Friday, 

April 30, 2010 

Part IV 

Department of 

Health and Human 

Services 

Centers for Medicare & Medicaid Services 

Medicare Program; Inpatient Psychiatric 

Facilities Prospective Payment System 

Payment—Update for Rate Year Beginning 

July 1, 2010 (RY 2011); Notice 


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23106 Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–1424–N] 

RIN 0938–AP83 

Medicare Program; Inpatient 

Psychiatric Facilities Prospective 

Payment System Payment—Update for 

Rate Year Beginning July 1, 2010 (RY 

2011) 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Notice 

SUMMARY: This notice updates the 

payment rates for the Medicare 

prospective payment system (PPS) for 

inpatient psychiatric hospital services 

provided by inpatient psychiatric 

facilities (IPFs). These changes are 

applicable to IPF discharges occurring 

during the rate year beginning July 1, 

2010 through June 30, 2011. We are also 

responding to comments on the IPF PPS 

teaching adjustment and the market 

basket, which we received in response 

to our May 2009 IPF PPS notice with 

request for comments. 

DATES: Effective Date: The updated IPF 

prospective payment rates are effective 

for discharges occurring on or after July 

1, 2010 through June 30, 2011. 

FOR FURTHER INFORMATION CONTACT: 

Dorothy Myrick or Jana Lindquist, (410) 

786–4533 (for general information). 

Mary Carol Barron, (410) 786–7943 (for 

information regarding the market 

basket and labor-related share). 

Theresa Bean, (410) 786–2287 (for 

information regarding the regulatory 

impact analysis). 

SUPPLEMENTARY INFORMATION: 

Table of Contents 

To assist readers in referencing 

sections contained in this document, we 

are providing the following table of 

contents. 

I. Background 

A. Annual Requirements for Updating the 

IPF PPS 

B. Overview of the Legislative 

Requirements of the IPF PPS 

C. IPF PPS—General Overview 

II. Transition Period for Implementation of 

the IPF PPS 

III. Updates to the IPF PPS for RY Beginning 

July 1, 2010 

A. Determining the Standardized BudgetNeutral Federal Per Diem Base Rate 

1. Standardization of the Federal Per Diem 

Base Rate and 

Electroconvulsive Therapy (ECT) Rate 

2. Calculation of the Budget Neutrality 

Adjustment 

a. Outlier Adjustment 

b. Stop-Loss Provision Adjustment 

c. Behavioral Offset 

B. Update of the Federal Per Diem Base 

Rate and Electroconvulsive Therapy Rate 

1. Market Basket for IPFs Reimbursed 

under the IPF PPS 

a. Market Basket Index for the IPF PPS 

b. Overview of the RPL Market Basket 

2. Labor-Related Share 

3. Comments on Creating a Stand-Alone 

IPF Market Basket 

IV. Update of the IPF PPS Adjustment 

Factors 

A. Overview of the IPF PPS Adjustment 

Factors 

B. Patient-Level Adjustments 

1. Adjustment for MS–DRG Assignment 

2. Payment for Comorbid Conditions 

3. Patient Age Adjustments 

4. Variable Per Diem Adjustments 

C. Facility-Level Adjustments 

1. Wage Index Adjustment 

a. Background 

b. Wage Index for RY 2011 

c. OMB Bulletins 

2. Adjustment for Rural Location 

3. Teaching Adjustment 

4. Cost of Living Adjustment for IPFs 

Located in Alaska and Hawaii 

5. Adjustment for IPFs With a Qualifying 

Emergency Department (ED) 

D. Other Payment Adjustments and 

Policies 

1. Outlier Payments 

a. Update to the Outlier Fixed Dollar Loss 

Threshold Amount 

b. Statistical Accuracy of Cost-to-Charge 

Ratios 

2. Expiration of the Stop-Loss Provision 

V. Comments Beyond the Scope of the May 

2009 IPF PPS Notice With Request for 

Comments 

VI. Waiver of Proposed Rulemaking 

VII. Collection of Information Requirements 

VIII. Regulatory Impact Analysis 

Addenda 

Acronyms 

Because of the many terms to which 

we refer by acronym in this notice, we 

are listing the acronyms used and their 

corresponding terms in alphabetical 

order below: 

BBRA Medicare, Medicaid and SCHIP 

[State Children’s Health Insurance 

Program] Balanced Budget Refinement Act 

of 1999, (Pub. L. 106–113). 

CBSA Core-Based Statistical Area. 

CCR Cost-to-charge ratio. 

CAH Critical access hospital. 

DSM–IV–TR Diagnostic and Statistical 

Manual of Mental Disorders Fourth 

Edition—Text Revision. 

DRGs Diagnosis-related groups. 

FY Federal fiscal year. 

ICD–9–CM International Classification of 

Diseases, 9th Revision, Clinical 

Modification. 

IPFs Inpatient psychiatric facilities. 

IRFs Inpatient rehabilitation facilities. 

LTCHs Long-term care hospitals. 

MedPAR Medicare provider analysis and 

review file. 

RY Rate Year. 

TEFRA Tax Equity and Fiscal 

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

248). 

I. Background 

A. Annual Requirements for Updating 

the IPF PPS 

In November 2004, we implemented 

the inpatient psychiatric facilities (IPF) 

prospective payment system (PPS) in a 

final rule that appeared in the 

November 15, 2004 Federal Register (69 

FR 66922). In developing the IPF PPS, 

in order to ensure that the IPF PPS is 

able to account adequately for each 

IPF’s case-mix, we performed an 

extensive regression analysis of the 

relationship between the per diem costs 

and certain patient and facility 

characteristics to determine those 

characteristics associated with 

statistically significant cost differences 

on a per diem basis. For characteristics 

with statistically significant cost 

differences, we used the regression 

coefficients of those variables to 

determine the size of the corresponding 

payment adjustments. 

In that final rule, we explained that 

we believe it is important to delay 

updating the adjustment factors derived 

from the regression analysis until we 

have IPF PPS data that includes as 

much information as possible regarding 

the patient-level characteristics of the 

population that each IPF serves. 

Therefore, we indicated that we did not 

intend to update the regression analysis 

and recalculate the Federal per diem 

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

that analysis. Until that analysis is 

complete, we stated our intention to 

publish a notice in the Federal Register 

each spring to update the IPF PPS (71 

FR 27041). 

Updates to the IPF PPS as specified in 

42 CFR § 412.428 include the following: 

• A description of the methodology 

and data used to calculate the updated 

Federal per diem base payment amount. 

• The rate of increase factor as 

described in § 412.424(a)(2)(iii), which 

is based on the excluded hospital with 

capital market basket under the update 

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

of the Social Security Act (the Act) for 

each year (effective from the 

implementation period until June 30, 

2006). 

• For discharges occurring on or after 

July 1, 2006, the rate of increase factor 

for the Federal portion of the IPF’s 

payment, which is based on the 

rehabilitation, psychiatric, and longterm care (RPL) market basket. 

• The best available hospital wage 

index and information regarding 

whether an adjustment to the Federal 


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per diem base rate is needed to maintain 

budget neutrality. 

• Updates to the fixed dollar loss 

threshold amount in order to maintain 

the appropriate outlier percentage. 

• Description of the International 

Classification of Diseases, 9th Revision, 

Clinical Modification (ICD–9–CM) 

coding and diagnosis-related groups 

(DRGs) classification changes discussed 

in the annual update to the hospital 

inpatient prospective payment system 

(IPPS) regulations. 

• Update to the electroconvulsive 

therapy (ECT) payment by a factor 

specified by CMS. 

• Update to the national urban and 

rural cost-to-charge ratio medians and 

ceilings. 

• Update to the cost of living 

adjustment factors for IPFs located in 

Alaska and Hawaii, if appropriate. 

Our most recent annual update 

occurred in the May 2009 IPF PPS 

notice with request for comments (74 FR 

20362) (hereinafter referred to as the 

May 2009 IPF PPS notice) that set forth 

updates to the IPF PPS payment rates 

for RY 2010. This notice updates the IPF 

per diem payment rates that were 

published in the May 2009 IPF PPS 

notice in accordance with our 

established policies. 

B. Overview of the Legislative 

Requirements of the IPF PPS 

Section 124 of the Medicare, 

Medicaid, and SCHIP (State Children’s 

Health Insurance Program) Balanced 

Budget Refinement Act of 1999, (Pub. L. 

106–113) (BBRA) required 

implementation of the IPF PPS. 

Specifically, section 124 of the BBRA 

mandated that the Secretary develop a 

per diem PPS for inpatient hospital 

services furnished in psychiatric 

hospitals and psychiatric units that 

includes an adequate patient 

classification system that reflects the 

differences in patient resource use and 

costs among psychiatric hospitals and 

psychiatric units. 

Section 405(g)(2) of the Medicare 

Prescription Drug, Improvement, and 

Modernization Act of 2003 (MMA) (Pub. 

L. 108–173) extended the IPF PPS to 

distinct part psychiatric units of critical 

access hospitals (CAHs). 

To implement these provisions, we 

published various proposed and final 

rules in the Federal Register. For more 

information regarding these rules, see 

the CMS Web sites http:// 

www.cms.hhs.gov/ 

InpatientPsychFacilPPS/and http:// 

www.cms.hhs.gov/ 

InpatientpsychfacilPPS/ 

02_regulations.asp. 

Section 1886(s)(3)(A) of the Act, 

which was added by Section 3401(f) of 

the Patient Protection and Affordable 

Care Act (Pub. L. 111–148) as amended 

by Section 10319(e) of that Act and by 

Section 1105 of the Health Care and 

Education Reconciliation Act of 2010 

(Pub. L. 111–152), requires the 

application of an ‘‘Other Adjustment’’ 

that reduces any update to the IPF PPS 

base rate by 0.25 percentage point for 

the rate year beginning in 2010. We are 

implementing that provision for RY 

2011 in this notice. 

C. IPF PPS—General Overview 

The November 2004 IPF PPS final 

rule (69 FR 66922) established the IPF 

PPS, as authorized under section 124 of 

the BBRA and codified at subpart N of 

part 412 of the Medicare regulations. 

The November 2004 IPF PPS final rule 

set forth the per diem Federal rates for 

the implementation year (the 18-month 

period from January 1, 2005 through 

June 30, 2006), and it provided payment 

for the inpatient operating and capital 

costs to IPFs for covered psychiatric 

services they furnish (that is, routine, 

ancillary, and capital costs, but not costs 

of approved educational activities, bad 

debts, and other services or items that 

are outside the scope of the IPF PPS). 

Covered psychiatric services include 

services for which benefits are provided 

under the fee-for-service Part A 

(Hospital Insurance Program) Medicare 

program. 

The IPF PPS established the Federal 

per diem base rate for each patient day 

in an IPF derived from the national 

average daily routine operating, 

ancillary, and capital costs in IPFs in FY 

2002. The average per diem cost was 

updated to the midpoint of the first year 

under the IPF PPS, standardized to 

account for the overall positive effects of 

the IPF PPS payment adjustments, and 

adjusted for budget neutrality. 

The Federal per diem payment under 

the IPF PPS is comprised of the Federal 

per diem base rate described above and 

certain patient- and facility-level 

payment adjustments that were found in 

the regression analysis to be associated 

with statistically significant per diem 

cost differences. 

The patient-level adjustments include 

age, DRG assignment, comorbidities, 

and variable per diem adjustments to 

reflect higher per diem costs in the early 

days of an IPF stay. Facility-level 

adjustments include adjustments for the 

IPF’s wage index, rural location, 

teaching status, a cost of living 

adjustment for IPFs located in Alaska 

and Hawaii, and presence of a 

qualifying emergency department (ED). 

The IPF PPS provides additional 

payment policies for: outlier cases; stoploss protection (which was applicable 

only during the IPF PPS transition 

period); interrupted stays; and a per 

treatment adjustment for patients who 

undergo ECT. 

A complete discussion of the 

regression analysis appears in the 

November 2004 IPF PPS final rule (69 

FR 66933 through 66936). 

Section 124 of BBRA does not specify 

an annual update rate strategy for the 

IPF PPS and is broadly written to give 

the Secretary discretion in establishing 

an update methodology. Therefore, in 

the November 2004 IPF PPS final rule, 

we implemented the IPF PPS using the 

following update strategy: 

• Calculate the final Federal per diem 

base rate to be budget neutral for the 18- 

month period of January 1, 2005 

through June 30, 2006. 

• Use a July 1 through June 30 annual 

update cycle. 

• Allow the IPF PPS first update to be 

effective for discharges on or after July 

1, 2006 through June 30, 2007. 

II. Transition Period for 

Implementation of the IPF PPS 

In the November 2004 IPF PPS final 

rule, we provided for a 3-year transition 

period. During this 3-year transition 

period, an IPF’s total payment under the 

PPS was based on an increasing 

percentage of the Federal rate with a 

corresponding decreasing percentage of 

the IPF PPS payment that is based on 

reasonable cost concepts. However, 

effective for cost reporting periods 

beginning on or after January 1, 2008, 

IPF PPS payments are based on 100 

percent of the Federal rate. 

III. Updates to the IPF PPS for RY 

Beginning July 1, 2010 

The IPF PPS is based on a 

standardized Federal per diem base rate 

calculated from IPF average per diem 

costs and adjusted for budget-neutrality 

in the implementation year. The Federal 

per diem base rate is used as the 

standard payment per day under the IPF 

PPS and is adjusted by the patient- and 

facility-level adjustments that are 

applicable to the IPF stay. A detailed 

explanation of how we calculated the 

average per diem cost appears in the 

November 2004 IPF PPS final rule (69 

FR 66926). 

A. Determining the Standardized 

Budget-Neutral Federal Per Diem Base 

Rate 

Section 124(a)(1) of the BBRA 

requires that we implement the IPF PPS 

in a budget neutral manner. In other 

words, the amount of total payments 


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under the IPF PPS, including any 

payment adjustments, must be projected 

to be equal to the amount of total 

payments that would have been made if 

the IPF PPS were not implemented. 

Therefore, we calculated the budgetneutrality factor by setting the total 

estimated IPF PPS payments to be equal 

to the total estimated payments that 

would have been made under the Tax 

Equity and Fiscal Responsibility Act of 

1982 (TEFRA) (Pub. L. 97–248) 

methodology had the IPF PPS not been 

implemented. 

Under the IPF PPS methodology, we 

calculated the final Federal per diem 

base rate to be budget neutral during the 

IPF PPS implementation period (that is, 

the 18-month period from January 1, 

2005 through June 30, 2006) using a July 

1 update cycle. We updated the average 

cost per day to the midpoint of the IPF 

PPS implementation period (that is, 

October 1, 2005), and this amount was 

used in the payment model to establish 

the budget-neutrality adjustment. 

A step-by-step description of the 

methodology used to estimate payments 

under the TEFRA payment system 

appears in the November 2004 IPF PPS 

final rule (69 FR 66926). 

1. Standardization of the Federal Per 

Diem Base Rate and Electroconvulsive 

Therapy (ECT) Rate 

In the November 2004 IPF PPS final 

rule, we describe how we standardized 

the IPF PPS Federal per diem base rate 

in order to account for the overall 

positive effects of the IPF PPS payment 

adjustment factors. To standardize the 

IPF PPS payments, we compared the IPF 

PPS payment amounts calculated from 

the FY 2002 Medicare Provider Analysis 

and Review (MedPAR) file to the 

projected TEFRA payments from the FY 

2002 cost report file updated to the 

midpoint of the IPF PPS 

implementation period (that is, October 

2005). The standardization factor was 

calculated by dividing total estimated 

payments under the TEFRA payment 

system by estimated payments under 

the IPF PPS. The standardization factor 

was calculated to be 0.8367. 

As described in detail in the May 

2006 IPF PPS final rule (71 FR 27045), 

in reviewing the methodology used to 

simulate the IPF PPS payments used for 

the November 2004 IPF PPS final rule, 

we discovered that due to a computer 

code error, total IPF PPS payments were 

underestimated by about 1.36 percent. 

Since the IPF PPS payment total should 

have been larger than the estimated 

figure, the standardization factor should 

have been smaller (0.8254 vs. 0.8367). In 

turn, the Federal per diem base rate and 

the ECT rate should have been reduced 

by 0.8254 instead of 0.8367. 

To resolve this issue, in RY 2007, we 

amended the Federal per diem base rate 

and the ECT payment rate 

prospectively. Using the standardization 

factor of 0.8254, the average cost per day 

was effectively reduced by 17.46 

percent (100 percent minus 82.54 

percent = 17.46 percent). 

2. Calculation of the Budget Neutrality 

Adjustment 

To compute the budget neutrality 

adjustment for the IPF PPS, we 

separately identified each component of 

the adjustment, that is, the outlier 

adjustment, stop-loss adjustment, and 

behavioral offset. 

A complete discussion of how we 

calculate each component of the budget 

neutrality adjustment appears in the 

November 2004 IPF PPS final rule (69 

FR 66932 through 66933) and in the 

May 2006 IPF PPS final rule (71 FR 

27044 through 27046). 

a. Outlier Adjustment 

Since the IPF PPS payment amount 

for each IPF includes applicable outlier 

amounts, we reduced the standardized 

Federal per diem base rate to account for 

aggregate IPF PPS payments estimated 

to be made as outlier payments. The 

outlier adjustment was calculated to be 

2 percent. As a result, the standardized 

Federal per diem base rate was reduced 

by 2 percent to account for projected 

outlier payments. 

b. Stop-Loss Provision Adjustment 

As explained in the November 2004 

IPF PPS final rule, we provided a stoploss payment during the transition from 

cost-based reimbursement to the per 

diem payment system to ensure that an 

IPF’s total PPS payments were no less 

than a minimum percentage of their 

TEFRA payment, had the IPF PPS not 

been implemented. We reduced the 

standardized Federal per diem base rate 

by the percentage of aggregate IPF PPS 

payments estimated to be made for stoploss payments. As a result, the 

standardized Federal per diem base rate 

was reduced by 0.39 percent to account 

for stop-loss payments. Since the 

transition was completed in RY 2009, 

the stop-loss provision is no longer 

applicable, and for cost reporting 

periods beginning on or after January 1, 

2008, IPFs were paid 100 percent PPS. 

c. Behavioral Offset 

As explained in the November 2004 

IPF PPS final rule, implementation of 

the IPF PPS may result in certain 

changes in IPF practices, especially with 

respect to coding for comorbid medical 

conditions. As a result, Medicare may 

make higher payments than assumed in 

our calculations. Accounting for these 

effects through an adjustment is 

commonly known as a behavioral offset. 

Based on accepted actuarial practices 

and consistent with the assumptions 

made in other PPSs, we assumed in 

determining the behavioral offset that 

IPFs would regain 15 percent of 

potential ‘‘losses’’ and augment payment 

increases by 5 percent. We applied this 

actuarial assumption, which is based on 

our historical experience with new 

payment systems, to the estimated 

‘‘losses’’ and ‘‘gains’’ among the IPFs. The 

behavioral offset for the IPF PPS was 

calculated to be 2.66 percent. As a 

result, we reduced the standardized 

Federal per diem base rate by 2.66 

percent to account for behavioral 

changes. As indicated in the November 

2004 IPF PPS final rule, we do not plan 

to change adjustment factors or 

projections until we analyze IPF PPS 

data. 

If we find that an adjustment is 

warranted, the percent difference may 

be applied prospectively to the 

established PPS rates to ensure the rates 

accurately reflect the payment level 

intended by the statute. In conducting 

this analysis, we will be interested in 

the extent to which improved coding of 

patients’ principal and other diagnoses, 

which may not reflect real increases in 

underlying resource demands, has 

occurred under the PPS. 

B. Update of the Federal Per Diem Base 

Rate and Electroconvulsive Therapy 

Rate 

1. Market Basket for IPFs Reimbursed 

under the IPF PPS 

As described in the November 2004 

IPF PPS final rule (69 FR 66931), the 

average per diem cost was updated to 

the midpoint of the implementation 

year. This updated average per diem 

cost of $724.43 was reduced by 17.46 

percent to account for standardization to 

projected TEFRA payments for the 

implementation period, by 2 percent to 

account for outlier payments, by 0.39 

percent to account for stop-loss 

payments, and by 2.66 percent to 

account for the behavioral offset. The 

Federal per diem base rate in the 

implementation year was $575.95. The 

increase in the per diem base rate for RY 

2009 included the 0.39 percent increase 

due to the removal of the stop-loss 

provision. We indicated in the 

November 2004 IPF PPS final rule (69 

FR 66932) that we would remove this 

0.39 percent reduction to the Federal 

per diem base rate after the transition. 

For RY 2009 and beyond, the stop-loss 


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provision has ended and is therefore no 

longer a part of budget neutrality. 

Due to new section 1886(s)(3)(A) of 

the Act, which requires the application 

of an ‘‘Other Adjustment’’ that reduces 

the update to the IPF PPS base rate for 

the rate year beginning in CY 2010, we 

reduced the update to the IPF PPS base 

rate by 0.25 percent for rate year 2011. 

Applying the market basket increase of 

2.4 percent, with the ‘‘Other 

Adjustment’’ of ¥0.25%, and the wage 

index budget neutrality factor of 0.9999 

to the RY 2010 Federal per diem base 

rate of $651.76 yields a Federal per diem 

base rate of $665.71 for RY 2011. 

Similarly, applying the market basket 

increase with the ‘‘Other Adjustment’’, 

and the wage index budget neutrality 

factor to the RY 2010 ECT rate yields an 

ECT rate of $286.60 for RY 2011. 

a. Market Basket Index for the IPF PPS 

The market basket index that was 

used to develop the IPF PPS was the 

excluded hospital with capital market 

basket. This market basket was based on 

1997 Medicare cost report data and 

included data for Medicare-participating 

IPFs, inpatient rehabilitation facilities 

(IRFs), long-term care hospitals 

(LTCHs), cancer, and children’s 

hospitals. 

Beginning with the May 2006 IPF PPS 

final rule (71 FR 27046 through 27054), 

IPF PPS payments were updated using 

a 2002-based market basket reflecting 

the operating and capital cost structures 

for IRFs, IPFs, and LTCHs (hereafter 

referred to as the rehabilitation, 

psychiatric, long-term care (RPL) market 

basket). 

We excluded cancer and children’s 

hospitals from the RPL market basket 

because their payments are based 

entirely on reasonable costs subject to 

rate-of-increase limits established under 

the authority of section 1886(b) of the 

Act, which are implemented in 

regulations at § 413.40. They are not 

reimbursed through a PPS. Also, the FY 

2002 cost structures for cancer and 

children’s hospitals are noticeably 

different than the cost structures of the 

IRFs, IPFs, and LTCHs. A complete 

discussion of the RPL market basket 

appears in the May 2006 IPF PPS final 

rule (71 FR 27046 through 27054). 

In the May 2009 IPF PPS notice (74 

FR 20362), we requested public 

comment on the possibility of creating 

a stand-alone IPF market basket. In this 

notice, we are responding to those 

comments in the ‘‘Comments on 

Creating a Stand-Alone IPF Market 

Basket’’ section. 

b. Overview of the RPL Market Basket 

The RPL market basket is a fixed 

weight, Laspeyres-type price index. A 

market basket is described as a fixedweight index because it answers the 

question of how much it would cost, at 

another time, to purchase the same mix 

(quantity and intensity) of goods and 

services needed to provide services in a 

base period. The effects on total 

expenditures resulting from changes in 

the mix of goods and services purchased 

subsequent to the base period are not 

measured. In this manner, the market 

basket measures pure price change only. 

Only when the index is rebased would 

changes in the quantity and intensity be 

captured in the cost weights. Therefore, 

we rebase the market basket periodically 

so that cost weights reflect recent 

changes in the mix of goods and 

services that hospitals purchase to 

furnish patient care between base 

periods. 

The terms ‘‘rebasing’’ and ‘‘revising,’’ 

while often used interchangeably, 

actually denote different activities. 

Rebasing means moving the base year 

for the structure of costs of an input 

price index (for example, shifting the 

base year cost structure from FY 1997 to 

FY 2002). Revising means changing data 

sources, methodology, or price proxies 

used in the input price index. In 2006, 

we rebased and revised the market 

basket used to update the IPF PPS. 

Table 1 below sets forth the completed 

FY 2002-based RPL market basket 

including the cost categories, weights, 

and price proxies. 

TABLE 1—FY 2002-BASED RPL MARKET BASKET COST CATEGORIES, WEIGHTS, AND PRICE PROXIES

Cost categories 

FY 2002- 

based RPL 

market basket 

cost weight 

FY 2002-based RPL market basket price proxies 

TOTAL ...................................................... 100.000 

Compensation ........................................... 65.877 

Wages and Salaries* ......................... 52.895 ECI—Wages and Salaries, Civilian Hospital Workers. 

Employee Benefits* ........................... 12.982 ECI—Benefits, Civilian Hospital Workers. 

Professional Fees, Non-Medical* ............. 2.892 ECI—Compensation for Professional & Related occupations. 

Utilities ...................................................... 0.656 

Electricity ........................................... 0.351 PPI—Commercial Electric Power. 

Fuel Oil, Coal, etc .............................. 0.108 PPI—Commercial Natural Gas. 

Water and Sewage ............................ 0.197 CPI—U—Water & Sewage Maintenance. 

Professional Liability Insurance ................ 1.161 CMS Professional Liability Premium Index. 

All Other Products and Services .............. 19.265 

All Other Products .................................... 13.323 

Pharmaceuticals ................................ 5.103 PPI Prescription Drugs. 

Food: Direct Purchase ....................... 0.873 PPI Processed Foods & Feeds. 

Food: Contract Service ...................... 0.620 CPI—U Food Away From Home. 

Chemicals .......................................... 1.100 PPI Industrial Chemicals. 

Medical Instruments .......................... 1.014 PPI Medical Instruments & Equipment. 

Photographic Supplies ....................... 0.096 PPI Photographic Supplies. 

Rubber and Plastics .......................... 1.052 PPI Rubber & Plastic Products. 

Paper Products .................................. 1.000 PPI Converted Paper & Paperboard Products. 

Apparel .............................................. 0.207 PPI Apparel. 

Machinery and Equipment ................. 0.297 PPI Machinery & Equipment. 

Miscellaneous Products** .................. 1.963 PPI Finished Goods less Food & Energy. 

All Other Services ..................................... 5.942 

Telephone .......................................... 0.240 CPI—U Telephone Services. 

Postage .............................................. 0.682 CPI—U Postage. 

All Other: Labor Intensive* ................ 2.219 ECI—Compensation for Private Service Occupations. 

All Other: Non-labor Intensive ........... 2.800 CPI—U All Items. 

Capital-Related Costs*** ........................... 10.149 


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TABLE 1—FY 2002-BASED RPL MARKET BASKET COST CATEGORIES, WEIGHTS, AND PRICE PROXIES—Continued 

Cost categories 

FY 2002- 

based RPL 

market basket 

cost weight 

FY 2002-based RPL market basket price proxies 

Depreciation .............................................. 6.186 

Fixed Assets ...................................... 4.250 Boeckh Institutional Construction 23-year useful life. 

Movable Equipment ........................... 1.937 PPI Machinery & Equipment 11-year useful life. 

Interest Costs ............................................ 2.775 

Nonprofit ............................................ 2.081 Average yield on domestic municipal bonds (Bond Buyer 20 bonds) vintage-weighted (23 years). 

For Profit ............................................ 0.694 Average yield on Moody’s Aaa bond vintage-weighted (23 years). 

Other Capital-Related Costs ..................... 1.187 CPI—U Residential Rent. 

* Labor-related. 

** Blood and blood-related products is included in miscellaneous products. 

*** A portion of capital costs (0.46) are labor-related. 

Note: Due to rounding, weights may not 

sum to total. 

We evaluated the price proxies using 

the criteria of reliability, timeliness, 

availability, and relevance. Reliability 

indicates that the index is based on 

valid statistical methods and has low 

sampling variability. Timeliness implies 

that the proxy is published regularly 

(preferably at least once a quarter). 

Availability means that the proxy is 

publicly available. Finally, relevance 

means that the proxy is applicable and 

representative of the cost category 

weight to which it is applied. The 

Consumer Price Indexes (CPIs), 

Producer Price Indexes (PPIs), and 

Employment Cost Indexes (ECIs) used as 

proxies in this market basket meet these 

criteria. 

We note that the proxies are the same 

as those used for the FY 1997-based 

excluded hospital with capital market 

basket. Because these proxies meet our 

criteria of reliability, timeliness, 

availability, and relevance, we believe 

they continue to be the best measure of 

price changes for the cost categories. For 

further discussion on the FY 1997-based 

excluded hospital with capital market 

basket, see the August 1, 2002 hospital 

inpatient prospective payment system 

(IPPS) final rule (67 FR at 50042). 

The RY 2011 (that is, beginning July 

1, 2010) update for the IPF PPS using 

the FY 2002-based RPL market basket 

and Information Handling Services 

(IHS) Global Insight’s 1st quarter 2010 

forecast for the market basket 

components is 2.4 percent. This 

includes increases in both the operating 

section and the capital section for the 

12-month RY period (that is, July 1, 

2010 through June 30, 2011). IHS Global 

Insight, Inc. is a nationally recognized 

economic and financial forecasting firm 

that contracts with CMS to forecast the 

components of the market baskets. 

2. Labor-Related Share 

Due to the variations in costs and 

geographic wage levels, we believe that 

payment rates under the IPF PPS should 

continue to be adjusted by a geographic 

wage index. This wage index applies to 

the labor-related portion of the Federal 

per diem base rate, hereafter referred to 

as the labor-related share. 

The labor-related share is determined 

by identifying the national average 

proportion of operating costs that are 

related to, influenced by, or vary with 

the local labor market. Using our current 

definition of labor-related, the laborrelated share is the sum of the relative 

importance of wages and salaries, fringe 

benefits, professional fees, laborintensive services, and a portion of the 

capital share from an appropriate 

market basket. We used the FY 2002- 

based RPL market basket cost weights 

relative importance to determine the 

labor-related share for the IPF PPS. 

The labor-related share for RY 2011 is 

the sum of the RY 2011 relative 

importance of each labor-related cost 

category, and reflects the different rates 

of price change for these cost categories 

between the base year (FY 2002) and RY 

2011. The sum of the relative 

importance for the RY 2011 operating 

costs (wages and salaries, employee 

benefits, professional fees, and laborintensive services) is 71.506 percent, as 

shown in Table 2 below. The portion of 

capital that is influenced by the local 

labor market is estimated to be 46 

percent, which is the same percentage 

used in the FY 1997-based IRF and IPF 

payment systems. 

Since the relative importance for 

capital is 8.466 percent of the FY 2002- 

based RPL market basket in RY 2011, we 

are taking 46 percent of 8.466 percent to 

determine the labor-related share of 

capital for RY 2011. The result is 3.894 

percent, which we added to 71.506 

percent for the operating cost amount to 

determine the total labor-related share 

for RY 2011. Thus, the labor-related 

share that we are using for IPF PPS in 

RY 2011 is 75.400 percent. Table 2 

below shows the RY 2011 labor-related 

share using the FY 2002-based RPL 

market basket. We note that this laborrelated share is determined by using the 

same methodology as employed in 

calculating all previous IPF laborrelated shares. 

A complete discussion of the IPF 

labor-related share methodology appears 

in the November 2004 IPF PPS final rule 

(69 FR 66952 through 66954). 

TABLE 2—TOTAL LABOR-RELATED SHARE—RELATIVE IMPORTANCE FOR RY 2011 

Cost category 

FY 2002-based 

RPL market basket labor-related 

share relative importance (percent) 

RY 2010 * 

FY 2002-based 

RPL market basket labor-related 

share relative importance (percent) 

RY 2011 ** 

Wages and salaries ..................................................................................................................................... 53.062 52.600 

Employee benefits ....................................................................................................................................... 13.852 13.935 

Professional fees ......................................................................................................................................... 2.895 2.853 


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TABLE 2—TOTAL LABOR-RELATED SHARE—RELATIVE IMPORTANCE FOR RY 2011—Continued 

Cost category 

FY 2002-based 

RPL market basket labor-related 

share relative importance (percent) 

RY 2010 * 

FY 2002-based 

RPL market basket labor-related 

share relative importance (percent) 

RY 2011 ** 

All other labor-intensive services ................................................................................................................. 2.126 2.118 

Subtotal ................................................................................................................................................. 71.935 71.506 

Labor-related share of capital costs (0.46) ................................................................................................. 3.954 3.894 

Total ...................................................................................................................................................... 75.889 75.400 

* Based on 2009 1st Quarter forecast. 

** Based on 2010 1st Quarter forecast. 

3. Comments on Creating a Stand-Alone 

IPF Market Basket 

In the May 2009 IPF PPS notice (74 

FR 20362), we expressed our interest in 

exploring the possibility of creating a 

stand-alone IPF market basket that 

reflects the cost structures of only IPF 

providers. Of the available options, one 

would be to join the Medicare cost 

report data from freestanding IPF 

providers (presently incorporated into 

the RPL market basket) with data from 

hospital-based IPF providers. An 

examination of the Medicare cost report 

data comparing freestanding and 

hospital-based IPFs reveals considerable 

differences between the two with 

respect to cost levels and cost 

structures. 

In order to better understand the 

observed cost differences between 

freestanding and hospital-based IPFs, 

we reviewed, in detail, several 

explanatory variables such as 

geographic variation, case mix 

(including DRG, comorbidity, and age), 

urban or rural status, length of stay, 

teaching status, and the presence of a 

qualifying emergency department. 

Despite this analysis, we were unable to 

sufficiently explain the differences in 

costs between these two types of IPF 

providers. As a result, we felt that 

further research was required and 

solicited public comment on additional 

information that would help us to better 

understand the reasons for the 

variations in costs and cost structures, 

as reported by cost report data, between 

freestanding and hospital-based IPFs (74 

FR 20376). 

We received several timely comments 

from the public on this issue. A 

summary of the comments and our 

responses to those comments are below. 

Comment: Several commenters 

recommended that CMS consider 

creating an IPF-specific market basket. 

These commenters stated that including 

hospital-based IPF data in the market 

basket and pursuing a greater 

understanding of the differences 

between freestanding and hospitalbased IPFs are both worthy 

undertakings. The commenters cited 

that from 2005 through 2007, the 

number of hospital-based IPFs has 

decreased by 1.4 percent while the 

number of freestanding IPFs has 

increased by 1.0 percent. The 

commenters expressed concern that 

these trends will continue, and likely 

accelerate. Furthermore, the 

commenters stated that in 2007, 

hospital-based IPFs experienced 

negative margins while freestanding IPF 

margins were positive. Given that more 

than 60 percent of IPF discharges are 

from hospital-based units, the 

commenters believe that preserving 

access to care for these patients 

(especially those who have coexisting 

physical conditions or experience a 

crisis and enter the emergency 

department for treatment) is vital. One 

commenter stated that including 

hospital-based IPF data in the market 

basket would increase transparency and 

highlight the differences between 

freestanding and hospital-based 

providers. 

Response: We are actively examining 

the technical merits of creating a standalone IPF market basket. Since 

publication of the May 2009 IPF PPS 

notice, we have been reviewing the 

Medicare cost report and claims data for 

both hospital-based and freestanding 

IPFs to better understand the differences 

in total Medicare costs per day. Parts of 

our analysis were based on comments 

received by the public, which we 

address in more detail below. Based on 

our research to date, which has not 

adequately explained the cost-per-day 

differences between freestanding and 

hospital-based providers, we do not 

believe it is technically appropriate to 

move from the RPL market basket to 

update IPF payments at this time. 

Comment: Several commenters 

supported the ongoing application of 

the RPL market basket to update 

inpatient psychiatric facility payment 

rates. One commenter recommended we 

continue this method in order to 

maintain a reasonable population size of 

facilities to ensure stability in the 

calculation of the market basket. The 

commenter asserted that if the RPL 

market basket was split into separate 

market baskets for IRFs, IPFs, and 

LTCHs, there would be much more 

volatility in the year-to-year changes, 

especially for LTCHs. 

Response: We appreciate the 

comments regarding the continued 

support for using the RPL market basket 

to update inpatient psychiatric facility 

payment rates. Likewise, we appreciate 

the comment regarding sample size 

considerations with respect to splitting 

the RPL market basket into its respective 

pieces. Indeed, sample size and its 

impact on the volatility of the estimates 

will be extensively scrutinized before 

we would propose to change the 

mechanism used to update payments to 

inpatient psychiatric facilities, inpatient 

rehabilitation facilities, and long-term 

care hospitals. 

Comment: One commenter supported 

the investigation of the differences in 

cost structures between hospital-based 

and freestanding IPFs. Besides 

determining the source of these 

differences, the commenter also stated it 

is important for CMS to determine 

whether the differences should be 

recognized (for example, are higher 

costs in IPF hospital-based facilities due 

to allocation of overhead to the unit or 

to differences in case mix or patient 

severity that is not measurable using 

available administrative data). This 

commenter also acknowledged that 

seeking outside input regarding 

differences in cost structures between 

hospital-based and freestanding IPFs is 

appropriate. However, the commenter 


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recommended that CMS proceed with 

caution as it may be difficult for CMS 

to confirm that the methods used to 

collect outside data are sound and that 

the data are representative of the 

industry as a whole. The commenter 

also stated that CMS should ultimately 

determine whether the market basket 

should in fact be based on the cost 

structure of hospital-based and 

freestanding IPFs (instead of just one 

type of facility) if the higher costs 

cannot be explained by differences in 

case mix and other patient 

characteristics. 

Response: Although we asked for 

outside information to help us better 

understand these differences, we agree 

with the commenter that any outside 

information should be carefully 

examined. 

As we have stated, we currently do 

not feel it is appropriate to incorporate 

data from hospital-based IPFs with that 

of freestanding IPFs to create a standalone IPF market basket given the 

observed and unexplained differences 

in cost structures. 

Comment: Several commenters stated 

that creating a stand-alone IPF market 

basket could be a more accurate index 

for the costs of delivering care incurred 

by IPFs. However, the commenters 

stated that they did not have any 

independent data to help CMS in 

developing a stand-alone market basket 

at this time. The commenters suggested 

that the issue of a stand-alone IPF 

market basket continue to be analyzed 

by CMS. 

Response: We agree with the 

commenters and plan to continue to 

analyze costs and Medicare claims data 

for hospital-based and freestanding 

providers. 

Comment: One commenter supports 

the development of a stand-alone IPF 

market basket. However, the commenter 

encourages CMS to avoid mixing data 

from hospital-based and freestanding 

IPFs. The commenter claims that 

hospital-based IPFs incur higher costs 

than freestanding IPFs in treating 

Medicare patients for the following 

reasons: 

• The acuity levels and medical 

needs of psychiatric patients that 

present in a hospital’s qualified 

emergency room will result in higher 

treatment costs and lengths of stay. 

• Hospitals provide a greater range of 

ancillary services. 

• Some hospitals operate approved 

psychiatric residency teaching 

programs. 

Therefore, the commenter is reluctant 

to support a combined hospital-based, 

freestanding IPF market basket at this 

time. The commenter also offered to 

assist CMS with any information he or 

she can provide. 

Response: We appreciate the 

commenter’s input on possible reasons 

why hospital-based IPFs have higher 

costs than freestanding IPFs. As stated 

above, we compared the medical needs 

of the patients, as measured by the 

adjustments for DRG, comorbidities, and 

age. Our analysis did show that 

hospital-based providers, on average, 

treat more complex patients; however, 

the differences in the complexity of the 

patients, as well as other facility-based 

adjustments, did not adequately explain 

the differences in total Medicare costs 

per day between hospital-based and 

freestanding providers. In addition, 

using both Medicare cost report and 

claims data, we found that hospitalbased providers, on average, had shorter 

lengths of stay than freestanding 

providers. 

Per the commenter’s suggestion, and 

using MCR data, we also compared the 

Medicare ancillary costs per day of 

hospital-based and freestanding 

providers. We found that hospital-based 

facilities, on average, tend to have 

higher Medicare ancillary costs per day 

than freestanding facilities. The 

differences were mostly attributable to 

higher emergency room and laboratory 

costs. These higher ancillary costs 

accounted for about ten percent of the 

overall difference between hospitalbased and freestanding providers’ total 

Medicare costs per day. 

In addition, we compared the average 

approved teaching costs for hospitalbased and freestanding providers. We 

found that hospital-based providers 

have higher teaching-related costs 

associated with Medicare approved 

programs relative to free standing 

providers; however, the difference 

accounted for only three percent of the 

total difference in Medicare costs per 

day for hospital-based and freestanding 

providers. 

Comment: One commenter simply 

agreed with CMS that before 

implementation of a new market basket 

method, the method should be fully 

evaluated and the projected impact 

known. 

Response: We agree with the 

commenter’s suggestion. Before any 

implementation, CMS will fully 

evaluate our methodology to ensure that 

any proposed market basket most 

accurately reflects the cost structures 

associated with providing psychiatric 

care to Medicare patients. 

Comment: One commenter does not 

support the adoption of a stand-alone 

IPF market basket at this time, pending 

further study, as the commenter is not 

convinced that CMS has the appropriate 

level of psychiatric cost data available to 

compile an accurate market basket for 

IPFs alone. These conclusions were 

based on the following reasons: 

• There are a small number of 

facilities and often limited data (for 

example, only 4 percent of IPFs reported 

contract labor costs for FY 2002). 

• Benefits, contract labor, and blood 

cost weights were developed using the 

FY 2002-based IPPS market basket. 

• Other detailed cost categories were 

derived from the FY 2002-based IPPS 

market basket. 

• No cost data specific to psychiatry 

(that is, Wages and Salaries—based on 

Civilian Hospital Workers). 

The commenter stated that without 

release of both relevant internal data 

available only to CMS on the previously 

mentioned IPF market basket issues, as 

well as specific data on the types of cost 

differences between the various cost 

categories of IRF, IPF, and LTCH 

facilities, they are unable to comment 

on an independent IPF market basket at 

this time. The commenter believes that 

more detailed analysis needs to be 

conducted and released before they 

could consider supporting any change 

to the current RPL-based market basket 

update process. 

Response: We are in the process of 

evaluating multiple years of data in 

order to determine whether a standalone IPF market basket would be a 

more appropriate index for updating IPF 

PPS payments. We agree with the 

commenter that there is a lack of IPFspecific benefit and contract labor cost 

data. Currently, benefit and contract 

labor cost data are collected on 

Worksheet S–3, part II of the Medicare 

cost report (MCR), but are only required 

of IPPS hospitals. We proposed under 

separate cover to modify the present-day 

hospital MCR in order to collect benefit 

and contract labor data on a separate 

worksheet (proposed Worksheet S–3, 

part V) which would be completed by 

all hospitals (http://www.cms.hhs.gov/

PaperworkReductionActof1995/PRAL/ 

itemdetail.asp?filterType=none&

filterByDID=-99&sortByDID=2&

sortOrder=descending&itemID

=CMS1224069&intNumPerPage). We 

disagree with the commenter that we are 

not capturing IPF-specific data for 

wages and salaries since all hospitals 

are required to report this data on the 

MCRs, which provides the sources of 

our wages and salaries cost weight. We 

believe the commenter may be 

referencing the Employment Cost Index 

(ECI) for wages and salaries for hospital 

civilian workers which we use to proxy 

price changes associated with the wages 

and salary cost weight. This proxy is 

used because the Bureau of Labor 


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Statistics does not publish a wages and 

salaries price index specific to IPFs 

only. However, the ECI for wages and 

salaries for hospital civilian workers 

does include the price changes of IPFs, 

as well as other hospital-types 

(including general surgical hospitals). 

IV. Update of the IPF PPS Adjustment 

Factors 

A. Overview of the IPF PPS Adjustment 

Factors 

The IPF PPS payment adjustments 

were derived from a regression analysis 

of 100 percent of the FY 2002 MedPAR 

data file, which contained 483,038 

cases. For this notice, we used the same 

results of the regression analysis used to 

implement the November 2004 IPF PPS 

final rule. For a more detailed 

description of the data file used for the 

regression analysis, see the November 

2004 IPF PPS final rule (69 FR 66935 

through 66936). While we have since 

used more recent claims data to set the 

fixed dollar loss threshold amount, we 

use the same results of this regression 

analysis to update the IPF PPS for RY 

2010 as well as RY 2011. 

As previously stated, we do not plan 

to update the regression analysis until 

we are able to analyze IPF PPS claims 

and cost report data. However, we 

continue to monitor claims and 

payment data independently from cost 

report data to assess issues, to determine 

whether changes in case-mix or 

payment shifts have occurred among 

freestanding governmental, non-profit 

and private psychiatric hospitals, and 

psychiatric units of general hospitals, 

and CAHs and other issues of 

importance to IPFs. 

B. Patient-Level Adjustments 

In the May 2008 IPF PPS notice (73 

FR 25709) and in the May 2009 IPF PPS 

notice (74 FR 20362), we provided 

payment adjustments for the following 

patient-level characteristics: Medicare 

Severity diagnosis related groups (MS– 

DRGs) assignment of the patient’s 

principal diagnosis, selected 

comorbidities, patient age, and the 

variable per diem adjustments. 

1. Adjustment for MS–DRG Assignment 

The IPF PPS includes payment 

adjustments for the psychiatric DRG 

assigned to the claim based on each 

patient’s principal diagnosis. The IPF 

PPS recognizes the MS–DRGs. The DRG 

adjustment factors were expressed 

relative to the most frequently reported 

psychiatric DRG in FY 2002, that is, 

DRG 430 (psychoses). The coefficient 

values and adjustment factors were 

derived from the regression analysis. 

In accordance with § 412.27(a), 

payment under the IPF PPS is 

conditioned on IPFs admitting ‘‘only 

patients whose admission to the unit is 

required for active treatment, of an 

intensity that can be provided 

appropriately only in an inpatient 

hospital setting, of a psychiatric 

principal diagnosis that is listed in 

Chapter Five (‘‘Mental Disorders’’) of the 

International Classification of Diseases, 

Ninth Revision, Clinical Modification 

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

Text Revision of the American 

Psychiatric Association’s Diagnostic and 

Statistical Manual, (DSM–IV–TR). IPF 

claims with a principal diagnosis 

included in Chapter Five of the ICD–9– 

CM or the DSM–IV–TR are paid the 

Federal per diem base rate under the IPF 

PPS and all other applicable 

adjustments, including any applicable 

DRG adjustment. Psychiatric principal 

diagnoses that do not group to one of 

the designated DRGs still receive the 

Federal per diem base rate and all other 

applicable adjustments, but the payment 

would not include a DRG adjustment. 

The Standards for Electronic 

Transaction final rule published in the 

Federal Register on August 17, 2000 (65 

FR 50312), adopted the ICD–9–CM as 

the designated code set for reporting 

diseases, injuries, impairments, other 

health related problems, their 

manifestations, and causes of injury, 

disease, impairment, or other health 

related problems. Therefore, we use the 

ICD–9–CM as the designated code set 

for the IPF PPS. 

We believe that it is important to 

maintain the same diagnostic coding 

and DRG classification for IPFs that are 

used under the IPPS for providing the 

psychiatric care. Therefore, when the 

IPF PPS was implemented for cost 

reporting periods beginning on or after 

January 1, 2005, we adopted the same 

diagnostic code set and DRG patient 

classification system (that is, the CMS 

DRGs) that was utilized at the time 

under the hospital inpatient prospective 

payment system (IPPS). Since the 

inception of the IPF PPS, the DRGs used 

as the patient classification system 

under the IPF PPS have corresponded 

exactly with the CMS DRGs applicable 

under the IPPS for acute care hospitals. 

Every year, changes to the ICD–9–CM 

coding system are addressed in the IPPS 

proposed and final rules. The changes to 

the codes are effective October 1 of each 

year and must be used by acute care 

hospitals as well as other providers to 

report diagnostic and procedure 

information. The IPF PPS has always 

incorporated ICD–9–CM coding changes 

made in the annual IPPS update. We 

publish coding changes in a 

Transmittal/Change Request, similar to 

how coding changes are announced by 

the IPPS and LTCH PPS. Those ICD–9– 

CM coding changes are also published 

in the following IPF PPS RY update, in 

either the IPF PPS proposed and final 

rules, or in an IPF PPS update notice. 

In the May 2008 IPF PPS notice (73 

FR 25714), we discussed CMS’ effort to 

better recognize resource use and the 

severity of illness among patients. CMS 

adopted the new MS–DRGs for the IPPS 

in the FY 2008 IPPS final rule with 

comment period (72 FR 47130). We 

believe by better accounting for patients’ 

severity of illness in Medicare payment 

rates, the MS–DRGs encourage hospitals 

to improve their coding and 

documentation of patient diagnoses. 

The MS–DRGs, which are based on the 

CMS DRGs, represent a significant 

increase in the number of DRGs (from 

538 to 745, an increase of 207). For a 

full description of the development and 

implementation of the MS–DRGs, see 

the FY 2008 IPPS final rule with 

comment period (72 FR 47141 through 

47175). 

All of the ICD–9–CM coding changes 

are reflected in the FY 2010 GROUPER, 

Version 27.0, effective for IPPS 

discharges occurring on or after October 

1, 2009 through September 30, 2010. 

The GROUPER Version 27.0 software 

package assigns each case to an MS– 

DRG on the basis of the diagnosis and 

procedure codes and demographic 

information (that is, age, sex, and 

discharge status). The Medicare Code 

Editor (MCE) 26.0 uses the new ICD–9– 

CM codes to validate coding for IPPS 

discharges on or after October 1, 2009. 

For additional information on the 

GROUPER Version 27.0 and MCE 26.0, 

see Transmittal 1816 (Change Request 

6634), dated October 1, 2009. The IPF 

PPS has always used the same 

GROUPER and Code Editor as the IPPS. 

Therefore, the ICD–9–CM changes, 

which were reflected in the GROUPER 

Version 27.0 and MCE 26.0 on October 

1, 2009, also became effective for the 

IPF PPS for discharges occurring on or 

after October 1, 2009. 

The impact of the new MS–DRGs on 

the IPF PPS was negligible. Mapping to 

the MS–DRGs resulted in the current 17 

MS–DRGs, instead of the original 15 

DRGs, for which the IPF PPS provides 

an adjustment. Although the code set is 

updated, the same associated 

adjustment factors apply now that have 

been in place since implementation of 

the IPF PPS, with one exception that is 

unrelated to the update to the codes. 

When DRGs 521 and 522 were 

consolidated into MS–DRG 895, we 

carried over the adjustment factor of 

1.02 from DRG 521 to the newly 


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consolidated MS–DRG. This was done 

to reflect the higher claims volume 

under DRG 521, with more than eight 

times the number of claims than billed 

under DRG 522. The updates are 

reflected in Table 5. For a detailed 

description of the mapping changes 

from the original DRG adjustment 

categories to the current MS–DRG 

adjustment categories, we refer readers 

to the May 2008 IPF PPS notice (73 FR 

25714). 

The official version of the ICD–9–CM 

is available on CD–ROM from the U.S. 

Government Printing Office. The FY 

2009 version can be ordered by 

contacting the Superintendent of 

Documents, U.S. Government Printing 

Office, Department 50, Washington, DC 

20402–9329, telephone number (202) 

512–1800. Questions concerning the 

ICD–9–CM should be directed to 

Patricia E. Brooks, Co-Chairperson, ICD– 

9–CM Coordination and Maintenance 

Committee, CMS, Center for Medicare 

Management, Hospital and Ambulatory 

Policy Group, Division of Acute Care, 

Mailstop C4–08–06, 7500 Security 

Boulevard, Baltimore, Maryland 21244– 

1850. 

Further information concerning the 

official version of the ICD–9–CM can be 

found in the IPPS final rule with 

comment period, ‘‘Changes to Hospital 

Inpatient Prospective Payment System 

and Fiscal Year 2010 Rates’’ in the 

August 27, 2009 Federal Register (74 FR 

43754) and at http://www.cms.hhs.gov/ 

AcuteInpatientPPS/IPPS/ 

list.asp#TopOfPage. 

Tables 3 and 4 below list the FY 2010 

new and invalid ICD–9–CM diagnosis 

codes that group to one of the 17 MS– 

DRGs for which the IPF PPS provides an 

adjustment. These tables are only a 

listing of FY 2010 changes and do not 

reflect all of the currently valid and 

applicable ICD–9–CM codes classified 

in the MS–DRGs. When coded as a 

principal code or diagnosis, these codes 

receive the correlating MS–DRG 

adjustment. 

TABLE 3—FY 2010 NEW DIAGNOSIS CODES

Diagnosis code Description MS–DRG 

438.13 ............... Late effects of cerebrovascular disease, dysarthria ............................................................................................. 056, 057 

438.14 ............... Late effects of cerebrovascular disease, fluency disorder ................................................................................... 056, 057 

799.21 ............... Nervousness ......................................................................................................................................................... 880 

799.22 ............... Irritability ............................................................................................................................................................... 880 

799.23 ............... Impulsiveness ....................................................................................................................................................... 882 

799.24 ............... Emotional lability ................................................................................................................................................... 883 

799.25 ............... Demoralization and apathy ................................................................................................................................... 880 

799.29 ............... Other signs and symptoms involving emotional state .......................................................................................... 880 

TABLE 4—FY 2010 INVALID

DIAGNOSIS CODES

Diagnosis 

code Description MS–DRG 

799.2 ...... Nervousness ........... 880 

We do not plan to update the 

regression analysis until we are able to 

analyze IPF PPS data. The MS–DRG 

adjustment factors (as shown in Table 5 

below) will continue to be paid for 

discharges occurring in RY 2011. 

TABLE 5—RY 2011 CURRENT MS–DRGS APPLICABLE FOR THE PRINCIPAL DIAGNOSIS ADJUSTMENT

MS–DRG MS–DRG descriptions Adjustment 

factor 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

2. Payment for Comorbid Conditions 

The intent of the comorbidity 

adjustments is to recognize the 

increased costs associated with 

comorbid conditions by providing 

additional payments for certain 

concurrent medical or psychiatric 

conditions that are expensive to treat. In 

the May 2009 IPF PPS notice (74 FR 

20362), we explained that the IPF PPS 

includes 17 comorbidity categories and 

identified the new, revised, and deleted 

ICD–9–CM diagnosis codes that generate 

a comorbid condition payment 

adjustment under the IPF PPS for RY 

2010 (77 FR 20372). 

Comorbidities are specific patient 

conditions that are secondary to the 

patient’s principal diagnosis and that 

require treatment during the stay. 


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Diagnoses that relate to an earlier 

episode of care and have no bearing on 

the current hospital stay are excluded 

and must not be reported on IPF claims. 

Comorbid conditions must exist at the 

time of admission or develop 

subsequently, and affect the treatment 

received, length of stay (LOS), or both 

treatment and LOS. 

For each claim, an IPF may receive 

only one comorbidity adjustment per 

comorbidity category, but it may receive 

an adjustment for more than one 

comorbidity category. Billing 

instructions require that IPFs must enter 

the full ICD–9–CM codes for up to 8 

additional diagnoses if they co-exist at 

the time of admission or develop 

subsequently and impact the treatment 

provided. 

The comorbidity adjustments were 

determined based on the regression 

analysis using the diagnoses reported by 

IPFs in FY 2002. The principal 

diagnoses were used to establish the 

DRG adjustments and were not 

accounted for in establishing the 

comorbidity category adjustments, 

except where ICD–9–CM ‘‘code first’’ 

instructions apply. As we explained in 

the May 2008 IPF PPS notice (73 FR 

25716), the code first rule applies when 

a condition has both an underlying 

etiology and a manifestation due to the 

underlying etiology. For these 

conditions, the ICD–9–CM has a coding 

convention that requires the underlying 

conditions to be sequenced first 

followed by the manifestation. 

Whenever a combination exists, there is 

a ‘‘use additional code’’ note at the 

etiology code and a code first note at the 

manifestation code. 

As discussed in the MS–DRG section, 

it is our policy to maintain the same 

diagnostic coding set for IPFs that is 

used under the IPPS for providing the 

same psychiatric care. Although the 

ICD–9–CM code set has been updated, 

the same adjustment factors have been 

in place since the implementation of the 

IPF PPS. Table 6 below lists the FY 2010 

new ICD diagnosis codes that impact the 

comorbidity adjustments under the IPF 

PPS. Table 6 is not a list of all currently 

valid ICD codes applicable for the IPF 

PPS comorbidity adjustments. 

TABLE 6—FY 2010 NEW ICD CODES APPLICABLE FOR THE COMORBIDITY ADJUSTMENT

Diagnosis code Description Comorbidity category 

209.31 ............... Merkel cell carcinoma of the face ........................................................................................................ Oncology Treatment. 

209.32 ............... Merkel cell carcinoma of the scalp and neck ...................................................................................... Oncology Treatment. 

209.33 ............... Merkel cell carcinoma of the upper limb ............................................................................................. Oncology Treatment. 

209.34 ............... Merkel cell carcinoma of the lower limb .............................................................................................. Oncology Treatment. 

209.35 ............... Merkel cell carcinoma of the trunk ...................................................................................................... Oncology Treatment. 

209.36 ............... Merkel cell carcinoma of other sites .................................................................................................... Oncology Treatment. 

209.70 ............... Secondary neuroendocrine tumor, unspecified site ............................................................................ Oncology Treatment. 

209.71 ............... Secondary neuroendocrine tumor of distant lymph nodes .................................................................. Oncology Treatment. 

209.72 ............... Secondary neuroendocrine tumor of liver ........................................................................................... Oncology Treatment. 

209.73 ............... Secondary neuroendocrine tumor of bone .......................................................................................... Oncology Treatment. 

209.74 ............... Secondary neuroendocrine tumor of peritoneum ................................................................................ Oncology Treatment. 

209.75 ............... Secondary Merkel cell carcinoma ........................................................................................................ Oncology Treatment. 

209.79 ............... Secondary neuroendocrine tumor of other sites ................................................................................. Oncology Treatment. 

239.81 ............... Neoplasms of unspecified nature, retina and choroid ......................................................................... Oncology Treatment. 

239.89 ............... Neoplasms of unspecified nature, other specified sites ...................................................................... Oncology Treatment. 

969.00 ............... Poisoning by antidepressant, unspecified ........................................................................................... Poisoning. 

969.01 ............... Poisoning by monoamine oxidase inhibitors ....................................................................................... Poisoning. 

969.02 ............... Poisoning by selective serotonin and norepinephrine reuptake inhibitors .......................................... Poisoning. 

969.03 ............... Poisoning by selective serotonin reuptake inhibitors .......................................................................... Poisoning. 

969.04 ............... Poisoning by tetracyclic antidepressants ............................................................................................. Poisoning. 

969.05 ............... Poisoning by tricyclic antidepressants ................................................................................................. Poisoning. 

969.09 ............... Poisoning by other antidepressants .................................................................................................... Poisoning. 

969.70 ............... Poisoning by psychostimulant, unspecified ......................................................................................... Poisoning. 

969.71 ............... Poisoning by caffeine ........................................................................................................................... Poisoning. 

969.72 ............... Poisoning by amphetamines ................................................................................................................ Poisoning. 

969.73 ............... Poisoning by methylphenidate ............................................................................................................. Poisoning. 

969.79 ............... Poisoning by other psychostimulants .................................................................................................. Poisoning. 

Table 7 below lists the FY 2010 

revised ICD diagnosis codes that are 

applicable for the comorbidity 

adjustment. 

TABLE 7—FY 2010 REVISED ICD CODES APPLICABLE FOR THE COMORBIDITY ADJUSTMENT

Diagnosis code Description Comorbidity category 

584.5 ................. Acute kidney failure with lesion of tubular necrosis ............................................................................ Renal Failure, Acute. 

584.6 ................. Acute kidney failure with lesion of renal cortical necrosis ................................................................... Renal Failure, Acute. 

584.7 ................. Acute kidney failure with lesion of renal medullary [papillary] necrosis .............................................. Renal Failure, Acute. 

584.8 ................. Acute kidney failure with other specified pathological lesion in kidney .............................................. Renal Failure, Acute. 

584.9 ................. Acute kidney failure, unspecified ......................................................................................................... Renal Failure, Acute. 

639.3 ................. Kidney failure following abortion and ectopic and molar pregnancies ................................................ Renal Failure, Acute. 

669.32 ............... Acute kidney failure following labor and delivery, delivered, with mention of postpartum complication.Renal Failure, Acute. 

669.34 ............... Acute kidney failure following labor and delivery, postpartum condition or complication ................... Renal Failure, Acute. 


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Table 8 below lists the invalid FY 

2010 ICD–9–CM codes no longer 

applicable for the comorbidity 

adjustment. 

TABLE 8—FY 2010 INVALID ICD CODES NO LONGER APPLICABLE FOR THE COMORBIDITY ADJUSTMENT

Diagnosis code Description Comorbidity category 

239.8 ................. Neoplasm of unspecified nature of other specified sites .................................................................... Oncology Treatment. 

969.0 ................. Poisoning by antidepressants .............................................................................................................. Poisoning. 

969.7 ................. Poisoning by psychostimulants ............................................................................................................ Poisoning. 

For RY 2011, we are applying the 

seventeen comorbidity categories for 

which we are providing an adjustment, 

their respective codes, including the 

new FY 2010 ICD–9–CM codes, and 

their respective adjustment factors in 

Table 9 below. 

TABLE 9—RY 2011 DIAGNOSIS CODES AND ADJUSTMENT FACTORS FOR COMORBIDITY CATEGORIES

Description of comorbidity ICD–9CM code Adjustment 

factor 

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

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

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

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

66932, 66934, 9585.

1.11 

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

5856, 5859, 586, V4511, V4512, V560, V561, and V562.

1.11 

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

code 99.25.

1.07 

Uncontrolled Diabetes-Mellitus with or 

without complications.

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

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

1.05 

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

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

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

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

1.07 

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

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

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

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

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

Severe Musculoskeletal and Connective 

Tissue Diseases.

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

73029.

1.09 

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

through 9839, 986, 9890 through 9897.

1.11 

3. Patient Age Adjustments 

As explained in the November 2004 

IPF PPS final rule (69 FR 66922), we 

analyzed the impact of age on per diem 

cost by examining the age variable (that 

is, the range of ages) for payment 

adjustments. 

In general, we found that the cost per 

day increases with age. The older age 

groups are more costly than the under 

45 age group, the differences in per 

diem cost increase for each successive 

age group, and the differences are 

statistically significant. 

For RY 2011, we are continuing to use 

the patient age adjustments currently in 

effect as shown in Table 10 below. 

TABLE 10—AGE GROUPINGS AND

ADJUSTMENT FACTORS

Age Adjustment 

factor 

Under 45 ................................. 1.00 

45 and under 50 ..................... 1.01 

50 and under 55 ..................... 1.02 

55 and under 60 ..................... 1.04 

60 and under 65 ..................... 1.07 

65 and under 70 ..................... 1.10 

70 and under 75 ..................... 1.13 

75 and under 80 ..................... 1.15 

80 and over ............................ 1.17 

4. Variable Per Diem Adjustments 

We explained in the November 2004 

IPF PPS final rule (69 FR 66946) that the 

regression analysis indicated that per 

diem cost declines as the LOS increases. 

The variable per diem adjustments to 

the Federal per diem base rate account 

for ancillary and administrative costs 

that occur disproportionately in the first 

days after admission to an IPF. 

We used a regression analysis to 

estimate the average differences in per 

diem cost among stays of different 

lengths. As a result of this analysis, we 

established variable per diem 

adjustments that begin on day 1 and 

decline gradually until day 21 of a 

patient’s stay. For day 22 and thereafter, 

the variable per diem adjustment 

remains the same each day for the 

remainder of the stay. However, the 

adjustment applied to day 1 depends 

upon whether the IPF has a qualifying 

ED. If an IPF has a qualifying ED, it 

receives a 1.31 adjustment factor for day 

1 of each stay. If an IPF does not have 

a qualifying ED, it receives a 1.19 

adjustment factor for day 1 of the stay. 

The ED adjustment is explained in more 

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


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For RY 2011, we are continuing to use 

the variable per diem adjustment factors 

currently in effect as shown in Table 11 

below. A complete discussion of the 

variable per diem adjustments appears 

in the November 2004 IPF PPS final rule 

(69 FR 66946). 

TABLE 11—VARIABLE PER DIEM

ADJUSTMENTS

Day-of-stay Adjustment 

factor 

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

Day 1—IPF With a Qualifying 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

C. Facility-Level Adjustments 

The IPF PPS includes facility-level 

adjustments for the wage index, IPFs 

located in rural areas, teaching IPFs, 

cost of living adjustments for IPFs 

located in Alaska and Hawaii, and IPFs 

with a qualifying ED. 

1. Wage Index Adjustment 

a. Background 

As discussed in the May 2006 IPF PPS 

final rule and in the May 2008 and May 

2009 update notices, in providing an 

adjustment for geographic wage levels, 

the labor-related portion of an IPF’s 

payment is adjusted using an 

appropriate wage index. Currently, an 

IPF’s geographic wage index value is 

determined based on the actual location 

of the IPF in an urban or rural area as 

defined in § 412.64(b)(1)(ii)(A) through 

§ 412.64(C). 

b. Wage Index for RY 2011 

Since the inception of the IPF PPS, we 

have used hospital wage data in 

developing a wage index to be applied 

to IPFs. We are continuing that practice 

for RY 2011. We apply the wage index 

adjustment to the labor-related portion 

of the Federal rate, which is 75.400 

percent. This percentage reflects the 

labor-related relative importance of the 

RPL market basket for RY 2011 (see 

section III.B.2 of this notice). The IPF 

PPS uses the pre-floor, pre-reclassified 

hospital wage index. Changes to the 

wage index are made in a budget neutral 

manner so that updates do not increase 

expenditures. 

For RY 2011, we are applying the 

most recent hospital wage index (that is, 

the FY 2010 pre-floor, pre-reclassified 

hospital wage index because this is the 

most appropriate index as it best reflects 

the variation in local labor costs of IPFs 

in the various geographic areas) using 

the most recent hospital wage data (that 

is, data from hospital cost reports for the 

cost reporting period beginning during 

FY 2006), and applying an adjustment 

in accordance with our budget 

neutrality policy. This policy requires 

us to estimate the total amount of IPF 

PPS payments in RY 2010 using the 

applicable wage index value divided by 

the total estimated IPF PPS payments in 

RY 2011 using the most recent wage 

index. The estimated payments are 

based on FY 2008 IPF claims, inflated 

to the appropriate RY. This quotient is 

the wage index budget neutrality factor, 

and it is applied in the update of the 

Federal per diem base rate for RY 2011 

in addition to the market basket 

described in section III.B.1 of this 

notice. The wage index budget 

neutrality factor for RY 2011 is 0.9999. 

The wage index applicable for RY 

2011 appears in Table 1 and Table 2 in 

Addendum B of this notice. As 

explained in the May 2006 IPF PPS final 

rule for RY 2007 (71 FR 27061), the IPF 

PPS applies the hospital wage index 

without a hold-harmless policy, and 

without an out-commuting adjustment 

or out-migration adjustment because the 

statutory authority for these policies 

applies only to the IPPS. 

Also in the May 2006 IPF PPS final 

rule for RY 2007 (71 FR 27061), we 

adopted the changes discussed in the 

Office of Management and Budget 

(OMB) Bulletin No. 03–04 (June 6, 

2003), which announced revised 

definitions for Metropolitan Statistical 

Areas (MSAs), and the creation of 

Micropolitan Statistical Areas and 

Combined Statistical Areas. In adopting 

the OMB Core-Based Statistical Area 

(CBSA) geographic designations, since 

the IPF PPS was already in a transition 

period from TEFRA payments to PPS 

payments, we did not provide a separate 

transition for the CBSA-based wage 

index. 

As was the case in RY 2010, for RY 

2011 we will continue to use the CBSAbased wage index values as presented in 

Tables 1 and 2 in Addendum B of this 

notice. A complete discussion of the 

CBSA labor market definitions appears 

in the May 2006 IPF PPS final rule (71 

FR 27061 through 27067). 

In summary, for RY 2011 we will use 

the FY 2010 wage index data (collected 

from cost reports submitted by hospitals 

for cost reporting periods beginning 

during FY 2006) to adjust IPF PPS 

payments beginning July 1,2010. 

c. OMB Bulletins 

The Office of Management and Budget 

(OMB) publishes bulletins regarding 

CBSA changes, including changes to 

CBSA numbers and titles. In the May 

2008 IPF PPS notice, we incorporated 

the CBSA nomenclature changes 

published in the most recent OMB 

bulletin that applies to the hospital 

wage data used to determine the current 

IPF PPS wage index (73 FR 25721). We 

will continue to do the same for all such 

OMB CBSA nomenclature changes in 

future IPF PPS rules and notices, as 

necessary. The OMB bulletins may be 

accessed online at http:// 

www.whitehouse.gov/omb/bulletins/ 

index.html. 

2. Adjustment for Rural Location 

In the November 2004 IPF PPS final 

rule, we provided a 17 percent payment 

adjustment for IPFs located in a rural 

area. This adjustment was based on the 

regression analysis, which indicated 

that the per diem cost of rural facilities 

was 17 percent higher than that of urban 

facilities after accounting for the 

influence of the other variables included 

in the regression. For RY 2011, we are 

applying a 17 percent payment 

adjustment for IPFs located in a rural 

area as defined at § 412.64(b)(1)(ii)(C). 

As stated in the November 2004 IPF PPS 

final rule, we do not intend to update 

the adjustment factors derived from the 

regression analysis until we are able to 

analyze IPF PPS data. A complete 

discussion of the adjustment for rural 

locations appears in the November 2004 

IPF PPS final rule (69 FR 66954). 

3. Teaching Adjustment 

In the November 2004 IPF PPS final 

rule, we implemented regulations at 

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

part of, teaching hospitals. The teaching 

adjustment accounts for the higher 

indirect operating costs experienced by 

hospitals that participate in graduate 

medical education (GME) programs. The 

payment adjustments are made based on 

the number of full-time equivalent (FTE) 

interns and residents training in the IPF 

and the IPF’s average daily census. 

Medicare makes direct GME payments 

(for direct costs such as resident and 


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teaching physician salaries, and other 

direct teaching costs) to all teaching 

hospitals including those paid under the 

IPPS, and those that were once paid 

under the TEFRA rate-of-increase limits 

but are now paid under other PPSs. 

These direct GME payments are made 

separately from payments for hospital 

operating costs and are not part of the 

PPSs. The direct GME payments do not 

address the estimated higher indirect 

operating costs teaching hospitals may 

face. 

For teaching hospitals paid under the 

TEFRA rate-of-increase limits, Medicare 

did not make separate payments for 

indirect medical education costs 

because payments to these hospitals 

were based on the hospitals’ reasonable 

costs which already included these 

higher indirect costs that may be 

associated with teaching programs. 

The results of the regression analysis 

of FY 2002 IPF data established the 

basis for the payment adjustments 

included in the November 2004 IPF PPS 

final rule. The results showed that the 

indirect teaching cost variable is 

significant in explaining the higher 

costs of IPFs that have teaching 

programs. We calculated the teaching 

adjustment based on the IPF’s ‘‘teaching 

variable,’’ which is one plus the ratio of 

the number of FTE residents training in 

the IPF (subject to limitations described 

below) to the IPF’s average daily census 

(ADC). 

We established the teaching 

adjustment in a manner that limited the 

incentives for IPFs to add FTE residents 

for the purpose of increasing their 

teaching adjustment. We imposed a cap 

on the number of FTE residents that 

may be counted for purposes of 

calculating the teaching adjustment. We 

emphasize that the cap limits the 

number of FTE residents that teaching 

IPFs may count for the purposes of 

calculating the IPF PPS teaching 

adjustment, not the number of residents 

teaching institutions can hire or train. 

We calculated the number of FTE 

residents that trained in the IPF during 

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

number as the cap. An IPF’s FTE 

resident cap is ultimately determined 

based on the final settlement of the IPF’s 

most recent cost report filed before 

November 15, 2004 (that is, the 

publication date of the IPF PPS final 

rule). 

In the regression analysis, the 

logarithm of the teaching variable had a 

coefficient value of 0.5150. We 

converted this cost effect to a teaching 

payment adjustment by treating the 

regression coefficient as an exponent 

and raising the teaching variable to a 

power equal to the coefficient value. We 

note that the coefficient value of 0.5150 

was based on the regression analysis 

holding all other components of the 

payment system constant. 

As with other adjustment factors 

derived through the regression analysis, 

we do not plan to rerun the regression 

analysis until we analyze IPF PPS data. 

Therefore, for RY 2011, we are retaining 

the coefficient value of 0.5150 for the 

teaching adjustment to the Federal per 

diem base rate. 

A complete discussion of how the 

teaching adjustment was calculated 

appears in the November 2004 IPF PPS 

final rule (69 FR 66954 through 66957) 

and the May 2008 IPF PPS notice (73 FR 

25721). 

FTE Intern and Resident Cap 

Adjustment 

CMS has been asked to reconsider the 

current policy on the FTE intern and 

resident cap adjustment and to permit 

an increase in the FTE resident cap 

when the IPF increases the number of 

FTE residents it trains due to the 

acceptance of relocated residents when 

another IPF closes or closes its 

psychiatry residency program. To help 

us assess how many IPFs have been, or 

expect to be adversely affected by their 

inability to adjust their caps under 

§ 412.424(d)(1) and under these 

situations, we specifically requested 

public comment from IPFs in the May 

2009 IPF PPS notice (74 FR 20362). A 

summary of the comments and our 

response to those comments are below. 

Comment: We received several 

comments on the FTE Intern and 

Resident Cap Adjustment. All of the 

commenters recommended that CMS 

modify the IPF PPS resident cap policy, 

supporting a policy change that would 

permit the IPF PPS residency cap to be 

increased when residents in a 

psychiatry residency program must be 

relocated from one IPF to another due 

to closure of an IPF or an IPF’s 

psychiatry residency training program. 

Many commenters expressed concern 

that a cap on the number of FTE 

residents used to calculate the teaching 

adjustment is based on a snapshot of 

activity essentially ‘‘freezing’’ the status 

of residency education at a random 

point in time, CY 2004. Commenters 

stated that it is time to substantially 

modify the resident cap policy for the 

IPF PPS. Several commenters stated that 

this change in residency policy could 

help address the psychiatrist shortage, 

and help ensure access to care for 

beneficiaries who suffer from mental 

health and substance use disorders. 

Other commenters pointed out that the 

demand for health care services will 

continue to rise with the growing needs 

of the 78 million ‘‘baby boomers’’ who 

will retire in 2010 and with the recent 

passage of Paul Wellstone and Pete 

Domenici Mental Health Parity and 

Addiction Equality Act of 2008. The 

commenters further stated that the U.S. 

already faces a shortage of psychiatrists, 

and these factors could potentially 

elevate what is now a problem to what 

could be a crisis. 

Several commenters stated that in FY 

2000, CMS instituted a temporary 

adjustment to the IPPS FTE cap policy 

when a hospital increases the number of 

FTE residents it trains due to the 

acceptance of relocated residents when 

another hospital closes (64 FR 41552). 

The commenters further stated that in 

FY 2002, CMS also implemented a 

similar policy for acute care hospitals 

that accept relocated residents from a 

closed program (66 FR 39899). The 

commenters indicated that the same 

need exists for IPFs that accept 

displaced residents when an IPF closes 

or when an IPF or acute care hospital 

closes its psychiatric residency program. 

The commenters recommended that 

CMS implement a temporary resident 

cap increase policy to the current FTE 

resident cap when an IPF increases the 

number of FTE residents it trains due to 

the acceptance of relocated residents. 

The commenters believe this change is 

necessary in order to promote 

consistency among payment systems 

and to ensure that residents training in 

psychiatry can continue their training 

when their original residency training 

program closes. 

Several commenters suggested that 

although the extent of the problem of 

displaced psychiatry residents is not 

clear at this time, the number of 

inpatient psychiatric units is declining. 

Therefore, they agreed that a temporary 

increase in the resident cap, similar to 

that allowed for acute care hospitals, 

would provide an incentive for IPFs to 

accept those psychiatry residents who 

are displaced by the closure of 

residency training programs. Some 

commenters expressed concern that 

inpatient psychiatric programs are 

closing in different parts of the country 

and believe the cap issue could become 

more of a problem in the future. 

One association surveyed IPFs and 

concluded that the cap does impact IPF 

training of psychiatric residents. 

Specifically, they stated that certain 

IPFs reported that they trained 

additional residents from a closed 

residency program and have exceeded 

their caps because of those residents. 

Other IPFs in the survey reported that 

they had been asked to train additional 

residents but had not agreed because 


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these additional residents would have 

caused them to exceed their cap. 

Another commenter believes the cap 

limits the flexibility of health systems to 

become more efficient by consolidating 

programs and residency training. This 

commenter indicated that while they 

have not heard of many facilities that 

have experienced a problem exceeding 

the cap, they were aware of specific 

cases where it has created problems and 

prevented some changes in the training 

of residents from one IPF to another. 

The example cited was a facility in the 

northwest that is part of a large health 

system, wanted to close down their 

training program in their outpatient 

department and shift the residents to an 

IPF owned by the health system. 

However, they indicated that the cap 

prevented the system from moving the 

residents from the outpatient program to 

the IPF. 

Another commenter believes this 

change is necessary and has personally 

encountered this situation when a local 

IPF was closed and their residents had 

to be relocated, some of which came to 

the commenter’s facility. The 

commenter stated that a change in this 

policy would help keep needed 

residency slots in the local 

communities. 

One commenter indicated that they 

trained 24.56 FTE(s), which included 

1.60 FTE(s) from a closed IPF. The 

commenter’s cap is 18.18. The 

commenter indicated training of the 

closed IPF’s residents did not give them 

relief from the cap. 

Response: We appreciate all 

comments received on the FTE intern 

and resident cap adjustment. We will 

take all comments into consideration as 

we assess the IPF PPS regulations with 

respect to developing the policy for the 

teaching cap adjustment in the future. 

4. Cost of Living Adjustment for IPFs 

Located in Alaska and Hawaii 

The IPF PPS includes a payment 

adjustment for IPFs located in Alaska 

and Hawaii based upon the county in 

which the IPF is located. As we 

explained in the November 2004 IPF 

PPS final rule, the FY 2002 data 

demonstrated that IPFs in Alaska and 

Hawaii had per diem costs that were 

disproportionately higher than other 

IPFs. Other Medicare PPSs (for example, 

the IPPS and LTCH PPS) have adopted 

a cost of living adjustment (COLA) to 

account for the cost differential of care 

furnished in Alaska and Hawaii. 

We analyzed the effect of applying a 

COLA to payments for IPFs located in 

Alaska and Hawaii. The results of our 

analysis demonstrated that a COLA for 

IPFs located in Alaska and Hawaii 

would improve payment equity for 

these facilities. As a result of this 

analysis, we provided a COLA in the 

November 2004 IPF PPS final rule. 

A COLA adjustment for IPFs located 

in Alaska and Hawaii is made by 

multiplying the non-labor share of the 

Federal per diem base rate by the 

applicable COLA factor based on the 

COLA area in which the IPF is located. 

As previously stated in the November 

2004 IPF PPS final rule, we will update 

the COLA factors according to updates 

established by the U.S. Office of 

Personnel Management (OPM), which 

issued a final rule, May 28, 2008 to 

change COLA rates. 

The COLA factors are published on 

the OPM Web site at (http:// 

www.opm.gov/oca/cola/rates.asp). 

We note that the COLA areas for 

Alaska are not defined by county as are 

the COLA areas for Hawaii. In 5 CFR 

591.207, the OPM established the 

following COLA areas: 

(a) City of Anchorage, and 80- 

kilometer (50-mile) radius by road, as 

measured from the Federal courthouse; 

(b) City of Fairbanks, and 80- 

kilometer (50-mile) radius by road, as 

measured from the Federal courthouse; 

(c) City of Juneau, and 80-kilometer 

(50-mile) radius by road, as measured 

from the Federal courthouse; 

(d) Rest of the State of Alaska. 

For RY 2011, IPFs located in Alaska 

and Hawaii will continue to receive the 

updated COLA factors based on the 

COLA area in which the IPF is located 

as shown in Table 12 below. 

TABLE 12—COLA FACTORS FOR

ALASKA AND HAWAII IPFS

Location COLA 

Alaska: 

Anchorage ..................................... 1.23 

Fairbanks ...................................... 1.23 

Juneau .......................................... 1.23 

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

Hawaii: 

Honolulu County ........................... 1.25 

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

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

Maui County .................................. 1.25 

Kalawao County ............................ 1.25 

5. Adjustment for IPFs With a 

Qualifying Emergency Department (ED) 

Currently, the IPF PPS includes a 

facility-level adjustment for IPFs with 

qualifying EDs. We provide an 

adjustment to the Federal per diem base 

rate to account for the costs associated 

with maintaining a full-service ED. The 

adjustment is intended to account for 

ED costs incurred by a freestanding 

psychiatric hospital with a qualifying 

ED or a distinct part psychiatric unit of 

an acute hospital or a CAH for 

preadmission services otherwise 

payable under the Medicare Outpatient 

Prospective Payment System (OPPS) 

furnished to a beneficiary during the 

day immediately preceding the date of 

admission to the IPF (see § 413.40(c)(2)) 

and the overhead cost of maintaining 

the ED. This payment is a facility-level 

adjustment that applies to all IPF 

admissions (with one exception 

described below), regardless of whether 

a particular patient receives 

preadmission services in the hospital’s 

ED. 

The ED adjustment is incorporated 

into the variable per diem adjustment 

for the first day of each stay for IPFs 

with a qualifying ED. That is, IPFs with 

a qualifying ED receive an adjustment 

factor of 1.31 as the variable per diem 

adjustment for day 1 of each stay. If an 

IPF does not have a qualifying ED, it 

receives an adjustment factor of 1.19 as 

the variable per diem adjustment for day 

1 of each patient stay. 

The ED adjustment is made on every 

qualifying claim except as described 

below. As specified in 

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

is not made where a patient is 

discharged from an acute care hospital 

or critical access hospital (CAH) and 

admitted to the same hospital’s or 

CAH’s psychiatric unit. An ED 

adjustment is not made in this case 

because the costs associated with ED 

services are reflected in the DRG 

payment to the acute care hospital or 

through the reasonable cost payment 

made to the CAH. If we provided the ED 

adjustment in these cases, the hospital 

would be paid twice for the overhead 

costs of the ED, as stated in the 

November 2004 IPF PPS final rule (69 

FR 66960). 

Therefore, when patients are 

discharged from an acute care hospital 

or CAH and admitted to the same 

hospital’s or CAH’s psychiatric unit, the 

IPF receives the 1.19 adjustment factor 

as the variable per diem adjustment for 

the first day of the patient’s stay in the 

IPF. 

For RY 2011, we are retaining the 1.31 

adjustment factor for IPFs with 

qualifying EDs. A complete discussion 

of the steps involved in the calculation 

of the ED adjustment factor appears in 

the November 2004 IPF PPS final rule 

(69 FR 66959 through 66960) and the 

May 2006 IPF PPS final rule (71 FR 

27070 through 27072). 

D. Other Payment Adjustments and 

Policies 

For RY 2011, the IPF PPS includes: 

An outlier adjustment to promote access 


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to IPF care for those patients who 

require expensive care and to limit the 

financial risk of IPFs treating unusually 

costly patients. In this section, we also 

explain the reason for ending the stoploss provision that was applicable 

during the transition period. 

1. Outlier Payments 

In the November 2004 IPF PPS final 

rule, we implemented regulations at 

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

payment for IPF stays that are 

extraordinarily costly. Providing 

additional payments to IPFs for 

extremely costly cases strongly 

improves the accuracy of the IPF PPS in 

determining resource costs at the patient 

and facility level. These additional 

payments reduce the financial losses 

that would otherwise be incurred in 

treating patients who require more 

costly care and, therefore, reduce the 

incentives for IPFs to under-serve these 

patients. 

We make outlier payments for 

discharges in which an IPF’s estimated 

total cost for a case exceeds a fixed 

dollar loss threshold amount 

(multiplied by the IPF’s facility-level 

adjustments) plus the Federal per diem 

payment amount for the case. 

In instances when the case qualifies 

for an outlier payment, we pay 80 

percent of the difference between the 

estimated cost for the case and the 

adjusted threshold amount for days 1 

through 9 of the stay (consistent with 

the median LOS for IPFs in FY 2002), 

and 60 percent of the difference for day 

10 and thereafter. We established the 80 

percent and 60 percent loss sharing 

ratios because we were concerned that 

a single ratio established at 80 percent 

(like other Medicare PPSs) might 

provide an incentive under the IPF per 

diem payment system to increase LOS 

in order to receive additional payments. 

After establishing the loss sharing ratios, 

we determined the current fixed dollar 

loss threshold amount of $6,565 through 

payment simulations designed to 

compute a dollar loss beyond which 

payments are estimated to meet the 2 

percent outlier spending target. 

a. Update to the Outlier Fixed Dollar 

Loss Threshold Amount 

In accordance with the update 

methodology described in § 412.428(d), 

we are updating the fixed dollar loss 

threshold amount used under the IPF 

PPS outlier policy. Based on the 

regression analysis and payment 

simulations used to develop the IPF 

PPS, we established a 2 percent outlier 

policy which strikes an appropriate 

balance between protecting IPFs from 

extraordinarily costly cases while 

ensuring the adequacy of the Federal 

per diem base rate for all other cases 

that are not outlier cases. 

We believe it is necessary to update 

the fixed dollar loss threshold amount 

because analysis of the latest available 

data (that is, FY 2008 IPF claims) and 

rate increases indicates adjusting the 

fixed dollar loss amount is necessary in 

order to maintain an outlier percentage 

that equals 2 percent of total estimated 

IPF PPS payments. 

In the May 2006 IPF PPS final rule (71 

FR 27072), we describe the process by 

which we calculate the outlier fixed 

dollar loss threshold amount. We 

continue to use this process for RY 

2011. We begin by simulating aggregate 

payments with and without an outlier 

policy, and applying an iterative process 

to determine an outlier fixed dollar loss 

threshold amount that will result in 

outlier payments being equal to 2 

percent of total estimated payments 

under the simulation. Based on this 

process, we are updating the outlier 

fixed dollar loss threshold amount to 

$6,372 to maintain estimated outlier 

payments at 2 percent of total estimated 

IPF payments for RY 2011. 

b. Statistical Accuracy of Cost-to-Charge 

Ratios 

As previously stated, under the IPF 

PPS, an outlier payment is made if an 

IPF’s cost for a stay exceeds a fixed 

dollar loss threshold amount. In order to 

establish an IPF’s cost for a particular 

case, we multiply the IPF’s reported 

charges on the discharge bill by its 

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

approach to determining an IPF’s cost is 

consistent with the approach used 

under the IPPS and other PPSs. In FY 

2004, we implemented changes to the 

IPPS outlier policy used to determine 

CCRs for acute care hospitals because 

we became aware that payment 

vulnerabilities resulted in inappropriate 

outlier payments. Under the IPPS, we 

established a statistical measure of 

accuracy for CCRs in order to ensure 

that aberrant CCR data did not result in 

inappropriate outlier payments. 

As we indicated in the November 

2004 IPF PPS final rule, because we 

believe that the IPF outlier policy is 

susceptible to the same payment 

vulnerabilities as the IPPS, we adopted 

an approach to ensure the statistical 

accuracy of CCRs under the IPF PPS (69 

FR 66961). Therefore, we adopted the 

following procedure in the November 

2004 IPF PPS final rule: 

• We calculated two national ceilings, 

one for IPFs located in rural areas and 

one for IPFs located in urban areas. We 

computed the ceilings by first 

calculating the national average and the 

standard deviation of the CCR for both 

urban and rural IPFs. 

To determine the rural and urban 

ceilings, we multiplied each of the 

standard deviations by 3 and added the 

result to the appropriate national CCR 

average (either rural or urban). The 

upper threshold CCR for IPFs in RY 

2011 is 1.7383 for rural IPFs, and 1.7377 

for urban IPFs, based on CBSA-based 

geographic designations. If an IPF’s CCR 

is above the applicable ceiling, the ratio 

is considered statistically inaccurate 

and we assign the appropriate national 

(either rural or urban) median CCR to 

the IPF. 

We are applying the national CCRs to 

the following situations: 

++ New IPFs that have not yet 

submitted their first Medicare cost 

report. 

++ IPFs whose overall CCR is in 

excess of 3 standard deviations above 

the corresponding national geometric 

mean (that is, above the ceiling). 

++ Other IPFs for which the Medicare 

contractor obtains inaccurate or 

incomplete data with which to calculate 

a CCR. 

For new IPFs, we are using these 

national CCRs until the facility’s actual 

CCR can be computed using the first 

tentatively or final settled cost report. 

We are not making any changes to the 

procedures for ensuring the statistical 

accuracy of CCRs in RY 2011. However, 

we are updating the national urban and 

rural CCRs (ceilings and medians) for 

IPFs for RY 2011 based on the CCRs 

entered in the latest available IPF PPS 

Provider Specific File. 

The national CCRs for RY 2011 are 

0.6480 for rural IPFs and 0.5170 for 

urban IPFs and will be used in each of 

the three situations listed above. These 

calculations are based on the IPF’s 

location (either urban or rural) using the 

CBSA-based geographic designations. 

A complete discussion regarding the 

national median CCRs appears in the 

November 2004 IPF PPS final rule (69 

FR 66961 through 66964). 

2. Expiration of the Stop-Loss Provision 

In the November 2004 IPF PPS final 

rule, we implemented a stop-loss policy 

that reduced financial risk to IPFs 

projected to experience substantial 

reductions in Medicare payments 

during the period of transition to the IPF 

PPS. This stop-loss policy guaranteed 

that each facility received total IPF PPS 

payments that were no less than 70 

percent of its TEFRA payments had the 

IPF PPS not been implemented. This 

policy was applied to the IPF PPS 

portion of Medicare payments during 

the 3-year transition. 


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In the implementation year, the 70 

percent of TEFRA payment stop-loss 

policy required a reduction in the 

standardized Federal per diem and ECT 

base rates of 0.39 percent in order to 

make the stop-loss payments budget 

neutral. As described in the May 2008 

IPF PPS notice for RY 2009, we 

increased the Federal per diem base rate 

and ECT rate by 0.39 percent because 

these rates were reduced by 0.39 percent 

in the implementation year to ensure 

stop-loss payments were budget neutral. 

The stop-loss provision ended during 

RY 2009 (that is for discharges occurring 

on or after July 1, 2008 through June 30, 

2009). The stop-loss policy is no longer 

applicable under the IPF PPS. 

V. Comments Beyond the Scope of the 

May 2009 IPF PPS Notice With Request 

for Comments 

In the May 2009 IPF PPS notice, 

which specifically solicited comments 

on the IPF PPS teaching adjustment and 

the market basket, we received several 

public comments which were outside 

the scope of that notice. Below, we are 

providing a summary of the comments 

and our response. 

Comment: Two commenters 

recommended that CMS continue its 

study of the wage index in favor of 

future changes that create a more 

equitable system and adequately 

reimburse hospitals for providing 

quality care to beneficiaries. The 

commenters recommend that the Bureau 

of Labor Statistics (BLS) data approach 

be used to construct a hospital 

compensation index. They support the 

elimination of the separate 

Occupational Mix Survey documents 

and the large additional reporting 

burden it creates for hospitals. 

One commenter expressed concern 

that a large increase in the fixed dollar 

threshold amount will significantly 

reduce the number of inpatient cases 

eligible for outlier payments and 

consequently, further reduce the ability 

of psychiatric facilities to provide 

necessary psychiatric care to Medicare 

beneficiaries. The commenter 

recommends that CMS continue 

examining its data to determine more 

specifically the causes for the increase 

and if further analysis suggests that the 

threshold increase is still valid, CMS 

should publish these reasons as part of 

the final rule. 

One commenter recommended that 

CMS revisit the Variable Per Diem 

Adjustments that have been established 

in the November 2004 IPF PPS final rule 

(69 FR 66946) and to validate these 

adjustments based on current claim 

information. The commenter believes 

the current system does not reflect all 

factors affecting cost. The example cited 

was that inpatient prospective payment 

system facilities receive a special 

payment treatment for servicing a 

disproportionate share of low-income 

patients, which is intended to reimburse 

a facility for additional cost incurred for 

handling such patients. The commenter 

stated that the current IPF PPS payment 

system does not consider this type of 

patient in its payment mechanism. 

Response: We are not addressing 

these comments in this notice because 

they are beyond the scope of the May 

2009 notice. However, we will consider 

the comments and decide whether to 

take actions based on the information or 

recommendations of the commenters in 

future rulemaking. 

VI. Waiver of Proposed Rulemaking 

We ordinarily publish a notice of 

proposed rulemaking in the Federal 

Register to provide a period for public 

comment before the provisions of a rule 

take effect. We can waive this 

procedure, however, if we find good 

cause that notice and comment 

procedures are impracticable, 

unnecessary, or contrary to the public 

interest and we incorporate a statement 

of finding and its reasons in the notice. 

We find it is unnecessary to undertake 

notice and comment rulemaking for the 

update in this notice because the update 

does not make any substantive changes 

in policy, but merely reflects the 

application of previously established 

methodologies. In addition, new section 

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

application of an ‘‘Other Adjustment’’ to 

the update to the IPF PPS base rate in 

RY 2011. We applied the statutorilyrequired adjustment in this notice. We 

find that notice and comment 

rulemaking is unnecessary to implement 

that statutory provision because it is a 

self-implementing provision of law, not 

requiring the exercise of any discretion 

on the part of CMS. Therefore, under 5 

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

waive notice and comment procedures. 

VII. Collection of Information 

Requirements 

This document does not impose any 

information collection and 

recordkeeping requirements. 

Consequently, it need not be reviewed 

by the Office of Management and 

Budget under the authority of the 

Paperwork Reduction Act of 1995 (44 

U.S.C. 35). 

VIII. Regulatory Impact Analysis 

A. Overall Impact 

We have examined the impacts of this 

notice as required by Executive Order 

12866 (September 1993, Regulatory 

Planning and Review), the September 

19, 1980 Regulatory Flexibility Act 

(RFA) (Pub. L. 96–354), section 1102(b) 

of the Act, the Unfunded Mandates 

Reform Act of 1995 (Pub. L. 104–4), 

Executive Order 13132 on Federalism, 

and the Congressional Review Act (5 

U.S.C. 804(2)). 

Executive Order 12866 directs 

agencies to assess all costs and benefits 

of available regulatory alternatives and, 

if regulation is necessary, to select 

regulatory approaches that maximize 

net benefits (including potential 

economic, environmental, public health 

and safety effects, distributive impacts, 

and equity). A regulatory impact 

analysis (RIA) must be prepared for 

major rules with economically 

significant effects ($100 million or more 

in any 1 year). Although this notice does 

not meet the $100 million threshold 

established by Executive Order 12866, 

we are considering this notice to be 

‘‘economically significant’’ because the 

redistributive effects are estimated to be 

close to constituting a shift of $100 

million. For purposes of Title 5, United 

States Code, section 804(2), we estimate 

that this rulemaking is ‘‘economically 

significant’’, and is also a major rule 

under the Congressional Review Act. 

Accordingly, we have prepared a 

Regulatory Impact Analysis that to the 

best of our ability presents the costs and 

benefits of the rulemaking on the 1,679 

IPFs. 

The updates to the IPF labor-related 

share and wage indices are made in a 

budget neutral manner and thus have no 

effect on estimated costs to the Medicare 

program. Therefore, the estimated 

increased cost to the Medicare program 

is due to the update to the IPF payment 

rates, which results in an approximate 

$91 million increase in payments (due 

to the 2.4% market basket increase with 

the 0.25% ‘‘Other Adjustment’’ 

reduction, as required by new section 

1886(a)(3)(A) of the Act, and the update 

to the outlier fixed dollar loss threshold 

amount, which results in about a $4 

million increase in payments). The 

distribution of these impacts is 

summarized in Table 13. The net effect 

of the updates described in this notice 

results in an overall estimated $95 

million increase in payments from RY 

2010 to RY 2011. 

The RFA requires agencies to analyze 

options for regulatory relief of small 

businesses, if a rule has a significant 

impact on a substantial number of small 

entities. For purposes of the RFA, we 

estimate that the great majority of IPFs 

are small entities as that term is used in 

the RFA (include small businesses, 

nonprofit organizations, and small 


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governmental jurisdictions). The 

majority of hospitals and most other 

health care providers and suppliers are 

small entities, either by being nonprofit 

organizations or by meeting the SBA 

definition of a small business (having 

revenues of $7 million to $34.5 million 

in any 1 year). (For details, see the 

Small Business Administration’s 

Interim final rule that set forth size 

standards at 70 FR 72577, December 6, 

2005.) Because we lack data on 

individual hospital receipts, we cannot 

determine the number of small 

proprietary IPFs or the proportion of 

IPFs’ revenue that is derived from 

Medicare payments. Therefore, we 

assume that all IPFs are considered 

small entities. The Department of Health 

and Human Services (HHS) generally 

uses a revenue impact of 3 to 5 percent 

as a significance threshold under the 

RFA. As shown in Table 13, we estimate 

that the net revenue impact of this 

notice on all IPFs is to increase 

estimated payments by about 2.26 

percent. Since the estimated impact of 

this notice is a net increase in revenue 

across all categories of IPFs, we believe 

that this notice would not impose a 

significant burden on small entities. 

Medicare fiscal intermediaries and 

carriers are not considered to be small 

entities. Individuals and States are not 

included in the definition of a small 

entity. 

Although section 1102(b) of the Act 

applies to regulations for which a 

proposed rule is published, the HHS 

policy is to prepare an analysis of the 

impact on small rural hospitals for any 

regulation published. As a result, we are 

voluntarily determining whether this 

notice will have a significant impact on 

the operations of a substantial number 

of small rural hospitals. For purposes of 

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

small rural hospital as a hospital with 

fewer than 100 beds that is located 

outside of an MSA. As discussed in 

detail below, the rates and policies set 

forth in this notice will not have an 

adverse impact on the rural hospitals 

based on the data of the 312 rural units 

and 64 rural hospitals in our database of 

1,679 IPFs for which data were 

available. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 (UMRA) 

also requires that agencies assess 

anticipated costs and benefits before 

issuing any rule whose mandates 

require spending in any 1 year of $100 

million in 1995 dollars, updated 

annually for inflation. In 2010, that 

threshold is approximately $135 

million. This notice will not impose 

spending costs on State, local, or Tribal 

governments in the aggregate, or by the 

private sector, of $135 million. 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed rule (and subsequent final 

rule) that imposes substantial direct 

requirement costs on State and local 

governments, preempts State law, or 

otherwise has Federalism implications. 

We have reviewed this notice under the 

criteria set forth in Executive Order 

13132 and have determined that the 

notice will not have any substantial 

direct impact on State or local 

governments, preempt State law, or 

otherwise have a Federalism 

implication. 

B. Anticipated Effects 

We discuss below the historical 

background of the IPF PPS and the 

impact of this notice on the Federal 

Medicare budget and on IPFs. 

1. Budgetary Impact 

As discussed in the November 2004 

and May 2006 IPF PPS final rules, we 

applied a budget neutrality factor to the 

Federal per diem and ECT base rates to 

ensure that total estimated payments 

under the IPF PPS in the 

implementation period would equal the 

amount that would have been paid if the 

IPF PPS had not been implemented. The 

budget neutrality factor includes the 

following components: Outlier 

adjustment, stop-loss adjustment, and 

the behavioral offset. As discussed in 

the May 2008 IPF PPS notice (73 FR 

25711), the stop-loss adjustment is no 

longer applicable under the IPF PPS. 

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

we indicated that we would evaluate the 

accuracy of the budget neutrality 

adjustment within the first 5 years after 

implementation of the payment system. 

We may make a one-time prospective 

adjustment to the Federal per diem and 

ECT base rates to account for differences 

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

budget neutrality adjustment) and 

estimates of TEFRA payments based on 

actual data from the first year of the IPF 

PPS. As part of that process, we will 

reassess the accuracy of all of the factors 

impacting budget neutrality. 

In addition, as discussed in section 

III.B.2 of this notice, we are using the 

wage index and labor market share in a 

budget neutral manner by applying a 

wage index budget neutrality factor to 

the Federal per diem and ECT base 

rates. Therefore, the budgetary impact to 

the Medicare program by this update to 

the IPF PPS will be due to the market 

basket update (see section III.B.2.a of 

this notice) with the ‘‘Other 

Adjustment,’’ as required by new section 

1886(s)(3)(A) of the Act, and the update 

to the outlier fixed dollar loss threshold 

amount. 

2. Impacts on Providers 

To understand the impact of the 

changes to the IPF PPS on providers, 

discussed in this notice, it is necessary 

to compare estimated payments under 

the IPF PPS rates and factors for RY 

2011 versus those under RY 2010. The 

estimated payments for RY 2010 and RY 

2011 will be 100 percent of the IPF PPS 

payment, since the transition period has 

ended and stop-loss payments are no 

longer paid. We determined the percent 

change of estimated RY 2011 IPF PPS 

payments to estimated RY 2010 IPF PPS 

payments for each category of IPFs. In 

addition, for each category of IPFs, we 

have included the estimated percent 

change in payments resulting from the 

update to the outlier fixed dollar loss 

threshold amount, the wage index 

changes for the RY 2011 IPF PPS, and 

the market basket update, as adjusted by 

the ‘‘Other Adjustment’’. 

To illustrate the impacts of the final 

RY 2011 changes in this notice, our 

analysis begins with an RY 2010 

baseline simulation model based on FY 

2008 IPF payments inflated to the 

midpoint of RY 2010 using IHS Global 

Insight’s most recent forecast of the 

market basket update (see section III.2.b 

of this notice); the estimated outlier 

payments in RY 2010; the CBSA 

designations for IPFs based on OMB’s 

MSA definitions after June 2003; the FY 

2009 pre-floor, pre-reclassified hospital 

wage index; the RY 2010 labor-market 

share; and the RY 2010 percentage 

amount of the rural adjustment. During 

the simulation, the total estimated 

outlier payments are maintained at 2 

percent of total estimated IPF PPS 

payments. 

Each of the following changes is 

added incrementally to this baseline 

model in order for us to isolate the 

effects of each change: 

• The update to the outlier fixed 

dollar loss threshold amount. 

• The FY 2010 pre-floor, prereclassified hospital wage index and RY 

2011 final labor-related share. 

• Our final comparison illustrates the 

percent change in payments from RY 

2010 (that is, July 1, 2009 to June 30, 

2010) to RY 2011 (that is, July 1, 2010 

to June 30, 2011) and includes a 2.4 

percent market basket update to the IPF 

PPS base rates with a ¥0.25% ‘‘Other 

Adjustment’’ to the IPF PPS base rates, 

as required by new section 1886(s)(3)(A) 

of the Act. 


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TABLE 13—PROJECTED IMPACTS

Projected impacts (% Change) 

Facility by type Number of 

facilities Outlier 

CBSA wage 

index & 

labor share 

Total with 

market basket 

& other 

adjustment 1

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

All Facilities ...................................................................................................... 1,679 0.11 0.00 2.26 

Total Urban ...................................................................................................... 1,303 0.11 0.02 2.28 

Total Rural ....................................................................................................... 376 0.09 ¥0.10 2.14 

Urban DPU ...................................................................................................... 899 0.15 ¥0.01 2.29 

Urban CAH unit ............................................................................................... 14 0.35 ¥0.30 2.20 

Urban hospital .................................................................................................. 390 0.03 0.07 2.26 

Rural DPU ........................................................................................................ 259 0.11 ¥0.13 2.13 

Rural CAH unit ................................................................................................. 53 0.06 0.17 2.39 

Rural hospital ................................................................................................... 64 0.03 ¥0.13 2.05 

Freestanding IPF By Type of Ownership: 

Urban Psychiatric Hospitals: 

Government ....................................................................................... 170 0.03 0.03 2.22 

Non-Profit .......................................................................................... 115 0.03 0.16 2.35 

For-Profit ............................................................................................ 105 0.03 0.02 2.20 

Rural Psychiatric Hospitals: 

Government ....................................................................................... 41 0.03 ¥0.51 1.66 

Non-Profit .......................................................................................... 10 0.04 0.20 2.40 

For-Profit ............................................................................................ 13 0.01 0.88 3.06 

IPF Units By Type of Ownership: 

Urban DPU: 

Government ....................................................................................... 156 0.23 0.30 2.69 

Non-Profit .......................................................................................... 616 0.14 ¥0.13 2.17 

For-Profit ............................................................................................ 127 0.10 0.12 2.37 

Urban CAH: 

Government ....................................................................................... 5 0.53 ¥1.61 1.03 

Non-Profit .......................................................................................... 8 0.28 0.13 2.56 

For-Profit ............................................................................................ 1 0.03 3.18 5.43 

Rural DPU: 

Government ....................................................................................... 61 0.12 0.08 2.35 

Non-Profit .......................................................................................... 150 0.11 ¥0.26 2.00 

For-Profit ............................................................................................ 48 0.11 ¥0.03 2.24 

Rural CAH: 

Government ....................................................................................... 21 0.05 0.43 2.64 

Non-Profit .......................................................................................... 28 0.07 ¥0.01 2.21 

For-Profit ............................................................................................ 4 0.07 0.09 2.32 

By Teaching Status: 

Non-teaching ............................................................................................ 1,442 0.10 ¥0.03 2.22 

Less than 10% interns and residents to beds .......................................... 131 0.11 0.15 2.42 

10% to 30% interns and residents to beds .............................................. 73 0.19 0.07 2.41 

More than 30% interns and residents to beds ......................................... 33 0.27 ¥0.11 2.31 

By Region: 

New England ............................................................................................ 118 0.15 0.52 2.83 

Mid-Atlantic ............................................................................................... 285 0.09 ¥0.04 2.20 

South Atlantic ........................................................................................... 234 0.09 ¥0.03 2.21 

East North Central .................................................................................... 284 0.14 ¥0.40 1.88 

East South Central ................................................................................... 167 0.08 0.01 2.24 

West North Central ................................................................................... 149 0.11 0.07 2.33 

West South Central .................................................................................. 228 0.09 ¥0.08 2.16 

Mountain ................................................................................................... 85 0.11 0.67 2.95 

Pacific ....................................................................................................... 129 0.15 0.02 2.32 

By Bed Size: 

Psychiatric Hospitals: 

Under 12 beds ................................................................................... 3 0.01 ¥0.31 1.84 

Beds: 12–24 ...................................................................................... 64 0.08 0.60 2.85 

Beds: 25–49 ...................................................................................... 69 0.08 0.09 2.32 

Beds: 50–75 ...................................................................................... 74 0.04 0.58 2.78 

Over 75 beds ..................................................................................... 244 0.02 ¥0.13 2.03 

Psychiatric Units: 

Under 12 beds ................................................................................... 191 0.18 ¥0.09 2.24 

Beds: 12–24 ...................................................................................... 529 0.16 ¥0.16 2.14 

Beds: 25–49 ...................................................................................... 335 0.14 0.00 2.30 

Beds: 50–75 ...................................................................................... 106 0.13 ¥0.15 2.13 


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TABLE 13—PROJECTED IMPACTS—Continued 

Projected impacts (% Change) 

Facility by type Number of 

facilities Outlier 

CBSA wage 

index & 

labor share 

Total with 

market basket 

& other 

adjustment 1

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

Over 75 beds ..................................................................................... 64 0.13 0.36 2.65 

1This column shows changes in payments from RY 2010 to RY 2011. It reflects the impact of the RY 2011 market basket update with the 

‘‘Other Adjustment’’ for the rate year beginning in 2010, as required by new section 1886(s)(3)(A) of the Act. The RY 2011 market basket update 

is 2.4% and the ‘‘Other Adjustment’’ for the rate year beginning in 2010 is ¥0.25%. It incorporates all of the changes displayed in Columns 3 

and 4. The product of these impacts may be different from the percentage changes shown here due to rounding effects. 

3. Results 

Table 13 above displays the results of 

our analysis. The table groups IPFs into 

the categories listed below based on 

characteristics provided in the Provider 

of Services (POS) file, the IPF provider 

specific file, and cost report data from 

HCRIS: 

• Facility Type. 

• Location. 

• Teaching Status Adjustment. 

• Census Region. 

• Size. 

The top row of the table shows the 

overall impact on the 1,679 IPFs 

included in the analysis. 

In column 3, we present the effects of 

the update to the outlier fixed dollar 

loss threshold amount. We estimate 

total outlier payments in RY 2010 to be 

approximately 1.9 percent of total 

estimated payments. Therefore, we are 

updating the threshold from $6,565 in 

RY 2010 to $6,372 in RY 2011 in order 

to maintain total estimated outlier 

payments equal to 2 percent of total 

estimated payments for RY 2011. The 

overall aggregate effect of this change (as 

shown in column 3 of table 13), across 

all hospital groups, is to increase total 

estimated payments to IPFs by about 

0.11 percent. All categories of IPFs are 

projected to receive either an increase or 

no change in payments. There are 

distributional effects of this change 

among different categories of IPFs. 

Urban and rural, freestanding 

psychiatric hospitals; urban, for-profit 

IPF units located in CAHs; and 

psychiatric hospitals with under 12 

beds and 50 or more will experience 

approximately a zero percent change in 

their payments. Alternatively, urban, 

government IPF units located in CAHs 

will receive the largest increase of 0.53 

percent. 

In column 4, we present the effects of 

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

adjustment under the CBSA geographic 

area definitions announced by OMB in 

June 2003. This is a comparison of the 

simulated RY 2011 payments under the 

FY 2010 hospital wage index under 

CBSA classification and associated 

labor-related share to the simulated RY 

2010 payments under the FY 2009 

hospital wage index under CBSA 

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

projected change in aggregate payments 

to IPFs, as indicated in the first row of 

column 4. However, there would be 

distributional effects among different 

categories of IPFs. For example, urban, 

government IPF units located in CAHs 

will experience a 1.61 percent decrease 

in payments. An urban, for-profit IPF 

CAH unit will receive the largest 

increase of 3.18 percent. 

Column 5 compares our estimates of 

the changes reflected in this notice for 

RY 2011, to our estimates of payments 

for RY 2010 (without these changes). 

This column reflects all RY 2011 

changes relative to RY 2010 (as shown 

in columns 3 and 4 and including the 

market basket update with the ¥.25% 

‘‘Other Adjustment’’). The average 

increase for all IPFs is approximately 

2.26 percent. This increase includes the 

effects of the market basket update 

(2.4%) with the ‘‘Other Adjustment’’ 

(¥0.25%) resulting in a 2.15 percent 

increase in total RY 2011 payments, and 

an approximate 0.11 percent increase in 

RY 2011 payments due to the update to 

the outlier fixed dollar loss threshold. 

Overall, the largest payment increases 

ranging from 3.06 percent to 5.43 

percent are projected to be among rural, 

for-profit freestanding IPFs and urban, 

for-profit IPF units located in CAHs. 

Urban, government IPF units located in 

CAHs will receive the smallest increase 

of 1.03 percent. 

4. Effect on the Medicare Program 

Based on actuarial projections 

resulting from our experience with other 

PPSs, we estimate that Medicare 

spending (total Medicare program 

payments) for IPF services over the next 

5 years would be as shown in Table 14 

below. 

TABLE 14—ESTIMATED PAYMENTS

Rate year Dollars in 

millions 

July 1, 2010 to June 30, 2011 ..... $4,438 

July 1, 2011 to June 30, 2012 ..... 4,685 

July 1, 2012 to June 30, 2013 ..... 4,930 

July 1, 2013 to June 30, 2014 ..... 5,178 

July 1, 2014 to June 30, 2015 ..... 5,450 

These estimates are based on the 

current forecast of the increases in the 

RPL market basket, including an 

adjustment for productivity, for which 

we are using a preliminary estimate, for 

the rate year beginning in 2012 and each 

subsequent rate year, as required by new 

section 1886(s)(3)(A) of the Act, as 

follows: 

• 2.4 percent for rate years beginning 

in 2010 (RY 2011). 

• 2.9 percent for rate years beginning 

in 2011 (RY 2012). 

• 1.7 percent for rate years beginning 

in 2012 (RY 2013). 

• 1.9 percent for rate years beginning 

in 2013 (RY 2014). 

• 2.1 percent for rate years beginning 

in 2014 (RY 2015). 

The estimates in Table 14 also include 

the application of the ‘‘Other 

Adjustment,’’ as required by section 

1886(s)(A)(3) of the Act, as follows: 

• ¥0.25 percent for rate years 

beginning in 2010. 

• ¥0.25 percent for rate years 

beginning in 2011. 

• ¥0.1 percent for rate years 

beginning in 2012. 

• ¥0.1 percent for rate years 

beginning in 2013. 

• ¥0.3 percent for rate years 

beginning in 2014. 

We estimate that there would be a 

change in fee-for-service Medicare 

beneficiary enrollment as follows: 

• 2.5 percent in RY 2011. 

• 3.2 percent in RY 2012. 

• 3.1 percent in RY 2013. 


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Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 23125 

• 3.1 percent in RY 2014. 

• 2.8 percent in RY 2015. 

5. Effect on Beneficiaries 

Under the IPF PPS, IPFs will receive 

payment based on the average resources 

consumed by patients for each day. We 

do not expect changes in the quality of 

care or access to services for Medicare 

beneficiaries under the RY 2011 IPF 

PPS. In fact, we believe that access to 

IPF services will be enhanced due to the 

patient- and facility-level adjustment 

factors, all of which are intended to 

adequately reimburse IPFs for expensive 

cases. Finally, the outlier policy is 

intended to assist IPFs that experience 

high-cost cases. 

C. Alternatives Considered 

The statute does not specify an update 

strategy for the IPF PPS and is broadly 

written to give the Secretary discretion 

in establishing an update methodology. 

Therefore, we are updating the IPF PPS 

using the methodology published in the 

November 2004 IPF PPS final rule. 

We note that this notice does not 

initiate any policy changes with regard 

to the IPF PPS; rather, it simply 

provides an update to the rates for RY 

2011. Therefore, no options were 

considered. 

D. Accounting Statement 

As required by OMB Circular A–4 

(available at http:// 

www.whitehouse.gov/omb/circulars/ 

a004/a-4.pdf), in Table 15 below, we 

have prepared an accounting statement 

showing the classification of the 

expenditures associated with the 

provisions of this notice. This table 

provides our best estimate of the 

increase in Medicare payments under 

the IPF PPS notice, as a result of the 

changes presented in this notice, and 

based on the data for 1,679 IPFs in our 

database. All expenditures are classified 

as transfers to Medicare providers (that 

is, IPFs). 

TABLE 15—ACCOUNTING STATEMENT: 

CLASSIFICATION OF ESTIMATED EXPENDITURES, FROM THE 2010 IPF 

PPS RY TO THE 2011 IPF PPS RY 

[In millions] 

Category Transfers 

Annualized Monetized 

Transfers.

$95. 

TABLE 15—ACCOUNTING STATEMENT: 

CLASSIFICATION OF ESTIMATED EXPENDITURES, FROM THE 2010 IPF 

PPS RY TO THE 2011 IPF PPS 

RY—Continued 

[In millions] 

Category Transfers 

From Whom To 

Whom? 

Federal Government 

To IPF Medicare 

Providers. 

In accordance with the provisions of 

Executive Order 12866, this notice was 

reviewed by OMB. 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: March 4, 2010. 

Charlene Frizzera, 

Acting Administrator, Centers for Medicare 

& Medicaid Services. 

Approved: April 20, 2010. 

Kathleen Sebelius, 

Secretary. 

Addendum A—Rate and Adjustment 

Factors 

PER DIEM RATE

Federal Per Diem Base Rate ......... $665.71 

Labor Share (0.75400) ................... 501.95 

Non-Labor Share (0.24600) ........... 163.76 

Fixed Dollar Loss Threshold Amount: 

$6,372. 

Wage Index Budget Neutrality Factor: 

0.9999. 

FACILITY ADJUSTMENTS

Rural Adjustment Factor.1.17. 

Teaching Adjustment 

Factor.

0.5150. 

Wage Index ............... Pre-reclass Hospital 

Wage Index (FY 

2010). 

COST OF LIVING ADJUSTMENTS

(COLAS) 

Alaska 

Anchorage ...................................... 1.23 

Fairbanks ........................................ 1.23 

Juneau ............................................ 1.23 

COST OF LIVING ADJUSTMENTS

(COLAS)—Continued 

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

Hawaii 

Honolulu County ............................. 1.25 

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

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

Maui County ................................... 1.25 

Kalawao County ............................. 1.25 

PATIENT ADJUSTMENTS

ECT—Per Treatment ...................... $286.60 

VARIABLE PER DIEM ADJUSTMENTS

Adjustment 

factor 

Day 1—Facility Without a 

Qualifying Emergency Department ................................ 1.19 

Day 1—Facility With a Qualifying Emergency Department 1.31 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

AGE ADJUSTMENTS

Age (in years) Adjustment 

factor 

Under 45 ................................... 1.00 

45 and under 50 ....................... 1.01 

50 and under 55 ....................... 1.02 

55 and under 60 ....................... 1.04 

60 and under 65 ....................... 1.07 

65 and under 70 ....................... 1.10 

70 and under 75 ....................... 1.13 

75 and under 80 ....................... 1.15 

80 and over .............................. 1.17 

DRG ADJUSTMENTS

MS–DRG MS–DRG descriptions Adjustment 

factor 

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


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23126 Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 

DRG ADJUSTMENTS—Continued 

MS–DRG MS–DRG descriptions Adjustment 

factor 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

COMORBIDITY ADJUSTMENTS

Comorbidity Adjustment 

factor 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Addendum B—RY 2011 CBSA Wage 

Index Tables 

In this addendum, we provide Tables 

1 and 2 which indicate the CBSA-based 

wage index values for urban and rural 

providers. 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS

CBSA code Urban area 

(constituent counties) 

Wage 

index 

10180 ................ Abilene, TX ..................................................................................................................................................................... 0.7946 

Callahan County, TX 

Jones County, TX 

Taylor County, TX 

10380 ................ Aguadilla-Isabela-San Sebastia ́n, PR ............................................................................................................................ 0.3462 

Aguada Municipio, PR 

Aguadilla Municipio, PR 

An ̃asco Municipio, PR 

Isabela Municipio, PR 

Lares Municipio, PR 

Moca Municipio, PR 

Rinco ́n Municipio, PR 

San Sebastia ́n Municipio, PR 

10420 ................ Akron, OH ...................................................................................................................................................................... 0.8850 

Portage County, OH 

Summit County, OH 

10500 ................ Albany, GA ..................................................................................................................................................................... 0.8899 


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TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Baker County, GA 

Dougherty County, GA 

Lee County, GA 

Terrell County, GA 

Worth County, GA 

10580 ................ Albany-Schenectady-Troy, NY ....................................................................................................................................... 0.8777 

Albany County, NY 

Rensselaer County, NY 

Saratoga County, NY 

Schenectady County, NY 

Schoharie County, NY 

10740 ................ Albuquerque, NM ........................................................................................................................................................... 0.9399 

Bernalillo County, NM 

Sandoval County, NM 

Torrance County, NM 

Valencia County, NM 

10780 ................ Alexandria, LA ................................................................................................................................................................ 0.8012 

Grant Parish, LA 

Rapides Parish, LA 

10900 ................ Allentown-Bethlehem-Easton, PA-NJ ............................................................................................................................ 0.9611 

Warren County, NJ 

Carbon County, PA 

Lehigh County, PA 

Northampton County, PA 

11020 ................ Altoona, PA .................................................................................................................................................................... 0.8863 

Blair County, PA 

11100 ................ Amarillo, TX .................................................................................................................................................................... 0.8689 

Armstrong County, TX 

Carson County, TX 

Potter County, TX 

Randall County, TX 

11180 ................ Ames, IA ......................................................................................................................................................................... 0.9493 

Story County, IA 

11260 ................ Anchorage, AK ............................................................................................................................................................... 1.2013 

Anchorage Municipality, AK 

Matanuska-Susitna Borough, AK 

11300 ................ Anderson, IN .................................................................................................................................................................. 0.9052 

Madison County, IN 

11340 ................ Anderson, SC ................................................................................................................................................................. 0.9023 

Anderson County, SC 

11460 ................ Ann Arbor, MI ................................................................................................................................................................. 1.0293 

Washtenaw County, MI 

11500 ................ Anniston-Oxford, AL ....................................................................................................................................................... 0.7643 

Calhoun County, AL 

11540 ................ Appleton, WI ................................................................................................................................................................... 0.9289 

Calumet County, WI 

Outagamie County, WI 

11700 ................ Asheville, NC .................................................................................................................................................................. 0.9057 

Buncombe County, NC 

Haywood County, NC 

Henderson County, NC 

Madison County, NC 

12020 ................ Athens-Clarke County, GA ............................................................................................................................................. 0.9492 

Clarke County, GA 

Madison County, GA 

Oconee County, GA 

Oglethorpe County, GA 

12060 ................ Atlanta-Sandy Springs-Marietta, GA .............................................................................................................................. 0.9591 

Barrow County, GA 

Bartow County, GA 

Butts County, GA 

Carroll County, GA 

Cherokee County, GA 

Clayton County, GA 

Cobb County, GA 

Coweta County, GA 

Dawson County, GA 

DeKalb County, GA 

Douglas County, GA 

Fayette County, GA 

Forsyth County, GA 


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TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Fulton County, GA 

Gwinnett County, GA 

Haralson County, GA 

Heard County, GA 

Henry County, GA 

Jasper County, GA 

Lamar County, GA 

Meriwether County, GA 

Newton County, GA 

Paulding County, GA 

Pickens County, GA 

Pike County, GA 

Rockdale County, GA 

Spalding County, GA 

Walton County, GA 

12100 ................ Atlantic City-Hammonton, NJ ......................................................................................................................................... 1.1554 

Atlantic County, NJ 

12220 ................ Auburn-Opelika, AL ........................................................................................................................................................ 0.8138 

Lee County, AL 

12260 ................ Augusta-Richmond County, GA-SC ............................................................................................................................... 0.9409 

Burke County, GA 

Columbia County, GA 

McDuffie County, GA 

Richmond County, GA 

Aiken County, SC 

Edgefield County, SC 

12420 ................ Austin-Round Rock, TX ................................................................................................................................................. 0.9518 

Bastrop County, TX 

Caldwell County, TX 

Hays County, TX 

Travis County, TX 

Williamson County, TX 

12540 ................ Bakersfield, CA .............................................................................................................................................................. 1.1232 

Kern County, CA 

12580 ................ Baltimore-Towson, MD ................................................................................................................................................... 1.0214 

Anne Arundel County, MD 

Baltimore County, MD 

Carroll County, MD 

Harford County, MD 

Howard County, MD 

Queen Anne’s County, MD 

Baltimore City, MD 

12620 ................ Bangor, ME .................................................................................................................................................................... 1.0154 

Penobscot County, ME 

12700 ................ Barnstable Town, MA ..................................................................................................................................................... 1.2618 

Barnstable County, MA 

12940 ................ Baton Rouge, LA ............................................................................................................................................................ 0.8180 

Ascension Parish, LA 

East Baton Rouge Parish, LA 

East Feliciana Parish, LA 

Iberville Parish, LA 

Livingston Parish, LA 

Pointe Coupee Parish, LA 

St. Helena Parish, LA 

West Baton Rouge Parish, LA 

West Feliciana Parish, LA 

12980 ................ Battle Creek, MI ............................................................................................................................................................. 1.0000 

Calhoun County, MI 

13020 ................ Bay City, MI .................................................................................................................................................................... 0.9267 

Bay County, MI 

13140 ................ Beaumont-Port Arthur, TX ............................................................................................................................................. 0.8383 

Hardin County, TX 

Jefferson County, TX 

Orange County, TX 

13380 ................ Bellingham, WA .............................................................................................................................................................. 1.1395 

Whatcom County, WA 

13460 ................ Bend, OR ....................................................................................................................................................................... 1.1446 

Deschutes County, OR 

13644 ................ Bethesda-Frederick-Gaithersburg, MD .......................................................................................................................... 1.0298 

Frederick County, MD 

Montgomery County, MD 


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TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

13740 ................ Billings, MT ..................................................................................................................................................................... 0.8781 

Carbon County, MT 

Yellowstone County, MT 

13780 ................ Binghamton, NY ............................................................................................................................................................. 0.8780 

Broome County, NY 

Tioga County, NY 

13820 ................ Birmingham-Hoover, AL ................................................................................................................................................. 0.8554 

Bibb County, AL 

Blount County, AL 

Chilton County, AL 

Jefferson County, AL 

St. Clair County, AL 

Shelby County, AL 

Walker County, AL 

13900 ................ Bismarck, ND ................................................................................................................................................................. 0.7637 

Burleigh County, ND 

Morton County, ND 

13980 ................ Blacksburg-Christiansburg-Radford, VA ........................................................................................................................ 0.8394 

Giles County, VA 

Montgomery County, VA 

Pulaski County, VA 

Radford City, VA 

14020 ................ Bloomington, IN .............................................................................................................................................................. 0.9043 

Greene County, IN 

Monroe County, IN 

Owen County, IN 

14060 ................ Bloomington-Normal, IL ................................................................................................................................................. 0.9378 

McLean County, IL 

14260 ................ Boise City-Nampa, ID .................................................................................................................................................... 0.9318 

Ada County, ID 

Boise County, ID 

Canyon County, ID 

Gem County, ID 

Owyhee County, ID 

14484 ................ Boston-Quincy, MA ........................................................................................................................................................ 1.2186 

Norfolk County, MA 

Plymouth County, MA 

Suffolk County, MA 

14500 ................ Boulder, CO ................................................................................................................................................................... 1.0266 

Boulder County, CO 

14540 ................ Bowling Green, KY ......................................................................................................................................................... 0.8469 

Edmonson County, KY 

Warren County, KY 

14600 ................ Bradenton-Sarasota-Venice, FL ..................................................................................................................................... 0.9735 

Manatee County, FL 

Sarasota County, FL 

14740 ................ Bremerton-Silverdale, WA .............................................................................................................................................. 1.0755 

Kitsap County, WA 

14860 ................ Bridgeport-Stamford-Norwalk, CT .................................................................................................................................. 1.2792 

Fairfield County, CT 

15180 ................ Brownsville-Harlingen, TX .............................................................................................................................................. 0.9020 

Cameron County, TX 

15260 ................ Brunswick, GA ................................................................................................................................................................ 0.9178 

Brantley County, GA 

Glynn County, GA 

McIntosh County, GA 

15380 ................ Buffalo-Niagara Falls, NY .............................................................................................................................................. 0.9740 

Erie County, NY 

Niagara County, NY 

15500 ................ Burlington, NC ................................................................................................................................................................ 0.8749 

Alamance County, NC 

15540 ................ Burlington-South Burlington, VT .................................................................................................................................... 1.0106 

Chittenden County, VT 

Franklin County, VT 

Grand Isle County, VT 

15764 ................ Cambridge-Newton-Framingham, MA ........................................................................................................................... 1.1278 

Middlesex County, MA 

15804 ................ Camden, NJ ................................................................................................................................................................... 1.0374 

Burlington County, NJ 

Camden County, NJ 

Gloucester County, NJ 


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TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

15940 ................ Canton-Massillon, OH .................................................................................................................................................... 0.8813 

Carroll County, OH 

Stark County, OH 

15980 ................ Cape Coral-Fort Myers, FL ............................................................................................................................................ 0.9076 

Lee County, FL 

16020 ................ Cape Girardeau-Jackson, MO-IL ................................................................................................................................... 0.9047 

Alexander County, IL 

Bollinger County, MO 

Cape Girardeau County, MO 

16180 ................ Carson City, NV ............................................................................................................................................................. 1.0531 

Carson City, NV 

16220 ................ Casper, WY .................................................................................................................................................................... 0.9520 

Natrona County, WY 

16300 ................ Cedar Rapids, IA ............................................................................................................................................................ 0.8984 

Benton County, IA 

Jones County, IA 

Linn County, IA 

16580 ................ Champaign-Urbana, IL ................................................................................................................................................... 1.0108 

Champaign County, IL 

Ford County, IL 

Piatt County, IL 

16620 ................ Charleston, WV .............................................................................................................................................................. 0.8141 

Boone County, WV 

Clay County, WV 

Kanawha County, WV 

Lincoln County, WV 

Putnam County, WV 

16700 ................ Charleston-North Charleston-Summerville, SC ............................................................................................................. 0.9279 

Berkeley County, SC 

Charleston County, SC 

Dorchester County, SC 

16740 ................ Charlotte-Gastonia-Concord, NC-SC ............................................................................................................................. 0.9474 

Anson County, NC 

Cabarrus County, NC 

Gaston County, NC 

Mecklenburg County, NC 

Union County, NC 

York County, SC 

16820 ................ Charlottesville, VA .......................................................................................................................................................... 0.9372 

Albemarle County, VA 

Fluvanna County, VA 

Greene County, VA 

Nelson County, VA 

Charlottesville City, VA 

16860 ................ Chattanooga, TN-GA ..................................................................................................................................................... 0.8831 

Catoosa County, GA 

Dade County, GA 

Walker County, GA 

Hamilton County, TN 

Marion County, TN 

Sequatchie County, TN 

16940 ................ Cheyenne, WY ............................................................................................................................................................... 0.9344 

Laramie County, WY 

16974 ................ Chicago-Naperville-Joliet, IL .......................................................................................................................................... 1.0471 

Cook County, IL 

DeKalb County, IL 

DuPage County, IL 

Grundy County, IL 

Kane County, IL 

Kendall County, IL 

McHenry County, IL 

Will County, IL 

17020 ................ Chico, CA ....................................................................................................................................................................... 1.1198 

Butte County, CA 

17140 ................ Cincinnati-Middletown, OH-KY-IN .................................................................................................................................. 0.9483 

Dearborn County, IN 

Franklin County, IN 

Ohio County, IN 

Boone County, KY 

Bracken County, KY 

Campbell County, KY 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 23131 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Gallatin County, KY 

Grant County, KY 

Kenton County, KY 

Pendleton County, KY 

Brown County, OH 

Butler County, OH 

Clermont County, OH 

Hamilton County, OH 

Warren County, OH 

17300 ................ Clarksville, TN-KY .......................................................................................................................................................... 0.7980 

Christian County, KY 

Trigg County, KY 

Montgomery County, TN 

Stewart County, TN 

17420 ................ Cleveland, TN ................................................................................................................................................................ 0.7564 

Bradley County, TN 

Polk County, TN 

17460 ................ Cleveland-Elyria-Mentor, OH ......................................................................................................................................... 0.8914 

Cuyahoga County, OH 

Geauga County, OH 

Lake County, OH 

Lorain County, OH 

Medina County, OH 

17660 ................ Coeur d’Alene, ID ........................................................................................................................................................... 0.9235 

Kootenai County, ID 

17780 ................ College Station-Bryan, TX ............................................................................................................................................. 0.9498 

Brazos County, TX 

Burleson County, TX 

Robertson County, TX 

17820 ................ Colorado Springs, CO .................................................................................................................................................... 0.9821 

El Paso County, CO 

Teller County, CO 

17860 ................ Columbia, MO ................................................................................................................................................................ 0.8618 

Boone County, MO 

Howard County, MO 

17900 ................ Columbia, SC ................................................................................................................................................................. 0.8789 

Calhoun County, SC 

Fairfield County, SC 

Kershaw County, SC 

Lexington County, SC 

Richland County, SC 

Saluda County, SC 

17980 ................ Columbus, GA-AL .......................................................................................................................................................... 0.8724 

Russell County, AL 

Chattahoochee County, GA 

Harris County, GA 

Marion County, GA 

Muscogee County, GA 

18020 ................ Columbus, IN ................................................................................................................................................................. 0.9536 

Bartholomew County, IN 

18140 ................ Columbus, OH ................................................................................................................................................................ 1.0101 

Delaware County, OH 

Fairfield County, OH 

Franklin County, OH 

Licking County, OH 

Madison County, OH 

Morrow County, OH 

Pickaway County, OH 

Union County, OH 

18580 ................ Corpus Christi, TX .......................................................................................................................................................... 0.8693 

Aransas County, TX 

Nueces County, TX 

San Patricio County, TX 

18700 ................ Corvallis, OR .................................................................................................................................................................. 1.1002 

Benton County, OR 

19060 ................ Cumberland, MD-WV ..................................................................................................................................................... 0.8045 

Allegany County, MD 

Mineral County, WV 

19124 ................ Dallas-Plano-Irving, TX .................................................................................................................................................. 0.9853 

Collin County, TX 

Dallas County, TX 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
23132 Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Delta County, TX 

Denton County, TX 

Ellis County, TX 

Hunt County, TX 

Kaufman County, TX 

Rockwall County, TX 

19140 ................ Dalton, GA ...................................................................................................................................................................... 0.8666 

Murray County, GA 

Whitfield County, GA 

19180 ................ Danville, IL ..................................................................................................................................................................... 0.8738 

Vermilion County, IL 

19260 ................ Danville, VA .................................................................................................................................................................... 0.8323 

Pittsylvania County, VA 

Danville City, VA 

19340 ................ Davenport-Moline-Rock Island, IA-IL ............................................................................................................................. 0.8284 

Henry County, IL 

Mercer County, IL 

Rock Island County, IL 

Scott County, IA 

19380 ................ Dayton, OH .................................................................................................................................................................... 0.9211 

Greene County, OH 

Miami County, OH 

Montgomery County, OH 

Preble County, OH 

19460 ................ Decatur, AL .................................................................................................................................................................... 0.7799 

Lawrence County, AL 

Morgan County, AL 

19500 ................ Decatur, IL ...................................................................................................................................................................... 0.7995 

Macon County, IL 

19660 ................ Deltona-Daytona Beach-Ormond Beach, FL ................................................................................................................. 0.8865 

Volusia County, FL 

19740 ................ Denver-Aurora-Broomfield, CO ...................................................................................................................................... 1.0731 

Adams County, CO 

Arapahoe County, CO 

Broomfield County, CO 

Clear Creek County, CO 

Denver County, CO 

Douglas County, CO 

Elbert County, CO 

Gilpin County, CO 

Jefferson County, CO 

Park County, CO 

19780 ................ Des Moines-West Des Moines, IA ................................................................................................................................. 0.9649 

Dallas County, IA 

Guthrie County, IA 

Madison County, IA 

Polk County, IA 

Warren County, IA 

19804 ................ Detroit-Livonia-Dearborn, MI .......................................................................................................................................... 0.9729 

Wayne County, MI 

20020 ................ Dothan, AL ..................................................................................................................................................................... 0.7406 

Geneva County, AL 

Henry County, AL 

Houston County, AL 

20100 ................ Dover, DE ....................................................................................................................................................................... 0.9931 

Kent County, DE 

20220 ................ Dubuque, IA ................................................................................................................................................................... 0.8869 

Dubuque County, IA 

20260 ................ Duluth, MN-WI ................................................................................................................................................................ 1.0448 

Carlton County, MN 

St. Louis County, MN 

Douglas County, WI 

20500 ................ Durham-Chapel Hill, NC ................................................................................................................................................ 0.9618 

Chatham County, NC 

Durham County, NC 

Orange County, NC 

Person County, NC 

20740 ................ Eau Claire, WI ................................................................................................................................................................ 0.9567 

Chippewa County, WI 

Eau Claire County, WI 

20764 ................ Edison-New Brunswick, NJ ............................................................................................................................................ 1.1061 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 23133 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Middlesex County, NJ 

Monmouth County, NJ 

Ocean County, NJ 

Somerset County, NJ 

20940 ................ El Centro, CA ................................................................................................................................................................. 0.8766 

Imperial County, CA 

21060 ................ Elizabethtown, KY .......................................................................................................................................................... 0.8388 

Hardin County, KY 

Larue County, KY 

21140 ................ Elkhart-Goshen, IN ......................................................................................................................................................... 0.9489 

Elkhart County, IN 

21300 ................ Elmira, NY ...................................................................................................................................................................... 0.8341 

Chemung County, NY 

21340 ................ El Paso, TX .................................................................................................................................................................... 0.8541 

El Paso County, TX 

21500 ................ Erie, PA .......................................................................................................................................................................... 0.8779 

Erie County, PA 

21660 ................ Eugene-Springfield, OR ................................................................................................................................................. 1.1034 

Lane County, OR 

21780 ................ Evansville, IN-KY ........................................................................................................................................................... 0.8522 

Gibson County, IN 

Posey County, IN 

Vanderburgh County, IN 

Warrick County, IN 

Henderson County, KY 

Webster County, KY 

21820 ................ Fairbanks, AK ................................................................................................................................................................. 1.1114 

Fairbanks North Star Borough, AK 

21940 ................ Fajardo, PR .................................................................................................................................................................... 0.3790 

Ceiba Municipio, PR 

Fajardo Municipio, PR 

Luquillo Municipio, PR 

22020 ................ Fargo, ND-MN ................................................................................................................................................................ 0.8172 

Cass County, ND 

Clay County, MN 

22140 ................ Farmington, NM ............................................................................................................................................................. 0.7889 

San Juan County, NM 

22180 ................ Fayetteville, NC .............................................................................................................................................................. 0.9358 

Cumberland County, NC 

Hoke County, NC 

22220 ................ Fayetteville-Springdale-Rogers, AR-MO ........................................................................................................................ 0.8775 

Benton County, AR 

Madison County, AR 

Washington County, AR 

McDonald County, MO 

22380 ................ Flagstaff, AZ ................................................................................................................................................................... 1.2475 

Coconino County, AZ 

22420 ................ Flint, MI .......................................................................................................................................................................... 1.1234 

Genesee County, MI 

22500 ................ Florence, SC .................................................................................................................................................................. 0.8114 

Darlington County, SC 

Florence County, SC 

22520 ................ Florence-Muscle Shoals, AL .......................................................................................................................................... 0.7998 

Colbert County, AL 

Lauderdale County, AL 

22540 ................ Fond du Lac, WI ............................................................................................................................................................ 0.9660 

Fond du Lac County, WI 

22660 ................ Fort Collins-Loveland, CO .............................................................................................................................................. 1.0175 

Larimer County, CO 

22744 ................ Fort Lauderdale-Pompano Beach-Deerfield Beach, FL ................................................................................................ 1.0383 

Broward County, FL 

22900 ................ Fort Smith, AR-OK ......................................................................................................................................................... 0.7861 

Crawford County, AR 

Franklin County, AR 

Sebastian County, AR 

Le Flore County, OK 

Sequoyah County, OK 

23020 ................ Fort Walton Beach-Crestview-Destin, FL ...................................................................................................................... 0.8758 

Okaloosa County, FL 

23060 ................ Fort Wayne, IN ............................................................................................................................................................... 0.9012 

Allen County, IN 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
23134 Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Wells County, IN 

Whitley County, IN 

23104 ................ Fort Worth-Arlington, TX ................................................................................................................................................ 0.9499 

Johnson County, TX 

Parker County, TX 

Tarrant County, TX 

Wise County, TX 

23420 ................ Fresno, CA ..................................................................................................................................................................... 1.1267 

Fresno County, CA 

23460 ................ Gadsden, AL .................................................................................................................................................................. 0.8266 

Etowah County, AL 

23540 ................ Gainesville, FL ............................................................................................................................................................... 0.8978 

Alachua County, FL 

Gilchrist County, FL 

23580 ................ Gainesville, GA .............................................................................................................................................................. 0.9123 

Hall County, GA 

23844 ................ Gary, IN .......................................................................................................................................................................... 0.9288 

Jasper County, IN 

Lake County, IN 

Newton County, IN 

Porter County, IN 

24020 ................ Glens Falls, NY .............................................................................................................................................................. 0.8456 

Warren County, NY 

Washington County, NY 

24140 ................ Goldsboro, NC ............................................................................................................................................................... 0.9056 

Wayne County, NC 

24220 ................ Grand Forks, ND-MN ..................................................................................................................................................... 0.7775 

Polk County, MN 

Grand Forks County, ND 

24300 ................ Grand Junction, CO ....................................................................................................................................................... 0.9721 

Mesa County, CO 

24340 ................ Grand Rapids-Wyoming, MI ........................................................................................................................................... 0.9178 

Barry County, MI 

Ionia County, MI 

Kent County, MI 

Newaygo County, MI 

24500 ................ Great Falls, MT .............................................................................................................................................................. 0.8354 

Cascade County, MT 

24540 ................ Greeley, CO ................................................................................................................................................................... 0.9578 

Weld County, CO 

24580 ................ Green Bay, WI ............................................................................................................................................................... 0.9621 

Brown County, WI 

Kewaunee County, WI 

Oconto County, WI 

24660 ................ Greensboro-High Point, NC ........................................................................................................................................... 0.9062 

Guilford County, NC 

Randolph County, NC 

Rockingham County, NC 

24780 ................ Greenville, NC ................................................................................................................................................................ 0.9401 

Greene County, NC 

Pitt County, NC 

24860 ................ Greenville-Mauldin-Easley, SC ...................................................................................................................................... 0.9980 

Greenville County, SC 

Laurens County, SC 

Pickens County, SC 

25020 ................ Guayama, PR ................................................................................................................................................................. 0.3537 

Arroyo Municipio, PR 

Guayama Municipio, PR 

Patillas Municipio, PR 

25060 ................ Gulfport-Biloxi, MS ......................................................................................................................................................... 0.8783 

Hancock County, MS 

Harrison County, MS 

Stone County, MS 

25180 ................ Hagerstown-Martinsburg, MD-WV ................................................................................................................................. 0.8965 

Washington County, MD 

Berkeley County, WV 

Morgan County, WV 

25260 ................ Hanford-Corcoran, CA ................................................................................................................................................... 1.1010 

Kings County, CA 

25420 ................ Harrisburg-Carlisle, PA .................................................................................................................................................. 0.9286 

Cumberland County, PA 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 23135 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Dauphin County, PA 

Perry County, PA 

25500 ................ Harrisonburg, VA ............................................................................................................................................................ 0.9025 

Rockingham County, VA 

Harrisonburg City, VA 

25540 ................ Hartford-West Hartford-East Hartford, CT ..................................................................................................................... 1.1194 

Hartford County, CT 

Middlesex County, CT 

Tolland County, CT 

25620 ................ Hattiesburg, MS ............................................................................................................................................................. 0.7664 

Forrest County, MS 

Lamar County, MS 

Perry County, MS 

25860 ................ Hickory-Lenoir-Morganton, NC ...................................................................................................................................... 0.9000 

Alexander County, NC 

Burke County, NC 

Caldwell County, NC 

Catawba County, NC 

25980 ................ Hinesville-Fort Stewart, GA1 ......................................................................................................................................... 0.9028 

Liberty County, GA 

Long County, GA 

26100 ................ Holland-Grand Haven, MI .............................................................................................................................................. 0.8696 

Ottawa County, MI 

26180 ................ Honolulu, HI ................................................................................................................................................................... 1.1662 

Honolulu County, HI 

26300 ................ Hot Springs, AR ............................................................................................................................................................. 0.9004 

Garland County, AR 

26380 ................ Houma-Bayou Cane-Thibodaux, LA .............................................................................................................................. 0.7875 

Lafourche Parish, LA 

Terrebonne Parish, LA 

26420 ................ Houston-Sugar Land-Baytown, TX ................................................................................................................................ 0.9841 

Austin County, TX 

Brazoria County, TX 

Chambers County, TX 

Fort Bend County, TX 

Galveston County, TX 

Harris County, TX 

Liberty County, TX 

Montgomery County, TX 

San Jacinto County, TX 

Waller County, TX 

26580 ................ Huntington-Ashland, WV-KY-OH ................................................................................................................................... 0.9097 

Boyd County, KY 

Greenup County, KY 

Lawrence County, OH 

Cabell County, WV 

Wayne County, WV 

26620 ................ Huntsville, AL ................................................................................................................................................................. 0.9064 

Limestone County, AL 

Madison County, AL 

26820 ................ Idaho Falls, ID ................................................................................................................................................................ 0.9436 

Bonneville County, ID 

Jefferson County, ID 

26900 ................ Indianapolis-Carmel, IN .................................................................................................................................................. 0.9742 

Boone County, IN 

Brown County, IN 

Hamilton County, IN 

Hancock County, IN 

Hendricks County, IN 

Johnson County, IN 

Marion County, IN 

Morgan County, IN 

Putnam County, IN 

Shelby County, IN 

26980 ................ Iowa City, IA ................................................................................................................................................................... 0.9548 

Johnson County, IA 

Washington County, IA 

27060 ................ Ithaca, NY ...................................................................................................................................................................... 1.0112 

Tompkins County, NY 

27100 ................ Jackson, MI .................................................................................................................................................................... 0.8720 

Jackson County, MI 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
23136 Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

27140 ................ Jackson, MS ................................................................................................................................................................... 0.8186 

Copiah County, MS 

Hinds County, MS 

Madison County, MS 

Rankin County, MS 

Simpson County, MS 

27180 ................ Jackson, TN ................................................................................................................................................................... 0.8581 

Chester County, TN 

Madison County, TN 

27260 ................ Jacksonville, FL .............................................................................................................................................................. 0.9105 

Baker County, FL 

Clay County, FL 

Duval County, FL 

Nassau County, FL 

St. Johns County, FL 

27340 ................ Jacksonville, NC ............................................................................................................................................................. 0.8026 

Onslow County, NC 

27500 ................ Janesville, WI ................................................................................................................................................................. 0.9201 

Rock County, WI 

27620 ................ Jefferson City, MO ......................................................................................................................................................... 0.8709 

Callaway County, MO 

Cole County, MO 

Moniteau County, MO 

Osage County, MO 

27740 ................ Johnson City, TN ........................................................................................................................................................... 0.7722 

Carter County, TN 

Unicoi County, TN 

Washington County, TN 

27780 ................ Johnstown, PA ............................................................................................................................................................... 0.8233 

Cambria County, PA 

27860 ................ Jonesboro, AR ............................................................................................................................................................... 0.7722 

Craighead County, AR 

Poinsett County, AR 

27900 ................ Joplin, MO ...................................................................................................................................................................... 0.8285 

Jasper County, MO 

Newton County, MO 

28020 ................ Kalamazoo-Portage, MI ................................................................................................................................................. 1.0264 

Kalamazoo County, MI 

Van Buren County, MI 

28100 ................ Kankakee-Bradley, IL ..................................................................................................................................................... 1.0174 

Kankakee County, IL 

28140 ................ Kansas City, MO-KS ...................................................................................................................................................... 0.9679 

Franklin County, KS 

Johnson County, KS 

Leavenworth County, KS 

Linn County, KS 

Miami County, KS 

Wyandotte County, KS 

Bates County, MO 

Caldwell County, MO 

Cass County, MO 

Clay County, MO 

Clinton County, MO 

Jackson County, MO 

Lafayette County, MO 

Platte County, MO 

Ray County, MO 

28420 ................ Kennewick-Pasco-Richland, WA .................................................................................................................................... 1.0448 

Benton County, WA 

Franklin County, WA 

28660 ................ Killeen-Temple-Fort Hood, TX ....................................................................................................................................... 0.8702 

Bell County, TX 

Coryell County, TX 

Lampasas County, TX 

28700 ................ Kingsport-Bristol-Bristol, TN-VA ..................................................................................................................................... 0.7999 

Hawkins County, TN 

Sullivan County, TN 

Bristol City, VA 

Scott County, VA 

Washington County, VA 

28740 ................ Kingston, NY .................................................................................................................................................................. 0.9367 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 23137 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Ulster County, NY 

28940 ................ Knoxville, TN .................................................................................................................................................................. 0.7881 

Anderson County, TN 

Blount County, TN 

Knox County, TN 

Loudon County, TN 

Union County, TN 

29020 ................ Kokomo, IN .................................................................................................................................................................... 0.9862 

Howard County, IN 

Tipton County, IN 

29100 ................ La Crosse, WI-MN ......................................................................................................................................................... 0.9915 

Houston County, MN 

La Crosse County, WI 

29140 ................ Lafayette, IN ................................................................................................................................................................... 0.9181 

Benton County, IN 

Carroll County, IN 

Tippecanoe County, IN 

29180 ................ Lafayette, LA .................................................................................................................................................................. 0.8516 

Lafayette Parish, LA 

St. Martin Parish, LA 

29340 ................ Lake Charles, LA ........................................................................................................................................................... 0.7985 

Calcasieu Parish, LA 

Cameron Parish, LA 

29404 ................ Lake County-Kenosha County, IL-WI ............................................................................................................................ 1.0475 

Lake County, IL 

Kenosha County, WI 

29420 ................ Lake Havasu City-Kingman, AZ ..................................................................................................................................... 1.0567 

Mohave County, AZ 

29460 ................ Lakeland-Winter Haven, FL ........................................................................................................................................... 0.8390 

Polk County, FL 

29540 ................ Lancaster, PA ................................................................................................................................................................. 0.9204 

Lancaster County, PA 

29620 ................ Lansing-East Lansing, MI .............................................................................................................................................. 0.9770 

Clinton County, MI 

Eaton County, MI 

Ingham County, MI 

29700 ................ Laredo, TX ..................................................................................................................................................................... 0.8078 

Webb County, TX 

29740 ................ Las Cruces, NM ............................................................................................................................................................. 0.8939 

Dona Ana County, NM 

29820 ................ Las Vegas-Paradise, NV ................................................................................................................................................ 1.2130 

Clark County, NV 

29940 ................ Lawrence, KS ................................................................................................................................................................. 0.8580 

Douglas County, KS 

30020 ................ Lawton, OK .................................................................................................................................................................... 0.7847 

Comanche County, OK 

30140 ................ Lebanon, PA .................................................................................................................................................................. 0.8119 

Lebanon County, PA 

30300 ................ Lewiston, ID-WA ............................................................................................................................................................ 0.9570 

Nez Perce County, ID 

Asotin County, WA 

30340 ................ Lewiston-Auburn, ME ..................................................................................................................................................... 0.9085 

Androscoggin County, ME 

30460 ................ Lexington-Fayette, KY .................................................................................................................................................... 0.8889 

Bourbon County, KY 

Clark County, KY 

Fayette County, KY 

Jessamine County, KY 

Scott County, KY 

Woodford County, KY 

30620 ................ Lima, OH ........................................................................................................................................................................ 0.9379 

Allen County, OH 

30700 ................ Lincoln, NE ..................................................................................................................................................................... 0.9563 

Lancaster County, NE 

Seward County, NE 

30780 ................ Little Rock-North Little Rock-Conway, AR ..................................................................................................................... 0.8559 

Faulkner County, AR 

Grant County, AR 

Lonoke County, AR 

Perry County, AR 

Pulaski County, AR 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
23138 Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Saline County, AR 

30860 ................ Logan, UT-ID .................................................................................................................................................................. 0.8993 

Franklin County, ID 

Cache County, UT 

30980 ................ Longview, TX ................................................................................................................................................................. 0.8049 

Gregg County, TX 

Rusk County, TX 

Upshur County, TX 

31020 ................ Longview, WA ................................................................................................................................................................ 1.0707 

Cowlitz County, WA 

31084 ................ Los Angeles-Long Beach-Santa Ana, CA ..................................................................................................................... 1.2039 

Los Angeles County, CA 

31140 ................ Louisville-Jefferson County, KY-IN ................................................................................................................................ 0.8964 

Clark County, IN 

Floyd County, IN 

Harrison County, IN 

Washington County, IN 

Bullitt County, KY 

Henry County, KY 

Meade County, KY 

Nelson County, KY 

Oldham County, KY 

Shelby County, KY 

Spencer County, KY 

Trimble County, KY 

31180 ................ Lubbock, TX ................................................................................................................................................................... 0.8751 

Crosby County, TX 

Lubbock County, TX 

31340 ................ Lynchburg, VA ................................................................................................................................................................ 0.8521 

Amherst County, VA 

Appomattox County, VA 

Bedford County, VA 

Campbell County, VA 

Bedford City, VA 

Lynchburg City, VA 

31420 ................ Macon, GA ..................................................................................................................................................................... 0.9826 

Bibb County, GA 

Crawford County, GA 

Jones County, GA 

Monroe County, GA 

Twiggs County, GA 

31460 ................ Madera-Chowchilla, CA ................................................................................................................................................. 0.7958 

Madera County, CA 

31540 ................ Madison, WI ................................................................................................................................................................... 1.1234 

Columbia County, WI 

Dane County, WI 

Iowa County, WI 

31700 ................ Manchester-Nashua, NH ................................................................................................................................................ 1.0171 

Hillsborough County, NH 

31740 ................ Manhattan, KS ............................................................................................................................................................... 0.7878 

Geary County, KS 

Pottawatomie County, KS 

Riley County, KS 

31860 ................ Mankato-North Mankato, MN ......................................................................................................................................... 0.9177 

Blue Earth County, MN 

Nicollet County, MN 

31900 ................ Mansfield, OH ................................................................................................................................................................ 0.9100 

Richland County, OH 

32420 ................ Mayagu ̈ez, PR ................................................................................................................................................................ 0.3704 

Hormigueros Municipio, PR 

Mayagu ̈ez Municipio, PR 

32580 ................ McAllen-Edinburg-Mission, TX ....................................................................................................................................... 0.8852 

Hidalgo County, TX 

32780 ................ Medford, OR ................................................................................................................................................................... 1.0070 

Jackson County, OR 

32820 ................ Memphis, TN-MS-AR ..................................................................................................................................................... 0.9268 

Crittenden County, AR 

DeSoto County, MS 

Marshall County, MS 

Tate County, MS 

Tunica County, MS 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 23139 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Fayette County, TN 

Shelby County, TN 

Tipton County, TN 

32900 ................ Merced, CA .................................................................................................................................................................... 1.2123 

Merced County, CA 

33124 ................ Miami-Miami Beach-Kendall, FL .................................................................................................................................... 0.9954 

Miami-Dade County, FL 

33140 ................ Michigan City-La Porte, IN ............................................................................................................................................. 0.9311 

LaPorte County, IN 

33260 ................ Midland, TX .................................................................................................................................................................... 0.9546 

Midland County, TX 

33340 ................ Milwaukee-Waukesha-West Allis, WI ............................................................................................................................ 1.0151 

Milwaukee County, WI 

Ozaukee County, WI 

Washington County, WI 

Waukesha County, WI 

33460 ................ Minneapolis-St. Paul-Bloomington, MN-WI .................................................................................................................... 1.1095 

Anoka County, MN 

Carver County, MN 

Chisago County, MN 

Dakota County, MN 

Hennepin County, MN 

Isanti County, MN 

Ramsey County, MN 

Scott County, MN 

Sherburne County, MN 

Washington County, MN 

Wright County, MN 

Pierce County, WI 

St. Croix County, WI 

33540 ................ Missoula, MT .................................................................................................................................................................. 0.9206 

Missoula County, MT 

33660 ................ Mobile, AL ...................................................................................................................................................................... 0.7785 

Mobile County, AL 

33700 ................ Modesto, CA .................................................................................................................................................................. 1.2502 

Stanislaus County, CA 

33740 ................ Monroe, LA ..................................................................................................................................................................... 0.7752 

Ouachita Parish, LA 

Union Parish, LA 

33780 ................ Monroe, MI ..................................................................................................................................................................... 0.8885 

Monroe County, MI 

33860 ................ Montgomery, AL ............................................................................................................................................................. 0.8304 

Autauga County, AL 

Elmore County, AL 

Lowndes County, AL 

Montgomery County, AL 

34060 ................ Morgantown, WV ............................................................................................................................................................ 0.8459 

Monongalia County, WV 

Preston County, WV 

34100 ................ Morristown, TN ............................................................................................................................................................... 0.7201 

Grainger County, TN 

Hamblen County, TN 

Jefferson County, TN 

34580 ................ Mount Vernon-Anacortes, WA ....................................................................................................................................... 1.0452 

Skagit County, WA 

34620 ................ Muncie, IN ...................................................................................................................................................................... 0.8386 

Delaware County, IN 

34740 ................ Muskegon-Norton Shores, MI ........................................................................................................................................ 0.9823 

Muskegon County, MI 

34820 ................ Myrtle Beach-North Myrtle Beach-Conway, SC ............................................................................................................ 0.8730 

Horry County, SC 

34900 ................ Napa, CA ........................................................................................................................................................................ 1.4453 

Napa County, CA 

34940 ................ Naples-Marco Island, FL ................................................................................................................................................ 0.9662 

Collier County, FL 

34980 ................ Nashville-Davidson—Murfreesboro—Franklin, TN ........................................................................................................ 0.9689 

Cannon County, TN 

Cheatham County, TN 

Davidson County, TN 

Dickson County, TN 

Hickman County, TN 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
23140 Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Macon County, TN 

Robertson County, TN 

Rutherford County, TN 

Smith County, TN 

Sumner County, TN 

Trousdale County, TN 

Williamson County, TN 

Wilson County, TN 

35004 ................ Nassau-Suffolk, NY ........................................................................................................................................................ 1.2477 

Nassau County, NY 

Suffolk County, NY 

35084 ................ Newark-Union, NJ-PA .................................................................................................................................................... 1.1419 

Essex County, NJ 

Hunterdon County, NJ 

Morris County, NJ 

Sussex County, NJ 

Union County, NJ 

Pike County, PA 

35300 ................ New Haven-Milford, CT .................................................................................................................................................. 1.1545 

New Haven County, CT 

35380 ................ New Orleans-Metairie-Kenner, LA ................................................................................................................................. 0.9092 

Jefferson Parish, LA 

Orleans Parish, LA 

Plaquemines Parish, LA 

St. Bernard Parish, LA 

St. Charles Parish, LA 

St. John the Baptist Parish, LA 

St. Tammany Parish, LA 

35644 ................ New York-White Plains-Wayne, NY-NJ ......................................................................................................................... 1.3005 

Bergen County, NJ 

Hudson County, NJ 

Passaic County, NJ 

Bronx County, NY 

Kings County, NY 

New York County, NY 

Putnam County, NY 

Queens County, NY 

Richmond County, NY 

Rockland County, NY 

Westchester County, NY 

35660 ................ Niles-Benton Harbor, MI ................................................................................................................................................ 0.8903 

Berrien County, MI 

35980 ................ Norwich-New London, CT .............................................................................................................................................. 1.1399 

New London County, CT 

36084 ................ Oakland-Fremont-Hayward, CA ..................................................................................................................................... 1.6404 

Alameda County, CA 

Contra Costa County, CA 

36100 ................ Ocala, FL ........................................................................................................................................................................ 0.8556 

Marion County, FL 

36140 ................ Ocean City, NJ ............................................................................................................................................................... 1.0160 

Cape May County, NJ 

36220 ................ Odessa, TX .................................................................................................................................................................... 0.9862 

Ector County, TX 

36260 ................ Ogden-Clearfield, UT ..................................................................................................................................................... 0.9361 

Davis County, UT 

Morgan County, UT 

Weber County, UT 

36420 ................ Oklahoma City, OK ........................................................................................................................................................ 0.8900 

Canadian County, OK 

Cleveland County, OK 

Grady County, OK 

Lincoln County, OK 

Logan County, OK 

McClain County, OK 

Oklahoma County, OK 

36500 ................ Olympia, WA .................................................................................................................................................................. 1.1531 

Thurston County, WA 

36540 ................ Omaha-Council Bluffs, NE-IA ........................................................................................................................................ 0.9608 

Harrison County, IA 

Mills County, IA 

Pottawattamie County, IA 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 23141 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Cass County, NE 

Douglas County, NE 

Sarpy County, NE 

Saunders County, NE 

Washington County, NE 

36740 ................ Orlando-Kissimmee, FL ................................................................................................................................................. 0.8951 

Lake County, FL 

Orange County, FL 

Osceola County, FL 

Seminole County, FL 

36780 ................ Oshkosh-Neenah, WI ..................................................................................................................................................... 0.9152 

Winnebago County, WI 

36980 ................ Owensboro, KY .............................................................................................................................................................. 0.8357 

Daviess County, KY 

Hancock County, KY 

McLean County, KY 

37100 ................ Oxnard-Thousand Oaks-Ventura, CA ............................................................................................................................ 1.2301 

Ventura County, CA 

37340 ................ Palm Bay-Melbourne-Titusville, FL ................................................................................................................................ 0.9060 

Brevard County, FL 

37380 ................ Palm Coast, FL .............................................................................................................................................................. 0.9603 

Flagler County, FL 

37460 ................ Panama City-Lynn Haven-Panama City Beach, FL ...................................................................................................... 0.8324 

Bay County, FL 

37620 ................ Parkersburg-Marietta-Vienna, WV-OH ........................................................................................................................... 0.7716 

Washington County, OH 

Pleasants County, WV 

Wirt County, WV 

Wood County, WV 

37700 ................ Pascagoula, MS ............................................................................................................................................................. 0.8433 

George County, MS 

Jackson County, MS 

37764 ................ Peabody, MA .................................................................................................................................................................. 1.0871 

Essex County, MA 

37860 ................ Pensacola-Ferry Pass-Brent, FL .................................................................................................................................... 0.8312 

Escambia County, FL 

Santa Rosa County, FL 

37900 ................ Peoria, IL ........................................................................................................................................................................ 0.9155 

Marshall County, IL 

Peoria County, IL 

Stark County, IL 

Tazewell County, IL 

Woodford County, IL 

37964 ................ Philadelphia, PA ............................................................................................................................................................. 1.0739 

Bucks County, PA 

Chester County, PA 

Delaware County, PA 

Montgomery County, PA 

Philadelphia County, PA 

38060 ................ Phoenix-Mesa-Scottsdale, AZ ........................................................................................................................................ 1.0630 

Maricopa County, AZ 

Pinal County, AZ 

38220 ................ Pine Bluff, AR ................................................................................................................................................................. 0.7281 

Cleveland County, AR 

Jefferson County, AR 

Lincoln County, AR 

38300 ................ Pittsburgh, PA ................................................................................................................................................................ 0.8625 

Allegheny County, PA 

Armstrong County, PA 

Beaver County, PA 

Butler County, PA 

Fayette County, PA 

Washington County, PA 

Westmoreland County, PA 

38340 ................ Pittsfield, MA .................................................................................................................................................................. 1.0658 

Berkshire County, MA 

38540 ................ Pocatello, ID ................................................................................................................................................................... 0.9239 

Bannock County, ID 

Power County, ID 

38660 ................ Ponce, PR ...................................................................................................................................................................... 0.4220 

Juana Dı ́az Municipio, PR 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
23142 Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Ponce Municipio, PR 

Villalba Municipio, PR 

38860 ................ Portland-South Portland-Biddeford, ME ......................................................................................................................... 1.0187 

Cumberland County, ME 

Sagadahoc County, ME 

York County, ME 

38900 ................ Portland-Vancouver-Beaverton, OR-WA ....................................................................................................................... 1.1498 

Clackamas County, OR 

Columbia County, OR 

Multnomah County, OR 

Washington County, OR 

Yamhill County, OR 

Clark County, WA 

Skamania County, WA 

38940 ................ Port St. Lucie, FL ........................................................................................................................................................... 0.9896 

Martin County, FL 

St. Lucie County, FL 

39100 ................ Poughkeepsie-Newburgh-Middletown, NY .................................................................................................................... 1.1216 

Dutchess County, NY 

Orange County, NY 

39140 ................ Prescott, AZ ................................................................................................................................................................... 1.0121 

Yavapai County, AZ 

39300 ................ Providence-New Bedford-Fall River, RI-MA .................................................................................................................. 1.0782 

Bristol County, MA 

Bristol County, RI 

Kent County, RI 

Newport County, RI 

Providence County, RI 

Washington County, RI 

39340 ................ Provo-Orem, UT ............................................................................................................................................................. 0.9548 

Juab County, UT 

Utah County, UT 

39380 ................ Pueblo, CO ..................................................................................................................................................................... 0.8570 

Pueblo County, CO 

39460 ................ Punta Gorda, FL ............................................................................................................................................................ 0.8774 

Charlotte County, FL 

39540 ................ Racine, WI ...................................................................................................................................................................... 0.9373 

Racine County, WI 

39580 ................ Raleigh-Cary, NC ........................................................................................................................................................... 0.9663 

Franklin County, NC 

Johnston County, NC 

Wake County, NC 

39660 ................ Rapid City, SD ............................................................................................................................................................... 1.0046 

Meade County, SD 

Pennington County, SD 

39740 ................ Reading, PA ................................................................................................................................................................... 0.9263 

Berks County, PA 

39820 ................ Redding, CA ................................................................................................................................................................... 1.4039 

Shasta County, CA 

39900 ................ Reno-Sparks, NV ........................................................................................................................................................... 1.0285 

Storey County, NV 

Washoe County, NV 

40060 ................ Richmond, VA ................................................................................................................................................................ 0.9521 

Amelia County, VA 

Caroline County, VA 

Charles City County, VA 

Chesterfield County, VA 

Cumberland County, VA 

Dinwiddie County, VA 

Goochland County, VA 

Hanover County, VA 

Henrico County, VA 

King and Queen County, VA 

King William County, VA 

Louisa County, VA 

New Kent County, VA 

Powhatan County, VA 

Prince George County, VA 

Sussex County, VA 

Colonial Heights City, VA 

Hopewell City, VA 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 23143 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

Petersburg City, VA 

Richmond City, VA 

40140 ................ Riverside-San Bernardino-Ontario, CA .......................................................................................................................... 1.1285 

Riverside County, CA 

San Bernardino County, CA 

40220 ................ Roanoke, VA .................................................................................................................................................................. 0.8671 

Botetourt County, VA 

Craig County, VA 

Franklin County, VA 

Roanoke County, VA 

Roanoke City, VA 

Salem City, VA 

40340 ................ Rochester, MN ............................................................................................................................................................... 1.1136 

Dodge County, MN 

Olmsted County, MN 

Wabasha County, MN 

40380 ................ Rochester, NY ................................................................................................................................................................ 0.8724 

Livingston County, NY 

Monroe County, NY 

Ontario County, NY 

Orleans County, NY 

Wayne County, NY 

40420 ................ Rockford, IL .................................................................................................................................................................... 1.0152 

Boone County, IL 

Winnebago County, IL 

40484 ................ Rockingham County, NH ............................................................................................................................................... 1.0125 

Rockingham County, NH 

Strafford County, NH 

40580 ................ Rocky Mount, NC ........................................................................................................................................................... 0.8845 

Edgecombe County, NC 

Nash County, NC 

40660 ................ Rome, GA ...................................................................................................................................................................... 0.8915 

Floyd County, GA 

40900 ................ Sacramento—Arden-Arcade—Roseville, CA ................................................................................................................. 1.4073 

El Dorado County, CA 

Placer County, CA 

Sacramento County, CA 

Yolo County, CA 

40980 ................ Saginaw-Saginaw Township North, MI .......................................................................................................................... 0.9122 

Saginaw County, MI 

41060 ................ St. Cloud, MN ................................................................................................................................................................. 1.1107 

Benton County, MN 

Stearns County, MN 

41100 ................ St. George, UT ............................................................................................................................................................... 0.9236 

Washington County, UT 

41140 ................ St. Joseph, MO-KS ........................................................................................................................................................ 1.0189 

Doniphan County, KS 

Andrew County, MO 

Buchanan County, MO 

DeKalb County, MO 

41180 ................ St. Louis, MO-IL ............................................................................................................................................................. 0.9102 

Bond County, IL 

Calhoun County, IL 

Clinton County, IL 

Jersey County, IL 

Macoupin County, IL 

Madison County, IL 

Monroe County, IL 

St. Clair County, IL 

Crawford County, MO 

Franklin County, MO 

Jefferson County, MO 

Lincoln County, MO 

St. Charles County, MO 

St. Louis County, MO 

Warren County, MO 

Washington County, MO 

St. Louis City, MO 

41420 ................ Salem, OR ...................................................................................................................................................................... 1.0974 

Marion County, OR 

Polk County, OR 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
23144 Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

41500 ................ Salinas, CA .................................................................................................................................................................... 1.5207 

Monterey County, CA 

41540 ................ Salisbury, MD ................................................................................................................................................................. 0.9110 

Somerset County, MD 

Wicomico County, MD 

41620 ................ Salt Lake City, UT .......................................................................................................................................................... 0.9378 

Salt Lake County, UT 

Summit County, UT 

Tooele County, UT 

41660 ................ San Angelo, TX .............................................................................................................................................................. 0.7914 

Irion County, TX 

Tom Green County, TX 

41700 ................ San Antonio, TX ............................................................................................................................................................. 0.8857 

Atascosa County, TX 

Bandera County, TX 

Bexar County, TX 

Comal County, TX 

Guadalupe County, TX 

Kendall County, TX 

Medina County, TX 

Wilson County, TX 

41740 ................ San Diego-Carlsbad-San Marcos, CA ........................................................................................................................... 1.1752 

San Diego County, CA 

41780 ................ Sandusky, OH ................................................................................................................................................................ 0.8888 

Erie County, OH 

41884 ................ San Francisco-San Mateo-Redwood City, CA .............................................................................................................. 1.5874 

Marin County, CA 

San Francisco County, CA 

San Mateo County, CA 

41900 ................ San Germa ́n-Cabo Rojo, PR ......................................................................................................................................... 0.4740 

Cabo Rojo Municipio, PR 

Lajas Municipio, PR 

Sabana Grande Municipio, PR 

San Germa ́n Municipio, PR 

41940 ................ San Jose-Sunnyvale-Santa Clara, CA ........................................................................................................................... 1.6404 

San Benito County, CA 

Santa Clara County, CA 

41980 ................ San Juan-Caguas-Guaynabo, PR ................................................................................................................................. 0.4363 

Aguas Buenas Municipio, PR 

Aibonito Municipio, PR 

Arecibo Municipio, PR 

Barceloneta Municipio, PR 

Barranquitas Municipio, PR 

Bayamo ́n Municipio, PR 

Caguas Municipio, PR 

Camuy Municipio, PR 

Cano ́vanas Municipio, PR 

Carolina Municipio, PR 

Catan ̃o Municipio, PR 

Cayey Municipio, PR 

Ciales Municipio, PR 

Cidra Municipio, PR 

Comerı ́o Municipio, PR 

Corozal Municipio, PR 

Dorado Municipio, PR 

Florida Municipio, PR 

Guaynabo Municipio, PR 

Gurabo Municipio, PR 

Hatillo Municipio, PR 

Humacao Municipio, PR 

Juncos Municipio, PR 

Las Piedras Municipio, PR 

Loı ́za Municipio, PR 

Manatı ́ Municipio, PR 

Maunabo Municipio, PR 

Morovis Municipio, PR 

Naguabo Municipio, PR 

Naranjito Municipio, PR 

Orocovis Municipio, PR 

Quebradillas Municipio, PR 

Rı ́o Grande Municipio, PR 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 23145 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

San Juan Municipio, PR 

San Lorenzo Municipio, PR 

Toa Alta Municipio, PR 

Toa Baja Municipio, PR 

Trujillo Alto Municipio, PR 

Vega Alta Municipio, PR 

Vega Baja Municipio, PR 

Yabucoa Municipio, PR 

42020 ................ San Luis Obispo-Paso Robles, CA ................................................................................................................................ 1.2550 

San Luis Obispo County, CA 

42044 ................ Santa Ana-Anaheim-Irvine, CA ...................................................................................................................................... 1.1972 

Orange County, CA 

42060 ................ Santa Barbara-Santa Maria-Goleta, CA ........................................................................................................................ 1.2213 

Santa Barbara County, CA 

42100 ................ Santa Cruz-Watsonville, CA .......................................................................................................................................... 1.6735 

Santa Cruz County, CA 

42140 ................ Santa Fe, NM ................................................................................................................................................................. 1.0694 

Santa Fe County, NM 

42220 ................ Santa Rosa-Petaluma, CA ............................................................................................................................................. 1.5891 

Sonoma County, CA 

42340 ................ Savannah, GA ................................................................................................................................................................ 0.9043 

Bryan County, GA 

Chatham County, GA 

Effingham County, GA 

42540 ................ Scranton—Wilkes-Barre, PA .......................................................................................................................................... 0.8375 

Lackawanna County, PA 

Luzerne County, PA 

Wyoming County, PA 

42644 ................ Seattle-Bellevue-Everett, WA ......................................................................................................................................... 1.1577 

King County, WA 

Snohomish County, WA 

42680 ................ Sebastian-Vero Beach, FL ............................................................................................................................................. 0.9362 

Indian River County, FL 

43100 ................ Sheboygan, WI ............................................................................................................................................................... 0.9166 

Sheboygan County, WI 

43300 ................ Sherman-Denison, TX .................................................................................................................................................... 0.8064 

Grayson County, TX 

43340 ................ Shreveport-Bossier City, LA ........................................................................................................................................... 0.8383 

Bossier Parish, LA 

Caddo Parish, LA 

De Soto Parish, LA 

43580 ................ Sioux City, IA-NE-SD ..................................................................................................................................................... 0.9094 

Woodbury County, IA 

Dakota County, NE 

Dixon County, NE 

Union County, SD 

43620 ................ Sioux Falls, SD .............................................................................................................................................................. 0.8983 

Lincoln County, SD 

McCook County, SD 

Minnehaha County, SD 

Turner County, SD 

43780 ................ South Bend-Mishawaka, IN-MI ...................................................................................................................................... 0.9690 

St. Joseph County, IN 

Cass County, MI 

43900 ................ Spartanburg, SC ............................................................................................................................................................ 0.9341 

Spartanburg County, SC 

44060 ................ Spokane, WA ................................................................................................................................................................. 1.0444 

Spokane County, WA 

44100 ................ Springfield, IL ................................................................................................................................................................. 0.9545 

Menard County, IL 

Sangamon County, IL 

44140 ................ Springfield, MA ............................................................................................................................................................... 1.0373 

Franklin County, MA 

Hampden County, MA 

Hampshire County, MA 

44180 ................ Springfield, MO .............................................................................................................................................................. 0.8453 

Christian County, MO 

Dallas County, MO 

Greene County, MO 

Polk County, MO 

Webster County, MO 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
23146 Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

44220 ................ Springfield, OH ............................................................................................................................................................... 0.9195 

Clark County, OH 

44300 ................ State College, PA ........................................................................................................................................................... 0.9096 

Centre County, PA 

44700 ................ Stockton, CA .................................................................................................................................................................. 1.2331 

San Joaquin County, CA 

44940 ................ Sumter, SC ..................................................................................................................................................................... 0.8152 

Sumter County, SC 

45060 ................ Syracuse, NY ................................................................................................................................................................. 0.9785 

Madison County, NY 

Onondaga County, NY 

Oswego County, NY 

45104 ................ Tacoma, WA .................................................................................................................................................................. 1.1195 

Pierce County, WA 

45220 ................ Tallahassee, FL .............................................................................................................................................................. 0.8406 

Gadsden County, FL 

Jefferson County, FL 

Leon County, FL 

Wakulla County, FL 

45300 ................ Tampa-St. Petersburg-Clearwater, FL ........................................................................................................................... 0.8982 

Hernando County, FL 

Hillsborough County, FL 

Pasco County, FL 

Pinellas County, FL 

45460 ................ Terre Haute, IN .............................................................................................................................................................. 0.9061 

Clay County, IN 

Sullivan County, IN 

Vermillion County, IN 

Vigo County, IN 

45500 ................ Texarkana, TX—Texarkana, AR .................................................................................................................................... 0.8113 

Miller County, AR 

Bowie County, TX 

45780 ................ Toledo, OH ..................................................................................................................................................................... 0.9541 

Fulton County, OH 

Lucas County, OH 

Ottawa County, OH 

Wood County, OH 

45820 ................ Topeka, KS .................................................................................................................................................................... 0.9026 

Jackson County, KS 

Jefferson County, KS 

Osage County, KS 

Shawnee County, KS 

Wabaunsee County, KS 

45940 ................ Trenton-Ewing, NJ ......................................................................................................................................................... 1.0552 

Mercer County, NJ 

46060 ................ Tucson, AZ ..................................................................................................................................................................... 0.9505 

Pima County, AZ 

46140 ................ Tulsa, OK ....................................................................................................................................................................... 0.8662 

Creek County, OK 

Okmulgee County, OK 

Osage County, OK 

Pawnee County, OK 

Rogers County, OK 

Tulsa County, OK 

Wagoner County, OK 

46220 ................ Tuscaloosa, AL .............................................................................................................................................................. 0.8698 

Greene County, AL 

Hale County, AL 

Tuscaloosa County, AL 

46340 ................ Tyler, TX ......................................................................................................................................................................... 0.8312 

Smith County, TX 

46540 ................ Utica-Rome, NY ............................................................................................................................................................. 0.8460 

Herkimer County, NY 

Oneida County, NY 

46660 ................ Valdosta, GA .................................................................................................................................................................. 0.7944 

Brooks County, GA 

Echols County, GA 

Lanier County, GA 

Lowndes County, GA 

46700 ................ Vallejo-Fairfield, CA ....................................................................................................................................................... 1.4934 

Solano County, CA 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 23147 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

47020 ................ Victoria, TX ..................................................................................................................................................................... 0.8054 

Calhoun County, TX 

Goliad County, TX 

Victoria County, TX 

47220 ................ Vineland-Millville-Bridgeton, NJ ..................................................................................................................................... 1.0207 

Cumberland County, NJ 

47260 ................ Virginia Beach-Norfolk-Newport News, VA-NC ............................................................................................................. 0.8960 

Currituck County, NC 

Gloucester County, VA 

Isle of Wight County, VA 

James City County, VA 

Mathews County, VA 

Surry County, VA 

York County, VA 

Chesapeake City, VA 

Hampton City, VA 

Newport News City, VA 

Norfolk City, VA 

Poquoson City, VA 

Portsmouth City, VA 

Suffolk City, VA 

Virginia Beach City, VA 

Williamsburg City, VA 

47300 ................ Visalia-Porterville, CA .................................................................................................................................................... 1.0221 

Tulare County, CA 

47380 ................ Waco, TX ....................................................................................................................................................................... 0.8377 

McLennan County, TX 

47580 ................ Warner Robins, GA ........................................................................................................................................................ 0.8754 

Houston County, GA 

47644 ................ Warren-Troy-Farmington Hills, MI .................................................................................................................................. 0.9806 

Lapeer County, MI 

Livingston County, MI 

Macomb County, MI 

Oakland County, MI 

St. Clair County, MI 

47894 ................ Washington-Arlington-Alexandria, DC-VA-MD-WV ........................................................................................................ 1.0882 

District of Columbia, DC 

Calvert County, MD 

Charles County, MD 

Prince George’s County, MD 

Arlington County, VA 

Clarke County, VA 

Fairfax County, VA 

Fauquier County, VA 

Loudoun County, VA 

Prince William County, VA 

Spotsylvania County, VA 

Stafford County, VA 

Warren County, VA 

Alexandria City, VA 

Fairfax City, VA 

Falls Church City, VA 

Fredericksburg City, VA 

Manassas City, VA 

Manassas Park City, VA 

Jefferson County, WV 

47940 ................ Waterloo-Cedar Falls, IA ................................................................................................................................................ 0.8518 

Black Hawk County, IA 

Bremer County, IA 

Grundy County, IA 

48140 ................ Wausau, WI .................................................................................................................................................................... 0.9440 

Marathon County, WI 

48260 ................ Weirton-Steubenville, WV-OH ........................................................................................................................................ 0.7368 

Jefferson County, OH 

Brooke County, WV 

Hancock County, WV 

48300 ................ Wenatchee-East Wenatchee, WA ................................................................................................................................. 0.9719 

Chelan County, WA 

Douglas County, WA 

48424 ................ West Palm Beach-Boca Raton-Boynton Beach, FL ...................................................................................................... 0.9879 

Palm Beach County, FL 


wwoods2 on DSKDVH8Z91PROD with NOTICES2
23148 Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 

TABLE 1—RY 2011 WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued 

CBSA code Urban area 

(constituent counties) 

Wage 

index 

48540 ................ Wheeling, WV-OH .......................................................................................................................................................... 0.6869 

Belmont County, OH 

Marshall County, WV 

Ohio County, WV 

48620 ................ Wichita, KS ..................................................................................................................................................................... 0.9018 

Butler County, KS 

Harvey County, KS 

Sedgwick County, KS 

Sumner County, KS 

48660 ................ Wichita Falls, TX ............................................................................................................................................................ 0.9197 

Archer County, TX 

Clay County, TX 

Wichita County, TX 

48700 ................ Williamsport, PA ............................................................................................................................................................. 0.7877 

Lycoming County, PA 

48864 ................ Wilmington, DE-MD-NJ .................................................................................................................................................. 1.0555 

New Castle County, DE 

Cecil County, MD 

Salem County, NJ 

48900 ................ Wilmington, NC .............................................................................................................................................................. 0.8986 

Brunswick County, NC 

New Hanover County, NC 

Pender County, NC 

49020 ................ Winchester, VA-WV ....................................................................................................................................................... 0.9777 

Frederick County, VA 

Winchester City, VA 

Hampshire County, WV 

49180 ................ Winston-Salem, NC ........................................................................................................................................................ 0.8953 

Davie County, NC 

Forsyth County, NC 

Stokes County, NC 

Yadkin County, NC 

49340 ................ Worcester, MA ............................................................................................................................................................... 1.1089 

Worcester County, MA 

49420 ................ Yakima, WA ................................................................................................................................................................... 0.9949 

Yakima County, WA 

49500 ................ Yauco, PR ...................................................................................................................................................................... 0.3348 

Gua ́nica Municipio, PR 

Guayanilla Municipio, PR 

Pen ̃uelas Municipio, PR 

Yauco Municipio, PR 

49620 ................ York-Hanover, PA .......................................................................................................................................................... 0.9299 

York County, PA 

49660 ................ Youngstown-Warren-Boardman, OH-PA ....................................................................................................................... 0.8679 

Mahoning County, OH 

Trumbull County, OH 

Mercer County, PA 

49700 ................ Yuba City, CA ................................................................................................................................................................ 1.1265 

Sutter County, CA 

Yuba County, CA 

49740 ................ Yuma, AZ ....................................................................................................................................................................... 0.9143 

Yuma County, AZ 

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

TABLE 2—RY 2011 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS

State 

code Nonurban area Wage index 

1 ........... Alabama ................. 0.7327 

2 ........... Alaska .................... 1.1669 

3 ........... Arizona ................... 0.8790 

4 ........... Arkansas ................ 0.7332 

5 ........... California ................ 1.2051 

6 ........... Colorado ................. 0.9929 

7 ........... Connecticut ............ 1.1093 

8 ........... Delaware ................ 0.9910 

TABLE 2—RY 2011 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS—Continued 

State 

code Nonurban area Wage index 

10 ......... Florida .................... 0.8566 

11 ......... Georgia .................. 0.7623 

12 ......... Hawaii .................... 1.1113 

13 ......... Idaho ...................... 0.7733 

14 ......... Illinois ..................... 0.8312 

15 ......... Indiana ................... 0.8529 

16 ......... Iowa ........................ 0.8624 

TABLE 2—RY 2011 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS—Continued 

State 

code Nonurban area Wage index 

17 ......... Kansas ................... 0.8167 

18 ......... Kentucky ................ 0.7813 

19 ......... Louisiana ................ 0.7611 

20 ......... Maine ..................... 0.8579 

21 ......... Maryland ................ 0.9131 

22 ......... Massachusetts 1 ..... 1.1700 

23 ......... Michigan ................. 0.8778 


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Federal Register / Vol. 75, No. 83 / Friday, April 30, 2010 / Notices 23149 

TABLE 2—RY 2011 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS—Continued 

State 

code Nonurban area Wage index 

24 ......... Minnesota ............... 0.9160 

25 ......... Mississippi .............. 0.7638 

26 ......... Missouri .................. 0.7671 

27 ......... Montana ................. 0.8399 

28 ......... Nebraska ................ 0.8705 

29 ......... Nevada ................... 0.9674 

30 ......... New Hampshire ..... 0.9957 

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

32 ......... New Mexico ........... 0.8938 

33 ......... New York ............... 0.8269 

34 ......... North Carolina ........ 0.8535 

35 ......... North Dakota .......... 0.7813 

36 ......... Ohio ........................ 0.8506 

37 ......... Oklahoma ............... 0.7654 

TABLE 2—RY 2011 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS—Continued 

State 

code Nonurban area Wage index 

38 ......... Oregon ................... 1.0236 

39 ......... Pennsylvania .......... 0.8306 

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

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

42 ......... South Carolina ....... 0.8394 

43 ......... South Dakota ......... 0.8510 

44 ......... Tennessee ............. 0.7808 

45 ......... Texas ..................... 0.7759 

46 ......... Utah ........................ 0.8363 

47 ......... Vermont .................. 0.9763 

48 ......... Virgin Islands ......... 0.7416 

49 ......... Virginia ................... 0.7869 

50 ......... Washington ............ 1.0224 

51 ......... West Virginia .......... 0.7396 

TABLE 2—RY 2011 WAGE INDEX

BASED ON CBSA LABOR MARKET

AREAS FOR RURAL AREAS—Continued 

State 

code Nonurban area Wage index 

52 ......... Wisconsin ............... 0.9206 

53 ......... Wyoming ................ 0.9535 

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

1All counties within the State are classified 

as urban, with the exception of Massachusetts 

and Puerto Rico. Massachusetts and Puerto 

Rico have areas designated as rural; however, 

no short-term, acute care hospitals are located 

in the area(s) for FY 2010. The rural Massachusetts wage index is calculated as the average of all contiguous CBSAs. The Puerto Rico 

wage index is the same as FY 2009. 

[FR Doc. 2010–9870 Filed 4–29–10; 8:45 am] 

BILLING CODE 4120–01–P 


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