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 Department of Health and Human Services Health Care Financing Administration [HCFA-1135-N]
[RIN 0938-AK13]
 AGENCY: Health Care Financing Administration (HCFA), HHS.
 ACTION: Notice.
 SUMMARY: This notice announces the annual update to the hospice wage index as required by statute. This update is effective October 1, 2000 through September 30, 2001. The wage index is used to reflect local differences in wage levels. The hospice wage index methodology and values are based on recommendations of a negotiated rulemaking advisory committee and were originally published in the 
                            **Federal Register**
                             on August 8, 1997.
 EFFECTIVE DATE: This notice is effective on October 1, 2000.
 FOR FURTHER INFORMATION CONTACT: Carol Blackford, (410) 786-5909.


SUPPLEMENTARY INFORMATION: I. Background A. Statute and Regulations Hospice Care is an approach to treatment that recognizes that the impending death of an individual warrants a change in the focus from curative care to palliative care (relief of pain and other uncomfortable symptoms). The goal of hospice care is to help terminally ill individuals continue life with minimal disruption to normal activities while remaining primarily in the home environment. A hospice uses an interdisciplinary approach to deliver medical, social, psychological, emotional, and spiritual services through use of a broad spectrum of professional and other caregivers, with the goal of making the individual as physically and emotionally comfortable as possible. Counseling and respite services are available to the family of the hospice patient. Hospice programs consider both the patient and the family as a unit of care. Section 1861(dd) of the Social Security Act (the Act) provides for coverage of hospice care for terminally ill Medicare beneficiaries who elect to receive care from a participating hospice. The statutory authority for payment to hospices participating in the Medicare program is contained in section 1814(i) of the Act. Our existing regulations under 42 CFR part 418 (issued on December 16, 1983, effective for hospice services furnished on or after November 1, 1983) establish eligibility requirements and payment standards and procedures, define covered services, and delineate the conditions a hospice must meet to be approved for participation in the Medicare program. Subpart G of Part 418 provides for payment to hospices based on one of four prospectively determined rates for each day in which a qualified Medicare beneficiary is under the care of a hospice. The four rate categories are routine home care, continuous home care, inpatient respite care, and general inpatient care. Payment rates are established for each category. The regulations at § 418.306(c), which require the rates to be adjusted by a wage index, were revised in the August 8, 1997 final rule (62 FR 42860). This rule implemented a new methodology for calculating the hospice wage index based on the recommendations of a negotiated rulemaking committee. The committee reached consensus on the methodology. We included the resulting committee statement, describing that consensus, as an appendix to the August 8, 1997 final rule (62 FR 42883). The provisions of the final hospice wage index rule are as follows: The revised hospice wage index will be calculated using the most current available hospital wage data.
                    The revised hospice wage index was phased in over a 3-year transition period. For the first year of the transition period, October 1, 1997 through September 30, 1998, a blended index was calculated by adding two-thirds of the 1983 index value for an area to one-third of the revised wage index value for that area. During the second year of the transition period, October 1, 1998 through September 30, 1999, the calculation was similar, except that the blend was one-third of the 1983 index value and two-thirds of the revised wage index value for that area. We fully implemented the revised wage index during the third transition period, October 1, 1999 through September 30, 2000.
                    All hospice wage index values of 0.8 or greater are subject to a budget-neutrality adjustment to ensure that we do not pay more in the aggregate than we would have paid under the original wage index. The budget-neutrality adjustment is calculated by multiplying the hospice wage index for a given area by the budget-neutrality adjustment factor. The budget-neutrality adjustment is to be applied annually, both during and after the transition period.
                    All hospice wage index values below 0.8 receive the greater of the following adjustments: the wage index floor, a 15-percent increase, subject to a maximum wage index value of 0.8; or, the budget-neutrality adjustment.
                    The wage index is to be updated annually, in the**Federal Register,**
                         based on the most current available hospital wage data. These data will include any changes to the definitions of Metropolitan Statistical Areas (MSA). Section 4441(a) of the Balanced Budget Act of 1997 (BBA) amended section 1814(i)(1)(C)(ii) of the Act to establish updates to hospice rates for fiscal years (FYs) 1998 through 2002. Hospice rates were to be updated by a factor equal to the market basket index, minus 1 percentage point. However, section 131(a) of the Balanced Budget Refinement Act of 1999 (BBRA) changed the payment rates for FYs 2001 and 2002 by increasing the FY 2001 rate by 0.5 percent and the FY 2002 rate by 0.75 percent. Section 131(b) of the BBRA states that any additional payments made under section 131(a) of the BBRA shall not be included in updating the hospice rates after those 2 years. B. Update to the Hospice Wage Index This annual update is effective October 1, 2000 through September 30, 2001. In accordance with the agreement signed by the Health Care Financing Administration (HCFA) and all other members of the Hospice Wage Index Negotiated Rulemaking Committee, we are using the most current HCFA hospital data available, including any changes to the definitions of MSAs. The FY 2000 hospital wage index was the most current hospital wage data available when the FY 2001 wage index values were calculated. We used the pre-reclassified and pre-floor hospital area wage index data. All wage index values are adjusted by a budget-neutrality factor of 1.065425 and are subject to the wage index floor adjustment, if applicable. We have completed all of the calculations described above and included them in the wage index values reflected in both Tables A and B below. A detailed description of the method used to compute the hospice wage index is contained in both the September 4, 1996 proposed rule (61 FR 46579) and the August 8, 1997 final rule (62 FR 42860). After the publication of the FY 2000 hospice wage index updates, we received a number of questions about the methodology used to calculate the hospice wage indices. We would like to take this opportunity to further explain the methodology used in determining the hospice wage indices. 
                        ( print page 60073) 1. Metropolitan Statistical Areas As explained in the September 4, 1996 hospice wage index proposed rule, each hospice=s labor market area would be established by the MSA definitions issued by the Office of Management and Budget (OMB) on December 28, 1992 based on the 1990 census, and updated periodically by OMB. Any changes to the MSA definitions would be effective annually and announced in the final rule updating the hospice wage index. 2. MSA Wage Index Values Lower Than Rural Values As explained above, any area not included in an MSA is considered to be nonurban and receives the statewide rural rate. We are aware that in the past, a number of MSAs have had wage index values that were lower than their rural statewide value. This difference is due to variations in local wage data as compared to national wage data. The hospice wage index is computed by dividing the hourly wage rate for an MSA or nonurban area by a national hourly wage rate. Nonurban areas could receive a higher wage index value than urban areas in the same state if the hourly wage rate in the nonurban area increased at a greater rate. C. Tables **Table A.—Hospice Wage Index for Urban Areas**
MSA code No.
Urban area (constituent counties or county equivalents) 1
Wage index 20040
Abilene, TX
0.8715Taylor, TX0060
Aguadilla, PR
0.4386Aguada, PRAguadilla, PRMoca, PR0080
Akron, OH
1.0829Portage, OHSummit, OH0120
Albany, GA
1.1052Dougherty, GALee, GA0160
Albany-Schenectady-Troy, NY
0.9328Albany, NYMontgomery, NYRensselaer, NYSaratoga, NYSchenectady, NYSchoharie, NY0200
Albuquerque, NM
0.9056Bernalillo, NMSandoval, NMValencia, NM0220
Alexandria, LA
0.8385Rapides, LA0240
Allentown-Bethlehem-Easton, PA
1.0897Carbon, PALehigh, PANorthampton, PA0280
Altoona, PA
0.9954Blair, PA0320
Amarillo, TX
0.8929Potter, TXRandall, TX0380
Anchorage, AK
1.3701Anchorage, AK0440
Ann Arbor, MI
1.2235Lenawee, MILivingston, MIWashtenaw, MI0450
Anniston, AL
0.9017Calhoun, AL0460
Appleton-Oshkosh-Neenah, WI
0.9496Calumet, WIOutagamie, WIWinnebago, WI0470
Arecibo, PR
0.5537Arecibo, PRCamuy, PRHatillo, PR0480
Asheville, NC
0.9466Buncombe, NCMadison, NC0500
Athens, GA
1.0340Clarke, GAMadison, GAOconee, GA0520
Atlanta, GA
1.0709Barrow, GABartow, GACarroll, GACherokee, GAClayton, GACobb, GACoweta, GADeKalb, GADouglas, GAFayette, GAForsyth, GAFulton, GAGwinnett, GAHenry, GANewton, GAPaulding, GAPickens, GARockdale, GASpalding, GAWalton, GA0560
Atlantic-Cape May, NJ
1.2051Atlantic, NJCape May, NJ0580
Aubrn-Opelika, AL
0.8256Lee, AL0600
Augusta-Aiken, GA-SC
0.9603Columbia, GAMcDuffie, GARichmond, GAAiken, SCEdgefield, SC0640
Austin-San Marcos, TX
0.9676Bastrop, TXCaldwell, TXHays, TXTravis, TXWilliamson, TX0680
Bakersfield, CA
1.0248Kern, CA0720
Baltimore, MD
1.0539Anne Arundel, MDBaltimore, MDBaltimore City, MDCarroll, MDHarford, MDHoward, MDQueen Anne's, MD0733
Bangor, ME
1.0239Penobscot, ME0743
Barnstable-Yarmouth, MA
1.4173Barnstable, MA0760
Baton Rouge, LA
0.9278Ascension, LAEast Baton Rouge, LALivingston, LAWest Baton Rouge, LA0840
Beaumont-Port Arthur, TX
0.9129Hardin, TXJefferson, TXOrange, TX0860
Bellingham, WA
1.2141Whatcom, WA0870
Benton Harbor, MI
0.9011Berrien, MI0875
Bergen-Passaic, NJ
1.2816Bergen, NJPassaic, NJ0880
Billings, MT
1.0696Yellowstone, MT0920
Biloxi-Gulfport-Pascagoula, MS
0.8383Hancock, MSHarrison, MSJackson, MS0960
Binghamton, NY
0.9324Broome, NYTioga, NY1000
Birmingham, AL
0.9584Blount, ALJefferson, ALSt. Clair, ALShelby, AL1010
Bismarck, ND
0.8267Burleigh, NDMorton, ND1020
Bloomington, IN
0.9155Monroe, IN1040
Bloomington-Normal, IL
0.9582McLean, IL1080
Boise City, ID
0.9654Ada, IDCanyon, ID1123
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH
1.2102Bristol, MAEssex, MAMiddlesex, MANorfolk, MAPlymouth, MASuffolk, MAWorcester, MAHillsborough, NHMerrimack, NHRockingham, NH( print page 60074)Strafford, NH1125
Boulder-Longmont, CO
1.0596Boulder, CO1145
Brazoria, TX
0.9074Brazoria, TX1150
Bremerton, WA
1.1733Kitsap, WA1240
Brownsville-Harlingen-San Benito, TX
0.9816Cameron, TX1260
Bryan-College Station, TX
0.9057Brazos, TX1280
Buffalo-Niagara Falls, NY
1.0233Erie, NYNiagara, NY1303
Burlington, VT
1.1250Chittenden, VTFranklin, VTGrand Isle, VT1310
Caguas, PR
0.5245Caguas, PRCayey, PRCidra, PRGurabo, PRSan Lorenzo, PR1320
Canton-Massillon, OH
0.9346Carroll, OHStark, OH1350
Casper, WY
0.9802Natrona, WY1360
Cedar Rapids, IA
0.9609Linn, IA1400
Champaign-Urbana, IL
0.9764Champaign, IL1440
Charleston-North Charleston, SC
0.9577Berkeley, SCCharleston, SCDorchester, SC1480
Charleston, WV
0.9691Kanawha, WVPutnam, WV1520
Charlotte-Gastonia-Rock Hill, NC-SC
1.0051Cabarrus, NCGaston, NCLincoln, NCMecklenburg, NCRowan, NCStanly, NCUnion, NCYork, SC1540
Charlottesville, VA
1.1267Albemarle, VACharlottesville City, VAFluvanna, VAGreene, VA1560
Chattanooga, TN-GA
1.0369Catoosa, GADade, GAWalker, GAHamilton, TNMarion, TN1580
Cheyenne, WY
0.8711Laramie, WY1600
Chicago, IL
1.1585Cook, ILDeKalb, ILDu Page, ILGrundy, ILKane, ILKendall, ILLake, ILMcHenry, ILWill, IL1620
Chico-Paradise, CA
1.1071Butte, CA1640
Cincinnati, OH-KY-IN
1.0035Brown, OHClermont, OHHamilton, OHWarren, OHBoone, KYCampbell, KYGallatin, KYGrant, KYKenton, KYPendleton, KYDearborn, INOhio, IN1660
Clarksville-Hopkinsville, TN-KY
0.8619Christian, KYMontgomery, TN1680
Cleveland-Lorain-Elyria, OH
1.0323Ashtabula, OHCuyahoga, OHGeauga, OHLake, OHLorain, OHMedina, OH1720
Colorado Springs, CO
0.9821El Paso, CO1740
Columbia, MO
0.9488Boone, MO1760
Columbia, SC
0.9970Lexington, SCRichland, SC1800
Columbus, GA-AL
0.9068Chattahochee, GAHarris, GAMuscogee, GARussell, AL1840
Columbus, OH
1.0556Delaware, OHFairfield, OHFranklin, OHLicking, OHMadison, OHPickaway, OH1880
Corpus Christi, TX
0.9271Nueces, TXSan Patricio, TX1890
Corvallis, Oregon
1.1813Benton, OR1900
Cumberland, MD-WV
0.9378Allegany, MDMineral, WV1920
Dallas, TX
1.0236Collin, TXDallas, TXDenton, TXEllis, TXHenderson, TXHunt, TXKaufman, TXRockwall, TX1950
Danville, VA
0.9277Danville City, VAPittsylvania, VA1960
Davenport-Moline-Rock Island, IA-IL
1.0080Scott, IAHenry, ILRock Island, IL2000
Dayton-Springfield, OH
0.9576Clark, OHGreene, OHMiami, OHMontgomery, OH2020
Daytona Beach, FL
0.9248Flagler, FLVolusia, FL2030
Decatur, AL
0.9248Lawrence, ALMorgan, AL2040
Decatur, IL
0.8867Macon, IL2080
Denver, CO
1.0857Adams, COArapahoe, CODenver, CODouglas, COJefferson, CO2120
Des Moines, IA
0.9328Dallas, IAPolk, IAWarren, IA2160
Detroit, MI
1.1104Lapeer, MIMacomb, MIMonroe, MIOakland, MISt. Clair, MIWayne, MI2180
Dothan, AL
0.8309Dale, ALHouston, AL2190
Dover, DE
0.9947Kent, DE2200
Dubuque, IA
0.9079Dubuque, IA2240
Duluth-Superior, MN-WI
1.0831St. Louis, MNDouglas, WI2281
Dutchess County, NY
1.1243Dutchess, NY2290
Eau Claire, WI
0.9544Chippewa, WIEau Claire, WI2320
El Paso, TX
0.9533El Paso, TX2330
Elkhart-Goshen, IN
0.9994Elkhart, IN2335
Elmira, NY
0.9092Chemung, NY2340
Enid, OK
0.8474Garfield, OK2360
Erie, PA
0.9614Erie, PA2400
Eugene-Springfield, OR
1.1298Lane, OR( print page 60075)2440
Evansville-Henderson, IN-KY
0.8847Posey, INVanderburgh, INWarrick, INHenderson, KY2520
Fargo-Moorhead, ND-MN
0.9185Clay, MNCass, ND2560
Fayetteville, NC
0.9051Cumberland, NC2580
Fayetteville-Springdale-Rogers, AR
0.8283Benton, ARWashington, AR2620
Flagstaff, AZ-UT
1.1026Coconino, AZKane, UT2640
Flint, MI
1.1742Genesee, MI2650
Florence, AL
0.8447Colbert, ALLauderdale, AL2655
Florence, SC
0.9183Florence, SC2670
Fort Collins-Loveland, CO
1.0977Larimer, CO2680
Ft. Lauderdale, FL
1.0839Broward, FL2700
Fort Myers-Cape Coral, FL
0.9537Lee, FL2710
Fort Pierce-Port St. Lucie, FL
1.0653Martin, FLSt. Lucie, FL2720
Fort Smith, AR-OK
0.8357Crawford, ARSebastian, ARSequoyah, OK2750
Fort Walton Beach, FL
0.9284Okaloosa, FL2760
Fort Wayne, IN
0.9692Adams, INAllen, INDe Kalb, INHuntington, INWells, INWhitley, IN2800
Fort Worth-Arlington, TX
1.0480Hood, TXJohnson, TXParker, TXTarrant, TX2840
Fresno, CA
1.0935Fresno, CAMadera, CA2880
Gadsden, AL
0.9258Etowah, AL2900
Gainesville, FL
1.0764Alachua, FL2920
Galveston-Texas City, TX
1.0370Galveston, TX2960
Gary, IN
1.0005Lake, INPorter, IN2975
Glens Falls, NY
0.9170Warren, NYWashington, NY2980
Goldsboro, NC
0.8879Wayne, NC2985
Grand Forks, ND-MN
0.9693Grand Forks, NDPolk, MN2995
Grand Junction, CO
0.9790Mesa, CO3000
Grand Rapids-Muskegon-Holland, MI
1.0799Allegan, MIKent, MIMuskegon, MIOttawa, MI3040
Great Falls, MT
1.1144Cascade, MT3060
Greeley, CO
1.0359Weld, CO3080
Green Bay, WI
0.9731Brown, WI3120
Greensboro-Winston-Salem-High Point, NC
0.9629Alamance, NCDavidson, NCDavie, NCForsyth, NCGuilford, NCRandolph, NCStokes, NCYadkin, NC3150
Greenville, NC
1.0123Pitt, NC3160
Greenville-Spartanburg-Anderson, SC
0.9790Anderson, SCCherokee, SCGreenville, SCPickens, SCSpartanburg, SC3180
Hagerstown, MD
0.9422Washington, MD3200
Hamilton-Middletown, OH
0.9532Butler, OH3240
Harrisburg-Lebanon-Carlisle, PA
1.0567Cumberland, PADauphin, PALebanon, PAPerry, PA3283
Hartford, CT
1.2483Hartford, CTLitchfield, CTMiddlesex, CTTolland, CT3285
Hattiesburg, MS
0.8134Forrest, MSLamar, MS3290
Hickory-Morganton-Lenoir, NC
0.9709Alexander, NCBurke, NCCaldwell, NCCatawba, NC3320
Honolulu, HI
1.2228Honolulu, HI3350
Houma, LA
0.8350Lafourche, LATerrebonne, LA3360
Houston, TX
1.0002Chambers, TXFort Bend, TXHarris, TXLiberty, TXMontgomery, TXWaller, TX3400
Huntington-Ashland, WV-KY-OH
1.0396Boyd, KYCarter, KYGreenup, KYLawrence, OHCabell, WVWayne, WV3440
Huntsville, AL
0.9400Limestone, ALMadison, AL3480
Indianapolis, IN
1.0434Boone, INHamilton, INHancock, INHendricks, INJohnson, INMadison, INMarion, INMorgan, INShelby, IN3500
Iowa City, IA
1.0237Johnson, IA3520
Jackson, MI
0.9419Jackson, MI3560
Jackson, MS
0.8936Hinds, MSMadison, MSRankin, MS3580
Jackson, TN
0.9164Madison, TNChester, TN3600
Jacksonville, FL
0.9544Clay, FLDuval, FLNassau, FLSt. Johns, FL3605
Jacksonville, NC
0.8367Onslow, NC3610
Jamestown, NY
0.8372Chautauqua, NY3620
Janesville-Beloit, WI
1.0289Rock, WI3640
Jersey City, NJ
1.2440Hudson, NJ3660
Johnson City-Kingsport-Bristol, TN-VA
0.9433Carter, TNHawkins, TNSullivan, TNUnicoi, TNWashington, TNBristol City, VAScott, VAWashington, VA3680
Johnstown, PA
0.9206Cambria, PASomerset, PA( print page 60076)3700
Jonesboro, AR
0.8000Craighead, AR3710
Joplin, MO
0.8181Jasper, MONewton, MO3720
Kalamazoo-Battlecreek, MI
1.0635Calhoun, MIKalamazoo, MIVan Buren, MI3740
Kankakee, IL
0.9162Kankakee, IL3760
Kansas City, KS-MO
0.9932Johnson, KSLeavenworth, KSMiami, KSWyandotte, KSCass, MOClay, MOClinton, MOJackson, MOLafayette, MOPlatte, MORay, MO3800
Kenosha, WI
0.9625Kenosha, WI3810
Killeen-Temple, TX
1.0583Bell, TXCoryell, TX3840
Knoxville, TN
0.9802Anderson, TNBlount, TNKnox, TNLoudon, TNSevier, TNUnion, TN3850
Kokomo, IN
0.9503Howard, INTipton, IN3870
La Crosse, WI-MN
0.9519Houston, MNLa Crosse, WI3880
Lafayette, LA
0.8886Acadia, LALafayette, LASt. Landry, LASt. Martin, LA3920
Lafayette, IN
0.9386Clinton, INTippecanoe, IN3960
Lake Charles, LA
0.8488Calcasieu, LA3980
Lakeland-Winter Haven, FL
0.9393Polk, FL4000
Lancaster, PA
0.9862Lancaster, PA4040
Lansing-East Lansing, MI
1.0631Clinton, MIEaton, MIIngham, MI4080
Laredo, TX
0.8868Webb, TX4100
Las Cruces, NM
0.9153Dona Ana, NM4120
Las Vegas, NV-AZ
1.1996Mohave, AZClarke, NVNye, NV4150
Lawrence, KS
0.8761Douglas, KS4200
Lawton, OK
1.0157Comanche, OK4243
Lewiston-Auburn, ME
0.9482Androscoggin, ME4280
Lexington, KY
0.9090Bourbon, KYClark, KYFayette, KYJessamine, KYMadison, KYScott, KYWoodford, KY4320
Lima, OH
0.9489Allen, OHAuglaize, OH4360
Lincoln, NE
1.0304Lancaster, NE4400
Little Rock-North Little Rock, AR
0.9179Faulkner, ARLonoke, ARPulaski, ARSaline, AR4420
Longview-Marshall, TX
0.9311Gregg, TXHarrison, TXUpshur, TX4480
Los Angeles-Long Beach, CA
1.2841Los Angeles, CA4520
Louisville, KY-IN
0.9996Clark, INFloyd, INHarrison, INScott, INBullitt, KYJefferson, KYOldham, KY4600
Lubbock, TX
0.8962Lubbock, TX4640
Lynchburg, VA
0.9392Amherst, VABedford, VABedford City, VACampbell, VALynchburg City, VA4680
Macon, GA
0.9089Bibb, GAHouston, GAJones, GAPeach, GATwiggs, GA4720
Madison, WI
1.0367Dane, WI4800
Mansfield, OH
0.9031Crawford, OHRichland, OH4840
Mayaguez, PR
0.5376Anasco, PRCabo Rojo, PRHormigueros, PRMayaguez, PRSabana Grande, PRSan German, PR4880
McAllen-Edinburg-Mission, TX
0.8652Hidalgo, TX4890
Medford-Ashland, OR
1.1180Jackson, OR4900
Melbourne-Titusville-Palm Bay, FL
0.9905Brevard, Fl4920
Memphis, TN-AR-MS
0.8784Crittenden, ARDeSoto, MSFayette, TNShelby, TNTipton, TN4940
Merced, CA
1.0950Merced, CA5000
Miami, FL
1.0904Dade, FL5015
Middlesex-Somerset-Hunterdon, NJ
1.1851Hunterdon, NJMiddlesex, NJSomerset, NJ5080
Milwaukee-Waukesha, WI
1.0490Milwaukee, WIOzaukee, WIWashington, WIWaukesha, WI5120
Minneapolis-St. Paul, MN-WI
1.1645Anoka, MNCarver, MNChisago, MN Dakota, MNHennepin, MNIsanti, MNRamsey, MNScott, MNSherbune, MNWashington, MNWright, MNPierce, WISt. Croix, WI5140
Missoula, MT
0.9681Missoula, MT5160
Mobile, AL
0.8809Baldwin, ALMobile, AL5170
Modesto, CA
1.0774Stanislaus, CA5190
Monmouth-Ocean, NJ
1.1996Monmouth, NJOcean, NJ5200
Monroe, LA
0.8760Ouachita, LA5240
Montgomery, AL
0.8208Autauga, ALElmore, ALMontgomery, AL5280
Muncie, IN
1.1544Delaware, IN5330
Myrtle Beach, SC
0.9088Horry, SC5345
Naples, FL
1.0484Collier, FL5360
Nashville, TN
1.0068Cheatham, TNDavidson, TNDickson, TNRobertson, TN( print page 60077)Rutherford TNSumner, TNWilliamson, TNWilson, TN5380
Nassau-Suffolk, NY
1.4997Nassau, NYSuffolk, NY5483
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT
1.3166Fairfield, CTNew Haven, CT5523
New London-Norwich, CT
1.3242New London, CT5560
New Orleans, LA
0.9685Jefferson, LAOrleans, LAPlaquemines, LASt. Bernard, LASt. Charles, LASt. James, LASt. John The Baptist, LASt. Tammany, LA5600
New York, NY
1.5469Bronx, NYKings, NYNew York, NYPutnam, NYQueens, NYRichmond, NYRockland, NYWestchester, NY5640
Newark, NJ
1.2409Essex, NJMorris, NJSussex, NJUnion, NJWarren, NJ5660
Newburgh, NY-PA
1.1624Orange, NYPike, PA5720
Norfolk-Virginia Beach-Newport News, VA-NC
0.8993Currituck, NCChesapeake City, VAGloucester, VAHampton City, VAJames City, VAIsle of Wight, VAMathews, VANewport News City, VANorfolk City, VAPoquoson City, VAPortsmouth City, VASuffolk City, VAVirginia Beach City VAWilliamsburg City, VAYork, VA5775
Oakland, CA
1.6044Alameda, CAContra Costa, CA5790
Ocala, FL
1.0245Marion, FL5800
Odessa-Midland, TX
0.9455Ector, TXMidland, TX5880
Oklahoma City, OK
0.9150Canadian, OKCleveland, OKLogan, OKMcClain, OKOklahoma, OKPottawatomie, OK5910
Olympia, WA
1.1648Thurston, WA5920
Omaha, NE-IA
1.1140Pottawattamie, IACass, NEDouglas, NESarpy, NEWashington, NE5945
Orange County, CA
1.2349Orange, CA5960
Orlando, FL
1.0437Lake, FLOrange, FLOsceola, FLSeminole, FL5990
Owensboro, KY
0.8635Daviess, KY6015
Panama City, FL
0.9770Bay, FL6020
Parkersburg-Marietta, WV-OH
0.8896Washington, OHWood, WV6080
Pensacola, FL
0.8995Escambia, FLSanta Rosa, FL6120
Peoria-Pekin, IL
0.8896Peoria, ILTazewell, ILWoodford, IL6160
Philadelphia, PA-NJ
1.1891Burlington, NJCamden, NJGloucester, NJSalem, NJBucks, PAChester, PADelaware, PAMontgomery, PAPhiladelphia, PA6200
Phoenix-Mesa, AZ
1.0084Maricopa, AZPinal, AZ6240
Pine Bluff, AR
0.8202Jefferson, AR6280
Pittsburgh, PA
1.0265Allegheny, PABeaver,PAButler, PAFayette, PAWashington, PAWestmoreland, PA6323
Pittsfield, MA
1.0927Berkshire, MA6340
Pocatello, ID
0.9561Bannock, ID6360
Ponce, PR
0.5717Guayanilla, PRJuana Diaz, PRPenuelas, PRPonce, PRVillalba, PRYauco, PR6403
Portland, ME
1.0096Cumberland, MESagadahoc, MEYork, ME6440
Portland-Vancouver, OR-WA
1.1694Clackamas, ORColumbia, ORMultnomah, ORWashington, ORYamhill, ORClark, WA6483
Providence-Warwick-Pawtucket, RI
1.1391Bristol, RIKent, RINewport, RIProvidence, RIWashington, RI6520
Provo-Orem, UT
1.0461Utah, UT6560
Pueblo, CO
0.9433Pueblo, CO6580
Punta Gorda, FL
0.9509Charlotte, FL6600
Racine, WI
0.9820Racine, WI6640
Raleigh-Durham-Chapel Hill, NC
1.0170Chatham, NCDurham, NCFranklin, NCJohnston, NCOrange, NCWake, NC6660
Rapid City, SD
0.8911Pennington, SD6680
Reading, PA
1.0054Berks, PA6690
Redding, CA
1.2002Shasta, CA6720
Reno, NV
1.1353Washoe, NV6740
Richland-Kennewick-Pasco, WA
1.1959Benton, WAFranklin, WA6760
Richmond-Petersburg, VA
1.0171Charles City County, VAChesterfield, VAColonial Heights City, VADinwiddie, VAGoochland, VAHanover, VAHenrico, VAHopewell City, VANew Kent, VAPetersburg City, VAPowhatan, VAPrince George, VARichmond City, VA6780
Riverside-San Bernardino, CA
1.1945Riverside, CASan Bernardino, CA( print page 60078)6800
Roanoke, VA
0.8672Botetourt, VARoanoke, VARoanoke City, VASalem City, VA6820
Rochester, MN
1.2178Olmsted, MN6840
Rochester, NY
0.9786Genesee, NYLivingston, NYMonroe, NYOntario, NYOrleans, NYWayne, NY6880
Rockford, IL
0.9359Boone, ILOgle, ILWinnebago, IL6895
Rocky Mount, NC
0.9307Edgecombe, NCNash, NC6920
Sacramento, CA
1.3089El Dorado, CAPlacer, CASacramento, CA6960
Saginaw-Bay City-Midland, MI
0.9895Bay, MIMidland, MISaginaw, MI6980
St. Cloud, MN
1.0038Benton, MNStearns, MN7000
St. Joseph, MO
0.9529Andrew, MOBuchanan, MO7040
St. Louis, MO-IL
0.9645Franklin, MOJefferson, MOLincoln, MOSt. Charles, MOSt. Louis, MOSt. Louis City, MOWarren, MOClinton, ILJersey, ILMadison, ILMonroe, ILSt. Clair, IL7080
Salem, OR
1.0601Marion, ORPolk, OR7120
Salinas, CA
1.5674Monterey, CA7160
Salt Lake City-Ogden, UT
1.0500Davis, UTSalt Lake, UTWeber, UT7200
San Angelo, TX
0.8359Tom Green, TX7240
San Antonio, TX
0.8862Bexar, TXComal, TXGuadalupe, TXWilson, TX7320
San Diego, CA
1.27127360
San Francisco, CA
1.4918Marin, CASan Francisco, CASan Mateo, CA7400
San Jose, CA
1.4500Santa Clara, CA7440
San Juan-Bayamon, PR
0.5357Aguas Buenas, PRBarceloneta, PRBayamon, PRCanovanas, PRCarolina, PRCatano, PRCeiba, PRComerio, PRCorozal, PRDorado, PRFajardo, PRFlorida, PRGuaynabo, PRHumacao, PRJuncos, PRLos Piedras, PRLoiza, PRLuguillo, PRManati, PRMorovis, PRNaguabo, PRNaranjito, PRRio Grande, PRSan Juan, PRToa Alta, PRToa Baja, PRTrujillo Alto, PRVega Alta, PRVega Baja, PRYabucoa, PR7460
San Luis Obispo-Atascadero-Paso Robles, CA
1.1156San Luis Obispo, CA7480
Santa Barbara-Santa Maria-Lompoc, CA
1.1528Santa Barbara, CA7485
Santa Cruz-Watsonville, CA
1.4840Santa Cruz, CA7490
Santa Fe, NM
1.1121Los Alamos, NMSanta Fe, NM7500
Santa Rosa, CA
1.3852Sonoma, CA7510
Sarasota-Bradenton, FL
1.0554Manatee, FLSarasota, FL7520
Savannah, GA
1.0605Bryan, GAChatham, GAEffingham, GA7560
Scranton—Wilkes-Barre—Hazleton, PA
0.8921Columbia, PALackawanna, PALuzerne, PAWyoming, PA7600
Seattle-Bellevue-Everett, WA
1.2030Island, WAKing, WASnohomish, WA7610
Sharon, PA
0.8826Mercer, PA7620
Sheboygan, WI
0.8740Sheboygan, WI7640
Sherman-Denison, TX
0.9940Grayson, TX7680
Shreveport-Bossier City, LA
0.9642Bossier, LACaddo, LAWebster, LA7720
Sioux City, IA-NE
0.9108Woodbury, IADakota, NE7760
Sioux Falls, SD
0.9351Lincoln, SDMinnehaha, SD7800
South Bend, IN
1.0435St. Joseph, IN7840
Spokane, WA
1.1507Spokane, WA7880
Springfield, IL
0.9252Menard, ILSangamon, IL7920
Springfield, MO
0.8515Christian, MOGreene, MOWebster, MO8003
Springfield, MA
1.1377Hampden, MAHampshire, MA8840
Washington, DC-MD-VA-WV
1.1778District of Columbia, DCCalvert, MDCharles, MDFrederick, MDMontgomery, MDPrince Georges, MDAlexandria City, VAArlington, VAClarke, VACulpeper, VAFairfax, VAFairfax City, VAFalls Church City, VAFauquier, VAFredericksburg City, VAKing George, VALoudoun, VAManassas City, VA( print page 60079)Manassas Park City, VAPrince William, VASpotsylvania, VAStafford, VAWarren, VABerkeley, WVJefferson, WV8920
Waterloo-Cedar Falls, IA
0.9075Black Hawk, IA8940
Wausau, WI
1.0064Marathon, WI8960
West Palm Beach-Boca Raton, FL
1.0668Palm Beach, FL9000
Wheeling, WV-OH
0.8144Belmont, OHMarshall, WVOhio, WV9040
Wichita, KS
1.0038Butler, KSHarvey, KSSedgwick, KS9080
Wichita Falls, TX
0.8154Archer, TXWichita, TX8050
State College, PA
0.9737Centre, PA8080
Steubenville-Weirton, OH-WV
0.9179Jefferson, OHBrooke, WVHancock, WV8120
Stockton-Lodi, CA
1.1207San Joaquin, CA8140
Sumter, SC
0.8778Sumter, SC8160
Syracuse, NY
1.1377Cayuga, NYMadison, NYOnondaga, NYOswego, NY8200
Tacoma, WA
1.2230Pierce, WA8240
Tallahassee, FL
0.9040Gadsden, FLLeon, FL8280
Tampa-St. Petersburg-Clearwater, FL
0.9637Hernando, FLHillsborough, FLPasco, FLPinellas, FL8320
Terre Haute, IN
0.9132Clay, INVermillion, INVigo, IN8360
Texarkana, AR-Texarkana, TX
0.8668Miller, ARBowie, TX8400
Toledo, OH
1.0458Fulton, OHLucas, OHWood, OH8440
Topeka, KS
0.9937Shawnee, KS8480
Trenton, NJ
1.0764Mercer, NJ8520
Tucson, AZ
0.9315Pima, AZ8560
Tulsa, OK
0.8616Creek, OKOsage, OKRogers, OKTulsa, OKWagoner, OK8600
Tuscaloosa, AL
0.8593Tuscaloosa, AL8640
Tyler, TX
0.9983Smith8680
Utica-Rome, NY
0.8842Herkimer, NYOneida, NY8720
Vallejo-Fairfield-Napa, CA
1.4220Napa, CASolano, CA8735
Ventura, CA
1.22068750
Victoria, TX
0.89278760
Vineland-Millville-Bridgeton, NJ
1.1206Cumberland, NJ8780
Visalia-Turlare-Porterville, CA
1.1093Tulare, CA8800
Waco, TX
0.8604McLennan, TX9140
Williamsport, PA
0.9003Lycoming, PA9160
Wilmington-Newark, DE-MD
1.2013New Castle, DECecil, MD9200
Wilmington, NC
1.0343Brunswick, NCNew Hanover, NC9260
Yakima, WA
1.1009Yakima, WA9270
Yolo, CA
1.0356Yolo, CA9280
York, PA
0.9919York, PA9320
Youngstown-Warren, OH
1.0651Columbiana, OHMahoning, OHTrumbull, OH9340
Yuba City, CA
1.1361Sutter, CAYuba, CA9360
Yuma, AZ
1.0574Yuma, AZ1
                             This column lists each MSA area name (in italics) and each county, or county equivalent, in the MSA area. Counties not listed in this Table are considered to be Rural Areas. Wage Index values for these areas are found in Table B.2
                             Wage index values are based on FY 1996 hospital cost report data before reclassification. This wage index is further adjusted. Wage index values greater than 0.8 are subject to a budget-neutrality adjustment of 1.065425. Wage index values below 0.8 are adjusted to be the greater of a 15-percent increase, subject to a maximum wage index value of 0.8, or an adjustment by multiplying the hospital wage index value for a given area by the budget-neutrality adjustment. We have completed all of these adjustments and included them in the wage index values reflected in this table.
 Table B.—Wage Index for Rural Areas
MSA code No.
Nonurban area
Wage index 19901
Alabama
0.80009902
Alaska
1.28479903
Arizona
0.91049904
Arkansas
0.80009905
California
1.06039906
Colorado
0.93919907
Connecticut
1.32269908
Delaware
0.97679910
Florida
0.95759911
Georgia
0.86259912
Hawaii
1.14309913
Idaho
0.92189914
Illinois
0.85759915
Indiana
0.89469916
Iowa
0.8446( print page 60080)9917
Kansas
0.80009918
Kentucky
0.85699919
Louisiana
0.80009920
Maine
0.92059921
Maryland
0.91979922
Massachusetts
1.21149923
Michigan
0.93929924
Minnesota
0.92379925
Mississippi
0.80009926
Missouri
0.82299927
Montana
0.89459928
Nebraska
0.85329929
Nevada
0.96939930
New Hampshire
1.05549931
New Jersey 29932
New Mexico
0.89279933
New York
0.92029934
North Carolina
0.88329935
North Dakota
0.81489936
Ohio
0.92169937
Oklahoma
0.80009938
Oregon
1.05149939
Pennsylvania
0.90839940
Puerto Rico
0.48869941
Rhode Island 29942
South Carolina
0.88059943
South Dakota
0.80739944
Tennessee
0.81529945
Texas
0.80009946
Utah
0.94909947
Vermont
1.00249948
Virgin Islands
0.72529949
Virginia
0.84219950
Washington
1.11319951
West Virginia
0.85979952
Wisconsin
0.93339953
Wyoming
0.94409965
Guam
1.02401
                             Wage index values are based on FY 1996 hospital cost report data before reclassification. This wage index is further adjusted. Wage index values greater than 0.8 are subject to a budget-neutrality adjustment of 1.065425. Wage index values below 0.8 are adjusted to be the greater of a 15-percent increase, subject to a maximum wage index value of 0.8, or an adjustment by multiplying the hospital wage index value for a given area by the budget-neutrality adjustment. We have completed all of these adjustments and have included them in the wage index values reflected in this table.2
                             All counties within the State are classified as urban.
 II. Regulatory Impact Statement We have examined the impacts of this notice as required by Executive Order 12866, the Unfunded Mandate Reform Act, and the Regulatory Flexibility Act (RFA) (Pub. L. 96-354). In this notice, we identified an impact on hospices as a result of changes in the way we compute the hospice wage index. The change in the methodology for computing the wage index was determined through a negotiated rulemaking committee and implemented in the August 8, 1997 final rule (62 FR 42860). We recognize that the BBRA adjusted hospice payments upward by 0.5 percent; however, we did not do a separate analysis of the impact of this payment adjustment. We used the new rates adjusted by the BBRA when estimating the payments to be made under the new wage index and when calculating the budget-neutrality adjustment factor. Overall, we believe the changes included in this notice to be insignificant. 1. Executive Order 12866 and RFA Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects; distributive impacts; and equity). We have determined that this notice is not an economically significant rule under this Executive Order. The RFA requires agencies to analyze options for regulatory relief for small businesses. For purposes of the RFA, States and individuals are not considered small entities. However, most providers, physicians, and health care suppliers are small entities, either by nonprofit status or by having revenues of $5 million or less annually. Approximately 73 percent of Medicare certified hospices are identified as voluntary, government, or other agencies, and, therefore, are considered small entities. Because the National Hospice Organization estimates that approximately 70 percent of hospice patients are Medicare beneficiaries, we have not considered other sources of revenue in this analysis. As discussed below, the estimated decreases in payment to hospices overall are very slight. The most significant change is an increase in estimated payments to rural areas in East and West South Central, at 4.8 and 9.1 percent, respectively. The effects of this notice on West South Central alone, indicate that 54 of the 85 hospices in urban West South Central can be considered small entities that will experience an 9.1-percent increase in Medicare payments. Therefore, we anticipate this notice will have a significant, albeit positive, impact on a substantial number of small entities. However, the methodology for the hospice wage index was previously determined by consensus through a negotiated rulemaking committee that included representatives of national hospice associations; rural, urban, large and small hospices; multi-site hospices; and consumer groups. Based on the options considered, the committee determined that the methodology described in the committee statement, and adopted into regulation in the August 8, 1997 final rule, was favorable for the hospice community as well as for beneficiaries. Therefore, we believe that mitigating any negative effects on small entities has been taken into consideration. 2. Congressional Review Section 804(2) of Title 5, United States Code (U.S.C.) (as added by section 251 of Pub. L. 104-121), specifies that a “major rule” is any rule that the Office of Management and Budget finds is likely to result in— An annual effect on the economy of $100 million or more;
                    A major increase in costs or prices for consumers, individual industries, Federal, State, or local government agencies, or geographic regions; or
                    Significant adverse effects on competition, employment, investment, productivity, innovation, or on the ability of United States-based enterprises to compete with foreign-based enterprises in domestic and export markets. We estimate that the impact of this notice will not be $100 million or more; therefore, this notice is not a major rule as defined in Title 5, United States Code, section 804(2) and is not being forwarded to the Congress for a 60-day review period. 3. Unfunded Mandate The Unfunded Mandate Reform Act of 1995 also requires (in section 202) that agencies prepare an assessment of anticipated costs and benefits for any rule that may result in an expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more in any one year. The notice has no consequential effect on State, local, or tribal governments. We believe the private sector costs of this notice fall below the threshold as well. 4. Rural Hospital Impact Section 1102(b) of the Act requires us to prepare a regulatory impact analysis for any notice that may have a significant impact on the operations of a substantial number of small rural hospitals. Such an 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 an MSA and has fewer than 50 beds. Because this notice has no direct impact on small hospitals, in accordance with 5 U.S.C. 604, the 
                        ( print page 60081)
                        Secretary certifies that this notice will not have a significant impact on the operations of a substantial number of small rural hospitals. 5. Federalism We have reviewed this notice under the threshold criteria of Executive Order 13132, Federalism, and have determined that this notice will not have any negative impact on the rights, roles, and responsibilities of State, local, or tribal governments. A. Anticipated Effects We have compared estimated payments using the FY 1983 hospice wage index to estimated payments using the FY 2001 wage index and determined the current hospice rates to be budget-neutral. As mentioned above, the negotiated rulemaking committee agreement required that we not pay more under the new wage index in the aggregate than we would have paid under the original wage index. This impact analysis compares hospice payments under the FY 2000 hospice wage index to the estimated payments using the FY 2001 wage index. The data used in developing the quantitative analysis for this notice were obtained from the March 2000 update of the national claims history file of all bills submitted during FY 1999. We deleted bills from hospices that have since closed. Table C demonstrates the results of our analysis. In Column 2 of Table C, we indicate the number of routine home care days that were included in our analysis, although the analysis was performed on all types of hospice care. Column 3 of Table C indicates payments that were made using the FY 2000 wage index. Column 4 of Table C is based on FY 1999 claims and estimates payments to be made to hospices using the FY 2001 wage index. The final column, which compares Columns 3 and 4, shows the percent change in estimated hospice payments made based on the category of the hospice. Table C categorizes hospices by various geographic and provider characteristics. The first row displays the results of the impact analysis for all Medicare certified hospices. The second and third rows of the table categorize hospices according to their geographic location (urban and rural). Our analysis indicated that there are 1,351 hospices located in urban areas and 798 hospices located in rural areas. The next two groupings in the table indicate the number of hospices by census region, also broken down by urban and rural hospices. The sixth grouping shows the impact on hospices based on the size of the hospice's program. We determined that the majority of hospice payments are made at the routine home care rate. Therefore, we based the size of each individual hospice's program on the number of routine home care days provided in 1999. The next grouping shows the impact on hospices by type of ownership. The final grouping shows the impact on hospices defined by whether they are provider-based or freestanding. The results of our analysis shows that the greatest increases in payment are for rural areas in the West and East South Central Regions, with a 9.1 percent and 4.8 percent increase, respectively. The greatest decreases in payment are for urban areas in the New England and Mountain regions, each with a 0.4 percent decrease, and for rural areas in the Middle Atlantic and Pacific regions, each with a 0.4 percent decrease. The breakdown by size, type of ownership, and facility base showed an increase in payments to all hospice programs. Small hospice programs showed significant increases of about 10 percent, while larger programs experienced only a negligible increase. Government-owned hospices showed the greatest estimated increase of 2.7 percent, while payments to voluntary hospices are expected to increase by 0.4 percent. In terms of hospice base, freestanding hospices showed the greatest estimated payment increase while home health agencies showed the smallest amount of payment increase. Table C.—Impact of Hospice Wage Index Change
Number of hospices 
                                 (1)
Number of routine home care days in thousands 
                                 (2)
Payments using FY 2000 wage index in thousands 
                                 (3)
Estimated payments using FY 2001 wage index in thousands 
                                 (4)
Percent change in Hospice payments 
                                 (5)(By geographic location):All Hospices
2,149
21,354
2,490,702
2,504,439
0.6Urban Hospices
1,351
18,120
2,185,780
2,190,590
0.2Rural Hospices
798
3,234
304,922
313,849
2.9By Region—Urban:New England
94
642
89,447
89,051
−0.4Middle Atlantic
170
2,245
290,927
291,894
0.3South Atlantic
185
4,030
509,079
511,583
0.5East North Central
224
2,862
334,861
336,694
0.5East South Central
94
1,169
123,023
123,530
0.4West North Central
96
1,061
113,167
113,498
0.3West South Central
188
2,408
261,632
261,287
−0.1Mountain
88
1,135
149,035
148,443
−0.4Pacific
183
2,325
298,138
298,086
0Puerto Rico
29
243
16,470
16,524
0.3By Region—Rural:New England
26
72
7,666
7,811
1.9Middle Atlantic
35
168
17,282
17,214
−0.4South Atlantic
117
681
63,904
65,005
1.7East North Central
136
561
53,801
54,541
1.4East South Central
81
524
48,159
50,481
4.8West North Central
174
409
37,622
38,969
3.6West South Central
85
362
29.640
32.351
9.1Mountain
87
217
21.359
22,048
3.2Pacific
54
217
24,012
23,922
−0.4( print page 60082)Puerto Rico
3
23
1,476
1,507
2.1(Skilled)Routine home care days:0-1,754 days
437
390
36,700
40,609
10.61,754-4,373 days
502
1,504
150,829
154,399
2.44,373-9,681 days
556
3,669
388,427
390,269
0.59,681 + days
653
15,449
1,875,339
1,879,969
0.2Type of ownership:Voluntary
1,351
13,975
1,638,339
1,644,677
0.4Proprietary
573
6,714
784,488
790,194
0.7Government
192
568
58,174
59,770
2.7Other
33
97
9,701
9,797
1.0Hospice base:Freestanding
874
12,368
1,451,898
1,461,421
0.7Home health agency
716
5,357
625,165
627,440
0.4Hospital
538
3,503
395,997
397,830
0.5Skilled nursing facility
21
126
17,642
17,748
0.6
 In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the Office of Management and Budget. Authority:
                        Section 1814(i) of the Social Security Act (42 U.S.C. 1395f (i)(1)). (Catalog of Federal Domestic Assistance Program No. 93.773 Medicare—Hospital Insurance Program; and No. 93.774, Medicare—Supplementary Medical Insurance Program) Dated: August 21, 2000. Nancy-Ann Min DeParle, Administrator, Health Care Financing Administration. Dated: September 22, 2000. Donna E. Shalala, Secretary.


[FR Doc. 00-25547 Filed 10-2-00; 12:23 pm] BILLING CODE 4120-01-P