounting Statement 

As required by OMB Circular A–4 

(available at http:// 

www.whitehouse.gov/omb/ 

circulars_a004_a-4), in Table 9 below, 

we have prepared an accounting 

statement showing the classification of 

the expenditures associated with the 

provisions of this notice. This table 

provides our best estimate of the 

increase in Medicare payments under 

the IPF PPS as a result of the changes 

presented in this notice and based on 

the data for 1,624 IPFs in our database. 

All expenditures are classified as 

Federal transfers to IPF Medicare 

providers. 

TABLE 9—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED EXPENDITURES, FROM THE 2013 IPF PPS FY TO

THE 2014 IPF PPS FY 

[In millions] 

Category Transfers 

Annualized Monetized Transfers ............................................................................................ $115.

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

In accordance with the provisions of 

Executive Order 12866, this notice was 

reviewed by the Office of Management 

and Budget. 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: May 29, 2013. 

Marilyn Tavenner, 

Administrator, Centers for Medicare & 

Medicaid Services. 

Approved: June 28, 2013. 

Kathleen Sebelius, 

Secretary. 

Addendum A—Rate and Adjustment 

Factors 

Per Diem Rate: 

Federal Per Diem Base Rate—$713.19 

Labor Share—(0.69494)—$495.62 

Non-Labor Share (0.30506)—$217.57 

Per Diem Rate Applying the 2 

Percentage Point Reduction: 

Federal Per Diem Base Rate—$699.21 

Labor Share (0.69494)—$485.91 

Non-Labor Share (0.30506)—$213.30 

Fixed Dollar Loss Threshold Amount: 

$10,245 

Wage Index Budget Neutrality Factor: 

1.0010 

Facility Adjustments: 

Rural Adjustment Factor—1.17 

Teaching Adjustment Factor—0.5150 

Wage Index—Pre-reclass Hospital 

Wage Index (FY2013) 

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COST OF LIVING ADJUSTMENTS (COLAS) 

Area Cost of living 

adjustment factor 

Alaska: 

City of Anchorage and 80-kilometer (50-mile) radius by road ............................................................................................. 1.23 

City of Fairbanks and 80-kilometer (50-mile) radius by road .............................................................................................. 1.23 

City of Juneau and 80-kilometer (50-mile) radius by road .................................................................................................. 1.23 

Rest of Alaska ...................................................................................................................................................................... 1.25 

Hawaii: 

City and County of Honolulu ................................................................................................................................................ 1.25 

County of Hawaii .................................................................................................................................................................. 1.18 

County of Kauai .................................................................................................................................................................... 1.25 

County of Maui and County of Kalawao .............................................................................................................................. 1.25 

Patient Adjustments: 

ECT—Per Treatment—$307.04 

ECT—Per Treatment Applying the 2 

Percentage Point Reduction— 

$301.02 

VARIABLE PER DIEM ADJUSTMENTS

Adjustment 

factor 

Day 1—Facility Without a Qualifying Emergency Department ............................................................................................................... 1.19 

Day 1—Facility With a Qualifying Emergency Department .................................................................................................................... 1.31 

Day 2 ....................................................................................................................................................................................................... 1.12 

Day 3 ....................................................................................................................................................................................................... 1.08 

Day 4 ....................................................................................................................................................................................................... 1.05 

Day 5 ....................................................................................................................................................................................................... 1.04 

Day 6 ....................................................................................................................................................................................................... 1.02 

Day 7 ....................................................................................................................................................................................................... 1.01 

Day 8 ....................................................................................................................................................................................................... 1.01 

Day 9 ....................................................................................................................................................................................................... 1.00 

Day 10 ..................................................................................................................................................................................................... 1.00 

Day 11 ..................................................................................................................................................................................................... 0.99 

Day 12 ..................................................................................................................................................................................................... 0.99 

Day 13 ..................................................................................................................................................................................................... 0.99 

Day 14 ..................................................................................................................................................................................................... 0.99 

Day 15 ..................................................................................................................................................................................................... 0.98 

Day 16 ..................................................................................................................................................................................................... 0.97 

Day 17 ..................................................................................................................................................................................................... 0.97 

Day 18 ..................................................................................................................................................................................................... 0.96 

Day 19 ..................................................................................................................................................................................................... 0.95 

Day 20 ..................................................................................................................................................................................................... 0.95 

Day 21 ..................................................................................................................................................................................................... 0.95 

After Day 21 ............................................................................................................................................................................................. 0.92 

AGE ADJUSTMENTS

Age 

(in years) 

Adjustment 

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

MS–DRG MS–DRG descriptions Adjustment 

factor 

056 ................. Degenerative nervous system disorders w MCC ....................................................................................................... 1.05 

057 ................. Degenerative nervous system disorders w/o MCC ....................................................................................................

080 ................. Nontraumatic stupor & coma w MCC ......................................................................................................................... 1.07 

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46754 Federal Register / Vol. 78, No. 148 / Thursday, August 1, 2013 / Notices 

DRG ADJUSTMENTS—Continued 

MS–DRG MS–DRG descriptions Adjustment 

factor 

081 ................. Nontraumatic stupor & coma w/o MCC ......................................................................................................................

876 ................. O.R. procedure w principal diagnoses of mental illness ............................................................................................ 1.22 

880 ................. Acute adjustment reaction & psychosocial dysfunction .............................................................................................. 1.05 

881 ................. Depressive neuroses ................................................................................................................................................... 0.99 

882 ................. Neuroses except depressive ....................................................................................................................................... 1.02 

883 ................. Disorders of personality & impulse control ................................................................................................................. 1.02 

884 ................. Organic disturbances & mental retardation ................................................................................................................ 1.03 

885 ................. Psychoses ................................................................................................................................................................... 1.00 

886 ................. Behavioral & developmental disorders ....................................................................................................................... 0.99 

887 ................. Other mental disorder diagnoses ................................................................................................................................ 0.92 

894 ................. Alcohol/drug abuse or dependence, left AMA ............................................................................................................ 0.97 

895 ................. Alcohol/drug abuse or dependence w rehabilitation therapy ...................................................................................... 1.02 

896 ................. Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC ..................................................................... 0.88 

897 ................. Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC ..................................................................

COMORBIDITY ADJUSTMENTS

Comorbidity Adjustment 

factor 

Developmental Disabilities ....................................................................................................................................................................... 1.04 

Coagulation Factor Deficit ....................................................................................................................................................................... 1.13 

Tracheostomy .......................................................................................................................................................................................... 1.06 

Eating and Conduct Disorders ................................................................................................................................................................ 1.12 

Infectious Diseases .................................................................................................................................................................................. 1.07 

Renal Failure, Acute ................................................................................................................................................................................ 1.11 

Renal Failure, Chronic ............................................................................................................................................................................. 1.11 

Oncology Treatment ................................................................................................................................................................................ 1.07 

Uncontrolled Diabetes Mellitus ................................................................................................................................................................ 1.05 

Severe Protein Malnutrition ..................................................................................................................................................................... 1.13 

Drug/Alcohol Induced Mental Disorders .................................................................................................................................................. 1.03 

Cardiac Conditions .................................................................................................................................................................................. 1.11 

Gangrene ................................................................................................................................................................................................. 1.10 

Chronic Obstructive Pulmonary Disease ................................................................................................................................................. 1.12 

Artificial Openings—Digestive & Urinary ................................................................................................................................................. 1.08 

Severe Musculoskeletal & Connective Tissue Diseases ........................................................................................................................ 1.09 

Poisoning ................................................................................................................................................................................................. 1.11 

Addendum B—FY 2014 CBSA Wage 

Index Tables 

In this addendum, we provide the 

wage index tables referred to in the 

preamble to this notice. The tables 

presented below are as follows: 

Table1—FY 2014 Wage Index For 

Urban Areas Based on CBSA Labor 

Market Areas. 

Table 2—FY 2014 Wage Index Based 

On CBSA Labor Market Areas For Rural 

Areas. 

TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS

CBSA code Urban area 

(constituent counties) Wage index 

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

Callahan County, TX.

Jones County, TX.

Taylor County, TX.

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

Aguada Municipio, PR.

Aguadilla Municipio, PR.

An ̃asco Municipio, PR.

Isabela Municipio, PR.

Lares Municipio, PR.

Moca Municipio, PR.

Rinco ́n Municipio, PR.

San Sebastia ́n Municipio, PR.

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

Portage County, OH.

Summit County, OH.

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

Baker County, GA.

Dougherty County, GA.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Lee County, GA.

Terrell County, GA.

Worth County, GA.

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

Albany County, NY.

Rensselaer County, NY.

Saratoga County, NY.

Schenectady County, NY.

Schoharie County, NY.

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

Bernalillo County, NM.

Sandoval County, NM.

Torrance County, NM.

Valencia County, NM.

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

Grant Parish, LA.

Rapides Parish, LA.

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

Warren County, NJ.

Carbon County, PA.

Lehigh County, PA.

Northampton County, PA.

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

Blair County, PA.

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

Armstrong County, TX.

Carson County, TX.

Potter County, TX.

Randall County, TX.

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

Story County, IA.

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

Anchorage Municipality, AK.

Matanuska-Susitna Borough, AK.

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

Madison County, IN.

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

Anderson County, SC.

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

Washtenaw County, MI.

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

Calhoun County, AL.

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

Calumet County, WI.

Outagamie County, WI.

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

Buncombe County, NC.

Haywood County, NC.

Henderson County, NC.

Madison County, NC.

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

Clarke County, GA.

Madison County, GA.

Oconee County, GA.

Oglethorpe County, GA.

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

Barrow County, GA.

Bartow County, GA.

Butts County, GA.

Carroll County, GA.

Cherokee County, GA.

Clayton County, GA.

Cobb County, GA.

Coweta County, GA.

Dawson County, GA.

DeKalb County, GA.

Douglas County, GA.

Fayette County, GA.

Forsyth County, GA.

Fulton County, GA.

Gwinnett County, GA.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Haralson County, GA.

Heard County, GA.

Henry County, GA.

Jasper County, GA.

Lamar County, GA.

Meriwether County, GA.

Newton County, GA.

Paulding County, GA.

Pickens County, GA.

Pike County, GA.

Rockdale County, GA.

Spalding County, GA.

Walton County, GA.

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

Atlantic County, NJ.

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

Lee County, AL.

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

Burke County, GA.

Columbia County, GA.

McDuffie County, GA.

Richmond County, GA.

Aiken County, SC.

Edgefield County, SC.

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

Bastrop County, TX.

Caldwell County, TX.

Hays County, TX.

Travis County, TX.

Williamson County, TX.

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

Kern County, CA.

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

Anne Arundel County, MD.

Baltimore County, MD.

Carroll County, MD.

Harford County, MD.

Howard County, MD.

Queen Anne’s County, MD.

Baltimore City, MD.

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

Penobscot County, ME.

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

Barnstable County, MA.

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

Ascension Parish, LA.

East Baton Rouge Parish, LA.

East Feliciana Parish, LA.

Iberville Parish, LA.

Livingston Parish, LA.

Pointe Coupee Parish, LA.

St. Helena Parish, LA.

West Baton Rouge Parish, LA.

West Feliciana Parish, LA.

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

Calhoun County, MI.

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

Bay County, MI.

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

Hardin County, TX.

Jefferson County, TX.

Orange County, TX.

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

Whatcom County, WA.

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

Deschutes County, OR.

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

Frederick County, MD.

Montgomery County, MD.

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

Carbon County, MT.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Yellowstone County, MT.

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

Broome County, NY.

Tioga County, NY.

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

Bibb County, AL.

Blount County, AL.

Chilton County, AL.

Jefferson County, AL.

St. Clair County, AL.

Shelby County, AL.

Walker County, AL.

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

Burleigh County, ND.

Morton County, ND.

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

Giles County, VA.

Montgomery County, VA.

Pulaski County, VA.

Radford City, VA.

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

Greene County, IN.

Monroe County, IN.

Owen County, IN.

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

McLean County, IL.

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

Ada County, ID.

Boise County, ID.

Canyon County, ID.

Gem County, ID.

Owyhee County, ID.

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

Norfolk County, MA.

Plymouth County, MA.

Suffolk County, MA.

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

Boulder County, CO.

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

Edmonson County, KY.

Warren County, KY.

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

Kitsap County, WA.

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

Fairfield County, CT.

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

Cameron County, TX.

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

Brantley County, GA.

Glynn County, GA.

McIntosh County, GA.

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

Erie County, NY.

Niagara County, NY.

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

Alamance County, NC.

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

Chittenden County, VT.

Franklin County, VT.

Grand Isle County, VT.

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

Middlesex County, MA.

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

Burlington County, NJ.

Camden County, NJ.

Gloucester County, NJ.

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

Carroll County, OH.

Stark County, OH.

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

Lee County, FL.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

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

Alexander County, IL.

Bollinger County, MO.

Cape Girardeau County, MO.

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

Carson City, NV.

16220 ....................................................... Casper, WY ................................................................................................................... 1.0143 

Natrona County, WY.

16300 ....................................................... Cedar Rapids, IA ........................................................................................................... 0.8944 

Benton County, IA.

Jones County, IA.

Linn County, IA.

16580 ....................................................... Champaign-Urbana, IL .................................................................................................. 0.9907 

Champaign County, IL.

Ford County, IL.

Piatt County, IL.

16620 ....................................................... Charleston, WV ............................................................................................................. 0.8050 

Boone County, WV.

Clay County, WV.

Kanawha County, WV.

Lincoln County, WV.

Putnam County, WV.

16700 ....................................................... Charleston-North Charleston-Summerville, SC ............................................................ 0.8820 

Berkeley County, SC.

Charleston County, SC.

Dorchester County, SC.

16740 ....................................................... Charlotte-Gastonia-Concord, NC-SC ............................................................................ 0.9215 

Anson County, NC.

Cabarrus County, NC.

Gaston County, NC.

Mecklenburg County, NC.

Union County, NC.

York County, SC.

16820 ....................................................... Charlottesville, VA ......................................................................................................... 0.9195 

Albemarle County, VA.

Fluvanna County, VA.

Greene County, VA.

Nelson County, VA.

Charlottesville City, VA.

16860 ....................................................... Chattanooga, TN-GA ..................................................................................................... 0.8678 

Catoosa County, GA.

Dade County, GA.

Walker County, GA.

Hamilton County, TN.

Marion County, TN.

Sequatchie County, TN.

16940 ....................................................... Cheyenne, WY .............................................................................................................. 0.9730 

Laramie County, WY.

16974 ....................................................... Chicago-Naperville-Joliet, IL ......................................................................................... 1.0600 

Cook County, IL.

DeKalb County, IL.

DuPage County, IL.

Grundy County, IL.

Kane County, IL.

Kendall County, IL.

McHenry County, IL.

Will County, IL.

17020 ....................................................... Chico, CA ...................................................................................................................... 1.1197 

Butte County, CA.

17140 ....................................................... Cincinnati-Middletown, OH-KY-IN ................................................................................. 0.9508 

Dearborn County, IN.

Franklin County, IN.

Ohio County, IN.

Boone County, KY.

Bracken County, KY.

Campbell County, KY.

Gallatin County, KY.

Grant County, KY.

Kenton County, KY.

Pendleton County, KY.

Brown County, OH.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Butler County, OH.

Clermont County, OH.

Hamilton County, OH.

Warren County, OH.

17300 ....................................................... Clarksville, TN-KY ......................................................................................................... 0.8082 

Christian County, KY.

Trigg County, KY.

Montgomery County, TN.

Stewart County, TN.

17420 ....................................................... Cleveland, TN ................................................................................................................ 0.7592 

Bradley County, TN.

Polk County, TN.

17460 ....................................................... Cleveland-Elyria-Mentor, OH ........................................................................................ 0.9082 

Cuyahoga County, OH.

Geauga County, OH.

Lake County, OH.

Lorain County, OH.

Medina County, OH.

17660 ....................................................... Coeur d’Alene, ID .......................................................................................................... 0.9218 

Kootenai County, ID.

17780 ....................................................... College Station-Bryan, TX ............................................................................................. 0.9584 

Brazos County, TX.

Burleson County, TX.

Robertson County, TX.

17820 ....................................................... Colorado Springs, CO ................................................................................................... 0.9364 

El Paso County, CO.

Teller County, CO.

17860 ....................................................... Columbia, MO ............................................................................................................... 0.8339 

Boone County, MO.

Howard County, MO.

17900 ....................................................... Columbia, SC ................................................................................................................ 0.8560 

Calhoun County, SC.

Fairfield County, SC.

Kershaw County, SC.

Lexington County, SC.

Richland County, SC.

Saluda County, SC.

17980 ....................................................... Columbus, GA-AL ......................................................................................................... 0.8857 

Russell County, AL.

Chattahoochee County, GA.

Harris County, GA.

Marion County, GA.

Muscogee County, GA.

18020 ....................................................... Columbus, IN ................................................................................................................. 0.9564 

Bartholomew County, IN.

18140 ....................................................... Columbus, OH ............................................................................................................... 0.9763 

Delaware County, OH.

Fairfield County, OH.

Franklin County, OH.

Licking County, OH.

Madison County, OH.

Morrow County, OH.

Pickaway County, OH.

Union County, OH.

18580 ....................................................... Corpus Christi, TX ......................................................................................................... 0.8591 

Aransas County, TX.

Nueces County, TX.

San Patricio County, TX.

18700 ....................................................... Corvallis, OR ................................................................................................................. 1.0715 

Benton County, OR.

18880 ....................................................... Crestview-Fort Walton Beach-Destin, FL ...................................................................... 0.8916 

Okaloosa County, FL.

19060 ....................................................... Cumberland, MD-WV .................................................................................................... 0.8836 

Allegany County, MD.

Mineral County, WV.

19124 ....................................................... Dallas-Plano-Irving, TX ................................................................................................. 0.9835 

Collin County, TX.

Dallas County, TX.

Delta County, TX.

Denton County, TX.

Ellis County, TX.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Hunt County, TX.

Kaufman County, TX.

Rockwall County, TX.

19140 ....................................................... Dalton, GA ..................................................................................................................... 0.8828 

Murray County, GA.

Whitfield County, GA.

19180 ....................................................... Danville, IL ..................................................................................................................... 0.9977 

Vermilion County, IL.

19260 ....................................................... Danville, VA ................................................................................................................... 0.8218 

Pittsylvania County, VA.

Danville City, VA.

19340 ....................................................... Davenport-Moline-Rock Island, IA-IL ............................................................................ 0.9145 

Henry County, IL.

Mercer County, IL.

Rock Island County, IL.

Scott County, IA.

19380 ....................................................... Dayton, OH .................................................................................................................... 0.9136 

Greene County, OH.

Miami County, OH.

Montgomery County, OH.

Preble County, OH.

19460 ....................................................... Decatur, AL ................................................................................................................... 0.7261 

Lawrence County, AL.

Morgan County, AL.

19500 ....................................................... Decatur, IL ..................................................................................................................... 0.7993 

Macon County, IL.

19660 ....................................................... Deltona-Daytona Beach-Ormond Beach, FL ................................................................ 0.8716 

Volusia County, FL.

19740 ....................................................... Denver-Aurora-Broomfield, CO ..................................................................................... 1.0469 

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 ................................................................................ 0.9616 

Dallas County, IA.

Guthrie County, IA.

Madison County, IA.

Polk County, IA.

Warren County, IA.

19804 ....................................................... Detroit-Livonia-Dearborn, MI ......................................................................................... 0.9361 

Wayne County, MI.

20020 ....................................................... Dothan, AL .................................................................................................................... 0.7398 

Geneva County, AL.

Henry County, AL.

Houston County, AL.

20100 ....................................................... Dover, DE ...................................................................................................................... 0.9893 

Kent County, DE.

20220 ....................................................... Dubuque, IA .................................................................................................................. 0.8662 

Dubuque County, IA.

20260 ....................................................... Duluth, MN-WI ............................................................................................................... 1.0741 

Carlton County, MN.

St. Louis County, MN.

Douglas County, WI.

20500 ....................................................... Durham-Chapel Hill, NC ................................................................................................ 0.9525 

Chatham County, NC.

Durham County, NC.

Orange County, NC.

Person County, NC.

20740 ....................................................... Eau Claire, WI ............................................................................................................... 0.9705 

Chippewa County, WI.

Eau Claire County, WI.

20764 ....................................................... Edison-New Brunswick, NJ ........................................................................................... 1.0806 

Middlesex County, NJ.

Monmouth County, NJ.

Ocean County, NJ.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Somerset County, NJ.

20940 ....................................................... El Centro, CA ................................................................................................................ 0.8602 

Imperial County, CA.

21060 ....................................................... Elizabethtown, KY ......................................................................................................... 0.8294 

Hardin County, KY.

Larue County, KY.

21140 ....................................................... Elkhart-Goshen, IN ........................................................................................................ 0.9097 

Elkhart County, IN.

21300 ....................................................... Elmira, NY ..................................................................................................................... 0.8205 

Chemung County, NY.

21340 ....................................................... El Paso, TX ................................................................................................................... 0.8426 

El Paso County, TX.

21500 ....................................................... Erie, PA ......................................................................................................................... 0.7823 

Erie County, PA.

21660 ....................................................... Eugene-Springfield, OR ................................................................................................ 1.1454 

Lane County, OR.

21780 ....................................................... Evansville, IN-KY ........................................................................................................... 0.8401 

Gibson County, IN.

Posey County, IN.

Vanderburgh County, IN.

Warrick County, IN.

Henderson County, KY.

Webster County, KY.

21820 ....................................................... Fairbanks, AK ................................................................................................................ 1.0816 

Fairbanks North Star Borough, AK.

21940 ....................................................... Fajardo, PR ................................................................................................................... 0.3663 

Ceiba Municipio, PR.

Fajardo Municipio, PR.

Luquillo Municipio, PR.

22020 ....................................................... Fargo, ND-MN ............................................................................................................... 0.8108 

Cass County, ND.

Clay County, MN.

22140 ....................................................... Farmington, NM ............................................................................................................. 0.9323 

San Juan County, NM.

22180 ....................................................... Fayetteville, NC ............................................................................................................. 0.8971 

Cumberland County, NC.

Hoke County, NC.

22220 ....................................................... Fayetteville-Springdale-Rogers, AR-MO ....................................................................... 0.9288 

Benton County, AR.

Madison County, AR.

Washington County, AR.

McDonald County, MO.

22380 ....................................................... Flagstaff, AZ .................................................................................................................. 1.2369 

Coconino County, AZ.

22420 ....................................................... Flint, MI .......................................................................................................................... 1.1257 

Genesee County, MI.

22500 ....................................................... Florence, SC ................................................................................................................. 0.8087 

Darlington County, SC.

Florence County, SC.

22520 ....................................................... Florence-Muscle Shoals, AL ......................................................................................... 0.7679 

Colbert County, AL.

Lauderdale County, AL.

22540 ....................................................... Fond du Lac, WI ............................................................................................................ 0.9158 

Fond du Lac County, WI.

22660 ....................................................... Fort Collins-Loveland, CO ............................................................................................. 0.9833 

Larimer County, CO.

22744 ....................................................... Fort Lauderdale-Pompano Beach-Deerfield Beach, FL ................................................ 1.0363 

Broward County, FL.

22900 ....................................................... Fort Smith, AR-OK ........................................................................................................ 0.7848 

Crawford County, AR.

Franklin County, AR.

Sebastian County, AR.

Le Flore County, OK.

Sequoyah County, OK.

23060 ....................................................... Fort Wayne, IN .............................................................................................................. 0.9633 

Allen County, IN.

Wells County, IN.

Whitley County, IN.

23104 ....................................................... Fort Worth-Arlington, TX ............................................................................................... 0.9516 

Johnson County, TX.

Parker County, TX.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Tarrant County, TX.

Wise County, TX.

23420 ....................................................... Fresno, CA .................................................................................................................... 1.1593 

Fresno County, CA.

23460 ....................................................... Gadsden, AL ................................................................................................................. 0.7697 

Etowah County, AL.

23540 ....................................................... Gainesville, FL ............................................................................................................... 0.9631 

Alachua County, FL.

Gilchrist County, FL.

23580 ....................................................... Gainesville, GA .............................................................................................................. 0.9327 

Hall County, GA.

23844 ....................................................... Gary, IN ......................................................................................................................... 0.9259 

Jasper County, IN.

Lake County, IN.

Newton County, IN.

Porter County, IN.

24020 ....................................................... Glens Falls, NY ............................................................................................................. 0.8340 

Warren County, NY.

Washington County, NY.

24140 ....................................................... Goldsboro, NC ............................................................................................................... 0.8560 

Wayne County, NC.

24220 ....................................................... Grand Forks, ND-MN .................................................................................................... 0.7250 

Polk County, MN.

Grand Forks County, ND.

24300 ....................................................... Grand Junction, CO ...................................................................................................... 0.9415 

Mesa County, CO.

24340 ....................................................... Grand Rapids-Wyoming, MI .......................................................................................... 0.9125 

Barry County, MI.

Ionia County, MI.

Kent County, MI.

Newaygo County, MI.

24500 ....................................................... Great Falls, MT ............................................................................................................. 0.7927 

Cascade County, MT.

24540 ....................................................... Greeley, CO .................................................................................................................. 0.9593 

Weld County, CO.

24580 ....................................................... Green Bay, WI ............................................................................................................... 0.9793 

Brown County, WI.

Kewaunee County, WI.

Oconto County, WI.

24660 ....................................................... Greensboro-High Point, NC .......................................................................................... 0.8638 

Guilford County, NC.

Randolph County, NC.

Rockingham County, NC.

24780 ....................................................... Greenville, NC ............................................................................................................... 0.9694 

Greene County, NC.

Pitt County, NC.

24860 ....................................................... Greenville-Mauldin-Easley, SC ..................................................................................... 0.9737 

Greenville County, SC.

Laurens County, SC.

Pickens County, SC.

25020 ....................................................... Guayama, PR ................................................................................................................ 0.3696 

Arroyo Municipio, PR.

Guayama Municipio, PR.

Patillas Municipio, PR.

25060 ....................................................... Gulfport-Biloxi, MS ........................................................................................................ 0.8544 

Hancock County, MS.

Harrison County, MS.

Stone County, MS.

25180 ....................................................... Hagerstown-Martinsburg, MD-WV ................................................................................ 0.9422 

Washington County, MD.

Berkeley County, WV.

Morgan County, WV.

25260 ....................................................... Hanford-Corcoran, CA ................................................................................................... 1.0992 

Kings County, CA.

25420 ....................................................... Harrisburg-Carlisle, PA .................................................................................................. 0.9525 

Cumberland County, PA.

Dauphin County, PA.

Perry County, PA.

25500 ....................................................... Harrisonburg, VA ........................................................................................................... 0.9087 

Rockingham County, VA.

Harrisonburg City, VA.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

25540 ....................................................... Hartford-West Hartford-East Hartford, CT .................................................................... 1.0869 

Hartford County, CT.

Middlesex County, CT.

Tolland County, CT.

25620 ....................................................... Hattiesburg, MS ............................................................................................................. 0.8035 

Forrest County, MS.

Lamar County, MS.

Perry County, MS.

25860 ....................................................... Hickory-Lenoir-Morganton, NC ...................................................................................... 0.8677 

Alexander County, NC.

Burke County, NC.

Caldwell County, NC.

Catawba County, NC.

25980 ....................................................... Hinesville-Fort Stewart, GA1 ......................................................................................... 0.8843 

Liberty County, GA.

Long County, GA.

26100 ....................................................... Holland-Grand Haven, MI ............................................................................................. 0.8024 

Ottawa County, MI.

26180 ....................................................... Honolulu, HI ................................................................................................................... 1.2156 

Honolulu County, HI.

26300 ....................................................... Hot Springs, AR ............................................................................................................ 0.8944 

Garland County, AR.

26380 ....................................................... Houma-Bayou Cane-Thibodaux, LA ............................................................................. 0.7928 

Lafourche Parish, LA.

Terrebonne Parish, LA.

26420 ....................................................... Houston-Sugar Land-Baytown, TX ............................................................................... 0.9933 

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 .................................................................................. 0.8635 

Boyd County, KY.

Greenup County, KY.

Lawrence County, OH.

Cabell County, WV.

Wayne County, WV.

26620 ....................................................... Huntsville, AL ................................................................................................................ 0.8667 

Limestone County, AL.

Madison County, AL.

26820 ....................................................... Idaho Falls, ID ............................................................................................................... 0.9114 

Bonneville County, ID.

Jefferson County, ID.

26900 ....................................................... Indianapolis-Carmel, IN ................................................................................................. 0.9870 

Boone County, IN.

Brown County, IN.

Hamilton County, IN.

Hancock County, IN.

Hendricks County, IN.

Johnson County, IN.

Marion County, IN.

Morgan County, IN.

Putnam County, IN.

Shelby County, IN.

26980 ....................................................... Iowa City, IA .................................................................................................................. 1.0120 

Johnson County, IA.

Washington County, IA.

27060 ....................................................... Ithaca, NY ...................................................................................................................... 0.9249 

Tompkins County, NY.

27100 ....................................................... Jackson, MI ................................................................................................................... 0.8511 

Jackson County, MI.

27140 ....................................................... Jackson, MS .................................................................................................................. 0.8177 

Copiah County, MS.

Hinds County, MS.

Madison County, MS.

Rankin County, MS.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Simpson County, MS.

27180 ....................................................... Jackson, TN .................................................................................................................. 0.7672 

Chester County, TN.

Madison County, TN.

27260 ....................................................... Jacksonville, FL ............................................................................................................. 0.8883 

Baker County, FL.

Clay County, FL.

Duval County, FL.

Nassau County, FL.

St. Johns County, FL.

27340 ....................................................... Jacksonville, NC ............................................................................................................ 0.7957 

Onslow County, NC.

27500 ....................................................... Janesville, WI ................................................................................................................ 0.9458 

Rock County, WI.

27620 ....................................................... Jefferson City, MO ........................................................................................................ 0.8263 

Callaway County, MO.

Cole County, MO.

Moniteau County, MO.

Osage County, MO.

27740 ....................................................... Johnson City, TN ........................................................................................................... 0.7359 

Carter County, TN.

Unicoi County, TN.

Washington County, TN.

27780 ....................................................... Johnstown, PA .............................................................................................................. 0.8116 

Cambria County, PA.

27860 ....................................................... Jonesboro, AR ............................................................................................................... 0.8084 

Craighead County, AR.

Poinsett County, AR.

27900 ....................................................... Joplin, MO ..................................................................................................................... 0.7828 

Jasper County, MO.

Newton County, MO.

28020 ....................................................... Kalamazoo-Portage, MI ................................................................................................. 0.9834 

Kalamazoo County, MI.

Van Buren County, MI.

28100 ....................................................... Kankakee-Bradley, IL .................................................................................................... 1.0127 

Kankakee County, IL.

28140 ....................................................... Kansas City, MO-KS ..................................................................................................... 0.9614 

Franklin County, KS.

Johnson County, KS.

Leavenworth County, KS.

Linn County, KS.

Miami County, KS.

Wyandotte County, KS.

Bates County, MO.

Caldwell County, MO.

Cass County, MO.

Clay County, MO.

Clinton County, MO.

Jackson County, MO.

Lafayette County, MO.

Platte County, MO.

Ray County, MO.

28420 ....................................................... Kennewick-Pasco-Richland, WA ................................................................................... 0.9708 

Benton County, WA.

Franklin County, WA.

28660 ....................................................... Killeen-Temple-Fort Hood, TX ...................................................................................... 0.9102 

Bell County, TX.

Coryell County, TX.

Lampasas County, TX.

28700 ....................................................... Kingsport-Bristol-Bristol, TN-VA .................................................................................... 0.7325 

Hawkins County, TN.

Sullivan County, TN.

Bristol City, VA.

Scott County, VA.

Washington County, VA.

28740 ....................................................... Kingston, NY ................................................................................................................. 0.8953 

Ulster County, NY.

28940 ....................................................... Knoxville, TN ................................................................................................................. 0.7575 

Anderson County, TN.

Blount County, TN.

Knox County, TN.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Loudon County, TN.

Union County, TN.

29020 ....................................................... Kokomo, IN .................................................................................................................... 0.8756 

Howard County, IN.

Tipton County, IN.

29100 ....................................................... La Crosse, WI-MN ......................................................................................................... 1.0070 

Houston County, MN.

La Crosse County, WI.

29140 ....................................................... Lafayette, IN .................................................................................................................. 0.9316 

Benton County, IN.

Carroll County, IN.

Tippecanoe County, IN.

29180 ....................................................... Lafayette, LA ................................................................................................................. 0.8565 

Lafayette Parish, LA.

St. Martin Parish, LA.

29340 ....................................................... Lake Charles, LA ........................................................................................................... 0.7813 

Calcasieu Parish, LA.

Cameron Parish, LA.

29404 ....................................................... Lake County-Kenosha County, IL-WI ........................................................................... 1.0558 

Lake County, IL.

Kenosha County, WI.

29420 ....................................................... Lake Havasu City-Kingman, AZ .................................................................................... 0.9760 

Mohave County, AZ.

29460 ....................................................... Lakeland-Winter Haven, FL .......................................................................................... 0.8262 

Polk County, FL.

29540 ....................................................... Lancaster, PA ................................................................................................................ 0.9452 

Lancaster County, PA.

29620 ....................................................... Lansing-East Lansing, MI .............................................................................................. 1.0065 

Clinton County, MI.

Eaton County, MI.

Ingham County, MI.

29700 ....................................................... Laredo, TX ..................................................................................................................... 0.7486 

Webb County, TX.

29740 ....................................................... Las Cruces, NM ............................................................................................................ 0.9044 

Dona Ana County, NM.

29820 ....................................................... Las Vegas-Paradise, NV ............................................................................................... 1.2076 

Clark County, NV.

29940 ....................................................... Lawrence, KS ................................................................................................................ 0.8676 

Douglas County, KS.

30020 ....................................................... Lawton, OK .................................................................................................................... 0.8351 

Comanche County, OK.

30140 ....................................................... Lebanon, PA .................................................................................................................. 0.7994 

Lebanon County, PA.

30300 ....................................................... Lewiston, ID-WA ............................................................................................................ 0.9326 

Nez Perce County, ID.

Asotin County, WA.

30340 ....................................................... Lewiston-Auburn, ME .................................................................................................... 0.9178 

Androscoggin County, ME.

30460 ....................................................... Lexington-Fayette, KY ................................................................................................... 0.9023 

Bourbon County, KY.

Clark County, KY.

Fayette County, KY.

Jessamine County, KY.

Scott County, KY.

Woodford County, KY.

30620 ....................................................... Lima, OH ....................................................................................................................... 0.9226 

Allen County, OH.

30700 ....................................................... Lincoln, NE .................................................................................................................... 0.9726 

Lancaster County, NE.

Seward County, NE.

30780 ....................................................... Little Rock-North Little Rock-Conway, AR .................................................................... 0.8595 

Faulkner County, AR.

Grant County, AR.

Lonoke County, AR.

Perry County, AR.

Pulaski County, AR.

Saline County, AR.

30860 ....................................................... Logan, UT-ID ................................................................................................................. 0.8456 

Franklin County, ID.

Cache County, UT.

30980 ....................................................... Longview, TX ................................................................................................................. 0.8550 

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Gregg County, TX.

Rusk County, TX.

Upshur County, TX.

31020 ....................................................... Longview, WA ............................................................................................................... 1.0081 

Cowlitz County, WA.

31084 ....................................................... Los Angeles-Long Beach-Glendale, CA ....................................................................... 1.2293 

Los Angeles County, CA.

31140 ....................................................... Louisville-Jefferson County, KY-IN ............................................................................... 0.8862 

Clark County, IN.

Floyd County, IN.

Harrison County, IN.

Washington County, IN.

Bullitt County, KY.

Henry County, KY.

Meade County, KY.

Nelson County, KY.

Oldham County, KY.

Shelby County, KY.

Spencer County, KY.

Trimble County, KY.

31180 ....................................................... Lubbock, TX .................................................................................................................. 0.8870 

Crosby County, TX.

Lubbock County, TX.

31340 ....................................................... Lynchburg, VA ............................................................................................................... 0.8615 

Amherst County, VA.

Appomattox County, VA.

Bedford County, VA.

Campbell County, VA.

Bedford City, VA.

Lynchburg City, VA.

31420 ....................................................... Macon, GA .................................................................................................................... 0.8584 

Bibb County, GA.

Crawford County, GA.

Jones County, GA.

Monroe County, GA.

Twiggs County, GA.

31460 ....................................................... Madera-Chowchilla, CA ................................................................................................. 0.8050 

Madera County, CA.

31540 ....................................................... Madison, WI .................................................................................................................. 1.1264 

Columbia County, WI.

Dane County, WI.

Iowa County, WI.

31700 ....................................................... Manchester-Nashua, NH ............................................................................................... 1.0042 

Hillsborough County, NH.

31740 ....................................................... Manhattan, KS ............................................................................................................... 0.7839 

Geary County, KS.

Pottawatomie County, KS.

Riley County, KS.

31860 ....................................................... Mankato-North Mankato, MN ........................................................................................ 0.9413 

Blue Earth County, MN.

Nicollet County, MN.

31900 ....................................................... Mansfield, OH ................................................................................................................ 0.8993 

Richland County, OH.

32420 ....................................................... Mayagu ̈ez, PR ............................................................................................................... 0.3586 

Hormigueros Municipio, PR.

Mayagu ̈ez Municipio, PR.

32580 ....................................................... McAllen-Edinburg-Mission, TX ...................................................................................... 0.8603 

Hidalgo County, TX.

32780 ....................................................... Medford, OR .................................................................................................................. 1.0400 

Jackson County, OR.

32820 ....................................................... Memphis, TN-MS-AR .................................................................................................... 0.9049 

Crittenden County, AR.

DeSoto County, MS.

Marshall County, MS.

Tate County, MS.

Tunica County, MS.

Fayette County, TN.

Shelby County, TN.

Tipton County, TN.

32900 ....................................................... Merced, CA ................................................................................................................... 1.2996 

Merced County, CA.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

33124 ....................................................... Miami-Miami Beach-Kendall, FL ................................................................................... 1.0130 

Miami-Dade County, FL.

33140 ....................................................... Michigan City-La Porte, IN ............................................................................................ 0.9694 

LaPorte County, IN.

33260 ....................................................... Midland, TX ................................................................................................................... 1.0640 

Midland County, TX.

33340 ....................................................... Milwaukee-Waukesha-West Allis, WI ............................................................................ 0.9931 

Milwaukee County, WI.

Ozaukee County, WI.

Washington County, WI.

Waukesha County, WI.

33460 ....................................................... Minneapolis-St. Paul-Bloomington, MN-WI ................................................................... 1.1336 

Anoka County, MN.

Carver County, MN.

Chisago County, MN.

Dakota County, MN.

Hennepin County, MN.

Isanti County, MN.

Ramsey County, MN.

Scott County, MN.

Sherburne County, MN.

Washington County, MN.

Wright County, MN.

Pierce County, WI.

St. Croix County, WI.

33540 ....................................................... Missoula, MT ................................................................................................................. 0.9001 

Missoula County, MT.

33660 ....................................................... Mobile, AL ..................................................................................................................... 0.7467 

Mobile County, AL.

33700 ....................................................... Modesto, CA .................................................................................................................. 1.2841 

Stanislaus County, CA.

33740 ....................................................... Monroe, LA .................................................................................................................... 0.7717 

Ouachita Parish, LA.

Union Parish, LA.

33780 ....................................................... Monroe, MI .................................................................................................................... 0.8472 

Monroe County, MI.

33860 ....................................................... Montgomery, AL ............................................................................................................ 0.7858 

Autauga County, AL.

Elmore County, AL.

Lowndes County, AL.

Montgomery County, AL.

34060 ....................................................... Morgantown, WV ........................................................................................................... 0.8284 

Monongalia County, WV.

Preston County, WV.

34100 ....................................................... Morristown, TN .............................................................................................................. 0.6768 

Grainger County, TN.

Hamblen County, TN.

Jefferson County, TN.

34580 ....................................................... Mount Vernon-Anacortes, WA ...................................................................................... 1.0340 

Skagit County, WA.

34620 ....................................................... Muncie, IN ..................................................................................................................... 0.8734 

Delaware County, IN.

34740 ....................................................... Muskegon-Norton Shores, MI ....................................................................................... 1.1007 

Muskegon County, MI.

34820 ....................................................... Myrtle Beach-North Myrtle Beach-Conway, SC ............................................................ 0.8717 

Horry County, SC.

34900 ....................................................... Napa, CA ....................................................................................................................... 1.6045 

Napa County, CA.

34940 ....................................................... Naples-Marco Island, FL ............................................................................................... 0.9265 

Collier County, FL.

34980 ....................................................... Nashville-Davidson-Murfreesboro-Franklin, TN ............................................................ 0.9061 

Cannon County, TN.

Cheatham County, TN.

Davidson County, TN.

Dickson County, TN.

Hickman County, TN.

Macon County, TN.

Robertson County, TN.

Rutherford County, TN.

Smith County, TN.

Sumner County, TN.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Trousdale County, TN.

Williamson County, TN.

Wilson County, TN.

35004 ....................................................... Nassau-Suffolk, NY ....................................................................................................... 1.2698 

Nassau County, NY.

Suffolk County, NY.

35084 ....................................................... Newark-Union, NJ-PA ................................................................................................... 1.1223 

Essex County, NJ.

Hunterdon County, NJ.

Morris County, NJ.

Sussex County, NJ.

Union County, NJ.

Pike County, PA.

35300 ....................................................... New Haven-Milford, CT ................................................................................................. 1.2061 

New Haven County, CT.

35380 ....................................................... New Orleans-Metairie-Kenner, LA ................................................................................ 0.8932 

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 ........................................................................ 1.2914 

Bergen County, NJ.

Hudson County, NJ.

Passaic County, NJ.

Bronx County, NY.

Kings County, NY.

New York County, NY.

Putnam County, NY.

Queens County, NY.

Richmond County, NY.

Rockland County, NY.

Westchester County, NY.

35660 ....................................................... Niles-Benton Harbor, MI ................................................................................................ 0.8237 

Berrien County, MI.

35840 ....................................................... North Port-Bradenton-Sarasota-Venice, FL .................................................................. 0.9375 

Manatee County, FL.

Sarasota County, FL.

35980 ....................................................... Norwich-New London, CT ............................................................................................. 1.1376 

New London County, CT.

36084 ....................................................... Oakland-Fremont-Hayward, CA .................................................................................... 1.6654 

Alameda County, CA.

Contra Costa County, CA.

36100 ....................................................... Ocala, FL ....................................................................................................................... 0.8455 

Marion County, FL.

36140 ....................................................... Ocean City, NJ .............................................................................................................. 1.0307 

Cape May County, NJ.

36220 ....................................................... Odessa, TX ................................................................................................................... 0.9741 

Ector County, TX.

36260 ....................................................... Ogden-Clearfield, UT .................................................................................................... 0.9031 

Davis County, UT.

Morgan County, UT.

Weber County, UT.

36420 ....................................................... Oklahoma City, OK ....................................................................................................... 0.8810 

Canadian County, OK.

Cleveland County, OK.

Grady County, OK.

Lincoln County, OK.

Logan County, OK.

McClain County, OK.

Oklahoma County, OK.

36500 ....................................................... Olympia, WA ................................................................................................................. 1.1397 

Thurston County, WA.

36540 ....................................................... Omaha-Council Bluffs, NE-IA ........................................................................................ 1.0037 

Harrison County, IA.

Mills County, IA.

Pottawattamie County, IA.

Cass County, NE.

Douglas County, NE.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Sarpy County, NE.

Saunders County, NE.

Washington County, NE.

36740 ....................................................... Orlando-Kissimmee, FL ................................................................................................. 0.9082 

Lake County, FL.

Orange County, FL.

Osceola County, FL.

Seminole County, FL.

36780 ....................................................... Oshkosh-Neenah, WI .................................................................................................... 0.9433 

Winnebago County, WI.

36980 ....................................................... Owensboro, KY ............................................................................................................. 0.8117 

Daviess County, KY.

Hancock County, KY.

McLean County, KY.

37100 ....................................................... Oxnard-Thousand Oaks-Ventura, CA ........................................................................... 1.3079 

Ventura County, CA.

37340 ....................................................... Palm Bay-Melbourne-Titusville, FL ............................................................................... 0.8838 

Brevard County, FL.

37380 ....................................................... Palm Coast, FL ............................................................................................................. 0.9880 

Flagler County, FL.

37460 ....................................................... Panama City-Lynn Haven-Panama City Beach, FL ..................................................... 0.7976 

Bay County, FL.

37620 ....................................................... Parkersburg-Marietta-Vienna, WV-OH .......................................................................... 0.7487 

Washington County, OH.

Pleasants County, WV.

Wirt County, WV.

Wood County, WV.

37700 ....................................................... Pascagoula, MS ............................................................................................................ 0.7662 

George County, MS.

Jackson County, MS.

37764 ....................................................... Peabody, MA ................................................................................................................. 1.0551 

Essex County, MA.

37860 ....................................................... Pensacola-Ferry Pass-Brent, FL ................................................................................... 0.7819 

Escambia County, FL.

Santa Rosa County, FL.

37900 ....................................................... Peoria, IL ....................................................................................................................... 0.8882 

Marshall County, IL.

Peoria County, IL.

Stark County, IL.

Tazewell County, IL.

Woodford County, IL.

37964 ....................................................... Philadelphia, PA ............................................................................................................ 1.0806 

Bucks County, PA.

Chester County, PA.

Delaware County, PA.

Montgomery County, PA.

Philadelphia County, PA.

38060 ....................................................... Phoenix-Mesa-Scottsdale, AZ ....................................................................................... 1.0477 

Maricopa County, AZ.

Pinal County, AZ.

38220 ....................................................... Pine Bluff, AR ................................................................................................................ 0.7847 

Cleveland County, AR.

Jefferson County, AR.

Lincoln County, AR.

38300 ....................................................... Pittsburgh, PA ............................................................................................................... 0.8585 

Allegheny County, PA.

Armstrong County, PA.

Beaver County, PA.

Butler County, PA.

Fayette County, PA.

Washington County, PA.

Westmoreland County, PA.

38340 ....................................................... Pittsfield, MA ................................................................................................................. 1.0721 

Berkshire County, MA.

38540 ....................................................... Pocatello, ID .................................................................................................................. 0.9555 

Bannock County, ID.

Power County, ID.

38660 ....................................................... Ponce, PR ..................................................................................................................... 0.4314 

Juana Dı ́az Municipio, PR.

Ponce Municipio, PR.

Villalba Municipio, PR.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

38860 ....................................................... Portland-South Portland-Biddeford, ME ........................................................................ 0.9975 

Cumberland County, ME.

Sagadahoc County, ME.

York County, ME.

38900 ....................................................... Portland-Vancouver-Beaverton, OR-WA ....................................................................... 1.1673 

Clackamas County, OR.

Columbia County, OR.

Multnomah County, OR.

Washington County, OR.

Yamhill County, OR.

Clark County, WA.

Skamania County, WA.

38940 ....................................................... Port St. Lucie, FL .......................................................................................................... 0.9577 

Martin County, FL.

St. Lucie County, FL.

39100 ....................................................... Poughkeepsie-Newburgh-Middletown, NY .................................................................... 1.1325 

Dutchess County, NY.

Orange County, NY.

39140 ....................................................... Prescott, AZ ................................................................................................................... 1.2009 

Yavapai County, AZ.

39300 ....................................................... Providence-New Bedford-Fall River, RI-MA ................................................................. 1.0699 

Bristol County, MA.

Bristol County, RI.

Kent County, RI.

Newport County, RI.

Providence County, RI.

Washington County, RI.

39340 ....................................................... Provo-Orem, UT ............................................................................................................ 0.9133 

Juab County, UT.

Utah County, UT.

39380 ....................................................... Pueblo, CO .................................................................................................................... 0.8518 

Pueblo County, CO.

39460 ....................................................... Punta Gorda, FL ............................................................................................................ 0.8590 

Charlotte County, FL.

39540 ....................................................... Racine, WI ..................................................................................................................... 0.9158 

Racine County, WI.

39580 ....................................................... Raleigh-Cary, NC .......................................................................................................... 0.9488 

Franklin County, NC.

Johnston County, NC.

Wake County, NC.

39660 ....................................................... Rapid City, SD ............................................................................................................... 0.9823 

Meade County, SD.

Pennington County, SD.

39740 ....................................................... Reading, PA .................................................................................................................. 0.9072 

Berks County, PA.

39820 ....................................................... Redding, CA .................................................................................................................. 1.4555 

Shasta County, CA.

39900 ....................................................... Reno-Sparks, NV .......................................................................................................... 1.0328 

Storey County, NV.

Washoe County, NV.

40060 ....................................................... Richmond, VA ............................................................................................................... 0.9695 

Amelia County, VA.

Caroline County, VA.

Charles City County, VA.

Chesterfield County, VA.

Cumberland County, VA.

Dinwiddie County, VA.

Goochland County, VA.

Hanover County, VA.

Henrico County, VA.

King and Queen County, VA.

King William County, VA.

Louisa County, VA.

New Kent County, VA.

Powhatan County, VA.

Prince George County, VA.

Sussex County, VA.

Colonial Heights City, VA.

Hopewell City, VA.

Petersburg City, VA.

Richmond City, VA.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

40140 ....................................................... Riverside-San Bernardino-Ontario, CA ......................................................................... 1.1396 

Riverside County, CA.

San Bernardino County, CA.

40220 ....................................................... Roanoke, VA ................................................................................................................. 0.9088 

Botetourt County, VA.

Craig County, VA.

Franklin County, VA.

Roanoke County, VA.

Roanoke City, VA.

Salem City, VA.

40340 ....................................................... Rochester, MN .............................................................................................................. 1.0708 

Dodge County, MN.

Olmsted County, MN.

Wabasha County, MN.

40380 ....................................................... Rochester, NY ............................................................................................................... 0.8704 

Livingston County, NY.

Monroe County, NY.

Ontario County, NY.

Orleans County, NY.

Wayne County, NY.

40420 ....................................................... Rockford, IL ................................................................................................................... 0.9935 

Boone County, IL.

Winnebago County, IL.

40484 ....................................................... Rockingham County-Strafford County, NH ................................................................... 1.0234 

Rockingham County, NH.

Strafford County, NH.

40580 ....................................................... Rocky Mount, NC .......................................................................................................... 0.8898 

Edgecombe County, NC.

Nash County, NC.

40660 ....................................................... Rome, GA ...................................................................................................................... 0.8844 

Floyd County, GA.

40900 ....................................................... Sacramento-Arden-Arcade-Roseville, CA ..................................................................... 1.4752 

El Dorado County, CA.

Placer County, CA.

Sacramento County, CA.

Yolo County, CA.

40980 ....................................................... Saginaw-Saginaw Township North, MI ......................................................................... 0.8820 

Saginaw County, MI.

41060 ....................................................... St. Cloud, MN ................................................................................................................ 1.1010 

Benton County, MN.

Stearns County, MN.

41100 ....................................................... St. George, UT .............................................................................................................. 0.8870 

Washington County, UT.

41140 ....................................................... St. Joseph, MO-KS ....................................................................................................... 0.9856 

Doniphan County, KS.

Andrew County, MO.

Buchanan County, MO.

DeKalb County, MO.

41180 ....................................................... St. Louis, MO-IL ............................................................................................................ 0.9420 

Bond County, IL.

Calhoun County, IL.

Clinton County, IL.

Jersey County, IL.

Macoupin County, IL.

Madison County, IL.

Monroe County, IL.

St. Clair County, IL.

Crawford County, MO.

Franklin County, MO.

Jefferson County, MO.

Lincoln County, MO.

St. Charles County, MO.

St. Louis County, MO.

Warren County, MO.

Washington County, MO.

St. Louis City, MO.

41420 ....................................................... Salem, OR ..................................................................................................................... 1.1069 

Marion County, OR.

Polk County, OR.

41500 ....................................................... Salinas, CA .................................................................................................................... 1.6074 

Monterey County, CA.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

41540 ....................................................... Salisbury, MD ................................................................................................................ 0.9260 

Somerset County, MD.

Wicomico County, MD.

41620 ....................................................... Salt Lake City, UT ......................................................................................................... 0.9063 

Salt Lake County, UT.

Summit County, UT.

Tooele County, UT.

41660 ....................................................... San Angelo, TX ............................................................................................................. 0.8221 

Irion County, TX.

Tom Green County, TX.

41700 ....................................................... San Antonio, TX ............................................................................................................ 0.8936 

Atascosa County, TX.

Bandera County, TX.

Bexar County, TX.

Comal County, TX.

Guadalupe County, TX.

Kendall County, TX.

Medina County, TX.

Wilson County, TX.

41740 ....................................................... San Diego-Carlsbad-San Marcos, CA .......................................................................... 1.1922 

San Diego County, CA.

41780 ....................................................... Sandusky, OH ............................................................................................................... 0.8347 

Erie County, OH.

41884 ....................................................... San Francisco-San Mateo-Redwood City, CA .............................................................. 1.6327 

Marin County, CA.

San Francisco County, CA.

San Mateo County, CA.

41900 ....................................................... San Germa ́n-Cabo Rojo, PR ........................................................................................ 0.4804 

Cabo Rojo Municipio, PR.

Lajas Municipio, PR.

Sabana Grande Municipio, PR.

San Germa ́n Municipio, PR.

41940 ....................................................... San Jose-Sunnyvale-Santa Clara, CA .......................................................................... 1.7396 

San Benito County, CA.

Santa Clara County, CA.

41980 ....................................................... San Juan-Caguas-Guaynabo, PR ................................................................................. 0.4318 

Aguas Buenas Municipio, PR.

Aibonito Municipio, PR.

Arecibo Municipio, PR.

Barceloneta Municipio, PR.

Barranquitas Municipio, PR.

Bayamo ́n Municipio, PR.

Caguas Municipio, PR.

Camuy Municipio, PR.

Cano ́vanas Municipio, PR.

Carolina Municipio, PR.

Catan ̃o Municipio, PR.

Cayey Municipio, PR.

Ciales Municipio, PR.

Cidra Municipio, PR.

Comerı ́o Municipio, PR.

Corozal Municipio, PR.

Dorado Municipio, PR.

Florida Municipio, PR.

Guaynabo Municipio, PR.

Gurabo Municipio, PR.

Hatillo Municipio, PR.

Humacao Municipio, PR.

Juncos Municipio, PR.

Las Piedras Municipio, PR.

Loı ́za Municipio, PR.

Manatı ́ Municipio, PR.

Maunabo Municipio, PR.

Morovis Municipio, PR.

Naguabo Municipio, PR.

Naranjito Municipio, PR.

Orocovis Municipio, PR.

Quebradillas Municipio, PR.

Rı ́o Grande Municipio, PR.

San Juan Municipio, PR.

San Lorenzo Municipio, PR.

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TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

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 ............................................................................... 1.3081 

San Luis Obispo County, CA.

42044 ....................................................... Santa Ana-Anaheim-Irvine, CA ..................................................................................... 1.2038 

Orange County, CA.

42060 ....................................................... Santa Barbara-Santa Maria-Goleta, CA ....................................................................... 1.2670 

Santa Barbara County, CA.

42100 ....................................................... Santa Cruz-Watsonville, CA .......................................................................................... 1.8062 

Santa Cruz County, CA.

42140 ....................................................... Santa Fe, NM ................................................................................................................ 1.0400 

Santa Fe County, NM.

42220 ....................................................... Santa Rosa-Petaluma, CA ............................................................................................ 1.6440 

Sonoma County, CA.

42340 ....................................................... Savannah, GA ............................................................................................................... 0.8968 

Bryan County, GA.

Chatham County, GA.

Effingham County, GA.

42540 ....................................................... Scranton-Wilkes-Barre, PA ........................................................................................... 0.8260 

Lackawanna County, PA.

Luzerne County, PA.

Wyoming County, PA.

42644 ....................................................... Seattle-Bellevue-Everett, WA ........................................................................................ 1.1771 

King County, WA.

Snohomish County, WA.

42680 ....................................................... Sebastian-Vero Beach, FL ............................................................................................ 0.8850 

Indian River County, FL.

43100 ....................................................... Sheboygan, WI .............................................................................................................. 0.9515 

Sheboygan County, WI.

43300 ....................................................... Sherman-Denison, TX ................................................................................................... 0.8544 

Grayson County, TX.

43340 ....................................................... Shreveport-Bossier City, LA .......................................................................................... 0.8412 

Bossier Parish, LA.

Caddo Parish, LA.

De Soto Parish, LA.

43580 ....................................................... Sioux City, IA-NE-SD .................................................................................................... 0.9010 

Woodbury County, IA.

Dakota County, NE.

Dixon County, NE.

Union County, SD.

43620 ....................................................... Sioux Falls, SD .............................................................................................................. 0.8338 

Lincoln County, SD.

McCook County, SD.

Minnehaha County, SD.

Turner County, SD.

43780 ....................................................... South Bend-Mishawaka, IN-MI ..................................................................................... 0.9531 

St. Joseph County, IN.

Cass County, MI.

43900 ....................................................... Spartanburg, SC ............................................................................................................ 0.9186 

Spartanburg County, SC.

44060 ....................................................... Spokane, WA ................................................................................................................ 1.0824 

Spokane County, WA.

44100 ....................................................... Springfield, IL ................................................................................................................ 0.9179 

Menard County, IL.

Sangamon County, IL.

44140 ....................................................... Springfield, MA .............................................................................................................. 1.0377 

Franklin County, MA.

Hampden County, MA.

Hampshire County, MA.

44180 ....................................................... Springfield, MO .............................................................................................................. 0.8581 

Christian County, MO.

Dallas County, MO.

Greene County, MO.

Polk County, MO.

Webster County, MO.

44220 ....................................................... Springfield, OH .............................................................................................................. 0.9236 

Clark County, OH.

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46774 Federal Register / Vol. 78, No. 148 / Thursday, August 1, 2013 / Notices 

TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

44300 ....................................................... State College, PA .......................................................................................................... 0.9510 

Centre County, PA.

44600 ....................................................... Steubenville-Weirton, OH-WV ....................................................................................... 0.7640 

Jefferson County, OH.

Brooke County, WV.

Hancock County, WV.

44700 ....................................................... Stockton, CA ................................................................................................................. 1.3356 

San Joaquin County, CA.

44940 ....................................................... Sumter, SC .................................................................................................................... 0.7454 

Sumter County, SC.

45060 ....................................................... Syracuse, NY ................................................................................................................ 0.9829 

Madison County, NY.

Onondaga County, NY.

Oswego County, NY.

45104 ....................................................... Tacoma, WA .................................................................................................................. 1.1741 

Pierce County, WA.

45220 ....................................................... Tallahassee, FL ............................................................................................................. 0.8521 

Gadsden County, FL.

Jefferson County, FL.

Leon County, FL.

Wakulla County, FL.

45300 ....................................................... Tampa-St. Petersburg-Clearwater, FL .......................................................................... 0.9032 

Hernando County, FL.

Hillsborough County, FL.

Pasco County, FL.

Pinellas County, FL.

45460 ....................................................... Terre Haute, IN ............................................................................................................. 0.9113 

Clay County, IN.

Sullivan County, IN.

Vermillion County, IN.

Vigo County, IN.

45500 ....................................................... Texarkana, TX-Texarkana, AR ..................................................................................... 0.7967 

Miller County, AR.

Bowie County, TX.

45780 ....................................................... Toledo, OH .................................................................................................................... 0.9034 

Fulton County, OH.

Lucas County, OH.

Ottawa County, OH.

Wood County, OH.

45820 ....................................................... Topeka, KS .................................................................................................................... 0.8969 

Jackson County, KS.

Jefferson County, KS.

Osage County, KS.

Shawnee County, KS.

Wabaunsee County, KS.

45940 ....................................................... Trenton-Ewing, NJ ......................................................................................................... 1.0360 

Mercer County, NJ.

46060 ....................................................... Tucson, AZ .................................................................................................................... 0.9065 

Pima County, AZ.

46140 ....................................................... Tulsa, OK ...................................................................................................................... 0.8139 

Creek County, OK.

Okmulgee County, OK.

Osage County, OK.

Pawnee County, OK.

Rogers County, OK.

Tulsa County, OK.

Wagoner County, OK.

46220 ....................................................... Tuscaloosa, AL .............................................................................................................. 0.8533 

Greene County, AL.

Hale County, AL.

Tuscaloosa County, AL.

46340 ....................................................... Tyler, TX ........................................................................................................................ 0.8361 

Smith County, TX.

46540 ....................................................... Utica-Rome, NY ............................................................................................................ 0.8653 

Herkimer County, NY.

Oneida County, NY.

46660 ....................................................... Valdosta, GA ................................................................................................................. 0.7918 

Brooks County, GA.

Echols County, GA.

Lanier County, GA.

Lowndes County, GA.

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Federal Register / Vol. 78, No. 148 / Thursday, August 1, 2013 / Notices 46775 

TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

46700 ....................................................... Vallejo-Fairfield, CA ....................................................................................................... 1.5844 

Solano County, CA.

47020 ....................................................... Victoria, TX .................................................................................................................... 0.8992 

Calhoun County, TX.

Goliad County, TX.

Victoria County, TX.

47220 ....................................................... Vineland-Millville-Bridgeton, NJ ..................................................................................... 1.0596 

Cumberland County, NJ.

47260 ....................................................... Virginia Beach-Norfolk-Newport News, VA-NC ............................................................ 0.9208 

Currituck County, NC.

Gloucester County, VA.

Isle of Wight County, VA.

James City County, VA.

Mathews County, VA.

Surry County, VA.

York County, VA.

Chesapeake City, VA.

Hampton City, VA.

Newport News City, VA.

Norfolk City, VA.

Poquoson City, VA.

Portsmouth City, VA.

Suffolk City, VA.

Virginia Beach City, VA.

Williamsburg City, VA.

47300 ....................................................... Visalia-Porterville, CA .................................................................................................... 1.0349 

Tulare County, CA.

47380 ....................................................... Waco, TX ....................................................................................................................... 0.8458 

McLennan County, TX.

47580 ....................................................... Warner Robins, GA ....................................................................................................... 0.8197 

Houston County, GA.

47644 ....................................................... Warren-Troy-Farmington Hills, MI ................................................................................. 0.9543 

Lapeer County, MI.

Livingston County, MI.

Macomb County, MI.

Oakland County, MI.

St. Clair County, MI.

47894 ....................................................... Washington-Arlington-Alexandria, DC-VA-MD-WV ....................................................... 1.0659 

District of Columbia, DC.

Calvert County, MD.

Charles County, MD.

Prince George’s County, MD.

Arlington County, VA.

Clarke County, VA.

Fairfax County, VA.

Fauquier County, VA.

Loudoun County, VA.

Prince William County, VA.

Spotsylvania County, VA.

Stafford County, VA.

Warren County, VA.

Alexandria City, VA.

Fairfax City, VA.

Falls Church City, VA.

Fredericksburg City, VA.

Manassas City, VA.

Manassas Park City, VA.

Jefferson County, WV.

47940 ....................................................... Waterloo-Cedar Falls, IA ............................................................................................... 0.8422 

Black Hawk County, IA.

Bremer County, IA.

Grundy County, IA.

48140 ....................................................... Wausau, WI ................................................................................................................... 0.8921 

Marathon County, WI.

48300 ....................................................... Wenatchee-East Wenatchee, WA ................................................................................. 1.0037 

Chelan County, WA.

Douglas County, WA.

48424 ....................................................... West Palm Beach-Boca Raton-Boynton Beach, FL ..................................................... 0.9661 

Palm Beach County, FL.

48540 ....................................................... Wheeling, WV-OH ......................................................................................................... 0.6863 

Belmont County, OH.

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46776 Federal Register / Vol. 78, No. 148 / Thursday, August 1, 2013 / Notices 

TABLE 1—FY 2014 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) Wage index 

Marshall County, WV.

Ohio County, WV.

48620 ....................................................... Wichita, KS .................................................................................................................... 0.8681 

Butler County, KS.

Harvey County, KS.

Sedgwick County, KS.

Sumner County, KS.

48660 ....................................................... Wichita Falls, TX ........................................................................................................... 0.9048 

Archer County, TX.

Clay County, TX.

Wichita County, TX.

48700 ....................................................... Williamsport, PA ............................................................................................................ 0.8230 

Lycoming County, PA.

48864 ....................................................... Wilmington, DE-MD-NJ ................................................................................................. 1.0687 

New Castle County, DE.

Cecil County, MD.

Salem County, NJ.

48900 ....................................................... Wilmington, NC ............................................................................................................. 0.9155 

Brunswick County, NC.

New Hanover County, NC.

Pender County, NC.

49020 ....................................................... Winchester, VA-WV ....................................................................................................... 0.9249 

Frederick County, VA.

Winchester City, VA.

Hampshire County, WV.

49180 ....................................................... Winston-Salem, NC ....................................................................................................... 0.8660 

Davie County, NC.

Forsyth County, NC.

Stokes County, NC.

Yadkin County, NC.

49340 ....................................................... Worcester, MA ............................................................................................................... 1.1205 

Worcester County, MA.

49420 ....................................................... Yakima, WA ................................................................................................................... 1.0097 

Yakima County, WA.

49500 ....................................................... Yauco, PR ..................................................................................................................... 0.4059 

Gua ́nica Municipio, PR.

Guayanilla Municipio, PR.

Pen ̃uelas Municipio, PR.

Yauco Municipio, PR.

49620 ....................................................... York-Hanover, PA ......................................................................................................... 0.9557 

York County, PA.

49660 ....................................................... Youngstown-Warren-Boardman, OH-PA ...................................................................... 0.8283 

Mahoning County, OH.

Trumbull County, OH.

Mercer County, PA.

49700 ....................................................... Yuba City, CA1 ............................................................................................................. 1.2004 

Sutter County, CA.

Yuba County, CA.

49740 ....................................................... Yuma, AZ ...................................................................................................................... 0.9517 

Yuma County, AZ.

1At this time, there are no hospitals located in this urban area on which to base a wage index. 

TABLE 2—FY 2014 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS

State 

code Nonurban area Wage index 

1 ........... Alabama ..................... 0.7121 

2 ........... Alaska ........................ 1.2807 

3 ........... Arizona ....................... 0.9182 

4 ........... Arkansas .................... 0.7350 

5 ........... California .................... 1.2567 

6 ........... Colorado .................... 1.0208 

7 ........... Connecticut ................ 1.1128 

8 ........... Delaware .................... 1.0171 

10 ......... Florida ........................ 0.8062 

11 ......... Georgia ...................... 0.7421 

TABLE 2—FY 2014 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS—Continued 

State 

code Nonurban area Wage index 

12 ......... Hawaii ........................ 1.0728 

13 ......... Idaho .......................... 0.7583 

14 ......... Illinois ......................... 0.8438 

15 ......... Indiana ....................... 0.8472 

16 ......... Iowa ........................... 0.8351 

17 ......... Kansas ....................... 0.7997 

18 ......... Kentucky .................... 0.7877 

19 ......... Louisiana .................... 0.7718 

20 ......... Maine ......................... 0.8300 

TABLE 2—FY 2014 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS—Continued 

State 

code Nonurban area Wage index 

21 ......... Maryland .................... 0.8797 

22 ......... Massachusetts ........... 1.3540 

23 ......... Michigan ..................... 0.8387 

24 ......... Minnesota .................. 0.9053 

25 ......... Mississippi .................. 0.7537 

26 ......... Missouri ...................... 0.7622 

27 ......... Montana ..................... 0.8600 

28 ......... Nebraska .................... 0.8733 

29 ......... Nevada ....................... 0.9739 

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Federal Register / Vol. 78, No. 148 / Thursday, August 1, 2013 / Notices 46777 

TABLE 2—FY 2014 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS—Continued 

State 

code Nonurban area Wage index 

30 ......... New Hampshire ......... 1.0372 

31 ......... New Jersey 1 ..............

32 ......... New Mexico ............... 0.8879 

33 ......... New York ................... 0.8199 

34 ......... North Carolina ............ 0.8271 

35 ......... North Dakota .............. 0.6891 

36 ......... Ohio ........................... 0.8470 

37 ......... Oklahoma ................... 0.7783 

38 ......... Oregon ....................... 0.9500 

39 ......... Pennsylvania .............. 0.8380 

40 ......... Puerto Rico 1 .............. 0.4047 

41 ......... Rhode Island 1 ...........

TABLE 2—FY 2014 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS—Continued 

State 

code Nonurban area Wage index 

42 ......... South Carolina ........... 0.8338 

43 ......... South Dakota ............. 0.8124 

44 ......... Tennessee ................. 0.7559 

45 ......... Texas ......................... 0.7978 

46 ......... Utah ........................... 0.8516 

47 ......... Vermont ..................... 0.9725 

48 ......... Virgin Islands ............. 0.7185 

49 ......... Virginia ....................... 0.7728 

50 ......... Washington ................ 1.0092 

51 ......... West Virginia .............. 0.7333 

52 ......... Wisconsin ................... 0.9142 

53 ......... Wyoming .................... 0.9238 

TABLE 2—FY 2014 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS—Continued 

State 

code Nonurban area Wage index 

65 ......... Guam ......................... 0.9611 

1All counties within the State are classified 

as urban, with the exception of Puerto Rico. 

Puerto Rico has areas designated as rural; 

however, no short-term, acute care hospitals 

are located in the area(s) for FY 2013. The 

Puerto Rico wage index is the same as FY 

2012. 

[FR Doc. 2013–18445 Filed 7–29–13; 4:15 pm] 

BILLING CODE P 

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