24000 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 

maintenance plan and 2002 base-year 

inventory for the Warren County Area 

because it meets the requirements of 

section 110(a)(1) of the CAA. EPA is 

soliciting public comments on the 

issues discussed in this document. 

These comments will be considered 

before taking final action. 

IV. Statutory and Executive Order 

Reviews 

Under the CAA, the Administrator is 

required to approve a SIP submission 

that complies with the provisions of the 

Act and applicable Federal regulations. 

42 U.S.C. 7410(k); 40 CFR 52.02(a). 

Thus, in reviewing SIP submissions, 

EPA’s role is to approve state choices, 

provided that they meet the criteria of 

the CAA. Accordingly, this action 

merely proposes to approve state law as 

meeting Federal requirements and does 

not impose additional requirements 

beyond those imposed by state law. For 

that reason, this proposed 

• Is not a ‘‘significant regulatory 

action’’ subject to review by the Office 

of Management and Budget under 

Executive Order 12866 (58 FR 51735, 

October 4, 1993); 

• Does not impose an information 

collection burden under the provisions 

of the Paperwork Reduction Act (44 

U.S.C. 3501 et seq.); 

• Is certified as not having a 

significant economic impact on a 

substantial number of small entities 

under the Regulatory Flexibility Act (5 

U.S.C. 601 et seq.); 

• Does not contain any unfunded 

mandate or significantly or uniquely 

affect small governments, as described 

in the Unfunded Mandates Reform Act 

of 1995 (Pub. L. 104–4); 

• Does not have Federalism 

implications as specified in Executive 

Order 13132 (64 FR 43255, August 10, 

1999); 

• Is not an economically significant 

regulatory action based on health or 

safety risks subject to Executive Order 

13045 (62 FR 19885, April 23, 1997); 

• Is not a significant regulatory action 

subject to Executive Order 13211 (66 FR 

28355, May 22, 2001); 

• Is not subject to requirements of 

Section 12(d) of the National 

Technology Transfer and Advancement 

Act of 1995 (15 U.S.C. 272 note) because 

application of those requirements would 

be inconsistent with the CAA; and 

• Does not provide EPA with the 

discretionary authority to address, as 

appropriate, disproportionate human 

health or environmental effects, using 

practicable and legally permissible 

methods, under Executive Order 12898 

(59 FR 7629, February 16, 1994). 

In addition, this proposed rule to 

approve the maintenance plan and the 

2002 base-year inventory for the Warren 

County Area in the Commonwealth of 

Pennsylvania does not have tribal 

implications as specified by Executive 

Order 13175 (65 FR 67249, November 9, 

2000), because the SIP is not approved 

to apply in Indian country located in the 

state, and EPA notes that it will not 

impose substantial direct costs on tribal 

governments or preempt tribal law. 

List of Subjects in 40 CFR Part 52 

Environmental protection, Air 

pollution control, Nitrogen dioxide, 

Ozone, Reporting and recordkeeping 

requirements, Volatile organic 

compounds. 

Authority: 42 U.S.C. 7401 et seq. 

Dated: April 24, 2008. 

William T. Wisniewski, 

Acting Regional Administrator, Region III. 

[FR Doc. E8–9613 Filed 4–30–08; 8:45 am] 

BILLING CODE 6560–50–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Part 418 

[CMS–1548–P] 

RIN 0938–AP14 

Medicare Program; Proposed Hospice 

Wage Index for Fiscal Year 2009 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Proposed rule. 

SUMMARY: This proposed rule proposes 

the hospice wage index for fiscal year 

2009. This proposed rule also proposes 

to phase-out the Medicare hospice 

budget neutrality adjustment factor and 

clarify two wage index issues, 

pertaining to the definition of rural and 

urban areas and to multi-campus 

hospital facilities. 

DATES: To be assured consideration, 

comments must be received at one of 

the addresses provided below, no later 

than 5 p.m. on June 27, 2008. 

ADDRESSES: In commenting, please refer 

to file code CMS–1548–P. Because of 

staff and resource limitations, we cannot 

accept comments by facsimile (FAX) 

transmission. 

You may submit comments in one of 

four ways (please choose only one of the 

ways listed): 

1. Electronically. You may submit 

electronic comments on this regulation 

to http://www.regulations.gov. Follow 

the instructions for ‘‘Comment or 

Submission’’ and enter the filecode to 

find the document accepting comments. 

2. By regular mail. You may mail 

written comments (one original and two 

copies) to the following address only: 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, Attention: CMS–1548–

P, P.O. Box 8012, Baltimore, MD 21244–

1850. 

Please allow sufficient time for mailed 

comments to be received before the 

close of the comment period. 

3. By express or overnight mail. You 

may send written comments (one 

original and two copies) to the following 

address ONLY: Centers for Medicare & 

Medicaid Services, Department of 

Health and Human Services, Attention: 

CMS–1548–P, Mail Stop C4–26–05, 

7500 Security Boulevard, Baltimore, MD 

21244–1850. 

4. By hand or courier. If you prefer, 

you may deliver (by hand or courier) 

your written comments (one original 

and two copies) before the close of the 

comment period to either of the 

following addresses: 

a. Room 445–G, Hubert H. Humphrey 

Building, 200 Independence Avenue, 

SW., Washington, DC 20201. 

(Because access to the interior of the 

HHH Building is not readily available to 

persons without Federal Government 

identification, commenters are 

encouraged to leave their comments in 

the CMS drop slots located in the main 

lobby of the building. A stamp-in clock 

is available for persons wishing to retain 

a proof of filing by stamping in and 

retaining an extra copy of the comments 

being filed.) 

b. 7500 Security Boulevard, Baltimore, 

MD 21244–1850. 

If you intend to deliver your 

comments to the Baltimore address, 

please call telephone number (410) 786–

9994 in advance to schedule your 

arrival with one of our staff members. 

Comments mailed to the addresses 

indicated as appropriate for hand or 

courier delivery may be delayed and 

received after the comment period. 

For information on viewing public 

comments, see the beginning of the 

SUPPLEMENTARY INFORMATION section. 

FOR FURTHER INFORMATION CONTACT: 

Randy Throndset (410) 786–0131 or 

Katie Lucas (410) 786–7723. 

SUPPLEMENTARY INFORMATION: 

Submitting Comments: We welcome 

comments from the public on all issues 

set forth in this rule to assist us in fully 

considering issues and developing 

policies. You can assist us by 


rfrederick on PROD1PC67 with PROPOSALS
Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24001 

referencing the file code CMS–1548–P 

and the specific ‘‘issue identifier’’ that 

precedes the section on which you 

choose to comment. 

Inspection of Public Comments: All 

comments received before the close of 

the comment period are available for 

viewing by the public, including any 

personally identifiable or confidential 

business information that is included in 

a comment. We post all comments 

received before the close of the 

comment period on the following Web 

site as soon as possible after they have 

been received: http:// 

www.regulations.gov. Follow the search 

instructions on that Web site to view 

public comments. 

Comments received timely will also 

be available for public inspection as 

they are received, generally beginning 

approximately 3 weeks after publication 

of a document, at the headquarters of 

the Centers for Medicare & Medicaid 

Services, 7500 Security Boulevard, 

Baltimore, Maryland 21244, Monday 

through Friday of each week from 8:30 

a.m. to 4 p.m. To schedule an 

appointment to view public comments, 

phone 1–800–743–3951. 

Table of Contents 

I. Background 

A. General 

1. Hospice Care 

2. Medicare Payment for Hospice Care 

B. Hospice Wage Index 

1. Raw Wage Index Values (Pre-Floor, PreReclassified Hospital Wage Index) 

2. Changes to Core-Based Statistical Area 

(CBSA) Designations 

3. Definition of Urban and Rural Areas 

4. Areas Without Hospital Wage Data 

5. CBSA Nomenclature Changes 

6. Hospice Payment Rates 

II. Provisions of the Proposed Rule 

A. Clarification of New England Deemed 

Counties 

B. Wage Data for Multi-Campus Hospitals 

C. FY 2009 Proposed Hospice Wage Index 

With Phase-Out of the Budget Neutrality 

Adjustment Factor (BNAF) 

1. Background 

2. Areas Without Hospital Wage Data 

3. Phase-Out of the BNAF 

a. Effects of phasing-out the BNAF using 

the published FY 2008 Hospice Wage 

Index Data 

b. Effects of phasing-out the BNAF using 

the Updated Pre-floor, Pre-reclassified 

Hospital Wage Index Data (FY 2009 

proposal) 

D. Summary of the Provisions of the 

Proposed Rule 

III. Collection of Information Requirements 

IV. Regulatory Impact Analysis 

A. Overall Impact 

B. Anticipated Effects 

1. Hospice Size 

2. Geographic Location 

3. Type of Ownership 

4. Hospice Base 

C. Accounting Statement 

Part 418—Hospice Care 

I. Background 

A. General 

1. Hospice Care 

Hospice care is an approach to 

treatment that recognizes that the 

impending death of an individual 

warrants a change in the focus from 

curative care to palliative care for relief 

of pain and for symptom management. 

The goal of hospice care is to help 

terminally ill individuals continue life 

with minimal disruption to normal 

activities while remaining primarily in 

the home environment. A hospice uses 

an interdisciplinary approach to deliver 

medical, nursing, social, psychological, 

emotional, and spiritual services 

through use of a broad spectrum of 

professional and other caregivers, with 

the goal of making the individual as 

physically and emotionally comfortable 

as possible. Counseling services and 

inpatient respite services are available 

to the family of the hospice patient. 

Hospice programs consider both the 

patient and the family as a unit of care. 

Section 1861(dd) of the Social 

Security Act (the Act) provides for 

coverage of hospice care for terminally 

ill Medicare beneficiaries who elect to 

receive care from a participating 

hospice. Section 1814(i) of the Act 

provides payment for Medicare 

participating hospices. 

2. Medicare Payment for Hospice Care 

Our regulations at 42 CFR part 418 

establish eligibility requirements, 

payment standards and procedures, 

define covered services, and delineate 

the conditions a hospice must meet to 

be approved for participation in the 

Medicare program. Part 418 subpart G 

provides for payment in one of four 

prospectively-determined rate categories 

(routine home care, continuous home 

care, inpatient respite care, and general 

inpatient care) to hospices based on 

each day a qualified Medicare 

beneficiary is under a hospice election. 

B. Hospice Wage Index 

Our regulations at § 418.306(c) require 

each hospice’s labor market to be 

established using the most current 

hospital wage data available, including 

any changes by OMB to the 

Metropolitan Statistical Areas (MSAs) 

definitions. OMB revised the MSA 

definitions beginning in 2003 with new 

designations called the Core Based 

Statistical Areas (CBSAs). For the 

purposes of the hospice benefit, the 

term ‘‘MSA-based’’ refers to wage index 

values and designations based on the 

previous MSA designations before 2003. 

Conversely, the term ‘‘CBSA-based’’

refers to wage index values and 

designations based on the OMB revised 

MSA designations in 2003, which now 

include CBSAs. In the August 11, 2004 

IPPS final rule (69 FR 48916, 49026), 

revised labor market area definitions 

were adopted at § 412.64(b), which were 

effective October 1, 2004 for acute care 

hospitals. CMS also revised the labor 

market areas for hospices using the new 

OMB standards that included CBSAs. In 

the FY 2006 hospice wage index final 

rule (70 FR 45130), we implemented a 

1-year transition policy using a 50/50 

blend of the CBSA-based wage index 

values and the Metropolitan Statistical 

Area (MSA)-based wage index values for 

FY 2006. The one-year transition policy 

ended on September 30, 2006. For FY 

2007 and FY 2008 we used wage index 

values based on CBSA designations. 

The hospice wage index is used to 

adjust payment rates for hospice 

agencies under the Medicare program to 

reflect local differences in area wage 

levels. The original hospice wage index 

was based on the 1981 Bureau of Labor 

Statistics hospital data and had not been 

updated since 1983. In 1994, because of 

disparity in wages from one 

geographical location to another, a 

committee was formulated to negotiate 

a wage index methodology that could be 

accepted by the industry and the 

government. This committee, 

functioning under a process established 

by the Negotiated Rulemaking Act of 

1990, was comprised of national 

hospice associations; rural, urban, large 

and small hospices; multi-site hospices; 

consumer groups; and a government 

representative. On April 13, 1995, the 

Hospice Wage Index Negotiated 

Rulemaking Committee signed an 

agreement for the methodology to be 

used for updating the hospice wage 

index. 

In the August 8, 1997 Federal 

Register (62 FR 42860), we published a 

final rule implementing a new 

methodology for calculating the hospice 

wage index based on the 

recommendations of the negotiated 

rulemaking committee. The committee 

statement was included in the appendix 

of that final rule (62 FR 42883). The 

hospice wage index is updated 

annually. Our most recent annual 

update notice published in the Federal 

Register (72 FR 50214) on August 31, 

2007 set forth updates to the hospice 

wage index for FY 2008. On October 1, 

2007, we published a correction notice 

in the Federal Register (72 FR 55672) to 

correct technical errors that appeared in 

the August 31, 2007 final rule. 


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1. Raw Wage Index Values (Pre-Floor, 

Pre-Reclassified Hospital Wage Index) 

As described in the August 8, 1997 

hospice wage index final rule (62 FR 

42860), the pre-floor and prereclassified hospital wage index is used 

as the raw wage index for the hospice 

benefit. These raw wage index values 

are then subject to either a budget 

neutrality adjustment or application of 

the hospice floor to compute the 

hospice wage index used to determine 

payments to hospices. 

Pre-floor, pre-reclassified hospital 

wage index values of 0.8 or greater are 

adjusted by the BNAF. Pre-floor, prereclassified hospital wage index values 

below 0.8 are adjusted by the greater of: 

(1) The hospice BNAF; or (2) the 

hospice floor (which is a 15 percent 

increase) subject to a maximum wage 

index value of 0.8. For example, if 

County A has a pre-floor, prereclassified hospital wage index (raw 

wage index) value of 0.4000, we would 

perform the following calculations using 

the budget neutrality factor (which for 

this example is 1.060988) and the 

hospice floor to determine County A’s 

hospice wage index: 

Pre-floor, pre-reclassified hospital wage 

index value below 0.8 multiplied by 

the BNAF: (0.4000 × 1.060988 = 

0.4244) 

Pre-floor, pre-reclassified hospital wage 

index value below 0.8 multiplied by 

the hospice floor: (0.4000 × 1.15 = 

0.4600) 

Based on these calculations, County 

A’s hospice wage index would be 

0.4600. 

As decided upon by the Hospice 

Wage Index Negotiated Rulemaking 

Committee, budget neutrality means 

that, in a given year, estimated aggregate 

payments for Medicare hospice services 

using the updated hospice values will 

equal estimated payments that would 

have been made for these services if the 

1983 hospice wage index values had 

remained in effect, after adjusting the 

payment rates for inflation. 

The BNAF has been computed and 

applied annually to the labor portion of 

the hospice payment. Currently, the 

labor portion of the payment rates is as 

follows: for Routine Home Care, 68.71 

percent; for Continuous Home Care, 

68.71 percent; for General Inpatient 

Care, 64.01 percent; and for Respite 

Care, 54.13 percent. The non-labor 

portion is equal to 100 percent minus 

the labor portion for each level of care. 

Therefore the non-labor portion of the 

payment rates is as follows: for Routine 

Home Care, 31.29 percent; for 

Continuous Home Care, 31.29 percent; 

for General Inpatient Care, 35.99 

percent; and for Respite Care, 45.87 

percent. 

2. Changes to Core-Based Statistical 

Area (CBSA) Designations 

The annual update to the hospice 

wage index is published in the Federal 

Register and is based on the most 

current available hospital wage data, as 

well as any changes by the Office of 

Management and Budget (OMB) to the 

definitions of MSAs, which now 

include CBSA designations. The August 

4, 2005 final rule (70 FR 45130) set forth 

the adoption of the changes discussed in 

the OMB Bulletin No. 03–04 (June 6, 

2003), which announced revised 

definitions for Micropolitan Statistical 

Areas and the creation of MSAs and 

Combined Statistical Areas. In adopting 

the OMB CBSA geographic 

designations, we provided for a 1-year 

transition with a blended hospice wage 

index for all hospices for FY 2006. For 

FY 2006, the hospice wage index for 

each provider consisted of a blend of 50 

percent of the FY 2006 MSA-based 

hospice wage index and 50 percent of 

the FY 2006 CBSA-based hospice wage 

index. Fiscal years 2007 and 2008 used 

the full CBSA-based hospice wage index 

values as discussed in their respective 

notices or rules (71 FR 52080 and 72 FR 

50214). 

3. Definition of Rural and Urban Areas 

Each hospice’s labor market is 

determined based on definitions of 

MSAs issued by OMB. In general, an 

urban area is defined as an MSA or New 

England County Metropolitan Area 

(NECMA) as defined by OMB. Under 

§ 412.64(b)(1)(ii)(C), a rural area is 

defined as any area outside of the urban 

area. The urban and rural area 

geographic classifications are defined in 

§ 412.64(b)(1)(ii)(A) through (C), and 

have been used for the Medicare 

hospice benefit since implementation. 

4. Areas Without Hospital Wage Data 

When adopting OMB’s new labor 

market designations in FY 2006, we 

identified some geographic areas where 

there were no hospitals, and thus, no 

hospital wage index data on which to 

base the calculation of the hospice wage 

index. Beginning in FY 2006, we 

adopted a policy to use the FY 2005 prefloor, pre-reclassified hospital wage 

index value for rural areas when no 

hospital wage data were available. We 

also adopted the policy that for urban 

labor markets without a hospital from 

which a hospital wage index data could 

be derived, all of the CBSAs within the 

State would be used to calculate a 

statewide urban average pre-floor, prereclassified hospital wage index value to 

use as a reasonable proxy for these 

areas. Consequently, in the FY 2006 

final rule, the FY 2007 update notice, 

and the FY 2008 final rule, we applied 

the average pre-floor, pre-reclassified 

hospital wage index data from all urban 

areas in that state to urban areas without 

a hospital. The only affected CBSA is 

25980, Hinesville-Fort Stewart, Georgia. 

Under the CBSA labor market areas, 

there are no hospitals in rural locations 

in Massachusetts and Puerto Rico. Since 

there was no rural proxy for more recent 

rural data within those areas, in the FY 

2006 hospice wage index proposed rule 

(70 FR 22394, 22398), we proposed 

applying the FY 2005 pre-floor, prereclassified hospital wage index value to 

rural areas where no hospital wage data 

were available. In the FY 2006 final rule 

and in the FY 2007 update notice, we 

applied the FY 2005 pre-floor, prereclassified hospital wage index data for 

areas lacking hospital wage data in both 

FY 2006 and FY 2007 for rural 

Massachusetts and rural Puerto Rico. 

In the FY 2008 final rule (72 FR 

50214, 50217) we considered 

alternatives to our methodology to 

update the pre-floor, pre-reclassified 

hospital wage index for rural areas 

without hospital wage data. We 

indicated that we believed that the best 

imputed proxy for rural areas, would: 

(1) Use pre-floor, pre-reclassified 

hospital data; (2) use the most local data 

available to impute a rural pre-floor, 

pre-reclassified hospital wage index; (3) 

be easy to evaluate; and, (4) be easy to 

update from year-to-year. 

Therefore, in FY 2008, in cases where 

there was a rural area without rural 

hospital wage data, we used the average 

pre-floor, pre-reclassified hospital wage 

index data from all contiguous CBSAs to 

represent a reasonable proxy for the 

rural area. This approach does not use 

rural data, however, the approach uses 

pre-floor, pre-reclassified hospital wage 

data, is easy to evaluate, is easy to 

update from year-to-year, and uses the 

most local data available. In the FY 2008 

rule (72 FR at 50217), we noted that in 

determining an imputed rural pre-floor, 

pre-reclassified hospital wage index, we 

interpret the term ‘‘contiguous’’ to mean 

sharing a border. For example, in the 

case of Massachusetts, the entire rural 

area consists of Dukes and Nantucket 

counties. We determined that the 

borders of Dukes and Nantucket 

counties are contiguous with Barnstable 

and Bristol counties. Under the adopted 

methodology, the pre-floor, prereclassified hospital wage index values 

for the counties of Barnstable (CBSA 

12700, Barnstable Town, MA) and 

Bristol (CBSA 39300, Providence-New 

Bedford-Fall River, RI–MA) would be 


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averaged resulting in an imputed prefloor, pre-reclassified rural hospital 

wage index for FY 2008. We noted in 

the FY 2008 final hospice wage index 

rule that while we believe that this 

policy could be readily applied to other 

rural areas that lack hospital wage data 

(possibly due to hospitals converting to 

a different provider type, such as a 

Critical Access Hospital, that does not 

submit the appropriate wage data), if a 

similar situation arose in the future, we 

would re-examine this policy. 

We also noted that we do not believe 

that this policy would be appropriate for 

Puerto Rico, as there are sufficient 

economic differences between hospitals 

in the United States and those in Puerto 

Rico, including the payment of hospitals 

in Puerto Rico using blended Federal/ 

Commonwealth-specific rates. Therefore 

we believe that a separate and distinct 

policy for Puerto Rico is necessary. Any 

alternative methodology for imputing a 

pre-floor, pre-reclassified hospital wage 

index for rural Puerto Rico would need 

to take into account the economic 

differences between hospitals in the 

United States and those in Puerto Rico. 

Our policy of imputing a rural pre-floor, 

pre-reclassified hospital wage index 

based on the pre-floor, pre-reclassified 

hospital wage index(es) of CBSAs 

contiguous to the rural area in question 

does not recognize the unique 

circumstances of Puerto Rico. While we 

have not yet identified an alternative 

methodology for imputing a pre-floor, 

pre-reclassified hospital wage index for 

rural Puerto Rico, we will continue to 

evaluate the feasibility of using existing 

hospital wage data and, possibly, wage 

data from other sources. For FY 2008, 

we used the most recent pre-floor, prereclassified hospital wage index 

available for Puerto Rico, which is 

0.4047. 

5. CBSA Nomenclature Changes 

The Office of Management and Budget 

(OMB) regularly publishes a bulletin 

that updates the titles of certain CBSAs. 

In the FY 2008 Final Rule (72 FR 50218) 

we noted that the FY 2008 rule and all 

subsequent hospice wage index rules 

and notices would incorporate CBSA 

changes from the most recent OMB 

bulletins. The OMB bulletins may be 

accessed at http://www.whitehouse.gov/ 

omb/bulletins/index.html. 

6. Hospice Payment Rates 

Section 4441(a) of the Balanced 

Budget Act of 1997 (BBA) amended 

section 1814(i)(1)(C)(ii) of the Act to 

establish updates to hospice rates for 

FYs 1998 through 2002. Hospice rates 

were to be updated by a factor equal to 

the market basket index, minus 1 

percentage point. However, neither the 

BBA nor subsequent legislation 

specified alteration to the market basket 

adjustment to be used to compute 

payment for fiscal years beyond 2002. 

Payment rates for FYs since 2002 have 

been updated according to section 

1814(i)(1)(C)(ii)(VII) of the Act, which 

states that the update to the payment 

rates for subsequent fiscal years will be 

the market basket percentage for the 

fiscal year. It has been longstanding 

practice to use the inpatient hospital 

market basket as a proxy for a hospice 

market basket. 

Historically, the rate update has been 

published through a separate 

administrative instruction issued 

annually in July to provide adequate 

time to implement system change 

requirements. Providers determine their 

payments by applying the hospice wage 

index in this notice to the labor portion 

of the published hospice rates. 

II. Provisions of the Proposed Rule 

A. Clarification of New England Deemed 

Counties 

We are taking the opportunity to 

address the change in the designation of 

‘‘New England deemed counties,’’

which are listed in § 412.64(b)(1)(ii)(B). 

These counties were deemed to be parts 

of urban areas under section 601(g) of 

the Social Security Amendments of 

1983, yet the OMB designates these 

counties as rural. In the FY 2008 

Inpatient Prospective Payment System 

(IPPS) final rule, IPPS adopted the OMB 

designation for the pre-floor, prereclassified hospital wage index. The 

counties include Litchfield County, 

Connecticut; York County, Maine; 

Sagadahoc County, Maine; Merrimack 

County, New Hampshire; and Newport 

County, Rhode Island. Of these five 

‘‘New England deemed counties,’’ three 

(York County, Sagadahoc County, and 

Newport County) are also included in 

metropolitan statistical areas defined by 

OMB and are considered urban under 

the current IPPS labor market area 

definitions in § 412.64(b)(1)(ii)(A). 

The remaining two, Litchfield County 

and Merrimack County, are 

geographically located in areas that are 

considered rural under the current IPPS 

labor market area definitions. However, 

they have been previously deemed 

urban under the IPPS in certain 

circumstances as discussed below. In 

the FY 2008 IPPS final rule with 

comment period (72 FR 47130, August 

22, 2007), § 412.64(b)(1)(ii)(B) was 

revised such that the two ‘‘New England 

deemed counties’’ that are still 

considered rural by OMB (Litchfield 

County, CT and Merrimack County, NH) 

are no longer considered urban effective 

for discharges occurring on or after 

October 1, 2007. Therefore, these two 

counties are considered rural in 

accordance with § 412.64(b)(1)(ii)(C). 

However, for purposes of payment 

under the IPPS, acute care hospitals 

located within those areas are treated as 

being reclassified to their deemed urban 

area effective for discharges occurring 

on or after October 1, 2007 (see 72 FR 

47337 through 47338). We also noted in 

this discussion that this policy change 

was limited to the ‘‘New England 

deemed counties’’ IPPS hospitals only, 

and that any change to non-IPPS 

provider wage indexes would be 

addressed in the respective payment 

system rules. The hospice program does 

not provide for such geographic 

reclassification as the IPPS does, and we 

are taking this opportunity to clarify 

treatment of ‘‘New England deemed 

counties’’ under the hospice program in 

this proposed rule. 

As discussed, our regulations at 

§ 418.306(c) require each hospice’s labor 

market to be established using the most 

current hospital wage data available. 

The original hospice wage index was 

based on the 1981 Bureau of Labor 

Statistics hospital data. In 1994, a 

committee functioning under a process 

established by the Negotiated 

Rulemaking Act of 1990, was formed to 

negotiate a hospice wage index 

methodology that could be accepted by 

the industry and the government. The 

revised hospice wage index was based 

on the recommendations of the 

Negotiated Rulemaking Advisory 

Committee. This committee was 

established to provide advice and make 

recommendations to the Secretary on 

the hospice wage index used to adjust 

payment rates for hospices under the 

Medicare program, to reflect local 

differences in area wage levels. The 

Committee recommended that the 

revised hospice wage index be based on 

the most current available data for each 

fiscal year, which would be used to 

construct a pre-floor, pre-reclassified 

hospital wage index under the 

prospective payment system before 

adjustments were made to take into 

account the geographic reclassification 

of hospitals in accordance with sections 

1886(d)(8)(B) and (d)(10) of the Act, as 

well as each hospice’s labor market area 

as established by OMB. The reason the 

unadjusted hospital wage data were 

recommended was to avoid further 

reductions in certain rural statewide 

wage index values that would result 

from reclassification. The 

recommendations are codified in 


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24004 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 

§ 418.306(c) of our regulations; however, 

there is no reference to § 412.64. 

In other words, while § 412.64 is not 

explicitly noted, the hospice program 

has used the urban definition in 

§ 412.64(b)(1)(ii)(A) and (B), and the 

rural definition as any area outside of an 

urban area in § 412.64(b)(1)(ii)(C). 

Historical changes to the labor market 

area/geographic classifications and 

annual updates to the hospice wage 

index values have been made effective 

October 1 each year. When we 

established the hospice wage index 

values effective October 1, 2007 through 

September 30, 2008, we considered the 

‘‘New England deemed counties’’

(including Litchfield County, CT and 

Merrimack County, NH) as urban for FY 

2008 in accordance with the definitions 

of urban and rural areas in the FY 2008 

hospice final rule (72 FR 50216). 

Therefore, Litchfield County was listed 

as one of the constituent counties of 

urban CBSA 25540 (Hartford-West 

Hartford-East Hartford, CT), and 

Merrimack County was listed as one of 

the constituent counties of urban CBSA 

31700 (Manchester-Nashua, NH) (72 FR 

50236 and 50239, respectively). As 

noted above, the terms ‘‘rural’’ and 

‘‘urban’’ areas are defined in IPPS 

according to the definitions of those 

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

(C). Litchfield county, CT and 

Merrimack county, NH are considered 

rural areas for hospital IPPS purposes in 

accordance with § 412.64. Under this 

proposal, effective October 1, 2008, 

Litchfield county, CT would no longer 

be considered part of urban CBSA 25540 

(Hartford-West Hartford-East Hartford, 

CT), and Merrimack County, NH would 

no longer be considered part of urban 

CBSA 31700 (Manchester-Nashua, NH). 

Rather, these counties would be 

considered to be rural areas within their 

respective states under the hospice 

payment system. This proposed policy 

is consistent with our policy of not 

taking into account IPPS geographic 

reclassifications in determining 

payments under the hospice wage 

index. We propose to amend 

§ 418.306(c) to cross-reference to the 

definitions of urban and rural in the 

IPPS regulations in 42 CFR part 412 

subpart D. 

B. Wage Data for Multi-Campus 

Hospitals 

In the 2007 IPPS final rule, we 

changed in the way that we treat multicampus hospital wage data in the 

creation of the pre-floor, pre-reclassified 

hospital wage index. The IPPS wage 

data used to determine the proposed FY 

2009 hospice wage index values now 

apportion the wage data for multicampus hospitals located in different 

labor market areas (CBSAs) to the 

CBSAs where the campuses are located 

(see 72 FR 47317 through 47320). 

Historically, the hospice wage index is 

derived from the pre-floor, prereclassified hospital wage index. 

Consequently, for this proposed rule we 

propose to continue to use the most 

recent available pre-floor, prereclassified hospital wage index in 

computing the hospice wage index. The 

pre-floor, pre-reclassified hospital wage 

index values for the following CBSAs 

are affected by this change in how wage 

data from multi-campus hospitals are 

used in the computation of the pre-floor, 

pre-reclassified hospital wage index: 

Boston-Quincy, MA (CBSA 14484), 

Providence-New Bedford-Falls River, 

RI–MA (CBSA 39300), ChicagoNaperville-Joliet, IL (CBSA 16974) and 

Lake-County-Kenosha County, IL–WI 

(CBSA 29404). 

C. FY 2009 Hospice Wage Index With 

Phase-Out of the Budget Neutrality 

Adjustment Factor (BNAF) 

[If you choose to comment on issues 

in this section, please include the 

caption, ‘‘FY 2009 Hospice Wage Index 

with Phase-out of the Budget Neutrality 

Adjustment Factor (BNAF)’’ at the 

beginning of your comments.] 

1. Background 

The hospice final rule published in 

the Federal Register on December 16, 

1983 (48 FR 56008) provided for 

adjustment to hospice payment rates to 

reflect differences in area wage levels. 

We apply the appropriate hospice wage 

index value to the labor portion of the 

hospice payment rates based on the 

geographic area where hospice care was 

furnished. As noted earlier, each 

hospice’s labor market area is based on 

definitions of Metropolitan Statistical 

Areas (MSAs) issued by the OMB. For 

FY 2009, we propose to again use a prefloor, pre-reclassified hospital wage 

index based solely on the CBSA 

designations. 

As noted above, our hospice payment 

rules utilize the wage adjustment factors 

used by the Secretary for purposes of 

section 1886(d)(3)(E) of the Act for 

hospital wage adjustments. We are 

proposing again to use the pre-floor and 

pre-reclassified hospital wage index 

data to adjust the labor portion of the 

hospice payment rates based on the 

geographic area where the beneficiary 

receives hospice care. We believe the 

use of the pre-floor, pre-reclassified 

hospital wage index data results in the 

appropriate adjustment to the labor 

portion of the costs. For the FY 2009 

update to hospice payment rates, we 

propose to continue to use the most 

recent pre-floor, pre-reclassified 

hospital wage index available at the 

time of publication. 

2. Areas Without Hospital Wage Data 

In adopting the CBSA designations, 

we identified some geographic areas 

where there are no hospitals, and thus 

no hospital wage data on which to base 

the calculation of the hospice wage 

index. These areas were described in 

section I.B.4 of this proposed rule. 

Beginning in FY 2006, we adopted a 

policy that, for urban labor markets 

without an urban hospital from which a 

pre-floor, pre-reclassified hospital wage 

index can be derived, all of the urban 

CBSA pre-floor, pre-reclassified hospital 

wage index values within the State 

would be used to calculate a statewide 

urban average pre-floor, pre-reclassified 

hospital wage index to use as a 

reasonable proxy for these areas. 

Currently, the only CBSA that would be 

affected by this policy is CBSA 25980, 

Hinesville, Georgia. We propose to 

continue this policy for FY 2009. 

Currently, the only rural areas where 

there are no hospitals from which to 

calculate a pre-floor, pre-reclassified 

hospital wage index are Massachusetts 

and Puerto Rico. In August 2007 (72 FR 

50217) we adopted the following 

methodology for imputing rural prefloor, pre-reclassified hospital wage 

index values for areas where no hospital 

wage data are available as an acceptable 

proxy. We imputed an average pre-floor, 

pre-reclassified hospital wage index 

value by averaging the pre-floor, prereclassified hospital wage index values 

from contiguous CBSAs as a reasonable 

proxy for rural areas with no hospital 

wage data from which to calculate a prefloor, pre-reclassified hospital wage 

index. In determining an imputed rural 

pre-floor, pre-reclassified hospital wage 

index, we define ‘‘contiguous’’ as 

sharing a border. For Massachusetts, 

rural Massachusetts currently consists 

of Dukes and Nantucket Counties. We 

determined that the borders of Dukes 

and Nantucket counties are 

‘‘contiguous’’ with Barnstable and 

Bristol counties. We are again proposing 

to apply this methodology for imputing 

a rural pre-floor, pre-reclassified 

hospital wage index for those rural areas 

without rural hospital wage data in FY 

2009. 

However, as we noted in our final rule 

at 72 FR 50218, we do not believe that 

this policy is appropriate for Puerto 

Rico. We noted that there are sufficient 

economic differences between the 

hospitals in the United States and those 

in Puerto Rico, including the fact that 

hospitals in Puerto Rico are paid on 


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blended Federal/Commonwealthspecific rates, to make a separate 

distinct policy for Puerto Rico 

necessary. For FY 2009, we again 

propose to continue to use the most 

recent pre-floor, pre-reclassified 

hospital wage index value available for 

Puerto Rico, which is 0.4047. This prefloor, pre-reclassified hospital wage 

index value is then adjusted upward by 

the hospice floor in the computing of 

the proposed FY 2009 hospice wage 

index. 

3. Phase-Out of the Budget Neutrality 

Adjustment Factor (BNAF) 

As noted in section 1.B of this 

proposed rule, the current hospice wage 

index methodology was developed 

through a negotiated rule making 

process and implemented in 1997. The 

rule making committee sought to 

address the inaccuracies in the original 

Bureau of Labor Statistics (BLS)-based 

hospice wage index, account better for 

disparities from one geographic location 

to another, and develop a wage index 

that would be as accurate, reliable and 

equitable as possible. The resulting 

hospice wage index reflects a special 

adjustment (a BNAF) to ensure 

payments in the aggregate are budget 

neutral to payments using the original 

1983 hospice wage index. The 

adjustment, still in place today, results 

in providers currently receiving about 4 

percent more in payments than they 

would receive if the adjustment factor 

were not applied. The rationale for 

maintaining this adjustment is outdated 

given the time that has elapsed since it 

was put into place and the growth that 

is occurring in the hospice benefit. In 

this section, we propose to phase-out 

this adjustment over 3 years, reducing it 

by 25 percent in FY 2009, by an 

additional 50 percent for a total of 75 

percent in FY 2010, and eliminating it 

completely in FY 2011. We also provide 

our rationale for the phase-out. 

As discussed in section I.B of this 

proposed rule, the original hospice wage 

index was based on the 1981 Bureau of 

Labor Statistics (BLS) hospital data and 

had not been updated since 1983. 

During earlier attempts to update the 

hospice wage index, the hospice 

industry raised concerns over the 

adverse financial impact of a new wage 

index on individual hospices and a 

possible overall reduction in Medicare 

payments. Thus, the result was that in 

the absence of agreement on a new wage 

index, we continued to use a wage 

index that was clearly obsolete for 

geographically adjusting Medicare 

hospice payments (see ‘‘Medicare 

Program; Notice Containing the 

Statement Drafted by the Committee 

Established to Negotiate the Wage Index 

to be Used to Adjust Hospice Payment 

Rates Under Medicare,’’ November 29, 

1995, 60 FR 61264). 

Changing to a new but more accurate 

wage index would result in some areas 

gaining as their wage index value would 

increase, but in other areas seeing 

declines in payments as their wage 

index value dropped. In 1994 we noted 

that a majority of hospices would have 

their wage index reduced with the new 

wage index based on using the pre-floor, 

pre-reclassified hospital wage index. 

These reductions would have occurred 

for two key reasons: (1) Hospices were 

located in areas where the original 

hospice wage index was artificially high 

due to flaws in the 1981 BLS data, and 

(2) hospices were located in areas where 

wages had gone down relative to other 

geographic areas (see ‘‘Hospice Services 

Under Medicare Program: Intent to 

Form Negotiated Rulemaking 

Committee,’’ October 14, 1994, 59 FR 

52130). 

Because of the negative impact to 

certain areas that was expected with the 

change to a new wage index, a 

committee was formulated in 1994, 

under the process established by the 

Negotiated Rulemaking Act of 1990 

(Pub. L. 101–648). The Committee was 

established to negotiate the hospice 

wage index methodology rather than to 

go through the usual rulemaking 

process. On September 4, 1996, we 

published a proposed rule (61 FR 

46579) in which we proposed a 

methodology to update the hospice 

wage index used to adjust Medicare 

hospice payment rates. 

In formulating the provisions of that 

proposed rule, the Committee 

considered criteria in evaluating the 

available data sources. The need for 

fundamental equity of the wage index; 

data that reflected actual work 

performed by hospice personnel; 

compatibility with wage indexes used 

by CMS for other Medicare providers; 

and availability of the data for timely 

implementation were considered. 

The Committee agreed that the 

hospice wage index be derived from the 

1993 hospital cost report data and that 

these data, prior to reclassification, 

would form the basis for the FY 1997 

hospice wage index. That is the prefloor, pre-reclassified hospital wage 

index would not be adjusted to take into 

account the geographic reclassification 

of hospitals in accordance with sections 

1886(d)(8)(B) and 1886(d)(10) of the Act. 

The methodology is codified in 

§ 418.306(c). The hospice wage index 

for subsequent years would be based on 

pre-floor, pre-reclassified hospital wage 

index data for a subsequent year. 

The Committee was also concerned 

that while some hospices would see 

increases, use of the pre-floor, prereclassified hospital wage index as the 

wage index for hospices would result in 

a net reduction in aggregate Medicare 

payments for hospices. As noted above, 

a majority of hospices would have had 

their wage index lowered by using the 

new wage index because the prior 

hospice wage indices were based on 

outdated data which were artificially 

high due to flaws in the 1981 BLS data, 

and because some hospices were located 

in areas where wages had gone down 

relative to other geographic areas. The 

reduction in overall Medicare payments 

if a new wage index were adopted was 

noted in the November 29, 1995 final 

rule (60 FR 61264). Therefore, the 

Committee also decided that, each year 

in updating the hospice wage index, 

aggregate Medicare payments to 

hospices would remain budget neutral 

to payments as if the 1983 wage index 

had been used. 

As decided upon by the Hospice 

Wage Index Negotiated Rulemaking 

Committee, budget neutrality means 

that, in a given year, estimated aggregate 

payments for Medicare hospice services 

using the updated hospice values will 

equal estimated payments that would 

have been made for these services if the 

1983 hospice wage index values had 

remained in effect, after adjusting the 

payment rates for inflations. Being 

budget neutral does not take into 

account annual market basket updates 

to hospice payment rates. Therefore, 

although payments to individual 

hospice programs may change each 

year, the total payments each year to 

hospices would not be affected by using 

the updated hospice wage index 

because total payments would be budget 

neutral as if the 1983 wage index had 

been used. To implement this provision 

a BNAF would be computed and 

applied annually. 

The BNAF is calculated by computing 

estimated payments using the most 

recent completed year of hospice claims 

data. The units (days or hours) from 

those claims are multiplied by the 

updated hospice payment rates to 

calculate estimated payments. The 

updated hospice wage index values are 

then applied to the labor portion of the 

payments. For this proposed rule, that 

means estimating payments for FY 2009 

using FY 2006 hospice claims data, and 

applying the estimated updated FY 2009 

hospice payment rates (updating the FY 

2008 rates by the estimated FY 2009 

market basket update). The proposed FY 

2009 hospice wage index values are 

then applied to the labor portion only. 

The procedure is repeated using the 


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same claims data and payment rates, but 

using the 1983 BLS-based wage index 

instead of the updated pre-floor, prereclassified hospital wage index. The 

total payments are then compared, and 

the adjustment required to make total 

payments equal is computed; that 

adjustment factor is the BNAF. In 1998, 

the BNAF increased all wage index 

values by just over 2 percent. 

All pre-floor, pre-reclassified hospital 

wage index values of 0.8 or greater 

would be adjusted by the BNAF. Also, 

all pre-floor, pre-reclassified hospital 

wage index values below 0.8 would 

receive the greater of the following: (1) 

A 15-percent increase subject to a 

maximum hospice wage index value of 

0.8; or (2) an adjustment by the BNAF. 

All hospice wage index values of 0.8 or 

greater would be adjusted by the BNAF. 

The BNAF would be calculated and 

applied annually. 

While the Committee sought to adopt 

a wage index methodology that would 

be as accurate, reliable, and equitable as 

possible, the Committee also decided to 

incorporate a BNAF into the calculation 

of the hospice wage index that would 

otherwise apply in order to mitigate 

adverse financial impacts some hospices 

would experience through a decrease in 

their wage index value by transitioning 

to a pre-floor, pre-reclassified hospital 

wage index. 

In the August 8, 1997 final rule (62 FR 

42860), we indicated that the annual 

updates of the hospice wage index 

values would be made in accordance 

with the methodology agreed to by the 

rulemaking committee. We also noted 

that in the event that if we decide to 

change this methodology by which the 

hospice wage index is computed, it 

would be reflected in a proposed rule 

published in the Federal Register. In 

this proposed rule, we now propose to 

change this methodology. 

In FY 1998, the BNAF was 1.020768; 

in FY 2008 it was 1.066671. In other 

words, any pre-floor, pre-reclassified 

hospital wage index value greater than 

0.8 was increased by over 2 percent in 

FY 1998 and increased by almost 7 

percent in FY 2008. In FY 2008, this 

adjustment resulted in hospice 

providers receiving about 4 percent 

more in payments than they would have 

received if the BNAF had not been 

applied. 

The negotiating committee also 

recommended that the transition to the 

new hospice wage index occur over 3 

years, from FY 1998 to FY 2001. The 

intent of both the three year transition 

and the budget neutrality adjustment 

was to mitigate the negative financial 

impact to many hospices resulting from 

the wage index change. Additionally, 

the committee sought to ensure that 

access to hospice care was not 

jeopardized as a result of the wage index 

change. 

We believe that the rationale for 

maintaining this adjustment is outdated 

for several reasons. 

First, the original purpose of the 

BNAF was to prevent reductions in 

payments to the majority of hospices 

whose wage index was based on the 

original hospice wage index which was 

artificially high due to flaws in the 1981 

BLS data. While incorporating a BNAF 

into hospice wage indices could be 

rationalized in 1997 as a way to smooth 

the transition from an old wage index to 

a new one, since hospices have had 

plenty of time to adjust to the new wage 

index, it is difficult to justify 

maintaining in perpetuity a BNAF 

which was in part compensating for 

artificially high data to begin with. 

Second, the new wage index adopted 

in 1997 resulted in increases in wage 

index values for hospices in certain 

areas. The BNAF applies to hospices in 

all areas. Thus, hospices in areas that 

would have had increases without the 

BNAF received an artificial boost in the 

wage index for the past 11 years. We 

believe that continuation of this excess 

payment can no longer be justified. 

Third, an adjustment factor that is 

based on 24-year old wage index values 

is contrary to our goal of using a hospice 

wage index that is as accurate, reliable 

and equitable as possible in accounting 

for geographic variation in wages. We 

believe that those goals can be better 

achieved by using the pre-floor, prereclassified hospital wage index, 

without an outdated BNAF, consistent 

with other providers. For instance, 

Medicare payments to home health 

agencies, that utilize a similar labor mix, 

are adjusted by the pre-floor, prereclassified hospital wage index, 

without any budget neutrality 

adjustment. We believe that using the 

unadjusted pre-floor, pre-reclassified 

hospital wage index provides a good 

measure of area wage differences for 

both these home-based reimbursement 

systems. 

Fourth, in the 13 years since concerns 

about the impact of switching from an 

old to a new wage index were voiced, 

the hospice industry and hospice 

payments have grown substantially. 

Hospice expenditures in 2006 were $9.2 

billion, compared to about $2.2 billion 

in 1998, a growth rate of almost 20 

percent per year. Aggregate hospice 

expenditures are increasing at a rate of 

about $1 billion per year. MedPAC 

projects that expenditures will continue 

to grow at a rate of 9 percent per year 

through 2015, outpacing the growth rate 

of projected expenditures for hospitals, 

skilled nursing facilities, and physician 

and home health services. We believe 

that this growth in Medicare spending 

for hospice indicates that the original 

rationale of the BNAF, to cushion the 

impact of using the new wage index, is 

no longer justified. These spending 

growth figures also indicate that any 

negative financial impact to the hospice 

industry as a result of eliminating the 

BNAF is no longer present, and thus the 

need for a transitional adjustment has 

passed. 

Fifth, 13 years ago the industry also 

voiced concerns about the negative 

financial impact on individual hospices 

that could occur by adopting a new 

wage index. In August 1994 there were 

1,602 hospices; currently there are 2,986 

hospices. Clearly any negative financial 

impact from adopting a new wage index 

in 1997 is no longer present, or we 

would not have seen an 86 percent 

increase in the number of hospices since 

1994. The number of Medicare-certified 

hospices has continued to increase, with 

a 26 percent increase in the number of 

hospice providers from 2001 to 2005. 

This ongoing growth in the industry 

also suggests that phasing out the BNAF 

would not have a negative impact on 

access to care. 

Therefore for these reasons, we 

believe that continuing to apply a BNAF 

for the purpose of mitigating any 

adverse financial impact on hospices or 

negative impact on access to care is no 

longer necessary. We are proposing to 

phase out the BNAF over a 3-year 

period, reducing the BNAF by 25 

percent in FY 2009, by 75 percent in FY 

2010, and eliminating it in FY 2011. We 

believe that the proposed 3-year phaseout period will reduce any adverse 

financial impact that the industry might 

experience if we eliminated the BNAF 

in a single year. However, depending on 

the comments received, updated data, 

and subsequent analysis, for the final 

rule we may determine that a different 

percentage reduction in the BNAF (for 

any of the years) or a different phase-out 

timeframe would be more appropriate. 

Specifically, it may be determined that 

a more aggressive phase-out alternative 

(e.g. a 50 percent reduction in the BNAF 

in FY 2009, a 75 percent reduction in 

the BNAF in FY 2010, and elimination 

of the BNAF in FY 2011) is more 

appropriate. Consequently, we will 

continue to look at reduction 

percentages and timeframe alternatives 

for the phase-out of the BNAF and, for 

the final rule, will implement what is 

determined to be the most appropriate 

option based on the above information. 

We propose to maintain the hospice 

floor, which offers protection to 


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hospices with pre-floor, pre-reclassified 

hospital wage index values less than 

0.8. 

We believe that we should have 

addressed this issue in previous years. 

We believe that using the BNAF has 

resulted in Medicare spending for 

hospice services in excess of what 

spending should have been in the 

absence of such an adjustment. 

However, we are not proposing to 

reduce Medicare payments to hospices 

for prior years. We are only proposing 

to remove the application of the BNAF 

on a prospective basis, beginning on 

October 1, 2008. 

Section II.C.3.a below discusses the 

effects of phasing out the BNAF over 

three years using the data from the 

published FY 2008 hospice wage index; 

by basing the analysis on this data, our 

simulations hold claims data, the wage 

index values, and payment rates 

constant, with the only change being the 

reduction in the BNAF. Section II.C.3.b 

discusses the effects of reducing the 

BNAF for FY 2009 using the proposed 

FY 2009 hospice wage index. 

a. Effects of Phasing-Out the BNAF 

Using the Published FY 2008 Hospice 

Wage Index 

For this proposed rule, we will use 

the FY 2008 hospice wage index (72 FR 

50214, published August 31, 2007) to 

illustrate the effects of phasing out the 

BNAF over 3 years. This analysis and 

discussion is for illustrative purposes 

only and does not affect any of the 

hospice wage index values for FY 2008. 

The BNAF that was calculated and 

applied to the 2007 pre-floor, prereclassified hospital wage index values 

was 6.6671 percent. We propose 

reducing the BNAF by 25 percent for FY 

2009, by 75 percent for FY 2010, and 

eliminating it altogether for FY 2011 

and beyond. A 25 percent reduction in 

the BNAF can be accomplished by 

blending 75 percent of the FY 2008 

hospice wage index that applied the full 

6.6671 percent BNAF with 25 percent of 

the FY 2008 hospice wage index that 

used no BNAF. This is mathematically 

equivalent to taking 75 percent of the 

full BNAF value, or multiplying 

0.066671 by 0.75, which equals 

0.050003, or 5.0003 percent. The BNAF 

of 5.0003 percent reflects a 25 percent 

reduction in the BNAF. The 25 percent 

reduction in the BNAF of 5.0003 

percent would be applied to the prefloor, pre-reclassified hospital wage 

index values of 0.8 or greater used in the 

published FY 2008 hospice wage index. 

The hospice floor calculation would 

still apply to any pre-floor, prereclassified hospital wage index values 

less then 0.8. Currently, the floor 

calculation has 4 steps. Pre-floor, prereclassified hospital wage index values 

that are less than 0.8 are first multiplied 

by 1.15; second, the minimum of 0.8 or 

the pre-floor, pre-reclassified hospital 

wage index value times 1.15 is chosen 

as the preliminary hospice wage index 

value. Third, the pre-floor, prereclassified hospital wage index value is 

multiplied by BNAF. Finally, the greater 

result of either step 2 or step 3 is chosen 

as the final hospice wage index value. 

We propose to leave the hospice floor 

unchanged, noting that steps 3 and 4 

will become unnecessary once the 

BNAF is eliminated. 

For the simulations of the BNAF 

phase-out for FY 2010 and FY 2011, we 

used the same pre-floor, pre-reclassified 

hospital wage index values and claims 

data as the example above, and simply 

changed the value of the BNAF to reflect 

either a 75 percent reduction for FY 

2010 or a 100 percent reduction for FY 

2011. In both cases we started with the 

full BNAF of 6.6671 percent. We 

changed the calculation to take 25 

percent of the full BNAF to reflect a 75 

percent reduction for FY 2010, or 

eliminated the BNAF altogether to 

reflect a 100 percent reduction for FY 

2011. For FY 2010, the reduced BNAF 

or the hospice floor was then applied to 

the 2008 pre-floor, pre-reclassified 

hospital wage index as described 

previously. For FY 2011 and subsequent 

years, the pre-floor, pre-reclassified 

hospital wage index values would be 

unadjusted unless they are less than 0.8, 

in which case the hospice floor 

calculation would be applied. 

For our simulations, the calculations 

of the BNAF are as follows: 

• A 75 percent reduction to the BNAF 

in FY 2010 would be 0.066671 × 

0.25 = 0.016668 or 1.6668 percent 

• A 100 percent reduction or 

elimination of the BNAF in FY 2011 

would be 0.066671 × 0.0 = 0.0 or 0 

percent 

We examined the effects of phasing 

out the BNAF versus using the full 

BNAF of 6.6671 percent on the FY 2008 

hospice wage index. The FY 2009 BNAF 

reduction of 25 percent resulted in 

approximately a 1.55 to 1.57 percent 

reduction in the hospice wage index 

value. The FY 2010 BNAF reduction of 

75 percent would result in an estimated 

additional 3.12 to 3.13 percent 

reduction from the FY 2009 hospice 

wage index values. The elimination of 

the BNAF in FY 2011 would result in 

an estimated final reduction of the FY 

2011 hospice wage index values of 

approximately 1.55 to 1.57 percent 

compared to FY 2010 hospice wage 

index values. 

Those CBSAs whose pre-floor, prereclassified hospital wage index values 

had the hospice floor calculation 

applied prior to the BNAF reduction 

would not be affected by this proposed 

phase-out of the BNAF. These CBSAs, 

which typically include rural areas, are 

protected by the hospice floor 

calculation. Additionally, those CBSAs 

whose hospice wage index values were 

previously 0.8 or greater after the BNAF 

was applied, but which would have 

values less than 0.8 after the reduced 

BNAF was applied would see a smaller 

reduction in their hospice wage index 

values since the hospice floor 

calculation would apply. We have 

estimated the number of CBSAs that 

would have their pre-floor, prereclassified hospital wage index value 

eligible for the floor calculation after 

applying the 25, 75, and 100 percent 

reductions in the BNAF. Three CBSAs 

would be affected by the 25 percent 

reduction, 12 would be affected by the 

75 percent reduction, and 22 would be 

affected by the 100 percent reduction. 

Because of the protection given by the 

hospice floor calculation, these CBSAs 

would see smaller percentage decreases 

in their hospice wage index values than 

those CBSAs that are not eligible for the 

floor calculation. This will benefit those 

hospices with lower hospice wage index 

values, which are typically in rural 

areas. 

Finally, the hospice wage index 

values only apply to the labor portion of 

the payment rates; the labor portion was 

described in Section I.B.1 of this 

proposed rule. Therefore the estimated 

reduction in payments due to this 

proposed phase-out of the BNAF would 

be less than the percentage reductions to 

the hospice wage index values that 

would result from reducing or 

eliminating the BNAF. In addition, the 

effects of the proposed phase-out of the 

BNAF could also be mitigated by a 

hospital market basket update in 

payments, which in FY 2008 was a 3.3 

percent increase in payment rates. We 

will not have the final market basket 

update for FY 2009 until the summer, 

but the current estimate of the hospital 

market basket update is expected to be 

around 3.0 percent. This update will be 

communicated through an 

administrative instruction and not 

through rulemaking. The estimated 

effects on payment described in column 

5 of Table 1 in section IV.B of this 

proposed rule include the projected 

effect of an estimated 3.0 percent 

hospital market basket update. CMS 

may implement updates to the payment 

rates in future rulemaking. 


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b. Effects of Phasing-Out the BNAF 

Using the Updated Pre-floor, Prereclassified Hospital Wage Index Data 

(FY 2009 Proposal) 

For FY 2009, we propose updating the 

hospice wage index using the 2008 prefloor, pre-reclassified hospital wage 

index and the most complete claims 

data available (FY 2006 claims). Using 

these data, we computed a full BNAF of 

6.5357 percent. For the first year of the 

BNAF phase-out (FY 2009), the BNAF 

would be reduced by 25 percent, or 

0.065357 × 0.75 = 0.049018, to 4.9018 

percent. This would decrease hospice 

wage index values by approximately 

1.53 to 1.54 percent from wage index 

values with the full BNAF applied. As 

noted in the previous discussion on the 

effects of the BNAF reduction in the 

published FY 2008 hospice wage index, 

those CBSAs which already have prefloor, pre-reclassified hospital wage 

index values that have the hospice floor 

applied prior to implementing a 

proposed BNAF reduction would be 

completely unaffected by this proposed 

BNAF reduction. Those CBSAs which 

previously had hospice wage index 

values above 0.8 after applying the full 

BNAF, but which now are below 0.8 

with the 25 percent reduction in the 

BNAF would be less affected by the 

BNAF reduction than those CBSAs 

which are 0.8 or above after applying 

the BNAF, as they are protected by the 

hospice floor calculation. Additionally, 

as mentioned in section I.B.1 of this 

proposed rule, the final hospice wage 

index is only applied to the labor 

portion of the payment rates, so the 

actual effect on estimated payment 

would be less than the anticipated 1.53 

to 1.54 percent reduction in the hospice 

wage index value. Furthermore, that 

effect may be mitigated by a market 

basket update. As noted earlier, the 

market basket update will not be 

available until the summer, but 

estimates of the update are at about 3.0 

percent. 

Column 3 of Table 1 (section IV of 

this proposed rule) shows the impact of 

using the most recent wage index data 

(the 2008 pre-floor, pre-reclassified 

hospital wage index not including any 

reclassification under section 

1886(d)(8)(B) of the Act) compared to 

the 2007 pre-floor, pre-reclassified 

hospital wage index data which was 

used to derive the FY 2008 hospice 

wage index. Column 4 of Table 1 in 

Section IV of this proposed rule shows 

the impact of incorporating the 25 

percent reduction in the BNAF in the 

proposed FY 2009 hospice wage index 

along with using the most recent wage 

index data (2008 pre-floor, prereclassified hospital wage index). 

Finally, column 5 of Table 1 shows the 

combined effects of using the updated 

pre-floor, pre-reclassified hospital wage 

index, the 25 percent reduced BNAF, 

and an estimated market basket update 

of 3.0 percent. The proposed FY 2009 

rural and urban hospice wage indexes 

can be found in Addenda A and B of 

this proposed rule. The pre-floor, prereclassified hospital wage index values 

were adjusted by the 25 percent reduced 

BNAF or by the hospice floor. 

D. Summary of the Provisions of the 

Proposed Rule 

• We propose to clarify that the 

hospice benefit will follow the 

definition of ‘‘urban’’ specified in 

§ 412.64(b)(1)(ii)(A) and (B), and the 

rural definition as any area outside of an 

urban area in § 412.64(b)(1)(ii)(C). The 

regulatory text of § 418.306(c) will be 

amended to reference 

§ 412.64(b)(1)(ii)(A) through (C). This 

affects two New England ‘‘deemed’’

counties that meet the OMB definition 

of rural, but were previously counted as 

urban; these two counties would now be 

considered rural. See section II.A of this 

proposed rule for details. 

• As a basis for the hospice wage 

index, we propose to continue to use the 

pre-floor, pre-reclassified hospital wage 

index, which includes a change to how 

wage data from multi-campus hospitals 

are apportioned. See section II.B of this 

proposed rule for more details. 

• We propose to continue to use a 

pre-floor, pre-reclassified hospital wage 

index based solely on the CBSA 

designations, using the most recent prefloor and pre-reclassified hospital wage 

index available at the time of 

publication. See section II.C.1 of this 

proposed rule for details. 

• We propose to continue the policy 

that for urban labor markets without an 

urban hospital from which a pre-floor, 

pre-reclassified hospital wage index 

could be derived, all of the urban CBSA 

pre-floor, pre-reclassified hospital wage 

index values within the State would be 

used to calculate a statewide urban 

average pre-floor, pre-reclassified 

hospital wage index to use as a 

reasonable proxy for these areas. See 

section II.C.2 of this proposed rule for 

details. 

• We propose to continue the policy 

that we impute an average pre-floor, 

pre-reclassified rural hospital wage 

index value by averaging the pre-floor, 

pre-reclassified hospital wage index 

values from contiguous CBSAs as a 

reasonable proxy for rural areas with no 

hospital wage data from which to 

calculate a pre-floor, pre-reclassified 

hospital wage index. See section II.C.2 

f of this proposed rule or details. 

• We propose to continue to utilize 

the most recent pre-floor, prereclassified hospital wage index value 

available for Puerto Rico. See section 

II.C.2 of this proposed rule for details. 

• We propose to phase-out the 

hospice BNAF over 3 years, reducing it 

by 25 percent for FY 2009, by 75 percent 

for FY 2010, and eliminating it 

completely for FY 2011. See sections 

II.C.3.a and II.C.3.b of this proposed rule 

for details. As stated in section II.C.3, 

based on comments received, updated 

data, and subsequent analysis, for the 

final rule we may determine that a 

different percentage reduction in the 

BNAF (for any of the years) or a 

different phase-out timeframe would be 

more appropriate. Specifically, it may 

be determined that a more aggressive 

alternative (e.g., a 50 percent reduction 

in the BNAF in FY 2009, a 75 percent 

reduction in the BNAF in FY 2010, and 

elimination of the BNAF in FY 2011) is 

more appropriate. Consequently, we 

will continue to look at reduction 

percentages and time period alternatives 

for the phase-out of the BNAF and, for 

the final rule, will implement what is 

determined to be the most appropriate 

option based on the above information. 

• We propose to continue to maintain 

the hospice floor calculation. See 

section II.C.3 of this proposed rule for 

details. 

Addendum A reflects the proposed 

FY 2009 hospice wage index values for 

urban areas designations. Addendum B 

reflects the proposed FY 2009 hospice 

wage index values for rural areas 

designations. 

III. Collection of Information 

Requirements 

This document does not impose any 

information collection and 

recordkeeping requirements. 

Consequently, it does not need to be 

reviewed by the Office of Management 

and Budget under the authority of the 

Paperwork Reduction Act of 1995 (44 

U.S.C. 35). 

IV. Regulatory Impact Analysis 

A. Overall Impact 

We have examined the impacts of this 

rule as required by Executive Order 

12866 (September 1993, Regulatory 

Planning and Review), the Regulatory 

Flexibility Act (RFA) (September 19, 

1980, Pub. L. 96–354), section 1102(b) of 

the Social Security 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)). We 


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estimated the impact on hospices, as a 

result of the changes to the proposed FY 

2009 hospice wage index and of 

reducing the BNAF by 25 percent. As 

discussed previously, the methodology 

for computing the hospice wage index 

was determined through a negotiated 

rulemaking committee and 

implemented in the August 8, 1997 final 

rule (62 FR 42860). This rule proposes 

updates to the hospice wage index in 

accordance with our regulation but 

proposes to revise the Negotiated 

Rulemaking Committee methodology of 

including a BNAF. 

Executive Order 12866 (as amended 

by Executive Order 13258, which 

merely reassigns responsibility of 

duties) 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). We have 

determined that this proposed rule is an 

economically significant rule under this 

Executive Order. 

Column 4 of Table 1 shows the 

combined effects of the proposed 25 

percent reduction in the BNAF and of 

the updated wage data, comparing 

estimated payments for FY 2009 to 

estimated payments for FY 2008. We 

estimate that the total hospice payments 

for FY 2009 will decrease by $100 

million as a result of the application of 

the 25 percent reduction in the BNAF 

and the updated wage data. This 

estimate does not take into account any 

market basket update, which is 

currently forecast to be about 3.0 

percent. The final market basket update 

will not be available until some time 

later this year and will be 

communicated through an 

administrative instruction. The 

estimated effect of a 3.0 percent 

forecasted market basket update on 

payments to hospices is approximately 

$280 million. If we were to take into 

account an estimated 3.0 percent market 

basket update, in addition to the 25 

percent reduction in the BNAF and the 

updated wage data, it is estimated that 

hospice payments would increase by 

approximately $180 million ($280 

million ¥ $100 million = $180 million). 

The percent change in payments to 

hospices due to the combined effects of 

the 25 percent reduction in the BNAF, 

the updated wage data, and the 

estimated market basket update of 3.0 

percent is reflected in column 5 of the 

impact table (Table 1). 

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. The great majority of hospices 

and most other providers and suppliers 

are small entities, either by nonprofit 

status or by having revenues of less than 

$6.5 million to $31.5 million in any one 

year (for details, see the Small Business 

Administration’s regulation at 65 FR 

69432, that sets forth size standards for 

health care industries). As indicated in 

Table 1 below, there are 2,986 hospices 

as of February 2008. Approximately 

52.7 percent of Medicare certified 

hospices are identified as voluntary, 

government, or other agencies and, 

therefore, are considered small entities. 

Most of these and most of the remainder 

are also small hospice entities because 

their revenues fall below the SBA size 

thresholds. We note that the hospice 

wage index methodology was 

previously guided by consensus, 

through a negotiated rulemaking 

committee that included representatives 

of national hospice associations, rural, 

urban, large and small hospices, multisite hospices, and consumer groups. 

Based on all of the options considered, 

the committee agreed on the 

methodology described in the 

committee statement, and after notice 

and comment, it was adopted into 

regulation in the August 8, 1997 final 

rule. In developing the process for 

updating the hospice wage index in the 

1997 final rule, we considered the 

impact of this methodology on small 

hospice entities and attempted to 

mitigate any potential negative effects. 

Small hospice entities are more likely to 

be in rural areas, which are less affected 

by the BNAF reduction than entities in 

urban areas. Generally, hospices in rural 

areas are protected by the hospice floor, 

which mitigates the effect of the BNAF 

reduction. The effects of this rule on 

hospices, as illustrated in Table 1, are 

small. Overall, Medicare payments to all 

hospices will decrease by an estimated 

1.1 percent, reflecting the combined 

effects of the 25 percent reduction in the 

BNAF and the updated wage data. 

Within the hospice subgroups, Medicare 

payments will decrease by no more than 

1.6 percent. Furthermore, when 

including the estimated market basket 

update of 3.0 percent into these figures, 

the combined effects of Medicare 

payment changes to all hospices will 

result in an increase of approximately 

1.9 percent. Overall average hospice 

revenue effects will be slightly less than 

these estimates since according the 

National Hospice and Palliative Care 

Organization, about 16 percent of 

hospice caseload is non-Medicare. 

Longstanding HHS practice in 

interpreting the RFA is to consider 

effects economically ‘‘significant’’ only 

if they reach a threshold of 3 to 5 

percent or more. Accordingly, we have 

determined that this proposed rule does 

not create a significant economic impact 

on a substantial number of small 

entities. 

In addition, section 1102(b) of the Act 

requires us to prepare a regulatory 

impact analysis if a rule may have a 

significant impact on the operations of 

a substantial number of small rural 

hospitals. This analysis must conform to 

the provisions of section 604 of the 

RFA. For purposes of section 1102(b) of 

the Act, we define a small rural hospital 

as a hospital that is located outside a 

CBSA and has fewer than 100 beds. We 

have determined that this proposed rule 

will not have a significant impact on the 

operations of a substantial number of 

small rural hospitals. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 (UMRA) 

also requires that agencies assess 

anticipated costs and benefits before 

issuing any rule whose mandates 

require spending in any 1 year of about 

$130 million or more (the threshold in 

the statute, updated for inflation 

through 2008). This proposed rule is not 

anticipated to have an effect on State, 

local, or tribal governments or on the 

private sector of $130 million or more. 

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 proposed rule 

under the threshold criteria of Executive 

Order 13132, Federalism, and have 

determined that it will not have an 

impact on the rights, roles, and 

responsibilities of State, local, or tribal 

governments. 

B. Anticipated Effects 

This section discusses the impact of 

the projected effects of the proposed 

provisions of this rule, including the 

estimated effects of a projected 3.0 

percent market basket update that will 

be communicated separately through an 

administrative instruction. The 

proposed provisions include continuing 

to use the CBSA-based pre-floor, prereclassified hospital wage index (to 

include the clarification of New England 

‘‘deemed’’ counties and a change in the 

way that multi-campus hospital wage 


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data are treated in the creation of the 

pre-floor, pre-reclassified hospital wage 

index), continuing the use the same 

policies for treatment of areas (rural and 

urban) without hospital wage data, and 

reducing the BNAF by 25 percent for the 

first year of a 3-year BNAF phase-out. 

The proposed FY 2009 hospice wage 

index is based upon the 2008 pre-floor, 

pre-reclassified hospital wage index and 

the most complete claims data available 

(FY 2006) with a 25 percent reduction 

in the BNAF. 

For the purposes of our impacts, our 

baseline is estimated FY 2008 payments 

using the 2007 pre-floor, pre-reclassified 

hospital wage index. Our first 

comparison (column 3, Table 1) 

compares our baseline to estimated FY 

2009 payments (holding payment rates 

constant) using the updated wage data 

(2008 pre-floor, pre-reclassified hospital 

wage index). Consequently, the 

estimated effects illustrated in column 3 

of Table 1 are for the updated wage data 

only. The effects of using the updated 

pre-floor, pre-reclassified hospital wage 

index data combined with the 25 

percent reduction in the BNAF are 

illustrated in column 4 of Table 1. 

Even though the market basket update 

is not part of this proposed rule, we 

have included a comparison of the 

combined effects of the 25 percent 

BNAF reduction, the updated pre-floor, 

pre-reclassified hospital wage index, 

and an estimated 3.0 percent market 

basket increase for FY 2009 (Table 1, 

column 5). Presenting this data gives the 

hospice industry a more complete 

picture of the effects of the proposed 

changes in this rule and the market 

basket update. Certain events may limit 

the scope or accuracy of our impact 

analysis, because such an analysis is 

susceptible to forecasting errors due to 

other changes in the forecasted impact 

time period. The nature of the Medicare 

program is such that the changes may 

interact, and the complexity of the 

interaction of these changes could make 

it difficult to predict accurately the full 

scope of the impact upon hospices. 

TABLE 1.—ANTICIPATED IMPACT ON MEDICARE HOSPICE PAYMENTS OF REDUCING THE BNAF, UPDATING THE PREFLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX DATA, AND APPLYING AN ESTIMATED 3.0 PERCENT MARKET BASKET UPDATE FOR THE PROPOSED FY 2009 HOSPICE WAGE INDEX, COMPARED TO THE PUBLISHED FINAL FY 2008 

HOSPICE WAGE INDEX

Number of 

hospices* 

Number of 

routine 

home care 

days in 

thousands 

Percent change in 

payments due to 

the effects of the 

updated wage 

data (FY 2009 

Proposed Wage 

Index) 

Percent change in 

payments due to 

the combined effects of the 25% 

reduction in the 

BNAF and the updated wage data 

(FY 2009 Proposed Wage 

Index) 

Percent change in payments due to the combined effects of the 

25% reduction in the 

BNAF, the updated 

wage data (FY 2009 

Proposed Wage Index), 

and estimated market 

basket update (3.0%) 

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

ALL HOSPICES ................................................. 2,986 61,351 ¥0.1 ¥1.1 1.9 

URBAN HOSPICES .................................... 1,996 52,642 ¥0.1 ¥1.1 1.8 

RURAL HOSPICES .................................... 990 8,709 ¥0.1 ¥0.9 2.1 

BY REGION—URBAN: 

NEW ENGLAND ......................................... 113 1,787 0.3 ¥0.8 2.2 

MIDDLE ATLANTIC .................................... 201 5,250 ¥0.5 ¥1.6 1.4 

SOUTH ATLANTIC ..................................... 288 11,388 ¥0.1 ¥1.1 1.8 

EAST NORTH CENTRAL ........................... 296 7,638 ¥0.3 ¥1.4 1.6 

EAST SOUTH CENTRAL ........................... 160 4,365 ¥0.4 ¥1.3 1.7 

WEST NORTH CENTRAL .......................... 152 3,413 0.0 ¥1.0 1.9 

WEST SOUTH CENTRAL .......................... 339 7,131 ¥0.2 ¥1.2 1.7 

MOUNTAIN ................................................. 183 4,543 0.0 ¥1.1 1.9 

PACIFIC ...................................................... 230 6,330 0.8 ¥0.4 2.6 

PUERTO RICO ........................................... 34 797 ¥1.1 ¥1.1 1.9 

BY REGION—RURAL: 

NEW ENGLAND ......................................... 26 147 ¥0.4 ¥1.4 1.5 

MIDDLE ATLANTIC .................................... 43 408 0.3 ¥0.7 2.3 

SOUTH ATLANTIC ..................................... 125 1,759 0.0 ¥0.9 2.0 

EAST NORTH CENTRAL ........................... 140 1,148 0.0 ¥1.0 1.9 

EAST SOUTH CENTRAL ........................... 145 2,017 ¥0.4 ¥1.1 1.8 

WEST NORTH CENTRAL .......................... 189 945 ¥0.3 ¥1.3 1.7 

WEST SOUTH CENTRAL .......................... 165 1,325 ¥0.6 ¥0.8 2.2 

MOUNTAIN ................................................. 104 580 0.4 ¥0.6 2.4 

PACIFIC ...................................................... 52 372 1.5 0.4 3.4 

PUERTO RICO ........................................... 1 7 0.0 0.0 3.0 

ROUTINE HOME CARE DAYS: 

0–3499 DAYS (small) ................................. 631 1,060 0.0 ¥0.9 2.0 

3500–19,999 DAYS (medium) .................... 1,445 14,385 ¥0.1 ¥1.1 1.9 

20,000+ DAYS (large) ................................ 910 45,906 ¥0.1 ¥1.1 1.9 

TYPE OF OWNERSHIP: 

VOLUNTARY .............................................. 1,194 27,185 ¥0.2 ¥1.2 1.8 

PROPRIETARY .......................................... 1,412 30,017 0.0 ¥1.0 1.9 

GOVERNMENT .......................................... 192 986 0.1 ¥0.8 2.2 

OTHER ....................................................... 188 3,163 0.0 ¥1.0 2.0 

HOSPICE BASE: 

FREESTANDING ........................................ 1,807 45,473 ¥0.1 ¥1.1 1.8 

HOME HEALTH AGENCY ......................... 597 8,908 0.0 ¥1.0 2.0 

HOSPITAL .................................................. 567 6,756 0.0 ¥1.1 1.9 


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TABLE 1.—ANTICIPATED IMPACT ON MEDICARE HOSPICE PAYMENTS OF REDUCING THE BNAF, UPDATING THE PREFLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX DATA, AND APPLYING AN ESTIMATED 3.0 PERCENT MARKET BASKET UPDATE FOR THE PROPOSED FY 2009 HOSPICE WAGE INDEX, COMPARED TO THE PUBLISHED FINAL FY 2008 

HOSPICE WAGE INDEX—Continued 

Number of 

hospices* 

Number of 

routine 

home care 

days in 

thousands 

Percent change in 

payments due to 

the effects of the 

updated wage 

data (FY 2009 

Proposed Wage 

Index) 

Percent change in 

payments due to 

the combined effects of the 25% 

reduction in the 

BNAF and the updated wage data 

(FY 2009 Proposed Wage 

Index) 

Percent change in payments due to the combined effects of the 

25% reduction in the 

BNAF, the updated 

wage data (FY 2009 

Proposed Wage Index), 

and estimated market 

basket update (3.0%) 

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

SKILLED NURSING FACILITY .................. 15 213 ¥0.6 ¥1.7 1.2 

BNAF = Budget Neutrality Adjustment Factor. 

* As of February 2008. 

Table 1 shows the results of our 

analysis. In column 1, we indicate the 

number of hospices included in our 

analysis as of February 2008. In column 

2, we indicate the number of routine 

home care days that were included in 

our analysis, although the analysis was 

performed on all types of hospice care. 

Column 3 shows the percentage change 

in estimated Medicare payments from 

FY 2008 to FY 2009 due to the effects 

of the updated wage data only. Column 

4 shows the percentage change in 

estimated hospice payments from FY 

2008 to FY 2009 due to the combined 

effects of using the 2008 pre-floor, prereclassified hospital wage index and 

reducing the BNAF by 25 percent. 

Column 5 shows the percentage change 

in estimated hospice payments from FY 

2008 to FY 2009 due to the combined 

effects of using updated wage data, a 25 

percent BNAF reduction, and a 3.0 

percent estimated market basket update. 

Table 1 also categorizes hospices by 

various geographic and provider 

characteristics. The first row of data 

displays the aggregate result of the 

impact for all Medicare-certified 

hospices. The second and third rows of 

the table categorize hospices according 

to their geographic location (urban and 

rural). Our analysis indicated that there 

are 1,996 hospices located in urban 

areas and 990 hospices located in rural 

areas. The next two row groupings in 

the table indicate the number of 

hospices by census region, also broken 

down by urban and rural hospices. The 

next grouping shows the impact on 

hospices based on the size of the 

hospice’s program. We determined that 

the majority of hospice payments are 

made at the routine home care rate. 

Therefore, we based the size of each 

individual hospice’s program on the 

number of routine home care days 

provided in FY 2006. The next grouping 

shows the impact on hospices by type 

of ownership. The final grouping shows 

the impact on hospices defined by 

whether they are provider-based or 

freestanding. 

As indicated in Table 1 below, there 

are 2,986 hospices. Approximately 52.7 

percent of Medicare-certified hospices 

are identified as voluntary, government, 

or other agencies and, therefore, are 

considered small entities. Because the 

National Hospice and Palliative Care 

Organization estimates that 

approximately 83.7 percent of hospice 

patients are Medicare beneficiaries, we 

have not considered other sources of 

revenue in this analysis. As noted 

earlier, those CBSAs which had the 

hospice floor applied prior to our 

proposal to reduce the BNAF are 

unaffected by this proposed change in 

methodology. Those CBSAs that were 

not previously less than 0.8 after 

applying the full BNAF but which now 

are less than 0.8 after applying the 

reduced BNAF will see less of a 

reduction in payments as the floor 

protects their hospice wage index value. 

As stated previously, the following 

discussions are limited to demonstrating 

trends rather than projected dollars. We 

used the pre-floor, pre-reclassified 

hospital wage indexes as well as the 

most complete claims data available (FY 

2006) in developing the impact analysis. 

The FY 2009 payment rates will be 

adjusted to reflect the full hospital 

market basket, as required by section 

1814(i)(1)(C)(ii)(VII) of the Act. As 

previously noted, we publish these rates 

through administrative instructions 

rather than in a proposed rule. The FY 

2008 update was 3.3 percent, and the 

FY 2009 update will not be available 

until the summer. Currently the FY 

2009 update is estimated to be 3.0 

percent; however this figure is subject to 

change. Since the inclusion of the effect 

of a market basket increase provides a 

more complete picture of estimated 

hospice payments for FY 2009, the last 

column of Table 1 shows the combined 

impacts of the 25 percent BNAF 

reduction, the updated wage index, and 

a projected 3.0 percent market basket 

update factor. 

As discussed in the FY 2006 final rule 

(70 FR 45129), hospice agencies may 

use multiple hospice wage index values 

to compute their payments based on 

potentially different geographic 

locations. Before January 1, 2008, the 

location of the beneficiary was used to 

determine the CBSA for routine and 

continuous home care and the location 

of the hospice agency was used to 

determine the CBSA for respite and 

general inpatient care. Beginning 

January 1, 2008, the hospice wage index 

utilized is based on the location of the 

site of service. As the location of the 

beneficiary’s home and the location of 

the facility may vary, there will still be 

variability in geographic location for an 

individual hospice. We anticipate that 

the location of the various sites will 

usually correspond with the geographic 

location of the hospice, and thus we 

will continue to use the location of the 

hospice for our analyses of the impact 

of the proposed changes to the hospice 

wage index in this rule. For this 

analysis, we use payments to the 

hospice in the aggregate based on the 

location of the hospice. 

The impact of hospice wage index 

changes has been analyzed according to 

the type of hospice, geographic location, 

type of ownership, hospice base, and 

size. Our analysis shows that most 

hospices are in urban areas and provide 

the vast majority of routine home care 

days. Most hospices are medium-sized 


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followed by large hospices. Hospices are 

almost equal in numbers by ownership 

with 1,574 designated as non-profit and 

1,412 as proprietary. The vast majority 

of hospices are freestanding. 

1. Hospice Size 

Under the Medicare hospice benefit, 

hospices can provide four different 

levels of care days. The majority of the 

days provided by a hospice are routine 

home care (RHC) days representing 

about 97 percent of the services 

provided by a hospice. Therefore, the 

number of RHC days can be used as a 

proxy for the size of the hospice, that is, 

the more days of care provided, the 

larger the hospice. As discussed in the 

August 4, 2005 final rule, we currently 

use three size designations to present 

the impact analyses. The three 

categories are: (1) Small agencies having 

0 to 3,499 RHC days; (2) medium 

agencies having 3,500 to 19,999 RHC 

days; and (3) large agencies having 

20,000 or more RHC days. The proposed 

FY 2009 wage index values without the 

BNAF reduction are anticipated to have 

virtually no impact on small hospice 

providers, with a slight decrease of 0.1 

percent anticipated for medium and 

large hospices (column 3); the proposed 

FY 2009 wage index values with the 25 

percent BNAF reduction and the 

updated wage data are anticipated to 

decrease estimated payments by 0.9 

percent to small hospices and by 1.1 

percent to medium and large hospices 

(column 4); and finally, the proposed 

FY 2009 wage index values with the 25 

percent BNAF reduction, the updated 

wage data, and the estimated 3.0 percent 

market basket update are projected to 

increase estimated payments by 2.0 

percent for small hospices and by 1.9 

percent for medium and large hospices 

(column 5). 

2. Geographic Location 

Column 3 of Table 1 shows that FY 

2009 wage index values without the 

BNAF reduction will result in little 

change in estimated payments with 

rural and urban hospices anticipated to 

experience a slight decrease of 0.1 

percent. For urban hospices, the greatest 

increase of 0.8 percent is anticipated to 

be experienced by the Pacific regions, 

followed by an increase for New 

England of 0.3 percent and no change 

for the West North Central and 

Mountain regions. The remaining urban 

regions are anticipated to experience a 

decrease ranging from 0.1 percent in the 

South Atlantic region 1.1 percent is for 

Puerto Rico. 

Column 3 shows that for rural 

hospices, Puerto Rico, the South 

Atlantic, and the East North Central 

regions are anticipated to experience no 

change. Four regions are anticipated to 

experience a decrease ranging from 0.3 

percent for the West North Central 

region to 0.6 percent for West South 

Central region. The remaining regions 

are anticipated to experience an 

increase ranging from 0.3 percent for the 

Middle Atlantic region to 1.5 percent for 

the Pacific region. 

Column 4 shows the combined effect 

of the 25 percent BNAF reduction and 

the updated pre-floor, pre-reclassified 

hospital wage index values on estimated 

payments, as compared to the published 

FY 2008 payments. Overall urban 

hospices are anticipated to experience a 

1.1 percent decrease in payments, while 

rural hospices expect a 0.9 percent 

decrease. The estimated percent 

decrease in payment for urban hospices 

ranged from 0.4 percent for Pacific 

hospices to 1.6 percent for Middle 

Atlantic hospices. 

The estimated percent decrease in 

payment for rural hospices ranged from 

0.6 percent for Mountain hospices to 1.4 

percent for New England hospices. 

Rural Puerto Rico’s estimated payments 

were unaffected, and the Pacific region 

saw a 0.4 percent increase in estimated 

payments. 

Column 5 shows the combined effects 

of the proposed FY 2009 wage index 

values with the 25 percent BNAF 

reduction, the updated wage data, and 

the estimated 3.0 percent market basket 

update on estimated payments as 

compared to the published FY 2008 

payments. Overall, urban hospices are 

anticipated to experience a 1.8 percent 

increase in payments while rural 

hospices should experience a 2.1 

percent increase in payments. Urban 

hospices are anticipated to see an 

increase in estimated payments ranging 

from 1.4 percent for the Middle Atlantic 

region to 2.6 percent for the Pacific 

region. Rural hospices are estimated to 

see an increase in estimated payments 

ranging from 1.5 percent for the New 

England region to 3.4 percent for the 

Pacific region. 

3. Type of Ownership 

Column 3 demonstrates the effect of 

the updated pre-floor, pre-reclassified 

hospital wage index on FY 2009 

estimated payments versus FY 2008 

estimated payments. We anticipate that 

using the updated pre-floor, prereclassified hospital wage index data 

will have no effect on proprietary 

hospices. While we estimate a slight 

decrease in estimated payments for 

voluntary (non-profit) hospices (0.2 

percent), other hospices are expected to 

experience no effect and government 

hospices are expected to experience a 

slight increase in payments (0.1 

percent). 

Column 4 demonstrates the combined 

effects of using updated pre-floor, prereclassified hospital wage index data 

and of incorporating a 25 percent BNAF 

reduction. Estimated payments to 

proprietary hospices are anticipated to 

decrease by 1.0 percent, while voluntary 

(non-profit), other, and government 

hospices are anticipated to experience 

decreases of 1.2 percent, 1.0 percent, 

and 0.8 percent, respectively. 

Column 5 shows the combined effects 

of the updated pre-floor, pre-reclassified 

hospital wage index values with the 25 

percent BNAF reduction, the updated 

wage data, and the estimated 3.0 percent 

market basket update on estimated 

payments, comparing FY 2009 to FY 

2008. Estimated FY 2009 payments are 

anticipated to increase for all hospices, 

regardless of ownership type. Estimated 

payments are forecast to increase from 

1.8 percent for voluntary hospices to 2.2 

percent for government hospices. 

4. Hospice Base 

Column 3 demonstrates the effect of 

using the updated pre-floor, prereclassified hospital wage index values, 

comparing estimated payments for FY 

2009 to FY 2008. Estimated payments 

are anticipated to decrease by 0.1 

percent for freestanding facilities and by 

0.6 percent for skilled nursing facilities. 

Home health and hospital based 

facilities are anticipated to experience 

no change in estimated payments. 

Column 4 shows the combined effects 

of reducing the BNAF by 25 percent and 

updating the pre-floor, pre-reclassified 

hospital wage index values, comparing 

FY 2009 to FY 2008 estimated 

payments. Skilled nursing facility based 

hospices are estimated to see a 1.7 

percent decline, while hospital based 

hospices and freestanding hospices are 

each anticipated to experience a 1.1 

percent decrease in payments. Home 

health agency based hospices are 

expected to experience a 1.0 percent 

decrease. 

Column 5 shows the combined effects 

of the 25 percent BNAF reduction, the 

updated pre-floor, pre-reclassified 

hospital wage index, and the estimated 

3.0 percent market basket update on 

estimated payments, comparing FY 

2009 to FY 2008. Estimated increases in 

payments range from 1.2 percent for 

skilled nursing facility based hospices 

to 2.0 percent for home health agency 

based hospices. 

We note that the President’s budget 

includes a proposal for a zero percent 

payment update for hospices in FY 

2009. The impacts outlined in Column 

5 of Table 1 in this proposed rule, 


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which include the effects of a 3.0 

percent market basket update, would 

need to change in the final rule to reflect 

any legislation that the Congress might 

enact which would affect the market 

basket update. 

C. Accounting Statement 

As required by OMB Circular A–4 

(available at http:// 

www.whitehouse.gov/omb/circulars/ 

a004/a-4.pdf), in Table 2 below, we 

have prepared an accounting statement 

showing the classification of the 

expenditures associated with the 

proposed provisions of this rule. This 

table provides our best estimate of the 

decrease in Medicare payments under 

the hospice benefit as a result of the 

changes presented in this proposed rule 

on data for 2,086 hospices in our 

database. All expenditures are classified 

as transfers to Medicare providers (that 

is, hospices). 

TABLE 2.—ACCOUNTING STATEMENT: 

CLASSIFICATION OF ESTIMATED EXPENDITURES, FROM FY 2008 TO FY 

2009 [IN MILLIONS] 

Category Transfers 

Annualized Monetized 

Transfers.

$–100*. 

TABLE 2.—ACCOUNTING STATEMENT: 

CLASSIFICATION OF ESTIMATED EXPENDITURES, FROM FY 2008 TO FY 

2009 [IN MILLIONS]—Continued 

Category Transfers 

From Whom to Whom Federal Government 

to Hospices. 

*

The $100 million reduction in transfers includes the 25 percent reduction in the BNAF 

and the updated wage data. It does not include the market basket update, which is currently forecast to be about 3.0%. 

In accordance with the provisions of 

Executive Order 12866, this regulation 

was reviewed by the Office of 

Management and Budget. 

List of Subjects in 42 CFR Part 418 

Health facilities, Health professions, 

Medicare, and Reporting and 

recordkeeping requirements. 

For the reasons set forth in the 

preamble, the Centers for Medicare and 

Medicare Services proposes to amend 

42 CFR chapter IV as set forth below: 

PART 418—HOSPICE CARE 

1. The authority citation for part 418 

continues to read as follows: 

Authority: Secs 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

Subpart G—Payment for Hospice Care 

2. Section § 418.306 is amended by 

revising paragraph (c) to read as follows: 

§ 418.306 Determination of payment rates. 

* * * * * 

(c) Each hospice’s labor market is 

determined based on definitions of 

Metropolitan Statistical Areas (MSAs) 

issued by OMB. CMS will issue 

annually, in the Federal Register, a 

hospice wage index based on the most 

current available CMS hospital wage 

data, including changes to the definition 

of MSAs. The urban and rural area 

geographic classifications are defined in 

§ 412.64(b)(1)(ii)(A) through (C) of this 

chapter. The payment rates established 

by CMS are adjusted by the 

intermediary to reflect local differences 

in wages according to the revised wage 

data. 

* * * * * 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Note: The following addendums will not 

appear in the Code of Federal Regulations. 

Dated: March 14, 2008. 

Kerry Weems, 

Acting Administrator, Centers for Medicare 

& Medicaid Services. 

Approved: April 7, 2008. 

Michael O. Leavitt, 

Secretary. 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

10180 ......................... Abilene, TX .............................................................................................................................................................. 0.8347 

Callahan County, TX.

Jones County, TX.

Taylor County, TX.

10380 ......................... Aguadilla-Isabela-San Sebastia ́n, PR ..................................................................................................................... 0.3965 

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 ................................................................................................................................................................ 0.9225 

Portage County, OH.

Summit County, OH.

10500 ......................... Albany, GA .............................................................................................................................................................. 0.8931 

Baker County, GA.

Dougherty County, GA.

Lee County, GA.

Terrell County, GA.

Worth County, GA.

10580 ......................... Albany-Schenectady-Troy, NY ................................................................................................................................ 0.9009 

Albany County, NY.

Rensselaer County, NY.

Saratoga County, NY.

Schenectady County, NY.


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ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Schoharie County, NY.

10740 ......................... Albuquerque, NM .................................................................................................................................................... 1.0022 

Bernalillo County, NM.

Sandoval County, NM.

Torrance County, NM.

Valencia County, NM.

10780 ......................... Alexandria, LA ......................................................................................................................................................... 0.8370 

Grant Parish, LA.

Rapides Parish, LA.

10900 ......................... Allentown-Bethlehem-Easton, PA-NJ ...................................................................................................................... 1.0349 

Warren County, NJ.

Carbon County, PA.

Lehigh County, PA.

Northampton County, PA.

11020 ......................... Altoona, PA ............................................................................................................................................................. 0.9040 

Blair County, PA.

11100 ......................... Amarillo, TX ............................................................................................................................................................. 0.9563 

Armstrong County, TX.

Carson County, TX.

Potter County, TX.

Randall County, TX.

11180 ......................... Ames, IA .................................................................................................................................................................. 1.0538 

Story County, IA.

11260 ......................... Anchorage, AK ........................................................................................................................................................ 1.2497 

Anchorage Municipality, AK.

Matanuska-Susitna Borough, AK.

11300 ......................... Anderson, IN ........................................................................................................................................................... 0.9260 

Madison County, IN.

11340 ......................... Anderson, SC .......................................................................................................................................................... 0.9531 

Anderson County, SC.

11460 ......................... Ann Arbor, MI .......................................................................................................................................................... 1.1056 

Washtenaw County, MI.

11500 ......................... Anniston-Oxford, AL ................................................................................................................................................ 0.8315 

Calhoun County, AL.

11540 ......................... Appleton, WI ............................................................................................................................................................ 1.0068 

Calumet County, WI.

Outagamie County, WI.

11700 ......................... Asheville, NC ........................................................................................................................................................... 0.9635 

Buncombe County, NC.

Haywood County, NC.

Henderson County, NC.

Madison County, NC.

12020 ......................... Athens-Clarke County, GA ...................................................................................................................................... 1.1033 

Clarke County, GA.

Madison County, GA.

Oconee County, GA.

Oglethorpe County, GA.

12060 ......................... Atlanta-Sandy Springs-Marietta, GA ....................................................................................................................... 1.0310 

Barrow County, GA.

Bartow County, GA.

Butts County, GA.

Carroll County, GA.

Cherokee County, GA.

Clayton County, GA.

Cobb County, GA.

Coweta County, GA.

Dawson County, GA.

DeKalb County, GA.

Douglas County, GA.

Fayette County, GA.

Forsyth County, GA.

Fulton County, GA.

Gwinnett County, GA.

Haralson County, GA.

Heard County, GA.

Henry County, GA.

Jasper County, GA.

Lamar County, GA.

Meriwether County, GA.

Newton County, GA.

Paulding County, GA.


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ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Pickens County, GA.

Pike County, GA.

Rockdale County, GA.

Spalding County, GA.

Walton County, GA.

12100 ......................... Atlantic City, NJ ....................................................................................................................................................... 1.2796 

Atlantic County, NJ.

12220 ......................... Auburn-Opelika, AL ................................................................................................................................................. 0.8487 

Lee County, AL.

12260 ......................... Augusta-Richmond County, GA-SC ........................................................................................................................ 1.0118 

Burke County, GA.

Columbia County, GA.

McDuffie County, GA.

Richmond County, GA.

Aiken County, SC.

Edgefield County, SC.

12420 ......................... Austin-Round Rock, TX ........................................................................................................................................... 1.0012 

Bastrop County, TX.

Caldwell County, TX.

Hays County, TX.

Travis County, TX.

Williamson County, TX.

12540 ......................... Bakersfield, CA ........................................................................................................................................................ 1.1593 

Kern County, CA.

12580 ......................... Baltimore-Towson, MD ............................................................................................................................................ 1.0631 

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 ............................................................................................................................................................. 1.0467 

Penobscot County, ME.

12700 ......................... Barnstable Town, MA .............................................................................................................................................. 1.3221 

Barnstable County, MA.

12940 ......................... Baton Rouge, LA ..................................................................................................................................................... 0.8428 

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 ...................................................................................................................................................... 1.0678 

Calhoun County, MI.

13020 ......................... Bay City, MI ............................................................................................................................................................. 0.9333 

Bay County, MI.

13140 ......................... Beaumont-Port Arthur, TX ....................................................................................................................................... 0.8949 

Hardin County, TX.

Jefferson County, TX.

Orange County, TX.

13380 ......................... Bellingham, WA ....................................................................................................................................................... 1.2036 

Whatcom County, WA.

13460 ......................... Bend, OR ................................................................................................................................................................. 1.1478 

Deschutes County, OR.

13644 ......................... Bethesda-Frederick-Gaithersburg, MD ................................................................................................................... 1.1026 

Frederick County, MD.

Montgomery County, MD.

13740 ......................... Billings, MT .............................................................................................................................................................. 0.9091 

Carbon County, MT.

Yellowstone County, MT.

13780 ......................... Binghamton, NY ...................................................................................................................................................... 0.9388 

Broome County, NY.

Tioga County, NY.

13820 ......................... Birmingham-Hoover, AL .......................................................................................................................................... 0.9334 

Bibb County, AL.

Blount County, AL.

Chilton County, AL.


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ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Jefferson County, AL.

St. Clair County, AL.

Shelby County, AL.

Walker County, AL.

13900 ......................... Bismarck, ND .......................................................................................................................................................... 0.8000 

Burleigh County, ND.

Morton County, ND.

13980 ......................... Blacksburg-Christiansburg-Radford, VA ................................................................................................................. 0.8594 

Giles County, VA.

Montgomery County, VA.

Pulaski County, VA.

Radford City, VA.

14020 ......................... Bloomington, IN ....................................................................................................................................................... 0.9352 

Greene County, IN.

Monroe County, IN.

Owen County, IN.

14060 ......................... Bloomington-Normal, IL ........................................................................................................................................... 0.9782 

McLean County, IL.

14260 ......................... Boise City-Nampa, ID .............................................................................................................................................. 0.9929 

Ada County, ID.

Boise County, ID.

Canyon County, ID.

Gem County, ID.

Owyhee County, ID.

14484 ......................... Boston-Quincy, MA ................................................................................................................................................. 1.2370 

Norfolk County, MA.

Plymouth County, MA.

Suffolk County, MA.

14500 ......................... Boulder, CO ............................................................................................................................................................. 1.0937 

Boulder County, CO.

14540 ......................... Bowling Green, KY .................................................................................................................................................. 0.8559 

Edmonson County, KY.

Warren County, KY.

14740 ......................... Bremerton-Silverdale, WA ....................................................................................................................................... 1.1438 

Kitsap County, WA.

14860 ......................... Bridgeport-Stamford-Norwalk, CT ........................................................................................................................... 1.3359 

Fairfield County, CT.

15180 ......................... Brownsville-Harlingen, TX ....................................................................................................................................... 0.9351 

Cameron County, TX.

15260 ......................... Brunswick, GA ......................................................................................................................................................... 0.9939 

Brantley County, GA.

Glynn County, GA.

McIntosh County, GA.

15380 ......................... Buffalo-Niagara Falls, NY ........................................................................................................................................ 1.0037 

Erie County, NY.

Niagara County, NY.

15500 ......................... Burlington, NC ......................................................................................................................................................... 0.9176 

Alamance County, NC.

15540 ......................... Burlington-South Burlington, VT .............................................................................................................................. 1.0134 

Chittenden County, VT.

Franklin County, VT.

Grand Isle County, VT.

15764 ......................... Cambridge-Newton-Framingham, MA ..................................................................................................................... 1.1765 

Middlesex County, MA.

15804 ......................... Camden, NJ ............................................................................................................................................................ 1.0921 

Burlington County, NJ.

Camden County, NJ.

Gloucester County, NJ.

15940 ......................... Canton-Massillon, OH ............................................................................................................................................. 0.9373 

Carroll County, OH.

Stark County, OH.

15980 ......................... Cape Coral-Fort Myers, FL ..................................................................................................................................... 0.9857 

Lee County, FL.

16180 ......................... Carson City, NV ...................................................................................................................................................... 1.0493 

Carson City, NV.

16220 ......................... Casper, WY ............................................................................................................................................................. 0.9845 

Natrona County, WY.

16300 ......................... Cedar Rapids, IA ..................................................................................................................................................... 0.9286 

Benton County, IA.

Jones County, IA.

Linn County, IA.


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ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

16580 ......................... Champaign-Urbana, IL ............................................................................................................................................ 0.9852 

Champaign County, IL.

Ford County, IL.

Piatt County, IL.

16620 ......................... Charleston, WV ....................................................................................................................................................... 0.8695 

Boone County, WV.

Clay County, WV.

Kanawha County, WV.

Lincoln County, WV.

Putnam County, WV.

16700 ......................... Charleston-North Charleston, SC ........................................................................................................................... 0.9571 

Berkeley County, SC.

Charleston County, SC.

Dorchester County, SC.

16740 ......................... Charlotte-Gastonia-Concord, NC-SC ...................................................................................................................... 0.9987 

Anson County, NC.

Cabarrus County, NC.

Gaston County, NC.

Mecklenburg County, NC.

Union County, NC.

York County, SC.

16820 ......................... Charlottesville, VA ................................................................................................................................................... 0.9732 

Albemarle County, VA.

Fluvanna County, VA.

Greene County, VA.

Nelson County, VA.

Charlottesville City, VA.

16860 ......................... Chattanooga, TN-GA ............................................................................................................................................... 0.9435 

Catoosa County, GA.

Dade County, GA.

Walker County, GA.

Hamilton County, TN.

Marion County, TN.

Sequatchie County, TN.

16940 ......................... Cheyenne, WY ........................................................................................................................................................ 0.9764 

Laramie County, WY.

16974 ......................... Chicago-Naperville-Joliet, IL ................................................................................................................................... 1.1240 

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 ................................................................................................................................................................ 1.1843 

Butte County, CA.

17140 ......................... Cincinnati-Middletown, OH-KY-IN ........................................................................................................................... 1.0264 

Dearborn County, IN.

Franklin County, IN.

Ohio County, IN.

Boone County, KY.

Bracken County, KY.

Campbell County, KY.

Gallatin County, KY.

Grant County, KY.

Kenton County, KY.

Pendleton County, KY.

Brown County, OH.

Butler County, OH.

Clermont County, OH.

Hamilton County, OH.

Warren County, OH.

17300 ......................... Clarksville, TN-KY ................................................................................................................................................... 0.8655 

Christian County, KY.

Trigg County, KY.

Montgomery County, TN.

Stewart County, TN.

17420 ......................... Cleveland, TN .......................................................................................................................................................... 0.8447 

Bradley County, TN.

Polk County, TN.


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ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

17460 ......................... Cleveland-Elyria-Mentor, OH .................................................................................................................................. 0.9797 

Cuyahoga County, OH.

Geauga County, OH.

Lake County, OH.

Lorain County, OH.

Medina County, OH.

17660 ......................... Coeur d’Alene, ID .................................................................................................................................................... 0.9999 

Kootenai County, ID.

17780 ......................... College Station-Bryan, TX ....................................................................................................................................... 0.9817 

Brazos County, TX.

Burleson County, TX.

Robertson County, TX.

17820 ......................... Colorado Springs, CO ............................................................................................................................................. 1.0195 

El Paso County, CO.

Teller County, CO.

17860 ......................... Columbia, MO ......................................................................................................................................................... 0.9082 

Boone County, MO.

Howard County, MO.

17900 ......................... Columbia, SC .......................................................................................................................................................... 0.9231 

Calhoun County, SC.

Fairfield County, SC.

Kershaw County, SC.

Lexington County, SC.

Richland County, SC.

Saluda County, SC.

17980 ......................... Columbus, GA-AL ................................................................................................................................................... 0.9157 

Russell County, AL.

Chattahoochee County, GA.

Harris County, GA.

Marion County, GA.

Muscogee County, GA.

18020 ......................... Columbus, IN ........................................................................................................................................................... 1.0004 

Bartholomew County, IN.

18140 ......................... Columbus, OH ......................................................................................................................................................... 1.0579 

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 ................................................................................................................................................... 0.9009 

Aransas County, TX.

Nueces County, TX.

San Patricio County, TX.

18700 ......................... Corvallis, OR ........................................................................................................................................................... 1.1496 

Benton County, OR.

19060 ......................... Cumberland, MD-WV .............................................................................................................................................. 0.8701 

Allegany County, MD.

Mineral County, WV.

19124 ......................... Dallas-Plano-Irving, TX ........................................................................................................................................... 1.0401 

Collin County, TX.

Dallas County, TX.

Delta County, TX.

Denton County, TX.

Ellis County, TX.

Hunt County, TX.

Kaufman County, TX.

Rockwall County, TX.

19140 ......................... Dalton, GA ............................................................................................................................................................... 0.9189 

Murray County, GA.

Whitfield County, GA.

19180 ......................... Danville, IL ............................................................................................................................................................... 0.9396 

Vermilion County, IL.

19260 ......................... Danville, VA ............................................................................................................................................................. 0.8644 

Pittsylvania County, VA.

Danville City, VA.

19340 ......................... Davenport-Moline-Rock Island, IA-IL ...................................................................................................................... 0.9263 

Henry County, IL.

Mercer County, IL.


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ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Rock Island County, IL.

Scott County, IA.

19380 ......................... Dayton, OH .............................................................................................................................................................. 0.9640 

Greene County, OH.

Miami County, OH.

Montgomery County, OH.

Preble County, OH.

19460 ......................... Decatur, AL ............................................................................................................................................................. 0.8272 

Lawrence County, AL.

Morgan County, AL.

19500 ......................... Decatur, IL ............................................................................................................................................................... 0.8470 

Macon County, IL.

19660 ......................... Deltona-Daytona Beach-Ormond Beach, FL .......................................................................................................... 0.9474 

Volusia County, FL.

19740 ......................... Denver-Aurora, CO ................................................................................................................................................. 1.1243 

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 .......................................................................................................................... 0.9678 

Dallas County, IA.

Guthrie County, IA.

Madison County, IA.

Polk County, IA.

Warren County, IA.

19804 ......................... Detroit-Livonia-Dearborn, MI ................................................................................................................................... 1.0489 

Wayne County, MI.

20020 ......................... Dothan, AL .............................................................................................................................................................. 0.8000 

Geneva County, AL.

Henry County, AL.

Houston County, AL.

20100 ......................... Dover, DE ................................................................................................................................................................ 1.0594 

Kent County, DE.

20220 ......................... Dubuque, IA ............................................................................................................................................................ 0.9502 

Dubuque County, IA.

20260 ......................... Duluth, MN-WI ......................................................................................................................................................... 1.0464 

Carlton County, MN.

St. Louis County, MN.

Douglas County, WI.

20500 ......................... Durham, NC ............................................................................................................................................................ 1.0297 

Chatham County, NC.

Durham County, NC.

Orange County, NC.

Person County, NC.

20740 ......................... Eau Claire, WI ......................................................................................................................................................... 0.9939 

Chippewa County, WI.

Eau Claire County, WI.

20764 ......................... Edison, NJ ............................................................................................................................................................... 1.1729 

Middlesex County, NJ.

Monmouth County, NJ.

Ocean County, NJ.

Somerset County, NJ.

20940 ......................... El Centro, CA .......................................................................................................................................................... 0.9351 

Imperial County, CA.

21060 ......................... Elizabethtown, KY ................................................................................................................................................... 0.9138 

Hardin County, KY.

Larue County, KY.

21140 ......................... Elkhart-Goshen, IN .................................................................................................................................................. 1.0082 

Elkhart County, IN.

21300 ......................... Elmira, NY ............................................................................................................................................................... 0.8669 

Chemung County, NY.

21340 ......................... El Paso, TX ............................................................................................................................................................. 0.9430 

El Paso County, TX.

21500 ......................... Erie, PA ................................................................................................................................................................... 0.8911 

Erie County, PA.


rfrederick on PROD1PC67 with PROPOSALS
24020 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

21660 ......................... Eugene-Springfield, OR .......................................................................................................................................... 1.1468 

Lane County, OR.

21780 ......................... Evansville, IN-KY ..................................................................................................................................................... 0.9087 

Gibson County, IN.

Posey County, IN.

Vanderburgh County, IN.

Warrick County, IN.

Henderson County, KY.

Webster County, KY.

21820 ......................... Fairbanks, AK .......................................................................................................................................................... 1.1592 

Fairbanks North Star Borough, AK.

21940 ......................... Fajardo, PR ............................................................................................................................................................. 0.5031 

Ceiba Municipio, PR.

Fajardo Municipio, PR.

Luquillo Municipio, PR.

22020 ......................... Fargo, ND-MN ......................................................................................................................................................... 0.8436 

Cass County, ND.

Clay County, MN.

22140 ......................... Farmington, NM ....................................................................................................................................................... 1.0057 

San Juan County, NM.

22180 ......................... Fayetteville, NC ....................................................................................................................................................... 0.9827 

Cumberland County, NC.

Hoke County, NC.

22220 ......................... Fayetteville-Springdale-Rogers, AR-MO ................................................................................................................. 0.9171 

Benton County, AR.

Madison County, AR.

Washington County, AR.

McDonald County, MO.

22380 ......................... Flagstaff, AZ ............................................................................................................................................................ 1.2260 

Coconino County, AZ.

22420 ......................... Flint, MI .................................................................................................................................................................... 1.1770 

Genesee County, MI.

22500 ......................... Florence, SC ........................................................................................................................................................... 0.8653 

Darlington County, SC.

Florence County, SC.

22520 ......................... Florence-Muscle Shoals, AL ................................................................................................................................... 0.8056 

Colbert County, AL.

Lauderdale County, AL.

22540 ......................... Fond du Lac, WI ...................................................................................................................................................... 1.0141 

Fond du Lac County, WI.

22660 ......................... Fort Collins-Loveland, CO ....................................................................................................................................... 1.0382 

Larimer County, CO.

22744 ......................... Fort Lauderdale-Pompano Beach-Deerfield Beach, FL .......................................................................................... 1.0730 

Broward County, FL.

22900 ......................... Fort Smith, AR-OK .................................................................................................................................................. 0.8322 

Crawford County, AR.

Franklin County, AR.

Sebastian County, AR.

Le Flore County, OK.

Sequoyah County, OK.

23020 ......................... Fort Walton Beach-Crestview-Destin, FL ................................................................................................................ 0.9172 

Okaloosa County, FL.

23060 ......................... Fort Wayne, IN ........................................................................................................................................................ 0.9739 

Allen County, IN.

Wells County, IN.

Whitley County, IN.

23104 ......................... Fort Worth-Arlington, TX ......................................................................................................................................... 1.0168 

Johnson County, TX.

Parker County, TX.

Tarrant County, TX.

Wise County, TX.

23420 ......................... Fresno, CA .............................................................................................................................................................. 1.1532 

Fresno County, CA.

23460 ......................... Gadsden, AL ........................................................................................................................................................... 0.8559 

Etowah County, AL.

23540 ......................... Gainesville, FL ......................................................................................................................................................... 0.9647 

Alachua County, FL.

Gilchrist County, FL.

23580 ......................... Gainesville, GA ........................................................................................................................................................ 0.9668 

Hall County, GA.

23844 ......................... Gary, IN ................................................................................................................................................................... 0.9676 


rfrederick on PROD1PC67 with PROPOSALS
Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24021 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Jasper County, IN.

Lake County, IN.

Newton County, IN.

Porter County, IN.

24020 ......................... Glens Falls, NY ....................................................................................................................................................... 0.8661 

Warren County, NY.

Washington County, NY.

24140 ......................... Goldsboro, NC ......................................................................................................................................................... 0.9743 

Wayne County, NC.

24220 ......................... Grand Forks, ND-MN .............................................................................................................................................. 0.8267 

Polk County, MN.

Grand Forks County, ND.

24300 ......................... Grand Junction, CO ................................................................................................................................................ 1.0348 

Mesa County, CO.

24340 ......................... Grand Rapids-Wyoming, MI .................................................................................................................................... 0.9772 

Barry County, MI.

Ionia County, MI.

Kent County, MI.

Newaygo County, MI.

24500 ......................... Great Falls, MT ....................................................................................................................................................... 0.9100 

Cascade County, MT.

24540 ......................... Greeley, CO ............................................................................................................................................................ 1.0131 

Weld County, CO.

24580 ......................... Green Bay, WI ......................................................................................................................................................... 1.0204 

Brown County, WI.

Kewaunee County, WI.

Oconto County, WI.

24660 ......................... Greensboro-High Point, NC .................................................................................................................................... 0.9452 

Guilford County, NC.

Randolph County, NC.

Rockingham County, NC.

24780 ......................... Greenville, NC ......................................................................................................................................................... 0.9863 

Greene County, NC.

Pitt County, NC.

24860 ......................... Greenville, SC ......................................................................................................................................................... 1.0343 

Greenville County, SC.

Laurens County, SC.

Pickens County, SC.

25020 ......................... Guayama, PR .......................................................................................................................................................... 0.3524 

Arroyo Municipio, PR.

Guayama Municipio, PR.

Patillas Municipio, PR.

25060 ......................... Gulfport-Biloxi, MS .................................................................................................................................................. 0.9203 

Hancock County, MS.

Harrison County, MS.

Stone County, MS.

25180 ......................... Hagerstown-Martinsburg, MD-WV .......................................................................................................................... 0.9455 

Washington County, MD.

Berkeley County, WV.

Morgan County, WV.

25260 ......................... Hanford-Corcoran, CA ............................................................................................................................................. 1.1014 

Kings County, CA.

25420 ......................... Harrisburg-Carlisle, PA ............................................................................................................................................ 0.9735 

Cumberland County, PA.

Dauphin County, PA.

Perry County, PA.

25500 ......................... Harrisonburg, VA ..................................................................................................................................................... 0.9302 

Rockingham County, VA.

Harrisonburg City, VA.

25540 ......................... Hartford-West Hartford-East Hartford, CT .............................................................................................................. 1.1496 

Hartford County, CT.

Middlesex County, CT.

Tolland County, CT.

25620 ......................... Hattiesburg, MS ....................................................................................................................................................... 0.8000 

Forrest County, MS.

Lamar County, MS.

Perry County, MS.

25860 ......................... Hickory-Lenoir-Morganton, NC ................................................................................................................................ 0.9471 

Alexander County, NC.

Burke County, NC.

Caldwell County, NC.


rfrederick on PROD1PC67 with PROPOSALS
24022 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Catawba County, NC.

25980 ......................... Hinesville-Fort Stewart, GA3 ................................................................................................................................... 0.9637 

Liberty County, GA.

Long County, GA.

26100 ......................... Holland-Grand Haven, MI ....................................................................................................................................... 0.9447 

Ottawa County, MI.

26180 ......................... Honolulu, HI ............................................................................................................................................................. 1.2122 

Honolulu County, HI.

26300 ......................... Hot Springs, AR ...................................................................................................................................................... 0.9556 

Garland County, AR.

26380 ......................... Houma-Bayou Cane-Thibodaux, LA ....................................................................................................................... 0.8279 

Lafourche Parish, LA.

Terrebonne Parish, LA.

26420 ......................... Houston-Sugar Land-Baytown, TX ......................................................................................................................... 1.0426 

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 ............................................................................................................................ 0.9484 

Boyd County, KY.

Greenup County, KY.

Lawrence County, OH.

Cabell County, WV.

Wayne County, WV.

26620 ......................... Huntsville, AL .......................................................................................................................................................... 0.9594 

Limestone County, AL.

Madison County, AL.

26820 ......................... Idaho Falls, ID ......................................................................................................................................................... 0.9718 

Bonneville County, ID.

Jefferson County, ID.

26900 ......................... Indianapolis-Carmel, IN ........................................................................................................................................... 1.0327 

Boone County, IN.

Brown County, IN.

Hamilton County, IN.

Hancock County, IN.

Hendricks County, IN.

Johnson County, IN.

Marion County, IN.

Morgan County, IN.

Putnam County, IN.

Shelby County, IN.

26980 ......................... Iowa City, IA ............................................................................................................................................................ 1.0037 

Johnson County, IA.

Washington County, IA.

27060 ......................... Ithaca, NY ................................................................................................................................................................ 1.0102 

Tompkins County, NY.

27100 ......................... Jackson, MI ............................................................................................................................................................. 0.9786 

Jackson County, MI.

27140 ......................... Jackson, MS ............................................................................................................................................................ 0.8404 

Copiah County, MS.

Hinds County, MS.

Madison County, MS.

Rankin County, MS.

Simpson County, MS.

27180 ......................... Jackson, TN ............................................................................................................................................................ 0.9101 

Chester County, TN.

Madison County, TN.

27260 ......................... Jacksonville, FL ....................................................................................................................................................... 0.9463 

Baker County, FL.

Clay County, FL.

Duval County, FL.

Nassau County, FL.

St. Johns County, FL.

27340 ......................... Jacksonville, NC ...................................................................................................................................................... 0.8475 

Onslow County, NC.


rfrederick on PROD1PC67 with PROPOSALS
Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24023 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

27500 ......................... Janesville, WI .......................................................................................................................................................... 1.0178 

Rock County, WI.

27620 ......................... Jefferson City, MO .................................................................................................................................................. 0.8894 

Callaway County, MO.

Cole County, MO.

Moniteau County, MO.

Osage County, MO.

27740 ......................... Johnson City, TN ..................................................................................................................................................... 0.8053 

Carter County, TN.

Unicoi County, TN.

Washington County, TN.

27780 ......................... Johnstown, PA ........................................................................................................................................................ 0.8000 

Cambria County, PA.

27860 ......................... Jonesboro, AR ......................................................................................................................................................... 0.8172 

Craighead County, AR.

Poinsett County, AR.

27900 ......................... Joplin, MO ............................................................................................................................................................... 0.9390 

Jasper County, MO.

Newton County, MO.

28020 ......................... Kalamazoo-Portage, MI ........................................................................................................................................... 1.0944 

Kalamazoo County, MI.

Van Buren County, MI.

28100 ......................... Kankakee-Bradley, IL .............................................................................................................................................. 1.0740 

Kankakee County, IL.

28140 ......................... Kansas City, MO-KS ............................................................................................................................................... 0.9970 

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-Richland-Pasco, WA ............................................................................................................................. 1.0569 

Benton County, WA.

Franklin County, WA.

28660 ......................... Killeen-Temple-Fort Hood, TX ................................................................................................................................ 0.8653 

Bell County, TX.

Coryell County, TX.

Lampasas County, TX.

28700 ......................... Kingsport-Bristol-Bristol, TN-VA .............................................................................................................................. 0.8033 

Hawkins County, TN.

Sullivan County, TN.

Bristol City, VA.

Scott County, VA.

Washington County, VA.

28740 ......................... Kingston, NY ........................................................................................................................................................... 1.0024 

Ulster County, NY.

28940 ......................... Knoxville, TN ........................................................................................................................................................... 0.8430 

Anderson County, TN.

Blount County, TN.

Knox County, TN.

Loudon County, TN.

Union County, TN.

29020 ......................... Kokomo, IN .............................................................................................................................................................. 1.0061 

Howard County, IN.

Tipton County, IN.

29100 ......................... La Crosse, WI-MN ................................................................................................................................................... 1.0160 

Houston County, MN.

La Crosse County, WI.

29140 ......................... Lafayette, IN ............................................................................................................................................................ 0.9304 

Benton County, IN.

Carroll County, IN.

Tippecanoe County, IN.


rfrederick on PROD1PC67 with PROPOSALS
24024 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

29180 ......................... Lafayette, LA ........................................................................................................................................................... 0.8651 

Lafayette Parish, LA.

St. Martin Parish, LA.

29340 ......................... Lake Charles, LA ..................................................................................................................................................... 0.8158 

Calcasieu Parish, LA.

Cameron Parish, LA.

29404 ......................... Lake County-Kenosha County, IL-WI ..................................................................................................................... 1.1123 

Lake County, IL.

Kenosha County, WI.

29420 ......................... Lake Havasu City - Kingman, AZ ........................................................................................................................... 0.9790 

Mohave County, AZ.

29460 ......................... Lakeland, FL ............................................................................................................................................................ 0.9086 

Polk County, FL.

29540 ......................... Lancaster, PA .......................................................................................................................................................... 0.9706 

Lancaster County, PA.

29620 ......................... Lansing-East Lansing, MI ........................................................................................................................................ 1.0615 

Clinton County, MI.

Eaton County, MI.

Ingham County, MI.

29700 ......................... Laredo, TX ............................................................................................................................................................... 0.8490 

Webb County, TX.

29740 ......................... Las Cruces, NM ...................................................................................................................................................... 0.9101 

Dona Ana County, NM.

29820 ......................... Las Vegas-Paradise, NV ......................................................................................................................................... 1.2377 

Clark County, NV.

29940 ......................... Lawrence, KS .......................................................................................................................................................... 0.8630 

Douglas County, KS.

30020 ......................... Lawton, OK .............................................................................................................................................................. 0.8418 

Comanche County, OK.

30140 ......................... Lebanon, PA ............................................................................................................................................................ 0.8594 

Lebanon County, PA.

30300 ......................... Lewiston, ID-WA ...................................................................................................................................................... 0.9917 

Nez Perce County, ID.

Asotin County, WA.

30340 ......................... Lewiston-Auburn, ME .............................................................................................................................................. 0.9644 

Androscoggin County, ME.

30460 ......................... Lexington-Fayette, KY ............................................................................................................................................. 0.9642 

Bourbon County, KY.

Clark County, KY.

Fayette County, KY.

Jessamine County, KY.

Scott County, KY.

Woodford County, KY.

30620 ......................... Lima, OH ................................................................................................................................................................. 0.9886 

Allen County, OH.

30700 ......................... Lincoln, NE .............................................................................................................................................................. 1.0544 

Lancaster County, NE.

Seward County, NE.

30780 ......................... Little Rock-North Little Rock, AR ............................................................................................................................ 0.9297 

Faulkner County, AR.

Grant County, AR.

Lonoke County, AR.

Perry County, AR.

Pulaski County, AR.

Saline County, AR.

30860 ......................... Logan, UT-ID ........................................................................................................................................................... 0.9633 

Franklin County, ID.

Cache County, UT.

30980 ......................... Longview, TX ........................................................................................................................................................... 0.9144 

Gregg County, TX.

Rusk County, TX.

Upshur County, TX.

31020 ......................... Longview, WA ......................................................................................................................................................... 1.1358 

Cowlitz County, WA.

31084 ......................... Los Angeles-Long Beach-Glendale, CA ................................................................................................................. 1.2348 

Los Angeles County, CA.

31140 ......................... Louisville, KY-IN ...................................................................................................................................................... 0.9509 

Clark County, IN.

Floyd County, IN.

Harrison County, IN.

Washington County, IN.


rfrederick on PROD1PC67 with PROPOSALS
Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24025 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Bullitt County, KY.

Henry County, KY.

Jefferson County, KY.

Meade County, KY.

Nelson County, KY.

Oldham County, KY.

Shelby County, KY.

Spencer County, KY.

Trimble County, KY.

31180 ......................... Lubbock, TX ............................................................................................................................................................ 0.9105 

Crosby County, TX.

Lubbock County, TX.

31340 ......................... Lynchburg, VA ......................................................................................................................................................... 0.9160 

Amherst County, VA.

Appomattox County, VA.

Bedford County, VA.

Campbell County, VA.

Bedford City, VA.

Lynchburg City, VA.

31420 ......................... Macon, GA .............................................................................................................................................................. 1.0009 

Bibb County, GA.

Crawford County, GA.

Jones County, GA.

Monroe County, GA.

Twiggs County, GA.

31460 ......................... Madera, CA ............................................................................................................................................................. 0.8465 

Madera County, CA.

31540 ......................... Madison, WI ............................................................................................................................................................ 1.1471 

Columbia County, WI.

Dane County, WI.

Iowa County, WI.

31700 ......................... Manchester-Nashua, NH ......................................................................................................................................... 1.0777 

Hillsborough County, NH.

31900 ......................... Mansfield, OH .......................................................................................................................................................... 0.9725 

Richland County, OH.

32420 ......................... Mayaguez, PR ......................................................................................................................................................... 0.4268 

Hormigueros Municipio, PR.

Mayaguez Municipio, PR.

32580 ......................... McAllen-Edinburg-Pharr, TX ................................................................................................................................... 0.9570 

Hidalgo County, TX.

32780 ......................... Medford, OR ............................................................................................................................................................ 1.0824 

Jackson County, OR.

32820 ......................... Memphis, TN-MS-AR .............................................................................................................................................. 0.9703 

Crittenden County, AR.

DeSoto County, MS.

Marshall County, MS.

Tate County, MS.

Tunica County, MS.

Fayette County, TN.

Shelby County, TN.

Tipton County, TN.

32900 ......................... Merced, CA ............................................................................................................................................................. 1.2714 

Merced County, CA.

33124 ......................... Miami-Miami Beach-Kendall, FL ............................................................................................................................. 1.0492 

Miami-Dade County, FL.

33140 ......................... Michigan City-La Porte, IN ...................................................................................................................................... 0.9351 

LaPorte County, IN.

33260 ......................... Midland, TX ............................................................................................................................................................. 1.0508 

Midland County, TX.

33340 ......................... Milwaukee-Waukesha-West Allis, WI ...................................................................................................................... 1.0715 

Milwaukee County, WI.

Ozaukee County, WI.

Washington County, WI.

Waukesha County, WI.

33460 ......................... Minneapolis-St. Paul-Bloomington, MN-WI ............................................................................................................. 1.1637 

Anoka County, MN.

Carver County, MN.

Chisago County, MN.

Dakota County, MN.

Hennepin County, MN.

Isanti County, MN.


rfrederick on PROD1PC67 with PROPOSALS
24026 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

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 ........................................................................................................................................................... 0.9392 

Missoula County, MT.

33660 ......................... Mobile, AL ............................................................................................................................................................... 0.8427 

Mobile County, AL.

33700 ......................... Modesto, CA ............................................................................................................................................................ 1.2548 

Stanislaus County, CA.

33740 ......................... Monroe, LA .............................................................................................................................................................. 0.8216 

Ouachita Parish, LA.

Union Parish, LA.

33780 ......................... Monroe, MI .............................................................................................................................................................. 0.9875 

Monroe County, MI.

33860 ......................... Montgomery, AL ...................................................................................................................................................... 0.8484 

Autauga County, AL.

Elmore County, AL.

Lowndes County, AL.

Montgomery County, AL.

34060 ......................... Morgantown, WV ..................................................................................................................................................... 0.8729 

Monongalia County, WV.

Preston County, WV.

34100 ......................... Morristown, TN ........................................................................................................................................................ 0.8000 

Grainger County, TN.

Hamblen County, TN.

Jefferson County, TN.

34580 ......................... Mount Vernon-Anacortes, WA ................................................................................................................................ 1.1045 

Skagit County, WA.

34620 ......................... Muncie, IN ............................................................................................................................................................... 0.8617 

Delaware County, IN.

34740 ......................... Muskegon-Norton Shores, MI ................................................................................................................................. 1.0318 

Muskegon County, MI.

34820 ......................... Myrtle Beach-Conway-North Myrtle Beach, SC ...................................................................................................... 0.9057 

Horry County, SC.

34900 ......................... Napa, CA ................................................................................................................................................................. 1.5186 

Napa County, CA.

34940 ......................... Naples-Marco Island, FL ......................................................................................................................................... 0.9952 

Collier County, FL.

34980 ......................... Nashville-Davidson—Murfreesboro, TN .................................................................................................................. 1.0164 

Cannon County, TN.

Cheatham County, TN.

Davidson County, TN.

Dickson County, TN.

Hickman County, TN.

Macon County, TN.

Robertson County, TN.

Rutherford County, TN.

Smith County, TN.

Sumner County, TN.

Trousdale County, TN.

Williamson County, TN.

Wilson County, TN.

35004 ......................... Nassau-Suffolk, NY ................................................................................................................................................. 1.3260 

Nassau County, NY.

Suffolk County, NY.

35084 ......................... Newark-Union, NJ-PA ............................................................................................................................................. 1.2443 

Essex County, NJ.

Hunterdon County, NJ.

Morris County, NJ.

Sussex County, NJ.

Union County, NJ.

Pike County, PA.

35300 ......................... New Haven-Milford, CT ........................................................................................................................................... 1.2453 

New Haven County, CT.

35380 ......................... New Orleans-Metairie-Kenner, LA .......................................................................................................................... 0.9333 

Jefferson Parish, LA.

Orleans Parish, LA.


rfrederick on PROD1PC67 with PROPOSALS
Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24027 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Plaquemines Parish, LA.

St. Bernard Parish, LA.

St. Charles Parish, LA.

St. John the Baptist Parish, LA.

St. Tammany Parish, LA.

35644 ......................... New York-Wayne-White Plains, NY-NJ .................................................................................................................. 1.3758 

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 .......................................................................................................................................... 0.9589 

Berrien County, MI.

35980 ......................... Norwich-New London, CT ....................................................................................................................................... 1.1992 

New London County, CT.

36084 ......................... Oakland-Fremont-Hayward, CA .............................................................................................................................. 1.6454 

Alameda County, CA.

Contra Costa County, CA.

36100 ......................... Ocala, FL ................................................................................................................................................................. 0.9050 

Marion County, FL.

36140 ......................... Ocean City, NJ ........................................................................................................................................................ 1.1527 

Cape May County, NJ.

36220 ......................... Odessa, TX ............................................................................................................................................................. 1.0534 

Ector County, TX.

36260 ......................... Ogden-Clearfield, UT .............................................................................................................................................. 0.9441 

Davis County, UT.

Morgan County, UT.

Weber County, UT.

36420 ......................... Oklahoma City, OK ................................................................................................................................................. 0.9247 

Canadian County, OK.

Cleveland County, OK.

Grady County, OK.

Lincoln County, OK.

Logan County, OK.

McClain County, OK.

Oklahoma County, OK.

36500 ......................... Olympia, WA ........................................................................................................................................................... 1.2076 

Thurston County, WA.

36540 ......................... Omaha-Council Bluffs, NE-IA .................................................................................................................................. 1.0030 

Harrison County, IA.

Mills County, IA.

Pottawattamie County, IA.

Cass County, NE.

Douglas County, NE.

Sarpy County, NE.

Saunders County, NE.

Washington County, NE.

36740 ......................... Orlando, FL ............................................................................................................................................................. 0.9678 

Lake County, FL.

Orange County, FL.

Osceola County, FL.

Seminole County, FL.

36780 ......................... Oshkosh-Neenah, WI .............................................................................................................................................. 1.0019 

Winnebago County, WI.

36980 ......................... Owensboro, KY ....................................................................................................................................................... 0.9076 

Daviess County, KY.

Hancock County, KY.

McLean County, KY.

37100 ......................... Oxnard-Thousand Oaks-Ventura, CA ..................................................................................................................... 1.2433 

Ventura County, CA.

37340 ......................... Palm Bay-Melbourne-Titusville, FL ......................................................................................................................... 0.9782 

Brevard County, FL.

37380 ......................... Palm Coast, FL ....................................................................................................................................................... 0.9383 

Flagler County, FL.

37460 ......................... Panama City-Lynn Haven, FL ................................................................................................................................. 0.8720 


rfrederick on PROD1PC67 with PROPOSALS
24028 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Bay County, FL.

37620 ......................... Parkersburg-Marietta, WV-OH ................................................................................................................................ 0.8502 

Washington County, OH.

Pleasants County, WV.

Wirt County, WV.

Wood County, WV.

37700 ......................... Pascagoula, MS ...................................................................................................................................................... 0.9071 

George County, MS.

Jackson County, MS.

37764 ......................... Peabody, MA ........................................................................................................................................................... 1.1172 

Essex County, MA.

37860 ......................... Pensacola-Ferry Pass-Brent, FL ............................................................................................................................. 0.8687 

Escambia County, FL.

Santa Rosa County, FL.

37900 ......................... Peoria, IL ................................................................................................................................................................. 0.9755 

Marshall County, IL.

Peoria County, IL.

Stark County, IL.

Tazewell County, IL.

Woodford County, IL.

37964 ......................... Philadelphia, PA ...................................................................................................................................................... 1.1461 

Bucks County, PA.

Chester County, PA.

Delaware County, PA.

Montgomery County, PA.

Philadelphia County, PA.

38060 ......................... Phoenix-Mesa-Scottsdale, AZ ................................................................................................................................. 1.0767 

Maricopa County, AZ.

Pinal County, AZ.

38220 ......................... Pine Bluff, AR .......................................................................................................................................................... 0.8223 

Cleveland County, AR.

Jefferson County, AR.

Lincoln County, AR.

38300 ......................... Pittsburgh, PA ......................................................................................................................................................... 0.8943 

Allegheny County, PA.

Armstrong County, PA.

Beaver County, PA.

Butler County, PA.

Fayette County, PA.

Washington County, PA.

Westmoreland County, PA.

38340 ......................... Pittsfield, MA ........................................................................................................................................................... 1.0586 

Berkshire County, MA.

38540 ......................... Pocatello, ID ............................................................................................................................................................ 0.9929 

Bannock County, ID.

Power County, ID.

38660 ......................... Ponce, PR ............................................................................................................................................................... 0.5118 

Juana Dı ́az Municipio, PR.

Ponce Municipio, PR.

Villalba Municipio, PR.

38860 ......................... Portland-South Portland-Biddeford, ME .................................................................................................................. 1.0534 

Cumberland County, ME.

Sagadahoc County, ME.

York County, ME.

38900 ......................... Portland-Vancouver-Beaverton, OR-WA ................................................................................................................. 1.2062 

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—Fort Pierce, FL ............................................................................................................................... 1.0507 

Martin County, FL.

St. Lucie County, FL.

39100 ......................... Poughkeepsie-Newburgh-Middletown, NY .............................................................................................................. 1.1520 

Dutchess County, NY.

Orange County, NY.

39140 ......................... Prescott, AZ ............................................................................................................................................................. 1.0511 

Yavapai County, AZ.

39300 ......................... Providence-New Bedford-Fall River, RI-MA ........................................................................................................... 1.1092 


rfrederick on PROD1PC67 with PROPOSALS
Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24029 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Bristol County, MA.

Bristol County, RI.

Kent County, RI.

Newport County, RI.

Providence County, RI.

Washington County, RI.

39340 ......................... Provo-Orem, UT ...................................................................................................................................................... 1.0025 

Juab County, UT.

Utah County, UT.

39380 ......................... Pueblo, CO .............................................................................................................................................................. 0.9285 

Pueblo County, CO.

39460 ......................... Punta Gorda, FL ...................................................................................................................................................... 0.9708 

Charlotte County, FL.

39540 ......................... Racine, WI ............................................................................................................................................................... 0.9964 

Racine County, WI.

39580 ......................... Raleigh-Cary, NC .................................................................................................................................................... 1.0321 

Franklin County, NC.

Johnston County, NC.

Wake County, NC.

39660 ......................... Rapid City, SD ......................................................................................................................................................... 0.9243 

Meade County, SD.

Pennington County, SD.

39740 ......................... Reading, PA ............................................................................................................................................................ 0.9815 

Berks County, PA.

39820 ......................... Redding, CA ............................................................................................................................................................ 1.4205 

Shasta County, CA.

39900 ......................... Reno-Sparks, NV .................................................................................................................................................... 1.1240 

Storey County, NV.

Washoe County, NV.

40060 ......................... Richmond, VA ......................................................................................................................................................... 0.9887 

Amelia County, VA.

Caroline County, VA.

Charles City County, VA.

Chesterfield County, VA.

Cumberland County, VA.

Dinwiddie County, VA.

Goochland County, VA.

Hanover County, VA.

Henrico County, VA.

King and Queen County, VA.

King William County, VA.

Louisa County, VA.

New Kent County, VA.

Powhatan County, VA.

Prince George County, VA.

Sussex County, VA.

Colonial Heights City, VA.

Hopewell City, VA.

Petersburg City, VA.

Richmond City, VA.

40140 ......................... Riverside-San Bernardino-Ontario, CA ................................................................................................................... 1.1644 

Riverside County, CA.

San Bernardino County, CA.

40220 ......................... Roanoke, VA ........................................................................................................................................................... 0.9117 

Botetourt County, VA.

Craig County, VA.

Franklin County, VA.

Roanoke County, VA.

Roanoke City, VA.

Salem City, VA.

40340 ......................... Rochester, MN ........................................................................................................................................................ 1.1282 

Dodge County, MN.

Olmsted County, MN.

Wabasha County, MN.

40380 ......................... Rochester, NY ......................................................................................................................................................... 0.9292 

Livingston County, NY.

Monroe County, NY.

Ontario County, NY.

Orleans County, NY.

Wayne County, NY.

40420 ......................... Rockford, IL ............................................................................................................................................................. 1.0295 


rfrederick on PROD1PC67 with PROPOSALS
24030 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Boone County, IL.

Winnebago County, IL.

40484 ......................... Rockingham County-Strafford County, NH ............................................................................................................. 1.0607 

Rockingham County, NH.

Strafford County, NH.

40580 ......................... Rocky Mount, NC .................................................................................................................................................... 0.9442 

Edgecombe County, NC.

Nash County, NC.

40660 ......................... Rome, GA ................................................................................................................................................................ 0.9485 

Floyd County, GA.

40900 ......................... Sacramento—Arden-Arcade—Roseville, CA .......................................................................................................... 1.4167 

El Dorado County, CA.

Placer County, CA.

Sacramento County, CA.

Yolo County, CA.

40980 ......................... Saginaw-Saginaw Township North, MI ................................................................................................................... 0.9244 

Saginaw County, MI.

41060 ......................... St. Cloud, MN .......................................................................................................................................................... 1.1066 

Benton County, MN.

Stearns County, MN.

41100 ......................... St. George, UT ........................................................................................................................................................ 0.9817 

Washington County, UT.

41140 ......................... St. Joseph, MO-KS ................................................................................................................................................. 0.9191 

Doniphan County, KS.

Andrew County, MO.

Buchanan County, MO.

DeKalb County, MO.

41180 ......................... St. Louis, MO-IL ...................................................................................................................................................... 0.9466 

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 ............................................................................................................................................................... 1.1090 

Marion County, OR.

Polk County, OR.

41500 ......................... Salinas, CA .............................................................................................................................................................. 1.5499 

Monterey County, CA.

41540 ......................... Salisbury, MD .......................................................................................................................................................... 0.9435 

Somerset County, MD.

Wicomico County, MD.

41620 ......................... Salt Lake City, UT ................................................................................................................................................... 0.9860 

Salt Lake County, UT.

Summit County, UT.

Tooele County, UT.

41660 ......................... San Angelo, TX ....................................................................................................................................................... 0.9000 

Irion County, TX.

Tom Green County, TX.

41700 ......................... San Antonio, TX ...................................................................................................................................................... 0.9267 

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 .................................................................................................................... 1.2055 

San Diego County, CA.


rfrederick on PROD1PC67 with PROPOSALS
Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24031 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

41780 ......................... Sandusky, OH ......................................................................................................................................................... 0.9254 

Erie County, OH.

41884 ......................... San Francisco-San Mateo-Redwood City, CA ........................................................................................................ 1.5940 

Marin County, CA.

San Francisco County, CA.

San Mateo County, CA.

41900 ......................... San Germa ́n-Cabo Rojo, PR .................................................................................................................................. 0.5438 

Cabo Rojo Municipio, PR.

Lajas Municipio, PR.

Sabana Grande Municipio, PR.

San Germa ́n Municipio, PR.

41940 ......................... San Jose-Sunnyvale-Santa Clara, CA .................................................................................................................... 1.6506 

San Benito County, CA.

Santa Clara County, CA.

41980 ......................... San Juan-Caguas-Guaynabo, PR ........................................................................................................................... 0.5207 

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.

Comer ́ıo Municipio, PR.

Corozal Municipio, PR.

Dorado Municipio, PR.

Florida Municipio, PR.

Guaynabo Municipio, PR.

Gurabo Municipio, PR.

Hatillo Municipio, PR.

Humacao Municipio, PR.

Juncos Municipio, PR.

Las Piedras Municipio, PR.

Lo ́ıza Municipio, PR.

Manat ́ı Municipio, PR.

Maunabo Municipio, PR.

Morovis Municipio, PR.

Naguabo Municipio, PR.

Naranjito Municipio, PR.

Orocovis Municipio, PR.

Quebradillas Municipio, PR.

R ́ıo Grande Municipio, PR.

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 ......................................................................................................................... 1.3100 

San Luis Obispo County, CA.

42044 ......................... Santa Ana-Anaheim-Irvine, CA ............................................................................................................................... 1.2343 

Orange County, CA.

42060 ......................... Santa Barbara-Santa Maria-Goleta, CA ................................................................................................................. 1.2288 

Santa Barbara County, CA.

42100 ......................... Santa Cruz-Watsonville, CA .................................................................................................................................... 1.6912 

Santa Cruz County, CA.

42140 ......................... Santa Fe, NM .......................................................................................................................................................... 1.1260 

Santa Fe County, NM.

42220 ......................... Santa Rosa-Petaluma, CA ...................................................................................................................................... 1.5416 

Sonoma County, CA.

42260 ......................... Sarasota-Bradenton-Venice, FL .............................................................................................................................. 1.0420 

Manatee County, FL.

Sarasota County, FL.


rfrederick on PROD1PC67 with PROPOSALS
24032 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

42340 ......................... Savannah, GA ......................................................................................................................................................... 0.9579 

Bryan County, GA.

Chatham County, GA.

Effingham County, GA.

42540 ......................... Scranton—Wilkes-Barre, PA ................................................................................................................................... 0.8872 

Lackawanna County, PA.

Luzerne County, PA.

Wyoming County, PA.

42644 ......................... Seattle-Bellevue-Everett, WA .................................................................................................................................. 1.2139 

King County, WA.

Snohomish County, WA.

42680 ......................... Sebastian-Vero Beach, FL ...................................................................................................................................... 0.9873 

Indian River County, FL.

43100 ......................... Sheboygan, WI ........................................................................................................................................................ 0.9415 

Sheboygan County, WI.

43300 ......................... Sherman-Denison, TX ............................................................................................................................................. 0.8728 

Grayson County, TX.

43340 ......................... Shreveport-Bossier City, LA .................................................................................................................................... 0.8891 

Bossier Parish, LA.

Caddo Parish, LA.

De Soto Parish, LA.

43580 ......................... Sioux City, IA-NE-SD .............................................................................................................................................. 0.9704 

Woodbury County, IA.

Dakota County, NE.

Dixon County, NE.

Union County, SD.

43620 ......................... Sioux Falls, SD ........................................................................................................................................................ 1.0032 

Lincoln County, SD.

McCook County, SD.

Minnehaha County, SD.

Turner County, SD.

43780 ......................... South Bend-Mishawaka, IN-MI ............................................................................................................................... 1.0088 

St. Joseph County, IN.

Cass County, MI.

43900 ......................... Spartanburg, SC ...................................................................................................................................................... 0.9884 

Spartanburg County, SC.

44060 ......................... Spokane, WA .......................................................................................................................................................... 1.0967 

Spokane County, WA.

44100 ......................... Springfield, IL .......................................................................................................................................................... 0.9382 

Menard County, IL.

Sangamon County, IL.

44140 ......................... Springfield, MA ........................................................................................................................................................ 1.0874 

Franklin County, MA.

Hampden County, MA.

Hampshire County, MA.

44180 ......................... Springfield, MO ........................................................................................................................................................ 0.9121 

Christian County, MO.

Dallas County, MO.

Greene County, MO.

Polk County, MO.

Webster County, MO.

44220 ......................... Springfield, OH ........................................................................................................................................................ 0.9120 

Clark County, OH.

44300 ......................... State College, PA .................................................................................................................................................... 0.9198 

Centre County, PA.

44700 ......................... Stockton, CA ........................................................................................................................................................... 1.2436 

San Joaquin County, CA.

44940 ......................... Sumter, SC .............................................................................................................................................................. 0.9021 

Sumter County, SC.

45060 ......................... Syracuse, NY .......................................................................................................................................................... 1.0396 

Madison County, NY.

Onondaga County, NY.

Oswego County, NY.

45104 ......................... Tacoma, WA ............................................................................................................................................................ 1.1597 

Pierce County, WA.

45220 ......................... Tallahassee, FL ....................................................................................................................................................... 0.9467 

Gadsden County, FL.

Jefferson County, FL.

Leon County, FL.

Wakulla County, FL.

45300 ......................... Tampa-St. Petersburg-Clearwater, FL .................................................................................................................... 0.9462 


rfrederick on PROD1PC67 with PROPOSALS
Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24033 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Hernando County, FL.

Hillsborough County, FL.

Pasco County, FL.

Pinellas County, FL.

45460 ......................... Terre Haute, IN ....................................................................................................................................................... 0.9237 

Clay County, IN.

Sullivan County, IN.

Vermillion County, IN.

Vigo County, IN.

45500 ......................... Texarkana, TX-Texarkana, AR ............................................................................................................................... 0.8151 

Miller County, AR.

Bowie County, TX.

45780 ......................... Toledo, OH .............................................................................................................................................................. 0.9893 

Fulton County, OH.

Lucas County, OH.

Ottawa County, OH.

Wood County, OH.

45820 ......................... Topeka, KS .............................................................................................................................................................. 0.8957 

Jackson County, KS.

Jefferson County, KS.

Osage County, KS.

Shawnee County, KS.

Wabaunsee County, KS.

45940 ......................... Trenton-Ewing, NJ ................................................................................................................................................... 1.1223 

Mercer County, NJ.

46060 ......................... Tucson, AZ .............................................................................................................................................................. 0.9698 

Pima County, AZ.

46140 ......................... Tulsa, OK ................................................................................................................................................................ 0.8749 

Creek County, OK.

Okmulgee County, OK.

Osage County, OK.

Pawnee County, OK.

Rogers County, OK.

Tulsa County, OK.

Wagoner County, OK.

46220 ......................... Tuscaloosa, AL ........................................................................................................................................................ 0.8710 

Greene County, AL.

Hale County, AL.

Tuscaloosa County, AL.

46340 ......................... Tyler, TX .................................................................................................................................................................. 0.9561 

Smith County, TX.

46540 ......................... Utica-Rome, NY ...................................................................................................................................................... 0.8902 

Herkimer County, NY.

Oneida County, NY.

46660 ......................... Valdosta, GA ........................................................................................................................................................... 0.8495 

Brooks County, GA.

Echols County, GA.

Lanier County, GA.

Lowndes County, GA.

46700 ......................... Vallejo-Fairfield, CA ................................................................................................................................................. 1.5385 

Solano County, CA.

47020 ......................... Victoria, TX .............................................................................................................................................................. 0.8709 

Calhoun County, TX.

Goliad County, TX.

Victoria County, TX.

47220 ......................... Vineland-Millville-Bridgeton, NJ ............................................................................................................................... 1.0630 

Cumberland County, NJ.

47260 ......................... Virginia Beach-Norfolk-Newport News, VA-NC ...................................................................................................... 0.9250 

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.


rfrederick on PROD1PC67 with PROPOSALS
24034 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Suffolk City, VA.

Virginia Beach City, VA.

Williamsburg City, VA.

47300 ......................... Visalia-Porterville, CA .............................................................................................................................................. 1.0586 

Tulare County, CA.

47380 ......................... Waco, TX ................................................................................................................................................................. 0.8936 

McLennan County, TX.

47580 ......................... Warner Robins, GA ................................................................................................................................................. 0.9575 

Houston County, GA.

47644 ......................... Warren-Troy-Farmington Hills, MI ........................................................................................................................... 1.0491 

Lapeer County, MI.

Livingston County, MI.

Macomb County, MI.

Oakland County, MI.

St. Clair County, MI.

47894 ......................... Washington-Arlington-Alexandria, DC-VA-MD-WV ................................................................................................. 1.1387 

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 ......................................................................................................................................... 0.8937 

Black Hawk County, IA.

Bremer County, IA.

Grundy County, IA.

48140 ......................... Wausau, WI ............................................................................................................................................................. 1.0153 

Marathon County, WI.

48260 ......................... Weirton-Steubenville, WV-OH ................................................................................................................................. 0.8312 

Jefferson County, OH.

Brooke County, WV.

Hancock County, WV.

48300 ......................... Wenatchee, WA ...................................................................................................................................................... 1.2031 

Chelan County, WA.

Douglas County, WA.

48424 ......................... West Palm Beach-Boca Raton-Boynton Beach, FL ............................................................................................... 1.0205 

Palm Beach County, FL.

48540 ......................... Wheeling, WV-OH ................................................................................................................................................... 0.8000 

Belmont County, OH.

Marshall County, WV.

Ohio County, WV.

48620 ......................... Wichita, KS .............................................................................................................................................................. 0.9506 

Butler County, KS.

Harvey County, KS.

Sedgwick County, KS.

Sumner County, KS.

48660 ......................... Wichita Falls, TX ..................................................................................................................................................... 0.8308 

Archer County, TX.

Clay County, TX.

Wichita County, TX.

48700 ......................... Williamsport, PA ...................................................................................................................................................... 0.8437 

Lycoming County, PA.

48864 ......................... Wilmington, DE-MD-NJ ........................................................................................................................................... 1.1355 

New Castle County, DE.

Cecil County, MD.

Salem County, NJ.

48900 ......................... Wilmington, NC ....................................................................................................................................................... 0.9871 


rfrederick on PROD1PC67 with PROPOSALS
Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24035 

ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Brunswick County, NC.

New Hanover County, NC.

Pender County, NC.

49020 ......................... Winchester, VA-WV ................................................................................................................................................. 1.0399 

Frederick County, VA.

Winchester City, VA.

Hampshire County, WV.

49180 ......................... Winston-Salem, NC ................................................................................................................................................. 0.9565 

Davie County, NC.

Forsyth County, NC.

Stokes County, NC.

Yadkin County, NC.

49340 ......................... Worcester, MA ......................................................................................................................................................... 1.1840 

Worcester County, MA.

49420 ......................... Yakima, WA ............................................................................................................................................................. 1.0770 

Yakima County, WA.

49500 ......................... Yauco, PR ............................................................................................................................................................... 0.3777 

Gua ́nica Municipio, PR.

Guayanilla Municipio, PR.

Pen ̃uelas Municipio, PR.

Yauco Municipio, PR.

49620 ......................... York-Hanover, PA ................................................................................................................................................... 0.9818 

York County, PA.

49660 ......................... Youngstown-Warren-Boardman, OH-PA ................................................................................................................ 0.9443 

Mahoning County, OH.

Trumbull County, OH.

Mercer County, PA.

49700 ......................... Yuba City, CA .......................................................................................................................................................... 1.1283 

Sutter County, CA.

Yuba County, CA.

49740 ......................... Yuma, AZ ................................................................................................................................................................ 0.9953 

Yuma County, AZ.

1Wage index values are based on FY 2004 hospital cost report data before reclassification. These data form the basis for the pre-floor, pre-reclassified hospital wage index. The budget neutrality adjustment or the hospice floor is then applied to the pre-floor, pre-reclassified hospital 

wage index to derive the hospice wage index. Wage index values greater than or equal to 0.8 are subject to a budget neutrality adjustment. The 

hospice floor calculation is as follows: Wage index values below 0.8 are adjusted to be the greater of either the a) the 25 percent reduced budget neutrality adjustment OR b) the minimum of the pre-floor, pre-reclassified hospital wage index value x 1.15, or 0.8000. For the proposed FY 

2009 hospice wage index, the budget neutrality adjustment was reduced by 25 percent. 2This column lists each CBSA area name and each county or county equivalent, in the CBSA area. Counties not listed in this Table are considered to be rural areas. Wage index values for these areas are found in Addendum B. 3Because there are no hospitals in this CBSA, the wage index value is calculated by taking the average of all other urban CBSAs in Georgia. 

ADDENDUM B.—PROPOSED HOSPICE

WAGE INDEX FOR RURAL AREAS BY

CBSA—FY 2009 

CBSA code Non-urban area Wage 

index 

1 ................... Alabama ............. 0.8000 

2 ................... Alaska ................ 1.2703 

3 ................... Arizona ............... 0.8895 

4 ................... Arkansas ............ 0.8000 

5 ................... California ............ 1.2612 

6 ................... Colorado ............ 1.0180 

7 ................... Connecticut ........ 1.1664 

8 ................... Delaware ............ 1.0204 

10 ................. Florida ................ 0.8880 

11 ................. Georgia .............. 0.8034 

12 ................. Hawaii ................ 1.1132 

13 ................. Idaho .................. 0.8308 

14 ................. Illinois ................. 0.8744 

15 ................. Indiana ............... 0.8996 

16 ................. Iowa ................... 0.8986 

17 ................. Kansas ............... 0.8372 

18 ................. Kentucky ............ 0.8175 

19 ................. Louisiana ........... 0.8000 

20 ................. Maine ................. 0.8891 

21 ................. Maryland ............ 0.9477 

22 ................. Massachusetts 1 1.2157 

ADDENDUM B.—PROPOSED HOSPICE

WAGE INDEX FOR RURAL AREAS BY

CBSA—FY 2009—Continued 

CBSA code Non-urban area Wage 

index 

23 ................. Michigan ............ 0.9392 

24 ................. Minnesota .......... 0.9524 

25 ................. Mississippi ......... 0.8077 

26 ................. Missouri ............. 0.8319 

27 ................. Montana ............. 0.8790 

28 ................. Nebraska ........... 0.9283 

29 ................. Nevada .............. 0.9726 

30 ................. New Hampshire 1.0983 

31 ................. New Jersey 2 ...... ................

32 ................. New Mexico ....... 0.9378 

33 ................. New York ........... 0.8673 

34 ................. North Carolina ... 0.9025 

35 ................. North Dakota ..... 0.8000 

36 ................. Ohio ................... 0.9141 

37 ................. Oklahoma .......... 0.8000 

38 ................. Oregon ............... 1.0392 

39 ................. Pennsylvania ..... 0.8796 

40 ................. Puerto Rico 3 ...... 0.4654 

41 ................. Rhode Island 2 ... ................

42 ................. South Carolina ... 0.9080 

43 ................. South Dakota ..... 0.8968 

ADDENDUM B.—PROPOSED HOSPICE

WAGE INDEX FOR RURAL AREAS BY

CBSA—FY 2009—Continued 

CBSA code Non-urban area Wage 

index 

44 ................. Tennessee ......... 0.8102 

45 ................. Texas ................. 0.8359 

46 ................. Utah ................... 0.8514 

47 ................. Vermont ............. 1.0405 

48 ................. Virgin Islands ..... 0.7855 

49 ................. Virginia ............... 0.8283 

50 ................. Washington ........ 1.0762 

51 ................. West Virginia ..... 0.8000 

52 ................. Wisconsin .......... 1.0141 

53 ................. Wyoming ............ 0.9742 

65 ................. Guam ................. 1.0082 

1There are no hospitals in the rural areas of 

Massachusetts, so the wage index value used 

is the average of the contiguous counties. 2There are no rural areas in this state. 

3Wage index values are obtained using the 

methodology described in this proposed rule. 

[FR Doc. 08–1198 Filed 4–28–08; 4:00 pm] 

BILLING CODE 4120–01–P 


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