[Federal Register Volume 65, Number 195 (Friday, October 6, 2000)]
[Notices]
[Pages 60072-60082]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-25547]



[[Page 60071]]

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Part VI





Department of Health and Human Services





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Health Care Financing Administration



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Medicare Program; Hospice Wage Index; Notice

Federal Register / Vol. 65, No. 195 / Friday, October 6, 2000 / 
Notices

[[Page 60072]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

[HCFA-1135-N]
[RIN 0938-AK13]


Medicare Program; Hospice Wage Index

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Notice.

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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 Sec. 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:
    <bullet> The revised hospice wage index will be calculated using 
the most current available hospital wage data.
    <bullet> 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.
    <bullet> 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.
    <bullet> 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.
    <bullet> 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.

[[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
------------------------------------------------------------------------
                              Urban area (constituent counties    Wage
        MSA code No.             or county equivalents) \1\       index
-------------------------------------------------------------------\2\--
0040........................  Abilene, TX.....................    0.8715
                              Taylor, TX
0060........................  Aguadilla, PR...................    0.4386
                              Aguada, PR
                              Aguadilla, PR
                              Moca, PR
0080........................  Akron, OH.......................    1.0829
                              Portage, OH
                              Summit, OH
0120........................  Albany, GA......................    1.1052
                              Dougherty, GA
                              Lee, GA
0160........................  Albany-Schenectady-Troy, NY.....    0.9328
                              Albany, NY
                              Montgomery, NY
                              Rensselaer, NY
                              Saratoga, NY
                              Schenectady, NY
                              Schoharie, NY
0200........................  Albuquerque, NM.................    0.9056
                              Bernalillo, NM
                              Sandoval, NM
                              Valencia, NM
0220........................  Alexandria, LA..................    0.8385
                              Rapides, LA
0240........................  Allentown-Bethlehem-Easton, PA..    1.0897
                              Carbon, PA
                              Lehigh, PA
                              Northampton, PA
0280........................  Altoona, PA.....................    0.9954
                              Blair, PA
0320........................  Amarillo, TX....................    0.8929
                              Potter, TX
                              Randall, TX
0380........................  Anchorage, AK...................    1.3701
                              Anchorage, AK
0440........................  Ann Arbor, MI...................    1.2235
                              Lenawee, MI
                              Livingston, MI
                              Washtenaw, MI
0450........................  Anniston, AL....................    0.9017
                              Calhoun, AL
0460........................  Appleton-Oshkosh-Neenah, WI.....    0.9496
                              Calumet, WI
                              Outagamie, WI
                              Winnebago, WI
0470........................  Arecibo, PR.....................    0.5537
                              Arecibo, PR
                              Camuy, PR
                              Hatillo, PR
0480........................  Asheville, NC...................    0.9466
                              Buncombe, NC
                              Madison, NC
0500........................  Athens, GA......................    1.0340
                              Clarke, GA
                              Madison, GA
                              Oconee, GA
0520........................  Atlanta, GA.....................    1.0709
                              Barrow, GA
                              Bartow, GA
                              Carroll, GA
                              Cherokee, GA
                              Clayton, GA
                              Cobb, GA
                              Coweta, GA
                              DeKalb, GA
                              Douglas, GA
                              Fayette, GA
                              Forsyth, GA
                              Fulton, GA
                              Gwinnett, GA
                              Henry, GA
                              Newton, GA
                              Paulding, GA
                              Pickens, GA
                              Rockdale, GA
                              Spalding, GA
                              Walton, GA
0560........................  Atlantic-Cape May, NJ...........    1.2051
                              Atlantic, NJ
                              Cape May, NJ
0580........................  Aubrn-Opelika, AL...............    0.8256
                              Lee, AL
0600........................  Augusta-Aiken, GA-SC............    0.9603
                              Columbia, GA
                              McDuffie, GA
                              Richmond, GA
                              Aiken, SC
                              Edgefield, SC
0640........................  Austin-San Marcos, TX...........    0.9676
                              Bastrop, TX
                              Caldwell, TX
                              Hays, TX
                              Travis, TX
                              Williamson, TX
0680........................  Bakersfield, CA.................    1.0248
                              Kern, CA
0720........................  Baltimore, MD...................    1.0539
                              Anne Arundel, MD
                              Baltimore, MD
                              Baltimore City, MD
                              Carroll, MD
                              Harford, MD
                              Howard, MD
                              Queen Anne's, MD
0733........................  Bangor, ME......................    1.0239
                              Penobscot, ME
0743........................  Barnstable-Yarmouth, MA.........    1.4173
                              Barnstable, MA
0760........................  Baton Rouge, LA.................    0.9278
                              Ascension, LA
                              East Baton Rouge, LA
                              Livingston, LA
                              West Baton Rouge, LA
0840........................  Beaumont-Port Arthur, TX........    0.9129
                              Hardin, TX
                              Jefferson, TX
                              Orange, TX
0860........................  Bellingham, WA..................    1.2141
                              Whatcom, WA
0870........................  Benton Harbor, MI...............    0.9011
                              Berrien, MI
0875........................  Bergen-Passaic, NJ..............    1.2816
                              Bergen, NJ
                              Passaic, NJ
0880........................  Billings, MT....................    1.0696
                              Yellowstone, MT
0920........................  Biloxi-Gulfport-Pascagoula, MS..    0.8383
                              Hancock, MS
                              Harrison, MS
                              Jackson, MS
0960........................  Binghamton, NY..................    0.9324
                              Broome, NY
                              Tioga, NY
1000........................  Birmingham, AL..................    0.9584
                              Blount, AL
                              Jefferson, AL
                              St. Clair, AL
                              Shelby, AL
1010........................  Bismarck, ND....................    0.8267
                                Burleigh, ND
                              Morton, ND
1020........................  Bloomington, IN.................    0.9155
                              Monroe, IN
1040........................  Bloomington-Normal, IL..........    0.9582
                              McLean, IL
1080........................  Boise City, ID..................    0.9654
                              Ada, ID
                              Canyon, ID
1123........................  Boston-Worcester-Lawrence-Lowell-   1.2102
                               Brockton, MA-NH.
                              Bristol, MA
                              Essex, MA
                              Middlesex, MA
                              Norfolk, MA
                              Plymouth, MA
                              Suffolk, MA
                              Worcester, MA
                              Hillsborough, NH
                              Merrimack, NH
                              Rockingham, NH

[[Page 60074]]

 
                              Strafford, NH
1125........................  Boulder-Longmont, CO............    1.0596
                              Boulder, CO
1145........................  Brazoria, TX....................    0.9074
                              Brazoria, TX
1150........................  Bremerton, WA...................    1.1733
                              Kitsap, WA
1240........................  Brownsville-Harlingen-San           0.9816
                               Benito, TX.
                              Cameron, TX
1260........................  Bryan-College Station, TX.......    0.9057
                              Brazos, TX
1280........................  Buffalo-Niagara Falls, NY.......    1.0233
                              Erie, NY
                              Niagara, NY
1303........................  Burlington, VT..................    1.1250
                              Chittenden, VT
                              Franklin, VT
                              Grand Isle, VT
1310........................  Caguas, PR......................    0.5245
                              Caguas, PR
                              Cayey, PR
                              Cidra, PR
                              Gurabo, PR
                              San Lorenzo, PR
1320........................  Canton-Massillon, OH............    0.9346
                              Carroll, OH
                              Stark, OH
1350........................  Casper, WY......................    0.9802
                              Natrona, WY
1360........................  Cedar Rapids, IA................    0.9609
                              Linn, IA
1400........................  Champaign-Urbana, IL............    0.9764
                              Champaign, IL
1440........................  Charleston-North Charleston, SC.    0.9577
                              Berkeley, SC
                              Charleston, SC
                              Dorchester, SC
1480........................  Charleston, WV..................    0.9691
                              Kanawha, WV
                              Putnam, WV
1520........................  Charlotte-Gastonia-Rock Hill, NC-   1.0051
                               SC.
                              Cabarrus, NC
                              Gaston, NC
                              Lincoln, NC
                              Mecklenburg, NC
                              Rowan, NC
                              Stanly, NC
                              Union, NC
                              York, SC
1540........................  Charlottesville, VA.............    1.1267
                              Albemarle, VA
                              Charlottesville City, VA
                              Fluvanna, VA
                              Greene, VA
 1560.......................  Chattanooga, TN-GA..............    1.0369
                              Catoosa, GA
                              Dade, GA
                              Walker, GA
                              Hamilton, TN
                              Marion, TN
 1580.......................  Cheyenne, WY....................    0.8711
                              Laramie, WY
 1600.......................  Chicago, IL.....................    1.1585
                              Cook, IL
                              DeKalb, IL
                              Du Page, IL
                              Grundy, IL
                              Kane, IL
                              Kendall, IL
                              Lake, IL
                              McHenry, IL
                              Will, IL
 1620.......................  Chico-Paradise, CA..............    1.1071
                              Butte, CA
 1640.......................  Cincinnati, OH-KY-IN............    1.0035
                              Brown, OH
                              Clermont, OH
                              Hamilton, OH
                              Warren, OH
                              Boone, KY
                              Campbell, KY
                              Gallatin, KY
                              Grant, KY
                              Kenton, KY......................
                              Pendleton, KY
                              Dearborn, IN
                              Ohio, IN
1660........................  Clarksville-Hopkinsville, TN-KY.    0.8619
                              Christian, KY
                              Montgomery, TN
 1680.......................  Cleveland-Lorain-Elyria, OH.....    1.0323
                              Ashtabula, OH
                              Cuyahoga, OH
                              Geauga, OH
                              Lake, OH
                              Lorain, OH
                              Medina, OH
 1720.......................  Colorado Springs, CO............    0.9821
                              El Paso, CO
 1740.......................  Columbia, MO....................    0.9488
                              Boone, MO
 1760.......................  Columbia, SC....................    0.9970
                              Lexington, SC
                              Richland, SC
 1800.......................  Columbus, GA-AL.................    0.9068
                              Chattahochee, GA
                              Harris, GA
                              Muscogee, GA
                              Russell, AL
 1840.......................  Columbus, OH....................    1.0556
                              Delaware, OH
                              Fairfield, OH
                              Franklin, OH
                              Licking, OH
                              Madison, OH
                              Pickaway, OH
 1880.......................  Corpus Christi, TX..............    0.9271
                              Nueces, TX
                              San Patricio, TX
 1890.......................  Corvallis, Oregon...............    1.1813
                              Benton, OR
 1900.......................  Cumberland, MD-WV...............    0.9378
                              Allegany, MD
                              Mineral, WV
 1920.......................  Dallas, TX......................    1.0236
                              Collin, TX
                              Dallas, TX
                              Denton, TX
                              Ellis, TX
                              Henderson, TX
                              Hunt, TX
                              Kaufman, TX
                              Rockwall, TX
 1950.......................  Danville, VA....................    0.9277
                              Danville City, VA
                              Pittsylvania, VA
 1960.......................  Davenport-Moline-Rock Island, IA-   1.0080
                               IL.
                              Scott, IA
                              Henry, IL
                              Rock Island, IL
 2000.......................  Dayton-Springfield, OH..........    0.9576
                              Clark, OH
                              Greene, OH
                              Miami, OH
                              Montgomery, OH
 2020.......................  Daytona Beach, FL...............    0.9248
                              Flagler, FL
                              Volusia, FL
 2030.......................  Decatur, AL.....................    0.9248
                              Lawrence, AL
                              Morgan, AL
 2040.......................  Decatur, IL.....................    0.8867
                              Macon, IL
 2080.......................  Denver, CO......................    1.0857
                              Adams, CO
                              Arapahoe, CO
                              Denver, CO
                              Douglas, CO
                              Jefferson, CO
 2120.......................  Des Moines, IA..................    0.9328
                              Dallas, IA
                              Polk, IA
                              Warren, IA
 2160.......................  Detroit, MI.....................    1.1104
                              Lapeer, MI
                              Macomb, MI
                              Monroe, MI
                              Oakland, MI
                              St. Clair, MI
                              Wayne, MI
 2180.......................  Dothan, AL......................    0.8309
                              Dale, AL
                              Houston, AL
 2190.......................  Dover, DE.......................    0.9947
                              Kent, DE
 2200.......................  Dubuque, IA.....................    0.9079
                              Dubuque, IA
 2240.......................  Duluth-Superior, MN-WI..........    1.0831
                              St. Louis, MN
                              Douglas, WI
 2281.......................  Dutchess County, NY.............    1.1243
                              Dutchess, NY
2290........................  Eau Claire, WI..................    0.9544
                              Chippewa, WI
                              Eau Claire, WI
2320........................  El Paso, TX.....................    0.9533
                              El Paso, TX
2330........................  Elkhart-Goshen, IN..............    0.9994
                              Elkhart, IN
2335........................  Elmira, NY......................    0.9092
                              Chemung, NY
2340........................  Enid, OK........................    0.8474
                              Garfield, OK
2360........................  Erie, PA........................    0.9614
                              Erie, PA
2400........................  Eugene-Springfield, OR..........    1.1298
                              Lane, OR

[[Page 60075]]

 
2440........................  Evansville-Henderson, IN-KY.....    0.8847
                              Posey, IN
                              Vanderburgh, IN
                              Warrick, IN
                              Henderson, KY
2520........................  Fargo-Moorhead, ND-MN...........    0.9185
                              Clay, MN
                              Cass, ND
2560........................  Fayetteville, NC................    0.9051
                              Cumberland, NC
2580........................  Fayetteville-Springdale-Rogers,     0.8283
                               AR.
                              Benton, AR
                              Washington, AR
2620........................  Flagstaff, AZ-UT................    1.1026
                              Coconino, AZ
                              Kane, UT
2640........................  Flint, MI.......................    1.1742
                              Genesee, MI
2650........................  Florence, AL....................    0.8447
                              Colbert, AL
                              Lauderdale, AL
2655........................  Florence, SC....................    0.9183
                              Florence, SC
2670........................  Fort Collins-Loveland, CO.......    1.0977
                              Larimer, CO
2680........................  Ft. Lauderdale, FL..............    1.0839
                              Broward, FL
2700........................  Fort Myers-Cape Coral, FL.......    0.9537
                              Lee, FL
2710........................  Fort Pierce-Port St. Lucie, FL..    1.0653
                              Martin, FL
                              St. Lucie, FL
2720........................  Fort Smith, AR-OK...............    0.8357
                              Crawford, AR
                              Sebastian, AR
                              Sequoyah, OK
2750........................  Fort Walton Beach, FL...........    0.9284
                              Okaloosa, FL
2760........................  Fort Wayne, IN..................    0.9692
                              Adams, IN
                              Allen, IN
                              De Kalb, IN
                              Huntington, IN
                              Wells, IN
                              Whitley, IN
2800........................  Fort Worth-Arlington, TX........    1.0480
                              Hood, TX
                              Johnson, TX
                              Parker, TX
                              Tarrant, TX
2840........................  Fresno, CA......................    1.0935
                              Fresno, CA
                              Madera, CA
2880........................  Gadsden, AL.....................    0.9258
                              Etowah, AL
2900........................  Gainesville, FL.................    1.0764
                              Alachua, FL
2920........................  Galveston-Texas City, TX........    1.0370
                              Galveston, TX
2960........................  Gary, IN........................    1.0005
                              Lake, IN
                              Porter, IN
2975........................  Glens Falls, NY.................    0.9170
                              Warren, NY
                              Washington, NY
2980........................  Goldsboro, NC...................    0.8879
                              Wayne, NC
2985........................  Grand Forks, ND-MN..............    0.9693
                              Grand Forks, ND
                              Polk, MN
2995........................  Grand Junction, CO..............    0.9790
                              Mesa, CO
3000........................  Grand Rapids-Muskegon-Holland,      1.0799
                               MI.
                              Allegan, MI
                              Kent, MI
                              Muskegon, MI
                              Ottawa, MI
3040........................  Great Falls, MT.................    1.1144
                              Cascade, MT
3060........................  Greeley, CO.....................    1.0359
                              Weld, CO
3080........................  Green Bay, WI...................    0.9731
                              Brown, WI
3120........................  Greensboro-Winston-Salem-High       0.9629
                               Point, NC.
                              Alamance, NC
                              Davidson, NC
                              Davie, NC
                              Forsyth, NC
                              Guilford, NC
                              Randolph, NC
                              Stokes, NC
                              Yadkin, NC
3150........................  Greenville, NC..................    1.0123
                              Pitt, NC
3160........................  Greenville-Spartanburg-Anderson,    0.9790
                               SC.
                              Anderson, SC
                              Cherokee, SC
                              Greenville, SC
                              Pickens, SC
                              Spartanburg, SC
3180........................  Hagerstown, MD..................    0.9422
                              Washington, MD
3200........................  Hamilton-Middletown, OH.........    0.9532
                              Butler, OH
3240........................  Harrisburg-Lebanon-Carlisle, PA.    1.0567
                              Cumberland, PA
                              Dauphin, PA
                              Lebanon, PA
                              Perry, PA
3283........................  Hartford, CT....................    1.2483
                              Hartford, CT
                              Litchfield, CT
                              Middlesex, CT
                              Tolland, CT
3285........................  Hattiesburg, MS.................    0.8134
                              Forrest, MS
                              Lamar, MS
3290........................  Hickory-Morganton-Lenoir, NC....    0.9709
                              Alexander, NC
                              Burke, NC
                              Caldwell, NC
                              Catawba, NC
3320........................  Honolulu, HI....................    1.2228
                              Honolulu, HI
3350........................  Houma, LA.......................    0.8350
                              Lafourche, LA
                              Terrebonne, LA
3360........................  Houston, TX.....................    1.0002
                              Chambers, TX
                              Fort Bend, TX
                              Harris, TX
                              Liberty, TX
                              Montgomery, TX
                              Waller, TX
3400........................  Huntington-Ashland, WV-KY-OH....    1.0396
                              Boyd, KY
                              Carter, KY
                              Greenup, KY
                              Lawrence, OH
                              Cabell, WV
                              Wayne, WV
3440........................  Huntsville, AL..................    0.9400
                              Limestone, AL
                              Madison, AL
3480........................  Indianapolis, IN................    1.0434
                              Boone, IN
                              Hamilton, IN
                              Hancock, IN
                              Hendricks, IN
                              Johnson, IN
                              Madison, IN
                              Marion, IN
                              Morgan, IN
                              Shelby, IN
3500........................  Iowa City, IA...................    1.0237
                              Johnson, IA
3520........................  Jackson, MI.....................    0.9419
                              Jackson, MI
3560........................  Jackson, MS.....................    0.8936
                              Hinds, MS
                              Madison, MS
                              Rankin, MS
3580........................  Jackson, TN.....................    0.9164
                              Madison, TN
                              Chester, TN
3600........................  Jacksonville, FL................    0.9544
                              Clay, FL
                              Duval, FL
                              Nassau, FL
                              St. Johns, FL
3605........................  Jacksonville, NC................    0.8367
                              Onslow, NC
3610........................  Jamestown, NY...................    0.8372
                              Chautauqua, NY
3620........................  Janesville-Beloit, WI...........    1.0289
                              Rock, WI
3640........................  Jersey City, NJ.................    1.2440
                              Hudson, NJ
3660........................  Johnson City-Kingsport-Bristol,     0.9433
                               TN-VA.
                              Carter, TN
                              Hawkins, TN
                              Sullivan, TN
                              Unicoi, TN
                              Washington, TN
                              Bristol City, VA
                              Scott, VA
                              Washington, VA
3680........................  Johnstown, PA...................    0.9206
                              Cambria, PA
                              Somerset, PA

[[Page 60076]]

 
3700........................  Jonesboro, AR...................    0.8000
                              Craighead, AR
3710........................  Joplin, MO......................    0.8181
                              Jasper, MO
                              Newton, MO
3720........................  Kalamazoo-Battlecreek, MI.......    1.0635
                              Calhoun, MI
                              Kalamazoo, MI
                              Van Buren, MI
3740........................  Kankakee, IL....................    0.9162
                              Kankakee, IL
3760........................  Kansas City, KS-MO..............    0.9932
                              Johnson, KS
                              Leavenworth, KS
                              Miami, KS
                              Wyandotte, KS
                              Cass, MO
                              Clay, MO
                              Clinton, MO
                              Jackson, MO
                              Lafayette, MO
                              Platte, MO
                              Ray, MO
3800........................  Kenosha, WI.....................    0.9625
                              Kenosha, WI
3810........................  Killeen-Temple, TX..............    1.0583
                              Bell, TX
                              Coryell, TX
3840........................  Knoxville, TN...................    0.9802
                              Anderson, TN
                              Blount, TN
                              Knox, TN
                              Loudon, TN
                              Sevier, TN
                              Union, TN
3850........................  Kokomo, IN......................    0.9503
                              Howard, IN
                              Tipton, IN
3870........................  La Crosse, WI-MN................    0.9519
                              Houston, MN
                              La Crosse, WI
3880........................  Lafayette, LA...................    0.8886
                              Acadia, LA
                              Lafayette, LA
                              St. Landry, LA
                              St. Martin, LA
3920........................  Lafayette, IN...................    0.9386
                              Clinton, IN
                              Tippecanoe, IN
3960........................  Lake Charles, LA................    0.8488
                              Calcasieu, LA
3980........................  Lakeland-Winter Haven, FL.......    0.9393
                              Polk, FL
4000........................  Lancaster, PA...................    0.9862
                              Lancaster, PA
4040........................  Lansing-East Lansing, MI........    1.0631
                              Clinton, MI
                              Eaton, MI
                              Ingham, MI
4080........................  Laredo, TX......................    0.8868
                              Webb, TX
4100........................  Las Cruces, NM..................    0.9153
                              Dona Ana, NM
4120........................  Las Vegas, NV-AZ................    1.1996
                              Mohave, AZ
                              Clarke, NV
                              Nye, NV
4150........................  Lawrence, KS....................    0.8761
                              Douglas, KS
4200........................  Lawton, OK......................    1.0157
                              Comanche, OK
4243........................  Lewiston-Auburn, ME.............    0.9482
                              Androscoggin, ME
4280........................  Lexington, KY...................    0.9090
                              Bourbon, KY
                              Clark, KY
                              Fayette, KY
                              Jessamine, KY
                              Madison, KY
                              Scott, KY
                              Woodford, KY
4320........................  Lima, OH........................    0.9489
                              Allen, OH
                              Auglaize, OH
4360........................  Lincoln, NE.....................    1.0304
                              Lancaster, NE
4400........................  Little Rock-North Little Rock,      0.9179
                               AR.
                              Faulkner, AR
                              Lonoke, AR
                              Pulaski, AR
                              Saline, AR
4420........................  Longview-Marshall, TX...........    0.9311
                              Gregg, TX
                              Harrison, TX                      ........
                              Upshur, TX
4480........................  Los Angeles-Long Beach, CA......    1.2841
                              Los Angeles, CA
4520........................  Louisville, KY-IN...............    0.9996
                              Clark, IN
                              Floyd, IN                         ........
                              Harrison, IN
                              Scott, IN
                              Bullitt, KY
                              Jefferson, KY
                              Oldham, KY
4600........................  Lubbock, TX.....................    0.8962
                              Lubbock, TX
4640........................  Lynchburg, VA...................    0.9392
                              Amherst, VA
                              Bedford, VA
                              Bedford City, VA
                              Campbell, VA
                              Lynchburg City, VA
4680........................  Macon, GA.......................    0.9089
                              Bibb, GA
                              Houston, GA
                              Jones, GA
                              Peach, GA
                              Twiggs, GA
4720........................  Madison, WI.....................    1.0367
                              Dane, WI
4800........................  Mansfield, OH...................    0.9031
                              Crawford, OH                      ........
                              Richland, OH
4840........................  Mayaguez, PR....................    0.5376
                              Anasco, PR
                              Cabo Rojo, PR
                              Hormigueros, PR
                              Mayaguez, PR
                              Sabana Grande, PR                 ........
                              San German, PR                    ........
4880........................  McAllen-Edinburg-Mission, TX....    0.8652
                              Hidalgo, TX
4890........................  Medford-Ashland, OR.............    1.1180
                              Jackson, OR
4900........................  Melbourne-Titusville-Palm Bay,      0.9905
                               FL.
                              Brevard, Fl
4920........................  Memphis, TN-AR-MS...............    0.8784
                              Crittenden, AR
                              DeSoto, MS
                              Fayette, TN
                              Shelby, TN
                              Tipton, TN
4940........................  Merced, CA......................    1.0950
                              Merced, CA
5000........................  Miami, FL.......................    1.0904
                              Dade, FL
5015........................  Middlesex-Somerset-Hunterdon, NJ    1.1851
                              Hunterdon, NJ
                              Middlesex, NJ
                              Somerset, NJ
5080........................  Milwaukee-Waukesha, WI..........    1.0490
                              Milwaukee, WI
                              Ozaukee, WI
                              Washington, WI
                              Waukesha, WI
5120........................  Minneapolis-St. Paul, MN-WI.....    1.1645
                              Anoka, MN
                              Carver, MN
                              Chisago, MN Dakota, MN
                              Hennepin, MN
                              Isanti, MN
                              Ramsey, MN
                              Scott, MN
                              Sherbune, MN
                              Washington, MN
                              Wright, MN
                              Pierce, WI
                              St. Croix, WI
5140........................  Missoula, MT....................    0.9681
                              Missoula, MT
5160........................  Mobile, AL......................    0.8809
                              Baldwin, AL
                              Mobile, AL
5170........................  Modesto, CA.....................    1.0774
                              Stanislaus, CA
5190........................  Monmouth-Ocean, NJ..............    1.1996
                              Monmouth, NJ
                              Ocean, NJ
5200........................  Monroe, LA......................    0.8760
                              Ouachita, LA
5240........................  Montgomery, AL..................    0.8208
                              Autauga, AL
                              Elmore, AL
                              Montgomery, AL
5280........................  Muncie, IN......................    1.1544
                              Delaware, IN
5330........................  Myrtle Beach, SC................    0.9088
                              Horry, SC
5345........................  Naples, FL......................    1.0484
                              Collier, FL
5360........................  Nashville, TN...................    1.0068
                              Cheatham, TN
                              Davidson, TN
                              Dickson, TN
                              Robertson, TN

[[Page 60077]]

 
                              Rutherford TN
                              Sumner, TN
                              Williamson, TN
                              Wilson, TN
5380........................  Nassau-Suffolk, NY..............    1.4997
                              Nassau, NY
                              Suffolk, NY
5483........................  New Haven-Bridgeport-Stamford-      1.3166
                               Waterbury-Danbury, CT.
                              Fairfield, CT
                              New Haven, CT
5523........................  New London-Norwich, CT..........    1.3242
                              New London, CT
5560........................  New Orleans, LA.................    0.9685
                              Jefferson, LA
                              Orleans, LA
                              Plaquemines, LA
                              St. Bernard, LA
                              St. Charles, LA
                              St. James, LA
                              St. John The Baptist, LA
                              St. Tammany, LA
5600........................  New York, NY....................    1.5469
                              Bronx, NY
                              Kings, NY
                              New York, NY
                              Putnam, NY
                              Queens, NY
                              Richmond, NY
                              Rockland, NY
                              Westchester, NY
5640........................  Newark, NJ......................    1.2409
                              Essex, NJ
                              Morris, NJ
                              Sussex, NJ
                              Union, NJ
                              Warren, NJ
5660........................  Newburgh, NY-PA.................    1.1624
                              Orange, NY
                              Pike, PA
5720........................  Norfolk-Virginia Beach-Newport      0.8993
                               News, VA-NC.
                              Currituck, NC
                              Chesapeake City, VA
                              Gloucester, VA
                              Hampton City, VA
                              James City, VA
                              Isle of Wight, VA
                              Mathews, VA
                              Newport News City, VA
                              Norfolk City, VA
                              Poquoson City, VA
                              Portsmouth City, VA
                              Suffolk City, VA
                              Virginia Beach City VA
                              Williamsburg City, VA
                              York, VA
5775........................  Oakland, CA.....................    1.6044
                              Alameda, CA
                              Contra Costa, CA
5790........................  Ocala, FL.......................    1.0245
                              Marion, FL
5800........................  Odessa-Midland, TX..............    0.9455
                              Ector, TX
                              Midland, TX
5880........................  Oklahoma City, OK...............    0.9150
                              Canadian, OK
                              Cleveland, OK
                              Logan, OK
                              McClain, OK
                              Oklahoma, OK
                              Pottawatomie, OK
5910........................  Olympia, WA.....................    1.1648
                              Thurston, WA
5920........................  Omaha, NE-IA....................    1.1140
                              Pottawattamie, IA
                              Cass, NE
                              Douglas, NE
                              Sarpy, NE
                              Washington, NE
5945........................  Orange County, CA...............    1.2349
                              Orange, CA
5960........................  Orlando, FL.....................    1.0437
                              Lake, FL
                              Orange, FL
                              Osceola, FL
                              Seminole, FL
5990........................  Owensboro, KY...................    0.8635
                              Daviess, KY
6015........................  Panama City, FL.................    0.9770
                              Bay, FL
6020........................  Parkersburg-Marietta, WV-OH.....    0.8896
                              Washington, OH
                              Wood, WV
6080........................  Pensacola, FL...................    0.8995
                              Escambia, FL
                              Santa Rosa, FL
6120........................  Peoria-Pekin, IL................    0.8896
                              Peoria, IL
                              Tazewell, IL
                              Woodford, IL
6160........................  Philadelphia, PA-NJ.............    1.1891
                              Burlington, NJ
                              Camden, NJ
                              Gloucester, NJ
                              Salem, NJ
                              Bucks, PA
                              Chester, PA
                              Delaware, PA
                              Montgomery, PA
                              Philadelphia, PA
6200........................  Phoenix-Mesa, AZ................    1.0084
                              Maricopa, AZ
                              Pinal, AZ
6240........................  Pine Bluff, AR..................    0.8202
                              Jefferson, AR
6280........................  Pittsburgh, PA..................    1.0265
                              Allegheny, PA
                              Beaver,PA
                              Butler, PA
                              Fayette, PA
                              Washington, PA
                              Westmoreland, PA
6323........................  Pittsfield, MA..................    1.0927
                              Berkshire, MA
6340........................  Pocatello, ID...................    0.9561
                              Bannock, ID
6360........................  Ponce, PR.......................    0.5717
                              Guayanilla, PR
                              Juana Diaz, PR
                              Penuelas, PR
                              Ponce, PR
                              Villalba, PR
                              Yauco, PR
6403........................  Portland, ME....................    1.0096
                              Cumberland, ME
                              Sagadahoc, ME
                              York, ME
6440........................  Portland-Vancouver, OR-WA.......    1.1694
                              Clackamas, OR
                              Columbia, OR
                              Multnomah, OR
                              Washington, OR
                              Yamhill, OR
                              Clark, WA
6483........................  Providence-Warwick-Pawtucket, RI    1.1391
                              Bristol, RI
                              Kent, RI
                              Newport, RI
                              Providence, RI
                              Washington, RI
6520........................  Provo-Orem, UT..................    1.0461
                              Utah, UT
6560........................  Pueblo, CO......................    0.9433
                              Pueblo, CO
6580........................  Punta Gorda, FL.................    0.9509
                              Charlotte, FL
6600........................  Racine, WI......................    0.9820
                              Racine, WI
6640........................  Raleigh-Durham-Chapel Hill, NC..    1.0170
                              Chatham, NC
                              Durham, NC                        ........
                              Franklin, NC
                              Johnston, NC
                              Orange, NC
                              Wake, NC
6660........................  Rapid City, SD..................    0.8911
                              Pennington, SD
6680........................  Reading, PA.....................    1.0054
                              Berks, PA
6690........................  Redding, CA.....................    1.2002
                              Shasta, CA
6720........................  Reno, NV........................    1.1353
                              Washoe, NV
6740........................  Richland-Kennewick-Pasco, WA....    1.1959
                              Benton, WA
                              Franklin, WA
6760........................  Richmond-Petersburg, VA.........    1.0171
                              Charles City County, VA
                              Chesterfield, VA
                              Colonial Heights City, VA
                              Dinwiddie, VA
                              Goochland, VA
                              Hanover, VA
                              Henrico, VA
                              Hopewell City, VA
                              New Kent, VA
                              Petersburg City, VA
                              Powhatan, VA
                              Prince George, VA
                              Richmond City, VA
6780........................  Riverside-San Bernardino, CA....    1.1945
                              Riverside, CA
                              San Bernardino, CA

[[Page 60078]]

 
6800........................  Roanoke, VA.....................    0.8672
                              Botetourt, VA
                              Roanoke, VA
                              Roanoke City, VA
                              Salem City, VA
6820........................  Rochester, MN...................    1.2178
                              Olmsted, MN
6840........................  Rochester, NY...................    0.9786
                              Genesee, NY
                              Livingston, NY
                              Monroe, NY
                              Ontario, NY
                              Orleans, NY
                              Wayne, NY
6880........................  Rockford, IL....................    0.9359
                              Boone, IL
                              Ogle, IL
                              Winnebago, IL
6895........................  Rocky Mount, NC.................    0.9307
                              Edgecombe, NC
                              Nash, NC
6920........................  Sacramento, CA..................    1.3089
                              El Dorado, CA
                              Placer, CA
                              Sacramento, CA
6960........................  Saginaw-Bay City-Midland, MI....    0.9895
                              Bay, MI
                              Midland, MI
                              Saginaw, MI
6980........................  St. Cloud, MN...................    1.0038
                              Benton, MN
                              Stearns, MN
7000........................  St. Joseph, MO..................    0.9529
                              Andrew, MO
                              Buchanan, MO
7040........................  St. Louis, MO-IL................    0.9645
                              Franklin, MO
                              Jefferson, MO
                              Lincoln, MO
                              St. Charles, MO
                              St. Louis, MO
                              St. Louis City, MO
                              Warren, MO
                              Clinton, IL
                              Jersey, IL
                              Madison, IL
                              Monroe, IL
                              St. Clair, IL
7080........................  Salem, OR.......................    1.0601
                              Marion, OR
                              Polk, OR
7120........................  Salinas, CA.....................    1.5674
                              Monterey, CA
7160........................  Salt Lake City-Ogden, UT........    1.0500
                              Davis, UT
                              Salt Lake, UT
                              Weber, UT
7200........................  San Angelo, TX..................    0.8359
                              Tom Green, TX
7240........................  San Antonio, TX.................    0.8862
                              Bexar, TX
                              Comal, TX
                              Guadalupe, TX
                              Wilson, TX
7320........................  San Diego, CA...................    1.2712
7360........................  San Francisco, CA...............    1.4918
                              Marin, CA
                              San Francisco, CA
                              San Mateo, CA
7400........................  San Jose, CA....................    1.4500
                              Santa Clara, CA
7440........................  San Juan-Bayamon, PR............    0.5357
                              Aguas Buenas, PR
                              Barceloneta, PR
                              Bayamon, PR
                              Canovanas, PR
                              Carolina, PR
                              Catano, PR
                              Ceiba, PR
                              Comerio, PR
                              Corozal, PR
                              Dorado, PR
                              Fajardo, PR
                              Florida, PR
                              Guaynabo, PR
                              Humacao, PR
                              Juncos, PR
                              Los Piedras, PR
                              Loiza, PR
                              Luguillo, PR
                              Manati, PR
                              Morovis, PR
                              Naguabo, PR
                              Naranjito, PR
                              Rio Grande, PR
                              San Juan, PR
                              Toa Alta, PR
                              Toa Baja, PR
                              Trujillo Alto, PR
                              Vega Alta, PR
                              Vega Baja, PR
                              Yabucoa, PR
7460........................  San Luis Obispo-Atascadero-Paso     1.1156
                               Robles, CA.
                              San Luis Obispo, CA
7480........................  Santa Barbara-Santa Maria-          1.1528
                               Lompoc, CA.
                              Santa Barbara, CA
7485........................  Santa Cruz-Watsonville, CA......    1.4840
                              Santa Cruz, CA
7490........................  Santa Fe, NM....................    1.1121
                              Los Alamos, NM
                              Santa Fe, NM
7500........................  Santa Rosa, CA..................    1.3852
                              Sonoma, CA
7510........................  Sarasota-Bradenton, FL..........    1.0554
                              Manatee, FL
                              Sarasota, FL
7520........................  Savannah, GA....................    1.0605
                              Bryan, GA
                              Chatham, GA
                              Effingham, GA
7560........................  Scranton--Wilkes-Barre--            0.8921
                               Hazleton, PA.
                              Columbia, PA
                              Lackawanna, PA
                              Luzerne, PA
                              Wyoming, PA
7600........................  Seattle-Bellevue-Everett, WA....    1.2030
                              Island, WA
                              King, WA
                              Snohomish, WA
7610........................  Sharon, PA......................    0.8826
                              Mercer, PA
7620........................  Sheboygan, WI...................    0.8740
                              Sheboygan, WI
7640........................  Sherman-Denison, TX.............    0.9940
                              Grayson, TX
7680........................  Shreveport-Bossier City, LA.....    0.9642
                              Bossier, LA
                              Caddo, LA
                              Webster, LA
7720........................  Sioux City, IA-NE...............    0.9108
                              Woodbury, IA
                              Dakota, NE
7760........................  Sioux Falls, SD.................    0.9351
                              Lincoln, SD
                              Minnehaha, SD
7800........................  South Bend, IN..................    1.0435
                              St. Joseph, IN
7840........................  Spokane, WA.....................    1.1507
                              Spokane, WA
7880........................  Springfield, IL.................    0.9252
                              Menard, IL
                              Sangamon, IL
7920........................  Springfield, MO.................    0.8515
                              Christian, MO
                              Greene, MO
                              Webster, MO
8003........................  Springfield, MA.................    1.1377
                              Hampden, MA
                              Hampshire, MA
8840........................  Washington, DC-MD-VA-WV.........    1.1778
                              District of Columbia, DC
                              Calvert, MD
                              Charles, MD
                              Frederick, MD
                              Montgomery, MD
                              Prince Georges, MD
                              Alexandria City, VA
                              Arlington, VA
                              Clarke, VA
                              Culpeper, VA
                              Fairfax, VA
                              Fairfax City, VA
                              Falls Church City, VA
                              Fauquier, VA
                              Fredericksburg City, VA
                              King George, VA
                              Loudoun, VA
                              Manassas City, VA

[[Page 60079]]

 
                              Manassas Park City, VA
                              Prince William, VA
                              Spotsylvania, VA
                              Stafford, VA
                              Warren, VA
                              Berkeley, WV
                              Jefferson, WV
8920........................  Waterloo-Cedar Falls, IA........    0.9075
                              Black Hawk, IA
8940........................  Wausau, WI......................    1.0064
                              Marathon, WI
8960........................  West Palm Beach-Boca Raton, FL..    1.0668
                              Palm Beach, FL
9000........................  Wheeling, WV-OH.................    0.8144
                              Belmont, OH
                              Marshall, WV
                              Ohio, WV
9040........................  Wichita, KS.....................    1.0038
                              Butler, KS
                              Harvey, KS
                              Sedgwick, KS
9080........................  Wichita Falls, TX...............    0.8154
                              Archer, TX
                              Wichita, TX
8050........................  State College, PA...............    0.9737
                              Centre, PA
8080........................  Steubenville-Weirton, OH-WV.....    0.9179
                              Jefferson, OH
                              Brooke, WV
                              Hancock, WV
8120........................  Stockton-Lodi, CA...............    1.1207
                              San Joaquin, CA
8140........................  Sumter, SC......................    0.8778
                              Sumter, SC
8160........................  Syracuse, NY....................    1.1377
                              Cayuga, NY
                              Madison, NY
                              Onondaga, NY
                              Oswego, NY
8200........................  Tacoma, WA......................    1.2230
                              Pierce, WA
8240........................  Tallahassee, FL.................    0.9040
                              Gadsden, FL
                              Leon, FL
8280........................  Tampa-St. Petersburg-Clearwater,    0.9637
                               FL.
                              Hernando, FL
                              Hillsborough, FL
                              Pasco, FL
                              Pinellas, FL
8320........................  Terre Haute, IN.................    0.9132
                              Clay, IN
                              Vermillion, IN
                              Vigo, IN
8360........................  Texarkana, AR-Texarkana, TX.....    0.8668
                              Miller, AR
                              Bowie, TX
8400........................  Toledo, OH......................    1.0458
                              Fulton, OH
                              Lucas, OH
                              Wood, OH
8440........................  Topeka, KS......................    0.9937
                              Shawnee, KS
8480........................  Trenton, NJ.....................    1.0764
                              Mercer, NJ
8520........................  Tucson, AZ......................    0.9315
                              Pima, AZ
8560........................  Tulsa, OK.......................    0.8616
                              Creek, OK
                              Osage, OK
                              Rogers, OK
                              Tulsa, OK
                              Wagoner, OK
8600........................  Tuscaloosa, AL..................    0.8593
                              Tuscaloosa, AL
8640........................  Tyler, TX.......................    0.9983
                              Smith
8680........................  Utica-Rome, NY..................    0.8842
                              Herkimer, NY
                              Oneida, NY
8720........................  Vallejo-Fairfield-Napa, CA......    1.4220
                              Napa, CA
                              Solano, CA
8735........................  Ventura, CA.....................    1.2206
8750........................  Victoria, TX....................    0.8927
8760........................  Vineland-Millville-Bridgeton, NJ    1.1206
                              Cumberland, NJ
8780........................  Visalia-Turlare-Porterville, CA.    1.1093
                              Tulare, CA
8800........................  Waco, TX........................    0.8604
                              McLennan, TX
9140........................  Williamsport, PA................    0.9003
                              Lycoming, PA
9160........................  Wilmington-Newark, DE-MD........    1.2013
                              New Castle, DE
                              Cecil, MD
9200........................  Wilmington, NC..................    1.0343
                              Brunswick, NC
                              New Hanover, NC
9260........................  Yakima, WA......................    1.1009
                              Yakima, WA
9270........................  Yolo, CA........................    1.0356
                              Yolo, CA
9280........................  York, PA........................    0.9919
                              York, PA
9320........................  Youngstown-Warren, OH...........    1.0651
                              Columbiana, OH
                              Mahoning, OH
                              Trumbull, OH
9340........................  Yuba City, CA...................    1.1361
                              Sutter, CA
                              Yuba, CA
9360........................  Yuma, AZ........................    1.0574
                              Yuma, AZ
------------------------------------------------------------------------
\1\ 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
------------------------------------------------------------------------
                                                                  Wage
         MSA code No.                   Nonurban area             index
-------------------------------------------------------------------\1\--
9901.........................  Alabama........................    0.8000
9902.........................  Alaska.........................    1.2847
9903.........................  Arizona........................    0.9104
9904.........................  Arkansas.......................    0.8000
9905.........................  California.....................    1.0603
9906.........................  Colorado.......................    0.9391
9907.........................  Connecticut....................    1.3226
9908.........................  Delaware.......................    0.9767
9910.........................  Florida........................    0.9575
9911.........................  Georgia........................    0.8625
9912.........................  Hawaii.........................    1.1430
9913.........................  Idaho..........................    0.9218
9914.........................  Illinois.......................    0.8575
9915.........................  Indiana........................    0.8946
9916.........................  Iowa...........................    0.8446

[[Page 60080]]

 
9917.........................  Kansas.........................    0.8000
9918.........................  Kentucky.......................    0.8569
9919.........................  Louisiana......................    0.8000
9920.........................  Maine..........................    0.9205
9921.........................  Maryland.......................    0.9197
9922.........................  Massachusetts..................    1.2114
9923.........................  Michigan.......................    0.9392
9924.........................  Minnesota......................    0.9237
9925.........................  Mississippi....................    0.8000
9926.........................  Missouri.......................    0.8229
9927.........................  Montana........................    0.8945
9928.........................  Nebraska.......................    0.8532
9929.........................  Nevada.........................    0.9693
9930.........................  New Hampshire..................    1.0554
9931.........................  New Jersey \2\.................  ........
9932.........................  New Mexico.....................    0.8927
9933.........................  New York.......................    0.9202
9934.........................  North Carolina.................    0.8832
9935.........................  North Dakota...................    0.8148
9936.........................  Ohio...........................    0.9216
9937.........................  Oklahoma.......................    0.8000
9938.........................  Oregon.........................    1.0514
9939.........................  Pennsylvania...................    0.9083
9940.........................  Puerto Rico....................    0.4886
9941.........................  Rhode Island \2\...............  ........
9942.........................  South Carolina.................    0.8805
9943.........................  South Dakota...................    0.8073
9944.........................  Tennessee......................    0.8152
9945.........................  Texas..........................    0.8000
9946.........................  Utah...........................    0.9490
9947.........................  Vermont........................    1.0024
9948.........................  Virgin Islands.................    0.7252
9949.........................  Virginia.......................    0.8421
9950.........................  Washington.....................    1.1131
9951.........................  West Virginia..................    0.8597
9952.........................  Wisconsin......................    0.9333
9953.........................  Wyoming........................    0.9440
9965.........................  Guam...........................   1.0240
------------------------------------------------------------------------
\1\ 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--
    <bullet> An annual effect on the economy of $100 million or more;
    <bullet> A major increase in costs or prices for consumers, 
individual industries, Federal, State, or local government agencies, or 
geographic regions; or
    <bullet> 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

[[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
----------------------------------------------------------------------------------------------------------------
                                                                                           Estimated
                                                                   Number of    Payments   payments     Percent
                                                       Number of    routine    using FY    using FY    change in
                                                       hospices    home care   2000 wage   2001 wage    Hospice
                                                          (1)       days in    index in    index in    payments
                                                                   thousands   thousands   thousands      (5)
                                                                      (2)         (3)         (4)
----------------------------------------------------------------------------------------------------------------
 (By geographic location):
    All Hospices....................................       2,149      21,354   2,490,702   2,504,439         0.6
        Urban Hospices..............................       1,351      18,120   2,185,780   2,190,590         0.2
        Rural Hospices..............................         798       3,234     304,922     313,849         2.9
    By Region--Urban:
        New England.................................          94         642      89,447      89,051        -0.4
        Middle Atlantic.............................         170       2,245     290,927     291,894         0.3
        South Atlantic..............................         185       4,030     509,079     511,583         0.5
        East North Central..........................         224       2,862     334,861     336,694         0.5
        East South Central..........................          94       1,169     123,023     123,530         0.4
        West North Central..........................          96       1,061     113,167     113,498         0.3
        West South Central..........................         188       2,408     261,632     261,287        -0.1
        Mountain....................................          88       1,135     149,035     148,443        -0.4
        Pacific.....................................         183       2,325     298,138     298,086           0
        Puerto Rico.................................          29         243      16,470      16,524         0.3
    By Region--Rural:
        New England.................................          26          72       7,666       7,811         1.9
        Middle Atlantic.............................          35         168      17,282      17,214        -0.4
        South Atlantic..............................         117         681      63,904      65,005         1.7
        East North Central..........................         136         561      53,801      54,541         1.4
        East South Central..........................          81         524      48,159      50,481         4.8
        West North Central..........................         174         409      37,622      38,969         3.6
        West South Central..........................          85         362      29.640      32.351         9.1
        Mountain....................................          87         217      21.359      22,048         3.2
        Pacific.....................................          54         217      24,012      23,922        -0.4

[[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        10.6
        1,754-4,373 days............................         502       1,504     150,829     154,399         2.4
        4,373-9,681 days............................         556       3,669     388,427     390,269         0.5
        9,681 + days................................         653      15,449   1,875,339   1,879,969         0.2
    Type of ownership:
        Voluntary...................................       1,351      13,975   1,638,339   1,644,677         0.4
        Proprietary.................................         573       6,714     784,488     790,194         0.7
        Government..................................         192         568      58,174      59,770         2.7
        Other.......................................          33          97       9,701       9,797         1.0
    Hospice base:
        Freestanding................................         874      12,368   1,451,898   1,461,421         0.7
        Home health agency..........................         716       5,357     625,165     627,440         0.4
        Hospital....................................         538       3,503     395,997     397,830         0.5
        Skilled 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