[Federal Register Volume 73, Number 85 (Thursday, May 1, 2008)]
[Proposed Rules]
[Pages 24000-24035]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 08-1198]


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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.

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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

[[Page 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, Pre-Reclassified 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 Sec.  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 Sec.  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.

[[Page 24002]]

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 pre-reclassified 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, pre-reclassified 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, pre-reclassified 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 x 1.060988 = 0.4244)
Pre-floor, pre-reclassified hospital wage index value below 0.8 
multiplied by the hospice floor: (0.4000 x 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 
Sec.  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 Sec.  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 pre-floor, 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, pre-reclassified 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, pre-reclassified 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, pre-reclassified 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, pre-reclassified 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

[[Page 24003]]

averaged resulting in an imputed pre-floor, 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, pre-
reclassified 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 
Sec.  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, pre-reclassified 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 Sec.  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), Sec.  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 Sec.  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 Sec.  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

[[Page 24004]]

Sec.  418.306(c) of our regulations; however, there is no reference to 
Sec.  412.64.
    In other words, while Sec.  412.64 is not explicitly noted, the 
hospice program has used the urban definition in Sec.  
412.64(b)(1)(ii)(A) and (B), and the rural definition as any area 
outside of an urban area in Sec.  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 Sec.  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 Sec.  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 Sec.  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 
multi-campus 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 multi-campus 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, pre-reclassified hospital wage index. Consequently, for 
this proposed rule we propose to continue to use the most recent 
available pre-floor, pre-reclassified 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), 
Chicago-Naperville-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 pre-floor, 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 pre-floor, 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, 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. 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

[[Page 24005]]

blended Federal/Commonwealth-specific 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 pre-floor, 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 pre-floor, 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 Sec.  
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, pre-reclassified 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

[[Page 24006]]

same claims data and payment rates, but using the 1983 BLS-based wage 
index instead of the updated pre-floor, pre-reclassified 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, pre-reclassified 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, pre-reclassified 
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 phase-
out 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

[[Page 24007]]

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, 
pre-reclassified 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 pre-floor, 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, 
pre-reclassified hospital wage index values less then 0.8. Currently, 
the floor calculation has 4 steps. Pre-floor, pre-reclassified 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, pre-reclassified 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:
<bullet> A 75 percent reduction to the BNAF in FY 2010 would be 
0.066671 x 0.25 = 0.016668 or 1.6668 percent
<bullet> A 100 percent reduction or elimination of the BNAF in FY 2011 
would be 0.066671 x 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, pre-reclassified 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, pre-
reclassified 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.

[[Page 24008]]

b. Effects of Phasing-Out the BNAF Using the Updated Pre-floor, Pre-
reclassified Hospital Wage Index Data (FY 2009 Proposal)
    For FY 2009, we propose updating the hospice wage index using the 
2008 pre-floor, 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 x 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 pre-floor, 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, pre-
reclassified 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, pre-reclassified 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

    <bullet> We propose to clarify that the hospice benefit will follow 
the definition of ``urban'' specified in Sec.  412.64(b)(1)(ii)(A) and 
(B), and the rural definition as any area outside of an urban area in 
Sec.  412.64(b)(1)(ii)(C). The regulatory text of Sec.  418.306(c) will 
be amended to reference Sec.  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.
    <bullet> 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.
    <bullet> We propose to continue to use a pre-floor, pre-
reclassified hospital wage index based solely on the CBSA designations, 
using the most recent pre-floor and pre-reclassified hospital wage 
index available at the time of publication. See section II.C.1 of this 
proposed rule for details.
    <bullet> 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.
    <bullet> 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.
    <bullet> We propose to continue to utilize the most recent pre-
floor, pre-reclassified hospital wage index value available for Puerto 
Rico. See section II.C.2 of this proposed rule for details.
    <bullet> 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.
    <bullet> 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

[[Page 24009]]

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, multi-site 
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, pre-
reclassified hospital wage index (to include the clarification of New 
England ``deemed'' counties and a change in the way that multi-campus 
hospital wage

[[Page 24010]]

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 Pre-Floor, 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
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                Percent change in    Percent change in
                                                                                             Percent change in   payments due to    payments due to the
                                                                                 Number of    payments due to      the combined     combined effects of
                                                                                  routine      the effects of     effects of the    the 25% reduction in
                                                                    Number of    home care    the updated wage   25% reduction in  the BNAF, the updated
                                                                    hospices*     days in      data (FY 2009     the BNAF and the    wage data (FY 2009
                                                                                 thousands     Proposed Wage    updated wage data  Proposed Wage Index),
                                                                                                   Index)       (FY 2009 Proposed   and estimated market
                                                                                                                   Wage Index)      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

[[Page 24011]]

 
    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, pre-reclassified 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

[[Page 24012]]

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, pre-reclassified 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, pre-reclassified 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, 
pre-reclassified 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,

[[Page 24013]]

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\*\.
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 Sec.  418.306 is amended by revising paragraph (c) to 
read as follows:


Sec.  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 Sec.  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
----------------------------------------------------------------------------------------------------------------
                                                                                                           Wage
                  CBSA code                              Urban area (constituent counties) \2\            index
                                                                                                           \1\
----------------------------------------------------------------------------------------------------------------
10180........................................  Abilene, TX.............................................   0.8347
                                                Callahan County, TX....................................
                                                Jones County, TX.......................................
                                                Taylor County, TX......................................
10380........................................  Aguadilla-Isabela-San Sebasti[aacute]n, PR..............   0.3965
                                                Aguada Municipio, PR...................................
                                                Aguadilla Municipio, PR................................
                                                A[ntilde]asco Municipio, PR............................
                                                Isabela Municipio, PR..................................
                                                Lares Municipio, PR....................................
                                                Moca Municipio, PR.....................................
                                                Rinc[oacute]n Municipio, PR............................
                                                San Sebasti[aacute]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.................................

[[Page 24014]]

 
                                                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....................................

[[Page 24015]]

 
                                                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.....................................

[[Page 24016]]

 
                                                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........................................

[[Page 24017]]

 
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........................................

[[Page 24018]]

 
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......................................

[[Page 24019]]

 
                                                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........................................

[[Page 24020]]

 
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

[[Page 24021]]

 
                                                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....................................

[[Page 24022]]

 
                                                Catawba County, NC.....................................
25980........................................  Hinesville-Fort Stewart, GA \3\.........................   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......................................

[[Page 24023]]

 
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..................................

[[Page 24024]]

 
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..................................

[[Page 24025]]

 
                                                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......................................

[[Page 24026]]

 
                                                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.....................................

[[Page 24027]]

 
                                                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

[[Page 24028]]

 
                                                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 D[iacute]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

[[Page 24029]]

 
                                                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

[[Page 24030]]

 
                                                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...................................

[[Page 24031]]

 
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 Germ[aacute]n-Cabo Rojo, PR.........................   0.5438
                                                Cabo Rojo Municipio, PR................................
                                                Lajas Municipio, PR....................................
                                                Sabana Grande Municipio, PR............................
                                                San Germ[aacute]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.............................
                                                Bayam[oacute]n Municipio, PR...........................
                                                Caguas Municipio, PR...................................
                                                Camuy Municipio, PR....................................
                                                Can[oacute]vanas Municipio, PR.........................
                                                Carolina Municipio, PR.................................
                                                Cata[ntilde]o Municipio, PR............................
                                                Cayey Municipio, PR....................................
                                                Ciales Municipio, PR...................................
                                                Cidra Municipio, PR....................................
                                                Comer[iacute]o Municipio, PR...........................
                                                Corozal Municipio, PR..................................
                                                Dorado Municipio, PR...................................
                                                Florida Municipio, PR..................................
                                                Guaynabo Municipio, PR.................................
                                                Gurabo Municipio, PR...................................
                                                Hatillo Municipio, PR..................................
                                                Humacao Municipio, PR..................................
                                                Juncos Municipio, PR...................................
                                                Las Piedras Municipio, PR..............................
                                                Lo[iacute]za Municipio, PR.............................
                                                Manat[iacute] Municipio, PR............................
                                                Maunabo Municipio, PR..................................
                                                Morovis Municipio, PR..................................
                                                Naguabo Municipio, PR..................................
                                                Naranjito Municipio, PR................................
                                                Orocovis Municipio, PR.................................
                                                Quebradillas Municipio, PR.............................
                                                R[iacute]o 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....................................

[[Page 24032]]

 
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

[[Page 24033]]

 
                                                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....................................

[[Page 24034]]

 
                                                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

[[Page 24035]]

 
                                                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
                                                Gu[aacute]nica Municipio, PR...........................
                                                Guayanilla Municipio, PR...............................
                                                Pe[ntilde]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 .......................................
----------------------------------------------------------------------------------------------------------------
\1\ Wage 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.
\2\ This 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.
\3\ Because 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
------------------------------------------------------------------------
                                                                  Wage
              CBSA code                    Non-urban area        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
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
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
------------------------------------------------------------------------
\1\ There are no hospitals in the rural areas of Massachusetts, so the
  wage index value used is the average of the contiguous counties.
\2\ There are no rural areas in this state.
\3\ Wage 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