[Federal Register Volume 73, Number 154 (Friday, August 8, 2008)]
[Rules and Regulations]
[Pages 46464-46522]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E8-17795]



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Part IV





Department of Health and Human Services





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 Centers for Medicare & Medicaid Services



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42 CFR Part 418



 Medicare Program; Hospice Wage Index for Fiscal Year 2009; Final Rule

Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules 
and Regulations

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 418

[CMS-1548-F]
RIN 0938-AP14


Medicare Program; Hospice Wage Index for Fiscal Year 2009

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Final rule.

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SUMMARY: This final rule sets forth the hospice wage index for fiscal 
year 2009. In addition, this final rule finalizes the policy to phase 
out the Medicare hospice budget neutrality adjustment factor, and 
clarifies two wage index issues pertaining to the definition of rural 
and urban areas and multi-campus hospital facilities.

DATES: Effective Dates: These regulations are effective on October 1, 
2008.

FOR FURTHER INFORMATION CONTACT: Katie Lucas (410) 786-7723 or Randy 
Throndset (410) 786-0131.

SUPPLEMENTARY INFORMATION:

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 the Office of Management and Budget 
(OMB) to the Metropolitan Statistical Areas (MSAs) definitions, which 
have been superseded by the Core Based Statistical Areas (CBSAs).
    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, the Hospice Wage Index Negotiated Rulemaking 
Committee was formulated to negotiate a wage index methodology to be 
used for updating the hospice wage index. This Committee, functioning 
under a process established by the Negotiated Rulemaking Act of 1990, 
signed an agreement for the methodology to be used for updating the 
hospice wage index on April 13, 1995.
    On August 8, 1997, we published in the Federal Register a final 
rule (62 FR 42860) 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 final rule (72 FR 50214) published in the Federal Register on 
August 31, 2007, set forth updates to the hospice wage index for fiscal 
year (FY) 2008.
1. Raw Wage Index Values (Raw 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.
    Raw pre-floor, pre-reclassified hospital wage index values of 0.8 
or greater are adjusted by the Budget Neutrality Adjustment Factor 
(BNAF). Raw 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.
    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.
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 OMB to the definitions of 
MSAs, which now include CBSA designations.
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 
42 CFR 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 no 
hospital wage index data on which to base the calculation of the 
hospice wage index. Beginning in FY 2006, we adopted a

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policy to use the FY 2005 raw pre-floor, pre-reclassified hospital wage 
index value for rural areas when no hospital wage data were available. 
Under the CBSA labor market areas, there are no hospitals in rural 
locations in Massachusetts and Puerto Rico. We also adopted the policy 
that for urban labor markets without a hospital from which hospital 
wage index data could be derived, all of the CBSAs within the State 
would be used to calculate a statewide urban average raw pre-floor, 
pre-reclassified hospital wage index value to use as a reasonable proxy 
for these areas. The only affected CBSA is 25980, Hinesville-Fort 
Stewart, Georgia.
    In the FY 2008 final rule (72 FR 50214, 50217), in cases where 
there was a rural area without rural hospital wage data, we used the 
average raw 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 
raw pre-floor, pre-reclassified hospital wage data, and is easy to 
evaluate, 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 raw 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 raw 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) were averaged, resulting in 
an imputed raw pre-floor, pre-reclassified rural hospital wage index 
for FY 2008.
    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 raw 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. While we have not yet identified an 
alternative methodology for imputing a raw 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 raw 
pre-floor, pre-reclassified hospital wage index available for Puerto 
Rico, which is 0.4047.
5. CBSA Nomenclature Changes
    The 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
    Payment rates 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 FYs since 2002 will be the market basket percentage 
for the fiscal year. According to section 1814(i)(1)(C) of the Act, 
hospices are 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 the summer to provide 
adequate time to implement system change requirements. Providers 
determine their payments by applying the hospice wage index in this 
final rule to the labor portion of the published hospice rates.
Requirements for Issuance of Regulations
    Section 902 of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA) amended section 1871(a) of the Act and 
requires the Secretary, in consultation with the Director of the OMB, 
to establish and publish timelines for the publication of Medicare 
final regulations based on the previous publication of a Medicare 
proposed or interim final regulation. Section 902 of the MMA also 
states that the timelines for these regulations may vary but shall not 
exceed 3 years after publication of the preceding proposed or interim 
final regulation except under exceptional circumstances.
    This final rule finalizes provisions proposed in the May 1, 2008 
proposed rule. In addition, this final rule has been published within 
the 3-year time limit imposed by section 902 of the MMA. Therefore, we 
believe that the final rule is in accordance with the Congress' intent 
to ensure timely publication of final regulations.

II. Provisions of the Proposed Rule and Analysis of and Responses to 
Public Comments

    On May 1, 2008, we published a proposed rule in the Federal 
Register (73 FR 24000) that set forth the proposed hospice wage index 
for FY 2009. We received 540 timely items of correspondence. The 
following is a summary of each of the proposals followed by our 
responses to these public comments.

A. Clarification of New England Deemed Counties

    In the May 1, 2008 proposed rule, we proposed to amend Sec.  
418.306(c) to cross-reference to the definitions of urban and rural in 
the Inpatient Prospective Payment System (IPPS) regulations in 42 CFR 
Part 412 subpart D. In that proposed rule, we addressed the IPPS 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 part of 
urban areas under section 601(g) of the Social Security Amendments of 
1983. However, under the OMB geographic definitions, these counties 
were considered rural. In the FY 2008 IPPS final rule, CMS adopted a 
change that resulted in these counties no longer being ``deemed'' 
urban. 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 included in metropolitan statistical areas defined 
by OMB and are therefore urban under the current IPPS labor market area 
definitions in Sec.  412.64(b)(1)(ii)(A). The remaining two counties, 
Litchfield County and Merrimack County, are geographically located in 
areas that are rural under the current IPPS labor market area 
definitions.
    In the August 22, 2007 FY 2008 IPPS final rule with comment period 
(72 FR 47130), Sec.  412.64(b)(1)(ii)(B) was revised such that the two 
``New England deemed counties'' that are still considered rural under 
the OMB definitions (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

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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 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.
    The recommendations to adjust payments to reflect local differences 
in wages are codified in Sec.  418.306(c) of our regulations; however 
there is no explicit reference to Sec.  412.64 in Sec.  418.306(c). 
Although Sec.  412.64 is not explicitly referred to, the hospice 
program has used the definition of urban in Sec.  412.64(b)(1)(ii)(A) 
and (B), and the definition of rural as any area outside of an urban 
area in Sec.  412.64(b)(1)(ii)(C). We proposed to explicitly refer to 
those provisions in Sec.  412.64 to make it absolutely clear how we 
define urban and rural for purposes of the hospice wage index. We 
received no comments on this proposal and will implement it as 
proposed.
    Litchfield county, CT and Merrimack county, NH are considered rural 
areas for hospital IPPS purposes in accordance with Sec.  412.64. 
Effective October 1, 2008, Litchfield county, CT will no longer be 
considered part of urban CBSA 25540 (Hartford-West Hartford-East 
Hartford, CT), and Merrimack county, NH will no longer be considered 
part of urban CBSA 31700 (Manchester-Nashua, NH). Rather, these 
counties will be considered to be rural areas within their respective 
States under the hospice payment system. When the raw pre-floor, pre-
reclassified hospital wage index was adopted for use in deriving the 
hospice wage, it was decided not to take into account IPPS geographic 
reclassifications. This proposed policy to follow OMB designations of 
rural or urban, rather than considering some counties to be ``deemed'' 
urban, is consistent with our policy of not taking into account IPPS 
geographic reclassifications in determining payments under the hospice 
wage index.
    We received no comments on this proposal, and will implement it as 
proposed without change.

B. Wage Data for Multi-Campus Hospitals

    Historically, under the Medicare hospice benefit, we have 
established hospice wage index values calculated from the raw pre-
floor, pre-reclassified hospital wage data (also called the IPPS wage 
index) without taking into account geographic reclassification under 
sections 1886(d)(8) and (d)(10) of the Act. The wage adjustment 
established under the Medicare hospice benefit is based on the location 
where services are furnished without any reclassification.
    For FY 2009, the data collected from cost reports submitted by 
hospitals for cost reporting periods beginning during FY 2004 were used 
to compute the 2008 raw pre-floor, pre-reclassified hospital wage index 
data without taking into account geographic reclassification under 
sections 1886(d)(8) and (d)(10) of the Act. This 2008 raw pre-floor, 
pre-reclassified hospital wage index was used to derive the applicable 
wage index values for the hospice wage index because these data (FY 
2004) are the most recent complete data (for information on the data 
used to compute the FY 2008 IPPS wage index, refer to the FY 2008 IPPS 
final rule with comment period (72 FR 47308 through 47309, 47315)).
    Beginning in FY 2008, the IPPS apportioned the wage data for multi-
campus hospitals located in different labor market areas (CBSAs) to 
each CBSA where the campuses are located (see the FY 2008 IPPS final 
rule with comment period (72 FR 47317 through 47320)). We are 
continuing to use the raw pre-floor, pre-reclassified hospital wage 
data as a basis to determine the hospice wage index values for FY 2009 
because hospitals and hospices both compete in the same labor markets, 
and therefore, experience similar wage-related costs. We note that the 
use of raw pre-floor, pre-reclassified hospital (IPPS) wage data, used 
to derive the FY 2009 hospice wage index values, reflects the 
application of our policy to use that data to establish the hospice 
wage index. The FY 2009 hospice wage index values presented in this 
final rule were computed consistent with our raw pre-floor, pre-
reclassified hospital (IPPS) wage index policy (that is, our historical 
policy of not taking into account IPPS geographic reclassifications in 
determining payments for hospice). For the FY 2009 Medicare hospice 
benefit, the wage index was computed from IPPS wage data (submitted by 
hospitals for cost reporting periods beginning in FY 2004 (just like 
the FY 2008 IPPS wage index)), which allocated salaries and hours to 
the campuses of two multi-campus hospitals with campuses that are 
located in different labor areas, one in Massachusetts and another in 
Illinois. Thus, the FY 2009 hospice wage index values for the following 
CBSAs are affected by this policy: 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).
    We received no comments on this proposal, and will implement it as 
proposed without change.

C. FY 2009 Hospice Wage Index With Phase Out of the Budget Neutrality 
Adjustment Factor (BNAF)

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 proposed to use a raw 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. Again, we 
proposed to use the raw 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 raw 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 proposed using the most recent raw pre-floor, pre-
reclassified hospital wage index available at the time of publication.
    Comment: A few commenters were unhappy with CMS' use of the raw 
pre-floor, pre-reclassified hospital wage index as the input for the 
hospice wage index, and suggested it is flawed. Some commenters noted 
that the hospital-based wage index has undergone multiple changes over 
the past 10 years and that providers were not invited to provide 
comment for CMS to consider when formalizing these changes. One 
commenter added that the existence of exceptions to the hospital wage 
index system in the form of reclassifications demonstrates the 
unfairness and inadequacy of the hospital-based wage index system.

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    Several commenters mentioned that a 2007 MedPAC report on the 
hospital wage index suggested that CMS repeal the existing hospital 
wage index, and develop a new one. The commenter stated that MedPAC 
recommended that CMS evaluate the use of the revised wage index in 
other Medicare payment systems, which includes hospice. A commenter 
asked CMS to devise a hospice-specific reimbursement system, rather 
than using the hospital-based wage index. Several of these commenters 
offered to work with CMS in reforming the wage index, and recommended 
use of the collaborative negotiated rulemaking process. They suggested 
that CMS use the established wage index methodology, including the 
BNAF, until a viable alternative is found.
    In addition, a commenter wrote that hospices compete in the same 
labor market as hospitals for staff but hospitals do not use the same 
wage index, and that the wage index does not reflect the reality of 
wages in a healthcare community.
    Response: The raw pre-floor, pre-reclassified hospital wage index 
was adopted in 1998 as the wage index from which the hospice wage index 
is derived. The Negotiated Rulemaking Committee considered several wage 
index options: (1) Continuing with Bureau of Labor Statistics data; (2) 
using updated hospital wage data; (3) using hospice-specific data; and 
(4) using data from the physician payment system. The Committee 
determined that the raw pre-floor, pre-reclassified hospital wage index 
was the best option for hospice. The raw pre-floor, pre-reclassified 
hospital wage index is updated annually, and reflects the wages of 
highly skilled hospital workers.
    We agree that the hospital-based wage index has undergone some 
changes in the past 10 years. Those changes were put forward through 
rulemaking, which provided the public an opportunity to provide 
comments. Therefore, we disagree that hospice providers have not had an 
opportunity to comment on hospital wage index changes.
    The reclassification provision provided at section 1886(d)(10) of 
the Act is specific to hospitals. We believe the use of the most recent 
available raw pre-floor and pre-reclassified hospital wage index 
results in the most appropriate adjustment to the labor portion of 
hospice costs as required in 42 CFR 418.306(c). Additionally, use of 
the unadjusted hospital wage data avoids further reductions in certain 
rural statewide wage index values that result from reclassification. We 
also note that the wage index adjustment is based on the geographic 
area where the beneficiary is located, and not where the hospice is 
located.
    We continue to believe that the unadjusted hospital wage index, 
which is updated yearly and is used by many other CMS payments systems 
including home health, appropriately accounts for geographic variances 
in labor costs for hospices. Home health agencies and hospices are 
Medicare's only home-based benefits, and home health agencies and 
hospices share labor pools. In the future, when looking into reforming 
the hospice payment system, we will consider wage index alternatives, 
to include those recommended by MedPAC.
    We are implementing as final the proposal to continue to use the 
raw pre-floor, pre-reclassified hospital wage index.
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 the proposed rule (73 FR 24004). 
Beginning in FY 2006, we adopted a policy that, for urban labor markets 
without an urban hospital from which a raw pre-floor, pre-reclassified 
hospital wage index can be derived, all of the urban CBSA raw pre-
floor, pre-reclassified hospital wage index values within the State 
would be used to calculate a statewide urban average raw 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-Fort Stewart, Georgia. We proposed to 
continue this policy for FY 2009.
    Currently, the only rural areas where there are no hospitals from 
which to calculate a raw pre-floor, pre-reclassified hospital wage 
index are in Massachusetts and Puerto Rico. In August 2007 (72 FR 
50217) we adopted the following methodology for imputing rural raw 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 raw pre-floor, pre-reclassified hospital wage index value by 
averaging the raw 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 raw pre-floor, pre-
reclassified hospital wage index. In determining an imputed rural raw 
pre-floor, pre-reclassified hospital wage index, we define 
``contiguous'' as sharing a border. In the proposed rule, we proposed 
to apply this methodology for imputing a rural raw pre-floor, pre-
reclassified hospital wage index for those rural areas without rural 
hospital wage data in FY 2009. 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 did not receive any comments on 
this proposal, and are implementing it as proposed.
    As we noted in our proposed rule, we do not believe that this 
methodology for imputing a rural raw pre-floor, pre-reclassified 
hospital wage index value 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 blended Federal/Commonwealth-
specific rates, to make a separate distinct policy for Puerto Rico 
necessary.
    We did not receive any comments on this proposal, and are 
implementing it as proposed without change. Therefore, in this final 
rule, for FY 2009, we are continuing to use the most recent raw pre-
floor, pre-reclassified hospital wage index value available for Puerto 
Rico, which is 0.4047. This raw pre-floor, pre-reclassified hospital 
wage index value is then adjusted upward by the hospice floor in the 
computing of the final FY 2009 hospice wage index.
3. Phase Out of the Budget Neutrality Adjustment Factor (BNAF)
    As previously stated, the current hospice wage index methodology 
was developed through a negotiated rulemaking process and implemented 
in 1997. The rulemaking 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, which is still in place today, results in providers 
currently receiving about 4 percent more in payments than they would 
have received if the adjustment factor were not applied. We believe the 
rationale for maintaining this adjustment is outdated, as explained in 
detail below, particularly given the

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amount of time that has elapsed since it was first put into place and 
the continuing growth that is occurring in the hospice benefit. In the 
proposed rule, we proposed 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. Additionally, from a parity perspective, because hospices and 
home health agencies have a similar labor mix, we believe that 
adjusting for geographic variances in both of these Medicare home-based 
benefits with the raw pre-floor and pre-reclassified hospital wage 
index is appropriate.
    The original hospice wage index that was used when the benefit was 
first implemented was based on the 1981 BLS hospital data and had not 
been updated from 1983 until the current raw pre-floor and pre-
reclassified hospital wage index was adopted. During earlier attempts 
to update the original 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 the original 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, more accurate wage index would result in some 
areas gaining as their wage index value would increase, but other areas 
would see 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 that is based on using the raw 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 (the 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. This proposed methodology contained the 
negotiated rule making committee's recommendations.
    In formulating the provisions of that proposed rule, the Committee 
considered criteria in evaluating the available data sources. These 
criteria included 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.
    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 1998 hospice wage 
index. That is the raw 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 raw pre-floor, pre-reclassified hospital wage index data.
    The Committee was also concerned that while some hospices would see 
increases in their payments, use of the raw 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 for 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 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. 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 policy, 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 
final rule, that means estimating payments for FY 2009 using FY 2007 
hospice claims data as of March 2008, and applying the estimated 
updated FY 2009 hospice payment rates (updating the FY 2008 rates by 
the FY 2009 market basket update). The final FY 2009 hospice wage index 
values are then applied to the labor portion only. The procedure is 
repeated using the same claims data and payment rates, but using the 
1983 BLS-based wage index instead of the updated raw 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.
    All raw pre-floor, pre-reclassified hospital wage index values of 
0.8 or greater would be adjusted by the BNAF, which would be calculated 
and applied annually. Also, all raw 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.
    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 raw pre-floor, 
pre-reclassified hospital wage index.

[[Page 46469]]

    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 Committee. We also 
noted that in the event that we decide to change this methodology by 
which the hospice wage index is computed, we would propose to do so in 
the Federal Register. In the May 2008 proposed rule, we proposed to 
change this methodology.
    In FY 1998, the BNAF was 1.020768 and in FY 2008, the BNAF was 
1.066671. Any raw 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 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 3-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 the BNAF 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. Additionally, the BNAF was adopted to 
ensure that aggregate payments made to the hospice industry would not 
be decreased or increased as a result of the wage index change. 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 then 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 not in keeping with 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 raw pre-floor, pre-reclassified hospital 
wage index, without the outdated BNAF, consistent with other providers. 
For instance, Medicare payments to home health agencies, that utilize a 
similar labor mix, are adjusted by the raw pre-floor, pre-reclassified 
hospital wage index without any budget neutrality adjustment. We 
believe that using the raw 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. Aggregate hospice expenditures are increasing at a rate of 
about $1 billion per year. MedPAC reports that expenditures are 
expected 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 3,111 hospices. Clearly any negative financial 
impact from adopting a new wage index in 1997 is no longer present, or 
we would not have seen this growth in the industry. 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.
    Finally, we proposed 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. 
We also proposed to maintain the hospice floor, which offers protection 
to hospices with raw pre-floor, pre-reclassified hospital wage index 
values less than 0.8, noting that the steps in the calculation which 
involve the BNAF will become unnecessary. We are implementing the BNAF 
phase-out as proposed, and maintaining the hospice floor as proposed.
    We received several comments on the phase-out of the BNAF. Specific 
comments and our responses to these comments are as follows:
    Comment: Several commenters disputed CMS' description of the 
purpose of the BNAF in the proposed rule. The commenters stated CMS 
asserted that the purpose was to smooth the transition from an outdated 
BLS-based wage index to the hospital-based wage index in 1998, the 
language in several payment rules suggested that the BNAF was not a 
time-limited adjustment and was to be applied annually, during and 
after the transition to the hospital-based wage index. One comment 
supported keeping the BNAF, stating that a payment reduction for FY 
2009 to FY 2011 is no less disruptive than any payment reduction which 
occurred through the wage index transition in 1997. Another commenter 
stated that the hospice negotiated wage index rule that was finalized 
by CMS in 1997 recognized the need to include a budget neutrality 
adjustment to offset the flaws in the hospital wage index, and 
therefore protect the viability of hospices. The commenter also stated 
that reason remains as valid today as eleven years ago. Another 
commenter said CMS' rationale for phasing out the BNAF suggested that 
eliminating the BNAF would restore fairness to the hospice wage index, 
when in reality no wage index methodology is perfect. Other commenters 
stated that CMS has previously recognized that BNAF protects hospices 
from inadequacies in the hospital wage index, and inadequacies in the 
hospice payment rates. Another commenter stated that the BNAF was put 
into place because of the dramatic changes triggered by

[[Page 46470]]

implementation of the new wage index, so that access to care was 
protected.
    In addition, a commenter asserted that the fundamental reason for 
the BNAF was that no component of the current reimbursement system 
accurately replicates hospice costs. A commenter also indicated that 
CMS stated that hospice payments and providers had increased over the 
past 10 years, and that the hospice wage index methodology is dated. 
The commenter further stated that by those standards, the wage index 
model used by every Medicare provider type would need revision. 
Furthermore, a commenter asked why, other than time passing, is the 
BNAF outdated. Commenters indicated that the rationale for applying the 
BNAF originally is still valid.
    Response: We continue to believe that the hospice wage index 
negotiating committee intended the BNAF to mitigate the negative 
financial impact of the 1998 hospice wage index change. We continue to 
believe that because of the growth in the industry and the amount of 
time that has passed since the transition, the rationale for 
maintaining the BNAF is no longer justified. In addition, from a parity 
perspective, we believe that an raw pre-floor, pre-reclassified 
hospital wage index is appropriate for use in adjusting rates for 
geographic variances in both of our home-based benefits, hospice and 
home health. Nothing in our data analysis has shown us that hospice 
labor costs differ substantially from home health labor costs. 
Therefore, we believe we can no longer justify the 6 percent increase 
in the hospice wage index, which results from the BNAF. We agree with 
the commenter that BNAF was put into place so that beneficiary access 
to hospice care would be protected. We believe the Committee was 
primarily concerned about those areas of the country that would see 
their payments reduced as a result of the wage index change. The 
Committee was concerned that the payment reductions might affect the 
viability of hospices in these areas, thus ultimately risking access to 
care. The Committee intended that aggregate payments to hospices not be 
reduced as a result of the wage index change. We do not believe that 
the Committee foresaw the amount of growth in the number of new 
hospices that would occur over the following decade. While we agree 
with the commenter that our regulations describe that the BNAF be 
applied during and after the transition to the new wage index, we 
continue to believe that those decisions were made as part of the 
negotiations to address transitional issues, and do not negate our 
ability to make future policy changes. We believe that our regulations, 
the negotiating committee statement, and the negotiating committee 
workgroup notes support these beliefs. We also believe that given the 
current industry climate, it is appropriate that a policy change now 
occur.
    The decision to transition from the BLS-based wage index to the 
hospital-based wage index was a long process. In the October 14, 1994, 
proposed rule (59 FR 52130), we noted that both CMS (formally HCFA) and 
industry projections indicated that most hospices would have their wage 
indices lowered if a new wage index were based on unadjusted hospital 
data. The preamble of the final rule stated that, ``During the 
discussions preliminary to developing a new wage index, the industry 
voiced concerns over the adverse financial impact of a new wage index 
on individual hospices and a possible reduction in overall Medicare 
hospice care payments'' (59 FR 52130). There were also concerns that 
access to hospice care could be affected. We noted that as a result of 
the impact of the lower payments to hospices in the aggregate, the new 
wage index would have to be at least budget neutral (59 FR 52131). The 
Committee Statement of April 13, 1995, which was published in a notice 
on November 29, 1995 (60 FR 61265), said that we would apply a factor 
to achieve budget neutrality, and noted that budget neutrality meant 
that aggregate Medicare hospice payments using the new hospital-based 
wage index would have to equal estimated payments that would have been 
made under the original hospice wage index.
    We do not believe that the Committee foresaw the tremendous growth 
in the industry. As a result of this growth, the surge of new entrants 
into the industry over the past 10 years has benefited from this 
adjustment. We continue to believe that the committee adopted the BNAF 
to help existing hospices transition to the 1998 wage index change, and 
did not expect that the BNAF would result in these payment increases to 
new providers in perpetuity. Impact analysis performed by participants 
in the negotiating process showed pockets of the country where the 
migration to the new hospital wage index would result in wage index 
values decreasing nearly 30 percent. The committee was clearly 
concerned about hospice viability in those areas of the country, with a 
corresponding concern about access to care. We continue to believe that 
the unique BNAF methodology, coupled with the 3-year transition period, 
served to address those transitional concerns. It also continues to be 
our belief that because of the growth in the number of hospices, and 
the growth in the beneficiaries served that has occurred during the 
last decade, the committee's goal to ensure that access to hospice care 
not be reduced as a result of the wage index change has been achieved. 
Therefore, we believe that this unique methodology for achieving budget 
neutrality has served its purpose and is no longer necessary to be 
continued.
    We disagree with the commenters who wrote that the BNAF was 
intended to offset flaws in the hospital wage index or address 
inadequacy of the hospice payment rates. None of our hospice 
regulations or notices from 1994 to 1998 which deal with the transition 
to a new wage index indicated that the BNAF was put into place because 
of flaws in the hospital-based wage index, rate inadequacies, or 
because of any inaccurate replication of hospice costs under the 
current reimbursement system. We continue to believe, as the Committee 
did, that the raw pre-floor, pre-reclassified hospital wage index is 
currently the best choice for use in deriving the hospice wage index.
    We agree with the commenter that the language in the August 8, 1997 
final rule indicated that the BNAF would be applied during and after 
the transition period (62 FR 42862), however this language did not 
imply that the BNAF could not be changed or eliminated. That same final 
rule also included a provision for us to change the wage index 
methodology, through notice and comment rulemaking (62 FR 42863).
    In our rationale for the BNAF phase-out, we noted the increase in 
payments and in the number of providers to show that the hospice 
industry was growing. Growth such as this, rather than industry 
contraction, typically occurs in a favorable business climate. The 
presence of a favorable business climate suggests that concerns about 
the financial impact of changing to a new wage index had passed. 
Finally, we did not state that all hospice wage index methodology was 
outdated, but only that the BNAF was outdated, and we continue to 
believe that is the case.
    Given that the impact of the BNAF phase-out is relatively small 
(1.1 percent payment reduction for FY 2009), and is being offset by a 
3.6 percent market basket update, we do not feel that the phase-out 
will be disruptive to the hospice industry. However, we will monitor 
the impact as the phase-out occurs.
    Comment: A commenter wrote that CMS justified phasing out the BNAF 
in part because the combination of increases in the wage index in 
certain

[[Page 46471]]

areas with the BNAF led to an artificial boost in the wage index for 
the past 11 years, which CMS concluded was an excess payment. The 
commenter also stated that CMS said that if there had been no wage 
index change in 1997, the total payments to hospices would be greater 
than the payments that will be made if the proposal is implemented. The 
commenter concludes that there is no excess spending triggered by the 
BNAF, but instead there is an unauthorized reduction under the CMS 
proposal.
    Another commenter felt that CMS is singling out the BNAF because 
some hospices benefited more from it than others. The commenter also 
suggested that CMS change the methodology for the limited number of 
hospices that benefited unduly from the ``artificial boost'' given by 
the BNAF.
    In addition, a commenter stated that CMS had indicated one reason 
for the BNAF phase-out was because the growth in hospice expenditures 
indicates that any negative financial impact from the transition to the 
hospital-based wage index in 1998 was no longer present. The commenter 
indicated that CMS assumed this growth in spending was excess spending, 
and that CMS had put forward no evidence that there was excess spending 
in hospice versus appropriate increases in spending.
    Response: We continue to believe that applying the BNAF to the raw 
hospital-based wage index does not, as accurately as possible, account 
for geographic variances in hospice labor costs. When the hospice 
industry changed from the BLS-based wage index to the raw pre-floor, 
pre-reclassified hospital wage index, it began using more accurate, 
more current data which are updated annually. When that transition 
occurred, there were hospices whose wage index value increased, but 
many hospices saw their wage index value decrease. This is because the 
BLS-based wage index values, which were applied to hospice payments, 
were artificially high in some areas of the country. The Committee 
itself acknowledged that the BLS data were ``inaccurate and outdated'' 
in its Committee Statement (62 FR 42883). The hospital-based wage index 
was considered more accurate, even though its wage index values were 
lower for many hospices. Therefore before the transition to the 
hospital-based wage index, many hospices were receiving payments that 
were inflated due to the artificially high BLS-based wage index.
    In addition, the BNAF was put into place to mitigate the adverse 
financial impact to hospice providers of changing wage indices, since 
the change would lead to a reduction in payments, which could threaten 
access to care. However, as we previously described in the comment 
above, the BNAF has been applied not only to those hospices that were 
in existence at the time of the wage index change, but also to those 
new hospices that were established after 1998. We continue to believe 
that these new entrants have received an artificial boost to their 
payments as a result of the BNAF, which was not the intent of the 
negotiating committee.
    The commenter is correct that if the hospice industry had not 
adopted the hospital-based wage index, but had remained with the BLS-
based data, each year's total Medicare hospice payments would be higher 
than they will be when the BNAF is phased out. However, as noted above, 
because of the inaccuracy and outdatedness of the BLS-based wage data, 
those payments would also be inaccurate, and CMS must do its best to 
ensure the accuracy of Medicare payments.
    The commenter correctly noted that we feel that the growth in 
hospice expenditures indicates that the need to mitigate any adverse 
financial impact from the change to a hospital-based wage index has 
passed. However we did not assume that this growth was due to excess 
spending associated with the BNAF. We recognize that many factors 
contribute to expected and appropriate growth in spending, including 
increased numbers of Medicare beneficiaries eligible for hospice care; 
increased awareness of the benefit by beneficiaries, their families, 
and physicians; some longer lengths of stay; etc.
    We believe that the growth in Medicare hospice expenditures 
indicates the overall good financial health of the hospice industry and 
that this further demonstrates that the BNAF has outlived its 
usefulness and is no longer appropriate. As stated previously, we 
believe that given the current industry climate, it is appropriate that 
a policy change to phase out the BNAF be implemented.
    Comment: A commenter wrote that CMS had justified the BNAF phase-
out by noting that there had been an 86 percent increase in growth in 
the number of hospices. The commenter maintained that growth in the 
number of hospice providers does not demonstrate that hospices can 
absorb the payment reduction triggered by the BNAF phase-out. The 
commenter also stated that CMS does not know the financial status of 
those hospices or the level of demand for their services.
    Several commenters stated that CMS has concluded that the growth in 
the hospice benefit was due to the BNAF, thereby justifying its 
elimination. The commenters noted a number of factors that have 
contributed to the hospice industry's growth, including an increased 
number of beneficiaries using the benefit, longer lengths of stay, 
increased acceptance of hospices for end-of-life care by the physician 
and patient/family communities, changes in the mix of patients using 
hospice, and educational efforts by providers and by CMS to 
beneficiaries and health care providers.
    Several commenters felt that the proposed BNAF reduction is a 
reaction to increasing hospice reimbursements overall. Another 
commenter stated that hospice is a small portion of all Medicare 
spending.
    Response: We appreciate these comments. As we indicated in our 
responses, the FY 2009 financial impact of the BNAF phase-out is no 
more than a 1.1 percent reduction in payments. Therefore, with a 3.6 
percent market basket update factor for FY 2009, we do not believe that 
there will be a significant adverse effect on the new providers, or on 
long-standing providers. We agree that demand for hospice services is 
growing as the U.S. population ages, and as the baby boomer generation 
begins to be eligible for Medicare.
    We disagree with the commenter's suggestion that CMS does not know 
the financial status of hospices. In fact, the Medicare Payment 
Advisory Commission (MedPAC) has performed extensive analysis on 
various aspects of hospice financial performance and utilization trends 
over the last few years, including an assessment of growth trends in 
the hospice industry. We believe that both the growth in hospice 
expenditures and the growth in the number of hospices are indicators of 
financial stability in the industry, especially given the growth surge 
in the number of for-profit providers. MedPAC noted that hospice care 
has changed considerably since the benefit's implementation. In 1983 
most providers were nonprofits affiliated with religious or community 
organizations, but now for-profit hospices constitute the majority of 
providers and the vast majority of new entrants into the program since 
2000 (MedPAC, p. 206). In 1998, for-profit providers comprised 26.9 
percent of the industry (63 FR 53456), while in 2007, for-profits 
comprised 51 percent (MedPAC, p. 216). The growth in not-for-profit 
hospices since 1998 has remained relatively flat.

[[Page 46472]]

    MedPAC has also provided some information about the financial 
health of hospices, particular those who are new entrants into the 
market. MedPAC noted that hospices that began participating in the 
market in 2000 or after had consistently and substantially higher 
margins than those participating in Medicare before 2000. In addition, 
these higher margins are consistent with the growth in the number of 
for-profit providers (MedPAC, p. 223-224). Therefore, we do not believe 
that the newer entrants will be more affected by the BNAF reduction 
than older hospices.
    We disagree with the comment that we asserted that the growth in 
the hospice industry was due to the BNAF or that the BNAF reduction is 
a reaction to the growth in hospice reimbursements. However, the 
commenters correctly noted several factors that have contributed to 
industry growth. We indicated that the BNAF phase-out was not a 
reaction to that growth--in the proposed rule, rather we stated that 
the BNAF was put in place to mitigate any adverse financial impact that 
individual hospices might experience as a result of transitioning to 
the new hospital-based wage index in 1998. We note that industries do 
not typically expand and grow during times of financial adversity; 
often there is industry contraction instead. We stated that the growth 
in the industry is an indication that any adverse financial effects of 
transitioning to a new wage index had ended.
    We agree that relative to all Medicare spending, hospice spending 
is a small portion accounting for an expected 2.3 percent of spending 
overall in FY 2009. However, we estimate that hospice spending will 
more than double in the next 10 years. The growth in hospice spending 
has outpaced the rate of growth for other Medicare provider types. 
Furthermore, CMS has a responsibility to safeguard trust fund dollars 
by paying accurately and appropriately for all Medicare services. 
Finally, we disagree with the commenter that the proposed reduction in 
the BNAF is simply a reaction to increasing hospice reimbursements. 
Rather, as we have stated in the previous responses, we believe that 
the purpose of the BNAF was to mitigate the negative financial impact 
of a 1998 wage index change. We believe this mitigation for the 
transition to a ``new'' wage index is no longer necessary. We also 
believe that phasing out the BNAF places both Medicare home-based 
benefits on a more equal footing in terms of recruiting staff.
    Comment: A commenter stated that cutting hospice payments 
disregards the significant, collaborative progress made in the Medicare 
hospice program over the last decade. A few commenters stated that CMS 
circumvented Congress by going through rulemaking to propose and 
possibly finalize a BNAF phase-out. Several commenters suggested CMS 
should use negotiated rulemaking to refine payment policy such as the 
BNAF. Another commenter stated that the wage index calculation is not 
and never has been intended to be used as a method to form payment 
policy. This commenter stated that role historically has been reserved 
for Congress. Another commenter stated that the BNAF phase-out was an 
administrative proposal put forward in the President's budget, and 
therefore should be enacted by Congress rather than effectuated through 
CMS rulemaking. Another commenter stated that the Secretary of the 
Department of Health and Human Services is required to propose reforms 
to the wage index calculations. One commenter stated that the proposed 
rulemaking process administratively circumvented the legislative intent 
to maintain and ensure adequate hospice funding levels.
    Response: We appreciate these comments, but respectfully disagree 
with the commenters. The BNAF was put into place through use of a 
Negotiated Rulemaking Committee. We recognized that the wage index 
methodology, including the BNAF, could be changed when we included the 
following statement in Section IV (B) of the August 8, 1997 Final Rule 
entitled ``Medicare Program; Hospice Wage Index'' (62 FR 42863):

    The annual updates will update the hospice wage index values 
according to the methodology agreed to by the rulemaking committee 
and implemented by this final rule. In the event that we decide to 
change the methodology by which the wage index is computed, this 
will be reflected in a proposed rule published in the Federal 
Register.

    The ``we'' in this paragraph refers to CMS (formally HCFA), which 
published the final rule in 1997. It is clear from this statement that 
the wage index methodology, including the BNAF, is subject to changes 
by CMS, and that any such changes do not have to go through negotiated 
rulemaking, but rather through our rulemaking process of publishing 
proposed and final rules in the Federal Register. There is no statutory 
requirement that requires wage adjustment methodology changes to go 
through Congress. While legislative proposals in the President's Budget 
require Congressional action, administrative proposals in the budget 
simply indicate intended administrative action, and do not require any 
Congressional action.
    We believe that the intent of the BNAF was to protect hospice 
payments during the transition to the hospital-based wage index. The 
growth in the industry and in payments suggests that the industry has 
adequate funding levels, and is one reason for our proposal to phase 
out the adjustment.
    We value the collaborative process, but do not feel that it is 
limited to Negotiated Rulemaking. The notice and comment rulemaking 
process, which we are following, allows for industry input and comment 
and is the general process by which changes to Medicare payment policy 
most often occur. We look forward to continuing to work with the 
industry in the future.
    Comment: Many commenters stated that achieving budget neutrality 
was always a goal of the negotiated rulemaking process. A commenter 
disputed CMS' assertion that the BNAF was intended 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 BLS data, and stated that the BNAF was never a 
point of contention during the Negotiated Rulemaking Process. The 
commenter stated that before the Negotiated Rulemaking Committee began 
its negotiations, CMS (formally HCFA) indicated that the wage index 
could not be used as a tool to increase payments to hospices, nor would 
it be used as a tool to lower aggregate payments to hospices. The 
commenter quoted our regulation (59 FR 52131), which stated that ``We 
[HCFA] consider it a given of negotiation that any revised wage index 
would have to be at least budget neutral; that is, total aggregate 
payments for the same services could not be more using the revised wage 
index than if such payments were made using the current index.''
    Response: We stand by our assertion that the BNAF was intended to 
prevent reductions in payment, and point to the quote from the 1994 
proposed rule (59 FR 52131), which the commenter included that the BNAF 
was designed to protect aggregate payments. We did not state or imply 
that the adoption of the BNAF was a point of contention during 
Negotiated Rulemaking. Rather, we said that the BNAF was now outdated, 
and is no longer needed for the reasons given in the proposed rule (73 
FR 24006).
    It is clear that we have the authority to make changes to the 
hospice wage index methodology, as noted in the August 8, 1997 final 
rule (62 FR 42862):

[[Page 46473]]

``In the event we decide to change the methodology by which the wage 
index is computed, this will be reflected in a proposed rule published 
in the Federal Register.
a. Effects of Phasing Out the BNAF Using the Published FY 2008 Hospice 
Wage Index
    In the proposed rule, we used the August 31, 2007 FY 2008 hospice 
wage index (72 FR 50214) 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 raw pre-floor, 
pre-reclassified hospital wage index values was 6.6671 percent. We will 
reduce the BNAF by 25 percent for FY 2009, by 75 percent for FY 2010, 
and eliminate 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 full BNAF. The 25 percent reduction in the BNAF of 
5.0003 percent would be applied to the raw 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 will still apply to any raw pre-
floor, pre-reclassified hospital wage index values less than 0.8. 
Currently, the floor calculation has 4 steps--(1) Raw pre-floor, pre-
reclassified hospital wage index values that are less than 0.8 are 
first multiplied by 1.15; (2) the minimum of 0.8 or the raw pre-floor, 
pre-reclassified hospital wage index value times 1.15 is chosen as the 
preliminary hospice wage index value; (3) the raw pre-floor, pre-
reclassified hospital wage index value is multiplied by BNAF; and (4) 
the greater result of either step 2 or step 3 is chosen as the final 
hospice wage index value. We left the hospice floor calculation 
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 raw 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 2007 raw pre-floor, pre-reclassified hospital wage 
index as described previously. For FY 2011 and subsequent years, the 
raw 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. Again, we note that the steps in 
the calculation that involve the BNAF will become unnecessary once the 
BNAF is phased out.
    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 values. 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 raw pre-floor, pre-reclassified hospital wage 
index values had the hospice floor calculation applied before any 
change to the BNAF would not be affected by the phase-out of the BNAF. 
These CBSAs, which typically include rural areas, are protected by the 
hospice floor calculation. Additionally, those CBSAs, which were 
eligible for the hospice floor calculation, but whose hospice wage 
index values were previously 0.8 or greater after the calculation was 
applied, but which would have values less than 0.8 after the 
calculation using a reduced BNAF was applied, would see a smaller 
reduction in their hospice wage index values. We have estimated the 
number of CBSAs that would have their raw 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 the proposed rule (73 FR 24002). Therefore, the 
estimated reduction in payments due to the 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 phase-out of the BNAF will also be mitigated by a 
hospital market basket update in payments, which in FY 2008 was a 3.3 
percent increase in payment rates. The hospital market basket update 
for FY 2009 will be 3.6 percent. This update and the FY 2009 payment 
rates will be officially communicated through an administrative 
instruction and not through rulemaking. The estimated effects on 
payment described in column 5 of Table 2 in section V of this final 
rule include the projected effect of a FY 2009 3.6 percent hospital 
market basket update.
b. Effects of Phasing Out the BNAF Using the Updated Raw Pre-Floor, 
Pre-Reclassified Hospital Wage Index Data (FY 2009 Proposal)
    In this final rule, for FY 2009, we are updating the hospice wage 
index using the 2008 raw pre-floor, pre-reclassified hospital wage 
index and the most complete claims data available (FY 2007 claims as of 
March 2008). Using these data, we computed a full BNAF of 6.6255 
percent. For the first year of the BNAF phase-out (FY 2009), the BNAF 
will be reduced by 25 percent, or 0.066255 x 0.75 = 0.049691, to 4.9691 
percent. This will decrease hospice wage index values by approximately 
1.55 to 1.56 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 raw

[[Page 46474]]

pre-floor, pre-reclassified hospital wage index values that have the 
hospice floor applied before implementing a BNAF reduction will be 
completely unaffected by this BNAF reduction (for example, rural West 
Virginia, and CBSA 13900, Bismarck, ND). Those CBSAs which are eligible 
for the hospice floor, and which previously had hospice wage index 
values above 0.8 after applying the full BNAF (as part of the floor 
calculation), but which now are below 0.8 with the 25 percent reduction 
in the BNAF, will be less affected by the BNAF reduction than those 
CBSAs which are 0.8 or above after applying the BNAF. They are 
protected by the hospice floor calculation (for example, rural Alabama 
would realize a decrease in its wage index value of only 0.40 percent, 
and CBSA 27780, Johnstown, PA, would realize a decrease in its wage 
index value of only 0.53 percent). Additionally, the final hospice wage 
index is only applied to the labor portion of the payment rates, so the 
actual effect on estimated payment will be less than the anticipated 
percent reduction in the hospice wage index value. Furthermore, that 
effect will be mitigated by a market basket update. The final market 
basket update for FY 2009 will be 3.6 percent rather than the 3.0 
percent estimated in the proposed rule.
    Column 3 of Table 2 (section V of this final rule) shows the impact 
of using the most recent wage index data (the 2008 raw pre-floor, pre-
reclassified hospital wage index not including any reclassification 
under section 1886(d)(8)(B) of the Act) compared to the 2007 raw pre-
floor, pre-reclassified hospital wage index data which was used to 
derive the FY 2008 hospice wage index. Column 4 of Table 2 in Section V 
of this final rule shows the impact of incorporating the 25 percent 
reduction in the BNAF in the FY 2009 hospice wage index along with 
using the most recent wage index data (2008 raw pre-floor, pre-
reclassified hospital wage index). Finally, column 5 of Table 2 shows 
the combined effects of using the updated raw pre-floor, pre-
reclassified hospital wage index, the 25 percent reduced BNAF, and a FY 
2009 market basket update of 3.6 percent. The FY 2009 rural and urban 
hospice wage indexes can be found in Addenda A and B of this final 
rule. The raw pre-floor, pre-reclassified hospital wage index values 
were adjusted by the 25 percent reduced BNAF or by the hospice floor.
    Comment: Many commenters stated that the impact of the phased 
elimination of the budget neutrality provision is much greater than the 
1.1 percent reduction in payment that was described in the proposed 
rule. These commenters stated that some providers will experience 
reductions ranging from 5 percent to in excess of 14 percent over the 3 
years as a result of the BNAF phase-out, and stated that the cuts would 
create hardship for hospices. Several commenters gave specific examples 
of CBSAs where wage index values decreased more than 1.1 percent, or of 
wage index values in contiguous CBSAs which decreased, but by differing 
amounts. The commenters stated that they cannot match pay scales with 
such a disparity in wage index values, and that there are no 
differences in medical costs between adjoining CBSAs.
    Response: We appreciate the comments about the financial impact of 
the proposed rule, but are very concerned that incorrect percentage 
impacts on payments from the BNAF reduction are being cited in many of 
the comments. Some commenters may have confused the effect of the BNAF 
reduction with the effect of fluctuations in the wage index values from 
the raw pre-floor, pre-reclassified hospital wage index. This hospital 
wage index is used to derive the hospice wage index. We emphasize that 
the BNAF reduction will result in a payment reduction to hospices of no 
more than 1.1 percent in FY 2009. The large payment cuts which hospices 
repeatedly cited are not due to the BNAF reduction. The impact table in 
the proposed rule shows the effects of using the updated wage index 
values, the combined effects of using updated wage index values and the 
25 percent reduction in the BNAF, and the combined effects of the 
updated wage index values, the 25 percent BNAF reduction, and the 
market basket update. Given the apparent confusion, we will clarify our 
methodology for calculating the FY 2009 hospice wage index to include 
the BNAF reduction, and we will expand our explanation of the 
associated impacts.
    In the proposed rule, using the most current data available, we 
first calculated the unreduced BNAF for FY 2009, which was 6.5357 
percent. We reduced that number by 25 percent, to arrive at 4.9018 
percent. The raw wage index values from the raw pre-floor, pre-
reclassified hospital wage index were increased by 4.9018 percent 
instead of by 6.5357 percent for every CBSA or rural area with a wage 
index value of 0.8 or greater (if the raw wage index value was less 
than 0.8, the hospice floor applied). The difference in the wage index 
value was 6.5357 percent - 4.9018 percent = 1.6339 percent. However, 
the wage index value only applies to the labor portion of payments, so 
the effect on payments is less. The labor percentages do not vary by 
hospice or by CBSA; they are the same for every provider. Therefore the 
impact of the BNAF reduction on payments does not and cannot vary from 
one location to another.
    In the proposed rule, our impacts showed the effect of the 25 
percent BNAF reduction (not including the effect of using the updated 
wage index) on total payments to be a 1.0 percent reduction (1.1 
percent in this final rule), compared to what hospices would have 
received if the full BNAF had been used. We noted in the proposed rule 
that this reduction would be offset by a market basket update that was 
estimated at 3.0 percent. Because the BNAF reduction is applied across 
the board to the raw pre-floor, pre-reclassified hospital wage index 
values as a percentage reduction, all hospices (except those subject to 
the floor) are affected the same in that this final rule's estimated 
reduction in payments to all hospices is approximately 1.1 percent. 
Over the course of the 3-year phase-out, the elimination of the BNAF 
will reduce payments by about 4 percent: We estimated a 1.1 percent 
reduction in FY 2009, an additional 2 percent reduction in FY 2010, and 
an additional 1 percent reduction in FY 2011. However those reductions 
do not include 3 years of market basket updates for FY 2009, FY 2010, 
and FY 2011. Therefore, assuming market basket updates' inclusion in FY 
2010 and FY 2011, hospices will still have a net gain in payments over 
the 3 years. While we do not know what the market basket updates will 
be for FY 2010 and FY 2011, hospices received market basket updates 
ranging from 3.3 percent to 3.7 percent from FY 2005 to FY 2008. The 
market basket update for FY 2009 is 3.6 percent. Because we do not know 
how the commenters calculated the percentage reductions they cited, it 
is unclear whether they accounted for market basket updates in their 
analyses. Therefore, not knowing the details of the analysis, we are 
unable to comment further on, or substantiate, the commenters' 
analysis.
    As with the estimated reduction for FY 2009, the reductions in FY 
2010 and FY 2011 payments will apply uniformly to all hospices with 
wage index values >=0.8. Therefore, for hospices with raw pre-floor, 
pre-reclassified hospital wage index values >=0.8, the reductions over 
the 3 years will not be larger for one hospice versus another. As noted 
in the proposed rule, those with raw pre-floor, pre-reclassified wage 
index values <0.8 will be less affected or unaffected by the BNAF 
phase-out.

[[Page 46475]]

    In this final rule, we calculated the BNAF using updated claims 
data (2007 claims as of March 2008). The full BNAF was slightly higher 
at 6.6255 percent; the 25 percent reduced BNAF was 4.9691 percent, 
which is slightly higher than the BNAF in the proposed rule. Therefore, 
the raw pre-floor, pre-reclassified hospital wage index values used to 
derive the hospice wage index were increased by 4.9691. Because of the 
increase in the BNAF itself from the proposed rule to the final rule, 
the hospice wage index values in this final rule are slightly higher 
than those that were in the proposed rule.
    Additionally, the final market basket update for FY 2009 is 3.6 
percent rather than the 3.0 percent estimated in the proposed rule. 
That means the total impact of using an updated wage index, of reducing 
the BNAF by 25 percent, and of the market basket update is estimated to 
be a 2.5 percent increase in payments to hospices in FY 2009.
    The impact of the BNAF reduction does not vary from hospice to 
hospice (except for those subject to the floor) as the same adjustment 
was applied across the board to the raw pre-floor, pre-reclassified 
hospital wage index values. Likewise, the impact of the market basket 
update does not vary from hospice to hospice, as the 3.6 percent 
increase is applied to the same base rates across the board. Therefore 
our impacts do not and cannot mask the effects of the BNAF reduction by 
presenting aggregate data.
    The only place for variation in payment at the individual hospice 
level is within the raw pre-floor, pre-reclassified hospital wage index 
values themselves. These raw wage index values are the input values 
which are adjusted by either the BNAF or the hospice floor calculation 
to derive the hospice wage index. To show the changes from FY 2008 to 
FY 2009 in the raw pre-floor, pre-reclassified hospital wage index, 
from which the hospice wage index is derived, see Addendum C in this 
final rule.
    Addendum C shows that large fluctuations in some wage index values 
exist from year to year, some positive and some negative. These 
fluctuations are the source of negative and positive effects on payment 
to hospices beyond the 1.1 percent reduction due to the BNAF and the 
3.6 percent increase due to the market basket update. Between FY 2008 
and FY 2009, there were 21 CBSAs or rural areas with raw pre-floor, 
pre-reclassified hospital wage index values which decreased 5 percent 
or more, and 16 CBSAs or rural areas with raw pre-floor, pre-
reclassified hospital wage index values which increased 5 percent or 
more. We have also included Addendum D, comparing FY 2008 raw pre-
floor, pre-reclassified hospital wage index values with those from FY 
2007 to demonstrate that fluctuations in raw wage index values occur 
every year. Addendum D shows that there were actually more fluctuations 
between FY 2007 and FY 2008 than between FY 2008 and FY2009; Addendum D 
also shows that between FY 2007 and FY 2008, 23 CBSAs or rural areas 
had raw pre-floor, pre-reclassified hospital wage index values that 
decreased by 5 percent or more, and 17 CBSAs or rural areas that 
increased by 5 percent or more. We remind commenters that these raw 
pre-floor, pre-reclassified hospital wage index values are adjusted 
upward by the hospice floor if the value is below 0.8. These 
fluctuations do not translate into an equivalent increase or decrease 
in payments, as the wage index value only applies to the labor portion 
of payments. Additionally, in considering the total impact on payments, 
commenters would need to account for the market basket increase that 
applies to hospice payment rates.
    The raw pre-floor, pre-reclassified hospital wage index originates 
from data provided on each hospital's cost reports. Hospitals must 
report their wages paid; Medicare takes those data for the hospitals in 
each CBSA and computes a CBSA average hourly rate. It also takes the 
data for all hospitals and computes a national average hourly rate, 
which becomes the standard. The raw pre-floor, pre-reclassified wage 
index values for each CBSA are computed by dividing the CBSA's average 
hourly rate by the national average hourly rate. Therefore, if a wage 
index value is increasing or decreasing, it is because hospital wages 
within that CBSA are increasing or decreasing relative to the national 
average.
    CMS performs an intensive review of the hospital wage data, mostly 
through use of edits to identify aberrant data. The Fiscal 
Intermediary/MAC then revises or verifies the data elements that 
resulted in specific edit failures.
    Table 1 below shows calculation of the hospice wage index for both 
FY 2008 and FY 2009, beginning with the raw pre-floor, pre-reclassified 
wage index value (the input), and applying the BNAF or hospice floor 
for 3 CBSAs. For the first CBSA (31020), the raw pre-floor/pre-
reclassified hospital wage index for FY 2009 is greater than it was in 
FY 2008. Conversely, the raw pre-floor/pre-reclassified hospital wage 
index values for CBSAs 41780 and 48540 are less in FY 2009 than in FY 
2008. Table 1 shows the computation of the hospice wage index values 
for these CBSAs for FY 2008 and for FY 2009 (using proposed rule BNAF 
values). The table also demonstrates that the hospice floor protects 
values <0.8 from the effects of the BNAF reduction. In this case (CBSA 
48540), the FY 2009 proposed wage index value is unchanged from the 
final wage index value for FY 2008. Therefore, as we noted in the 
proposed rule, the BNAF reduction had no effect in this circumstance.
    The cities and counties which make up CBSAs are not determined by 
CMS, but instead are set by the OMB. Information about CBSA 
designations is available at the following Web site: http://www.whitehouse.gov/omb/bulletins/fy2008/b08-01.pdf. We continue to 
believe that OMB's CBSA designations reflect the most recent available 
geographic classifications and are a reasonable and appropriate way to 
define geographic areas for the purposes of determining wage index 
values.
    Currently there are limited data available for analysis of the 
impact of the phase-out of the BNAF on quality. The new claims data 
(with visit reporting beginning July 1st, 2008) and the new Conditions 
of Participation will provide data related to quality of care. We will 
monitor these data for any unanticipated effects of the BNAF phase-out.

[[Page 46476]]



                                      Table 1--Examples of How the Proposed FY 2009 Wage Index Values Were Derived
--------------------------------------------------------------------------------------------------------------------------------------------------------
                               FY08 input--                                                   FY09 input--    FY 09 proposed BNAF-- 25%
                               raw pre-floor    FY 08 BNAF-- Full BNAF =      Output-- FY     raw pre-floor    reduced BNAF = 0.049018      Output-- FY
                                   pre-         0.066671 increases input       2008 final         pre-        increases input value for      2009 NPRM
            CBSA               reclassified   value for all providers w/WI    hospice wage    reclassified    all providers w/WI values    hospice wage
                               hospital wage     values >= 0.8; or apply      index value     hospital wage    >= 0.8; or apply hospice     index value
                              index for FY08          hospice floor                          index for FY09             floor
--------------------------------------------------------------------------------------------------------------------------------------------------------
31020.......................          1.0011  x 1.066671                            1.0678           1.0827  x 1.049018                           1.1358
41780.......................          0.9302  x 1.066671                            0.9922           0.8822  x 1.049018                           0.9254
                              ..............  FY08 input < 0.8; hospice     ...............  ..............  FY09 input < 0.8; hospice    ..............
                                               floor applies                                                  floor applies
                              ..............  0.7010 x 1.15 = 0.8062;       ...............  ..............  0.6961 x 1.15 = 0.8005;      ..............
                                               (Subject to 0.8000 max)                                        (Subject to 0.8000 max)
                              ..............  0.7010 x 1.066671 = 0.7477    ...............  ..............  0.6961 x 1.049018 = 0.7302   ..............
48540.......................          0.7010  Take greater of 15% increase          0.8000           0.6961  Take greater of 15%                  0.8000
                                               (subject to 0.8 maximum) or                                    increase (subject to 0.8
                                               BNAF increase                                                  maximum) or BNAF increase
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Comment: A number of commenters referred to the BNAF phase-out as a 
``rate reduction'' or stated that CMS was cutting rates. In addition, a 
commenter asked CMS to publish the rate updates as part of the rule in 
the Federal Register, rather than in an administrative notice such as a 
Change Request.
    Response: The BNAF is an adjustment which increases the raw pre-
floor, pre-reclassified hospital wage index values that are 0.8 or 
greater, with the result being the hospice wage index. Raw pre-floor, 
pre-reclassified hospital wage index values <0.8 have the hospice floor 
calculation applied instead.
    The hospice payment rates are per diems for routine home care, 
continuous home care, respite care, and general inpatient care. They 
were put into place by Congress, and are updated annually by the market 
basket update. We have not proposed any cut to the payment rates. In 
the proposed rule, we estimated that the per diems would increase due 
to a 3.0 percent market basket update; for the final FY 2009 rule the 
market basket update to be applied to the per diems increased to 3.6 
percent. Therefore, we are not cutting hospice payment rates. 
Conversely, hospice payment rates for FY 2009 will be increased by the 
hospital market basket update of 3.6 percent, and will be communicated 
through a separate administrative instruction/issuance this summer.
    We appreciate the comment about where payment rate updates are 
published. Historically, the payment rate updates have been issued 
through a separate administrative instruction or administrative 
issuance in the summer of each year to provide adequate time to 
implement the necessary system changes. In previous years, the hospice 
wage regulation was often published after August 1st, which does not 
allow sufficient time for system changes to be made to accommodate the 
October 1st implementation of payment updates. We will look into 
including the updated payment rates in the Federal Register in the 
future.
    Comment: CMS received a number of comments suggesting that a BNAF 
phase-out would limit access to hospice care. Multiple commenters noted 
that costs were rising, including gasoline, wages, pharmacy costs, 
medical supplies, insurance, utilities, and food, and that hospices 
cannot absorb these costs in addition to the BNAF reduction without 
adversely affecting Medicare beneficiary hospice care. One commenter 
mentioned the high cost of converting to electronic health records. 
Many commenters stated that the BNAF reduction exacerbates the 
financial strain that CMS has already imposed on hospices this year, 
noting new hospice costs resulting from CMS's requirements to implement 
new Hospice Conditions of Participation (CoPs), and CMS's new visit 
data collection requirements (CR 5567). A few commenters stated that 
agencies are having difficulty soliciting donations in this economic 
downturn. Some rural providers commented that their staff may drive 100 
miles each way to visit patients, and that they cannot afford the 
rising cost of gasoline. Rural and urban commenters stated that they 
could not survive a reduction in payments in the face of rising costs. 
These commenters stated that as a result of the BNAF reduction, they 
would have to limit the geographic areas they service, thus limiting 
hospice access to beneficiaries, especially in rural areas.
    In addition, few commenters stated that there was anecdotal 
evidence that an increasing number of hospices had ceased operations or 
were in danger of closing, due to rising gas prices and to cap 
overpayments. Other commenters stated that they may have to delay 
expansion. Some commenters stated that they would have to discontinue 
programs, including bereavement programs, outreach programs, programs 
to specific underserved groups (for example, to inner city 
beneficiaries), complementary treatments (that is, acupuncture and art 
therapy) or comfort items such as overlay airflow mattresses, and 
charity care. Several commenters mentioned that hospices would be 
forced to limit access by restricting admissions, limiting the number 
of admissions for costly, medically complex patients such as cancer 
patients needing expensive palliative treatments. There was concern 
among many commenters that the BNAF phase-out would lead to cost-
cutting within hospices, including staff reductions that would 
jeopardize quality patient care. Commenters stated that quality care 
takes time, but if staffing is reduced, the nurse-to-patient ratio will 
be unfavorable, and hospice workers will spend less time with patients. 
One commenter stated that hospices may cut the number of visits they 
make, and use phone contact instead. Another stated that the reduction 
disproportionately punishes best practices which hold true to the 
hospice concept. A commenter felt that the BNAF reduction punishes high 
quality, high quantity providers.
    Response: We appreciate the commenters' concerns about rising costs 
and about access to hospice care. We agree that costs are rising and 
that it is vital to preserve access to hospice care for Medicare 
beneficiaries. As noted in our response to a previous comment, it 
appears that the changes in payments to individual hospices have been

[[Page 46477]]

misunderstood as being due to the BNAF reduction. For FY 2009, the BNAF 
reduction cannot affect any hospice by more than 1.1 percent. As stated 
in an earlier response, it is worth noting that while it is true that, 
in a given year, some areas will see what could be considered a 
significant decrease in their raw pre-floor, pre-reclassified hospital 
wage index value, other areas will see significant increases in their 
raw pre-floor, pre-reclassified hospital wage index value. These 
fluctuations in the raw pre-floor, pre-reclassified hospital wage index 
occur every year (Addenda C and D of this final rule show fluctuations 
from FY 2007 to FY 2008 and from FY 2008 to FY 2009). These 
fluctuations are not related to the BNAF reduction, and we believe the 
1.1 percent impact of the BNAF, which is offset by the 3.6 percent FY 
2009 market basket update, will not force hospices to close their doors 
or otherwise affect access to the quality, compassionate care which 
beneficiaries expect and deserve.
    We agree that rising gas prices are a concern for hospices, and 
note that the hospital market basket update which is used by hospices 
includes an energy component that is sensitive to petroleum costs. It 
is reasonable to expect that future market basket updates will continue 
to account for any continuation of rising fuel costs. The FY 2009 
market basket update increased from 3.0 percent in the proposed rule to 
3.6 percent in this final rule, partly due to rising energy costs. We 
refer the reader to the comment about the market basket update later in 
this section for more details on the market basket update.
    In addition, we believe that the requirements associated with the 
CoPs and CR5567 are part of the cost of doing business, and that the 
industry has had ample time to plan and budget for these changes. We do 
not believe that these requirements will have adverse affects on 
admissions or services, but instead expect that the emphasis on quality 
and the increased awareness of visits provided could enhance services.
    We believe that in a time of inflationary pressure, all businesses, 
including hospices, will seek to operate more efficiently. We do not 
believe that the BNAF reduction will lead to the type of cost-cutting 
that would jeopardize quality care. However, we plan to monitor the 
effect of the BNAF reduction to assess whether unanticipated effects 
occur.
    Comment: Several commenters mentioned the Medicare Payment Advisory 
Commission's (MedPAC's) June 2008 report which includes a discussion of 
hospice margins. Commenters stated that MedPAC reports hospice margins 
for the period 2001 through 2005 averaged 3.4 percent, and margins for 
some categories of providers were even lower. For example, commenters 
stated that MedPAC reported margins for not-for-profit hospices that 
were -2.8 percent during this period. Commenters stated that hospices 
cannot withstand the payment reductions resulting from the BNAF phase-
out, stating that complete elimination of the BNAF would result in 
negative margins for all hospice provider types. Commenters were 
especially concerned about the effect any BNAF reduction would have on 
not-for-profit hospices, stating that the reduction will further reduce 
margins which are already in the negative range. Commenters were 
concerned that the BNAF reduction will reduce profitability and 
increases losses such that hospices will close.
    Response: In June 2008, MedPAC published a report entitled 
``Evaluating Medicare's Hospice Benefit'' (MedPAC, pp. 203-237). This 
is the first time margins have been analyzed for hospices. MedPAC 
estimated Medicare hospice margins using Medicare claims and cost 
report data for the period from 2001 to 2005. Their report stated, 
``These margins may not provide a full picture of hospices' financial 
status. Nonprofit hospices derive revenues from philanthropic 
donations, which are an integral part of their operations and mission; 
these revenues are not consistently reported on Medicare cost reports. 
These revenues may help offset the generally negative margins we 
observe for nonprofit hospice providers. Additionally * * * hospitals 
may find it desirable to operate hospices, even in light of negative 
hospice margins. Harrison and colleagues (2005) found that hospitals 
that operated hospice programs had higher return on assets and higher 
hospital occupancy rates, as well as shorter lengths of stay, than 
hospitals without hospices'' (MedPAC, p. 224).
    As noted above, the margins that MedPAC showed in its report may 
not tell the full story of hospice profitability. MedPAC noted that 
financial analysts have estimated margins of 6 to 15 percent for 2006 
for the 3 largest publicly traded hospice chains. Further, MedPAC noted 
that Security and Exchange Commission (SEC) filings on publicly traded 
hospices estimated margins based on all revenues and costs (not just 
Medicare, which accounts for more than 90 percent hospice revenues). 
Two major for-profit chains had 7 percent and 7.8 percent margins in CY 
2006. A third chain showed a loss of 3 percent for FY 2007, but 
attributed it partly to corporate restructuring costs and their cap 
liability (they have since reduced their cap exposure). MedPAC noted 
that the chain with the 7.8 percent margin was seeking to acquire the 
chain with the loss. In addition, analysts project that the prospective 
buyer's margins will be 11 to 12 percent over the next several years.
    We will continue to work with MedPAC to assess the appropriateness 
of future enhancements to the Hospice payment system. We will work 
closely with them as they review and refine their margin analysis and 
assess the impact of the BNAF reduction on margins. Phasing out the 
BNAF rather than eliminating it all at once enables us to iteratively 
assess the impact of the reduction.
    Comment: Many commenters wrote about the financial hardship to 
hospices as a result of rising fuel costs. Two commenters said they do 
not reimburse volunteers for mileage, and that they were losing 
volunteers because of high gasoline prices, with rural areas being 
particularly hard hit. Several providers, particularly rural ones, 
noted that their staff may drive 100 miles each way to see a patient or 
that their service area may cover over 1,000 square miles. A commenter 
also asked that we develop a hospice-specific reimbursement system that 
would entail developing a hospice-specific market basket. A commenter 
noted that the per diems are updated by an index which is not hospice 
specific, and that the assumptions in the per diem components had 
changed. Pharmacy costs, travel costs, and salaries have risen at rates 
that are not provided for in the subsequent market basket updates. 
Several noted that using the hospital market basket was disadvantageous 
to hospices because of differences in the way hospices and hospitals 
operate; some mentioned that hospice providers have been adversely 
impacted by the tremendous rise in gasoline prices far more than 
hospitals, because hospice services are provided where the patient 
resides rather than in a single facility. A commenter added that the 
market basket updates are not driven by an objective analysis of 
hospice costs.
    Response: Section 1814(i)(1)(C)(ii)(I) of the Act requires that the 
hospice PPS market basket update factor be based on the IPPS hospital 
market basket (as defined in Section 1886(b)(3)(B)(iii) of the Act). 
The IPPS market basket reflects the operating cost structures of IPPS 
hospitals and the inflationary pressures

[[Page 46478]]

facing these providers. The market basket update factor includes any 
associated price changes with labor, energy, insurance, food, pharmacy, 
and other IPPS hospital operating costs.
    Hospitals and hospice facilities both hire staff from the same 
healthcare worker labor pool; however, hospitals tend to have a higher 
skill occupation mix compared to hospice facilities. The IPPS market 
basket update factor reflects the inflationary pressures on these 
highly skilled healthcare occupations.
    The hospice per diems are updated using the hospital market basket, 
which we agree is not hospice-specific. While the hospital market 
basket does not have a specific transportation factor, it does include 
energy costs. It also includes pharmacy costs and wage costs. To see 
the components in the hospital market basket, we refer the reader to: 
http://www.cms.hhs.gov/MedicareProgramRatesStats/downloads/mktbskt-pps-hospital-2002.pdf. To better understand the market baskets and how they 
are constructed, we also refer the reader to: http://www.cms.hhs.gov/MedicareProgramRatesStats/downloads/info.pdf.
    Regarding the development of a hospice-specific market basket, CMS 
will investigate the cost structures specific to hospice facilities and 
how they compare to IPPS hospitals. However, we believe that Congress 
intended us to use the hospital market basket to adjust for hospice 
inflationary pressures, and therefore, the authority to create and use 
a hospice-specific market basket is determined by Congress.
    Comment: Several commenters stated that there were likely to be 
major revisions to the hospital wage index in the future and that CMS 
should not remove the BNAF when the wage index is fluctuating. A few 
commenters indicated that CMS has not studied the impact on the hospice 
payment system of hospital wage index changes which occurred over the 
past 10 years. These commenters also stated that CMS justified the 
application of hospital-specific changes to the hospice payment system 
by application of the BNAF, which serves as a ``cushion'' for hospice. 
They also indicated that hospice providers were never given an 
opportunity to study the impact of these changes. Finally, these 
commenters stated that eliminating the BNAF now would subject hospices 
to multiple, significant changes over a short period of time. One 
commenter stated that CMS proposal to phase-out the BNAF is not reform. 
Another commenter indicated that wage index is as important to the 
stability of hospice care as are base payment rates, the annual 
inflation rate update, and the aggregate annual hospice cap, and 
suggested that stability would be lost if the BNAF were phased-out.
    Furthermore, a commenter indicated that the current hospital-based 
wage index was not accurate, reliable, or equitable. The commenter 
stated that some hospices are part of health systems that have wage 
indices lower than a hospital in the same system and the same 
geographic area. Therefore, the commenter asserts, CMS cannot reason 
that the BNAF phase-out is needed for accuracy, reliability, and 
equity.
    Response: In the May 1, 2008 proposed rule, we proposed phasing out 
the BNAF over 3 years because this adjustment has served its purpose, 
which was to mitigate the adverse financial impact of transitioning to 
a new wage index in 1998. The need for the BNAF has passed for a 
variety of reasons, as stated in section II.C.3 of this final rule. We 
did not propose to reform the raw pre-floor, pre-reclassified hospital 
wage index or the hospice payment system, but only to phase out the 
BNAF. We did not propose to phase out the hospice floor calculation, 
which continues to apply when raw pre-floor, pre-reclassified hospital 
wage index values are < 0.8, though we noted that the steps involving 
the BNAF would become unnecessary once the phase-out is complete.
    The raw pre-floor, pre-reclassified hospital wage index is the same 
wage index used by the other home-based Medicare benefit, home health, 
which draws from the same labor pool as hospices. Home health agencies 
experience the same wage index fluctuations, but do not receive an 
adjustment such as the BNAF; therefore, we do not believe that phasing 
out the hospice BNAF in the presence of normal wage index fluctuation 
will be detrimental to the industry or threaten stability.
    Our purpose in phasing out the BNAF is not to reform the wage 
index, but rather to phase out an adjustment which served its purpose. 
The BNAF helped hospices adjust to the negative financial impact of 
changing from the Bureau of Labor Statistics-based wage index to the 
raw pre-floor, pre-reclassified hospital wage index. There is no longer 
a need for this adjustment given that the transition occurred over 10 
years ago and the growth that has occurred in the industry.
    In our proposed rule, we stated that one reason for phasing out the 
BNAF is that it is not as accurate, reliable, and equitable as possible 
in accounting for geographic variation. The BNAF ties payments back to 
an outdated 1981 BLS-based wage index that the Negotiated Rulemaking 
Committee called ``inaccurate'' in its Committee Statement (62 FR 
42883). We are unable to respond to the comment about one health 
system's wage index being different from that of a hospital in the same 
area as it is outside the scope of this rule.
    Comment: One commenter suggested that CMS conduct a study to 
determine the appropriate per diems for rural hospices, asserting that 
rural costs are not adequately addressed in the current payment system. 
This commenter suggested CMS include an additional time and distance 
factor for rural hospices to align the per diem with rural costs.
    Response: Medicare pays one of four daily rates to hospice 
providers, based on the intensity level of care the patient requires. 
These per diem payment rates are the same, regardless of whether the 
services are provided in an urban area or a rural area. The hospice 
wage index, which includes a floor calculation which benefits many 
rural providers, is the vehicle we use to adjust for geographic 
variances in labor costs. In a time of high gasoline costs, we are 
sensitive to concerns from rural hospices that the additional time and 
distance required to visit a rural patient adds significantly to their 
costs, and their assertion that payments are not adequate. However, we 
believe that an additional payment for rural providers, which is 
sometimes called a rural add-on payment, would have to be legislated.
    Comment: Several commenters indicated that hospices sometimes care 
for high cost patients such as those who require more expensive 
palliative radiation or chemotherapy, and that hospice reimbursements 
are not sufficient to provide quality care to these complex patients. 
Another commenter stated that the original hospice per diems were 
arbitrarily set by CMS (formally HCFA) and had to be raised by 
Congress. A commenter stated that increased case mix and new treatment 
options have also affected hospice costs. A commenter recommended that 
CMS study the real costs of hospice care and devise a 21st century, 
hospice-specific reimbursement system. One commenter recommended that 
CMS raise the wage-related per diem.
    Several commenters asked CMS not to decrease payments because they 
are already providing services above the level of reimbursement that is 
presently provided in the daily rate. Another

[[Page 46479]]

commenter stated that Medicare does not pay for staff consultations, 
pre-admission consults, travel time to patients' homes, or the cost of 
fuel. A few commenters stated that hospices now provide an ever-
expanding array of costly palliative treatments.
    Response: While these comments addressed issues that are beyond the 
scope of this final rule because they concern issues about which we did 
not make any proposals, we will address them briefly since they pertain 
to overall hospice reimbursement. In its June 2008 report, MedPAC wrote 
that hospice payments are generally adequate in the aggregate, but 
noted that individual hospices' performance varies (MedPAC, p. 205).
    The hospice per diems were designed to cover hospice costs and were 
developed based on cost information gathered from a demonstration 
project that began in October, 1980 and which included 26 hospices. The 
per diems include costs of the services hospices provide, plus overhead 
costs such as maintenance, depreciation, general accounting, capital, 
and other administrative costs in the calculation of the individual 
service components (that is, nursing services and aide services). A 
cost component is included for hospital outpatient charges for 
palliative radiation and chemotherapy, based on a sample of Medicare 
patients who died from cancer in 1980, and adjusted for inflation. In 
the future, we plan to perform analyses on hospice resource 
utilization, in the hopes of refining our hospice payment system. We 
will consider the high cost of certain palliative treatments in future 
payment refinements analyses.
    As some commenters stated there have been changes in hospice case 
mix, with proportionally fewer cancer patients and more patients with 
other diagnoses such as dementia and congestive heart failure. At this 
time, we do not have the data on services provided to patients with 
specific diagnoses, and therefore cannot easily determine the adequacy 
of Medicare payments relative to the cost of care. However, hospices 
were required to begin reporting visits for nurses, physicians, social 
workers, and aides as of July 1, 2008 (This is just a beginning in data 
collection efforts that should provide the information needed to refine 
payments in the future). We note that because hospice rates are 
currently described in statute, any hospice payment refinements which 
affect those rates would need to be enacted by Congress.
    Comment: Many commenters praised the benefits of hospice, which 
provides care to the most vulnerable Medicare beneficiaries for 
example, the dying and does so in a cost-effective fashion that saves 
Medicare money. They suggested that if hospice utilization declines, 
beneficiaries would be forced to use more costly medical care, driving 
up Medicare costs in the long run. Others commented on the quality, 
compassionate care and comfort that hospice provides to patients and 
their families. Another commenter stated that hospice provides 
tremendous aid at end of life, serving the dying equally, regardless of 
color and economic status. These commenters and others asked that CMS 
not reduce payments. Several commenters also questioned the timing of 
CMS' proposal to eliminate the BNAF. They felt CMS should not be 
cutting hospice benefits at a time when the demand for services is 
growing. One commenter stated that the industry growth is a testament 
to the service gap that hospice fills, the growing awareness of 
hospice, and preference for a hospice death. A few mentioned that CMS 
has encouraged hospice usage. One commenter indicated that studies show 
that patients live longer on hospice, but there is still a need for 
earlier referrals to the benefit. The commenters stated that the 
population is aging and the baby boomer generation is getting older.
    Response: We agree that the Medicare hospice benefit has been of 
tremendous benefit to those at end-of-life and to their families, and 
applaud those who serve the dying as hospice staff and volunteers. We 
also agree that the hospice benefit often saves Medicare money, and 
appreciate the studies which have highlighted the areas where it 
provides costs savings to the Medicare program. However, hospice care 
does not save money in every instance. MedPAC has noted that 
``hospice's net reduction in Medicare spending decreases the longer the 
patient is enrolled and beneficiaries with very long hospice stays may 
incur higher Medicare spending than those who do not elect hospice.'' 
(MedPAC, p. 209). We do not believe that hospice utilization will 
decline due to the BNAF phase-out, and therefore, do not believe that 
Medicare costs will be shifted from hospice to more expensive forms of 
care. As noted in our response to a previous comment, the FY 2009 
impact of the BNAF phase-out is, at most, 1.1 percent for every 
provider, and is being offset by a 3.6 percent FY 2009 market basket 
update, resulting in a 2.5 percent increase in payments to hospice 
providers in FY 2009.
    We agree that the hospice industry is growing and that the demand 
for hospice services is likely to grow in the future, particularly with 
an aging population. We also agree that CMS has encouraged hospice 
usage. We have not cut Medicare hospice benefits in any way--terminally 
ill Medicare patients are still eligible to receive the same quality, 
compassionate end-of-life care that has been the hallmark of hospice. 
We expect the hospice benefit to continue to grow: CMS' Office of the 
Actuary projects that Medicare hospice spending will more than double 
in the next 10 years. However, we will monitor the impact of the BNAF 
phase-out for any unintended impact.
    Comment: Several commenters recommended that CMS delay any BNAF 
reduction or phase-out. They suggested waiting for better and more 
reliable data, for time to evaluate the impact of the requirements from 
the new Conditions of Participation and from CR 5567. A commenter 
stated that CMS lacks the data to conduct a reasoned analysis, citing 
MedPAC's June 2008 report which stated that CMS needs substantially 
more data. One commenter recommended that CMS consider a 1-year freeze 
on any reductions and wait for more available data. Another commenter 
recommended that CMS delay until we had gathered data on the potential 
impact on hospice operations and quality of care of eliminating the 
BNAF. A commenter stated that there was not enough time to prepare for 
a change due to a BNAF phase-out. Other commenters asked CMS to wait 
until MedPAC completes its hospice analysis and CMS updates its hospice 
payment system, before eliminating the BNAF. Several other commenters 
recommended phasing out the BNAF more gradually. Some recommended a 
gradual phase-out that would help minimize the economic impact of such 
a change, particularly at a time of rising gas prices. One commenter 
recommended a 5-year phase-out, and another recommended a 7-year phase-
out, with a 25 percent reduction in FY 2009, a 15 percent reduction in 
FY 2010, and a 10 percent reduction through FY 2016. Another commenter 
recommended that implementing the BNAF reduction on a more gradual 
schedule would allow hospices time to evaluate the impact of the 
reduction of the new CoPs, hospital versus hospice costs, and of the 
June 2008 MedPAC report. Even with the proposed schedule for reducing, 
and ultimately eliminating the BNAF, commenters suggested that by CMS 
not providing impacts for the 2nd and 3rd year of reducing the BNAF, 
the industry was not afforded information as to the impact on hospices 
beyond the

[[Page 46480]]

proposed first year's reduction of the BNAF.
    Response: We appreciate the commenters' input. However, we continue 
to believe that our phase-out approach as described in the proposed 
rule is appropriate. One reason we decided to implement a phased-out 
approach to reducing the BNAF was to ensure we would have the ability 
to assess the impact of the BNAF reduction iteratively. We plan to 
monitor the impact of the BNAF reduction for unintended effects. The 
financial impact of the phase-out is very clear; in FY 2009 it is 
estimated to affect hospices by no more than negative 1.1 percent. We 
continue to believe that because the FY 2009 market basket update is 
3.6 percent, and hospices will receive 2.5 percent more in payments in 
FY 2009 than they received in FY 2008, the FY 2009 reduction should not 
have an adverse impact on hospice operations or quality.
    The hospice CoPs were developed with input from the industry. The 
CoPs have been in development for 9 years and have widespread support 
from the industry. Hospices have been expecting these since the 
Conditions of Participation proposed rule was published in May of 2005, 
providing time to plan and budget for these changes accordingly. 
Hospices were required to report certain visit data as of July 1, 2008. 
This requirement was implemented through CR 5567 after MedPAC, the 
General Accounting Office, and the Office of the Inspector General 
recommended that CMS gather data on Medicare hospice service 
utilization. While the most recent revision of CR 5567 occurred on 
April 29, 2008, the initial issuance of the CR occurred on July 20, 
2007, providing ample time for hospices to plan and budget for these 
requirements. CR 5567 requires reporting of visit data that many 
hospice software programs already track. We do not feel it will cause 
undue burden, especially since we recently revised the CR 5567 
requirements to suspend a subset of the reporting requirements to 
address an industry concern. Additionally, we believe the industry has 
ample time to prepare for the BNAF phase-out. The FY 2009 President's 
budget was published in February, 2008 and contained a provision to 
phase out the BNAF. In the interest of transparency, we made public our 
intent to propose the BNAF reduction via FY 2009 rulemaking shortly 
after publication of the budget, over 2 months in advance of our 
proposed rule publication.
    We agree that MedPAC recommended that CMS collect additional data 
to better understand what services we are paying for, and for use in 
future payment refinements. We did not propose to reform the payment 
system, but simply to remove an outdated adjustment.
    We acknowledge that the impacts reflected in this rule are for FY 
2009 only. The purpose of this final rule, so far as impacts, is to 
show the estimated impacts on hospice providers for FY 2009. We have, 
in the proposed rule (72 FR 24005, 24006) and in a response to a 
previous comment, communicated that over the course of the three-year 
phase-out, the elimination of the BNAF will reduce payments by about 4 
percent: We estimated a 1.1 percent reduction in FY 2009, an additional 
2 percent reduction for a cumulative reduction of 3.1 percent in FY 
2010, and an additional 1 percent reduction for a cumulative reduction 
of 4.1 percent in FY 2011. However those reductions do not include 3 
years of market basket updates for FY 2009, FY 2010, and FY 2011. 
Therefore, assuming market basket updates' inclusion in FY 2010 and FY 
2011, hospices will still have a net gain in payments over the 3 years. 
While we do not know what the market basket updates will be for FY 2010 
and FY 2011, hospices received market basket updates ranging from 3.3 
percent to 3.7 percent from FY 2005 to FY 2008. The market basket 
update for FY 2009 is 3.6 percent. We will provide similar impacts for 
FY 2010 and FY 2011 in future rulemaking.
    For all of these reasons, we do not feel that there is a reason to 
delay the phase-out of an outdated adjustment. While we believe that a 
3-year phase-out is fair and appropriate, we will monitor the effects 
of the phase-out as it occurs.
    Comment: A commenter wrote that hospitals and home health agencies 
receive the BNAF. The commenter said that since hospices compete with 
home health agencies and hospitals for staff, phasing out the BNAF for 
hospice creates an uneven playing field for recruiting and retaining 
staff. A few commenters stated that CMS should not justify removing the 
BNAF so that the hospice and home health wage indices were consistent. 
One commenter stated that the new CoPs recognized the differences 
between hospice and home care patients, noting that hospice patients 
are more fragile. Additionally, other aspects of the hospice and home 
health payment systems differ. These commenters indicated that the 
rules regarding hospice payment should remain unique, and do not need 
to mirror those for home health.
    Response: We agree that there should be a level playing field for 
recruiting and retaining staff for home-based benefits such as hospice 
and home health. As we described in our proposed rule, because hospices 
and home health agencies share labor pools, we believe that there 
should be consistency in the wage index used by both these home-based 
benefits. Nothing in our data analysis has shown us that hospice labor 
costs differ substantially from home health labor costs, making it 
difficult to justify a 6 percent increase in the hospice wage index. We 
continue to believe that the raw pre-floor, pre-reclassified hospital 
wage index provides a good measure to account for geographic variances 
in labor costs for both these home-based benefits. Phasing-out the BNAF 
enables us to achieve this consistency.
    The other commenters noted the differences between services 
provided in hospice care and home health care, citing the hospice CoPs. 
We agree that hospice patients can be more fragile and that hospice 
care is unique, and it is appropriate for hospice and home health to 
have different payment systems. However, the purpose of a wage index is 
to account for geographic variances in labor costs. We believe that the 
use of a consistent wage index in both these home-based benefits 
enables hospices and home health agencies to compete for staff on a 
level playing field.
    Comment: One commenter stated that hospice reimbursement does not 
consider the higher cost of hospice care in the home versus in a 
nursing home. Hospice patients in the home require more staff visits, 
increased on-call expense, and increased mileage expense. The commenter 
stated that hospice patients in nursing homes do not need the same 
intensity of care as hospice patients who are residing in their own 
homes.
    Response: While these comments address issues that are beyond the 
scope of this final rule, we will address them briefly since they 
generally relate to hospice reimbursement. The hospice benefit was 
designed as a home-based benefit, and the per diems were set up 
assuming that most care was routine care given in the home. Rather than 
considering the per diem inadequate because home care is more costly, 
we view the per diem as adequate for home care but possibly more than 
adequate for hospice patients residing in a nursing home. The routine 
home care per diem was built assuming costs for aides, and hospices do 
not have to provide the personal care that aides normally give to their 
patients who reside in nursing homes, because the nursing home staff is 
required to provide that care.

[[Page 46481]]

Likewise, if the hospice has multiple patients in the same nursing 
home, then hospice patients in nursing homes are less costly in terms 
of mileage and driving time. Hospice patients in nursing homes may 
require an equal intensity of service as patients in the home, and 
hospices should be prepared to provide all necessary services for their 
patients who reside in nursing homes.
    Comment: A few commenters felt that CMS had not provided the 
sufficient data analysis to justify the elimination of the BNAF. They 
felt CMS's decision to eliminate it was arbitrary and capricious, and 
recommended that CMS withdraw the proposal. A few commenters stated 
that CMS did not follow the Administrative Procedures Act in proposing 
the BNAF phase-out. Another commenter stated that CMS advanced the 
proposal to phase out the BNAF because it offers the potential for 
reducing hospice payments quickly, to meet short term budget goals, 
without the need to collect and analyze data.
    Response: We believe we complied fully with the Administrative 
Procedures Act in proposing to phase out the BNAF, by fully describing 
our proposals and rationale for our proposals, by providing the full 
impact of the proposal, and by providing opportunity for public 
comment. The effect of the BNAF is clearly illustrated in the impact 
analysis presented in the proposed rule, and in the updated impacts 
presented in this final rule. For FY 2009, the BNAF will not affect any 
hospice's estimated payments by more than 1.1 percent, and either has 
no effect on hospices with raw pre-floor, pre-reclassified wage index 
values <0.8, or affects them less than 1.1 percent. We believe that 
through misunderstanding, some in the hospice industry have shifted the 
focus of the impacts from the BNAF phase-out to the impact of 
fluctuations which occur in the raw pre-floor, pre-reclassified 
hospital wage index every year. We have added Addenda C and D to show 
the hospital-based wage index fluctuations for the last 2 years to 
demonstrate that they are a regular occurrence, and that there are 
fewer fluctuations from the prior year in FY 2009 than in FY 2008.
    We believe the rationale for phasing out the BNAF which we 
discussed in the proposed rule (72 FR 24006), highlights data that 
justify our adoption of our proposal. Specifically, we described our 
analysis which we believe shows that the negotiating committee adopted 
the BNAF to mitigate the negative financial impact of the 1998 hospice 
wage index change. Our rationale in the proposed rule also describes 
our analysis of the growth in aggregate expenditures, the growth surge 
in the number of for-profit hospices, and the growth in the 
beneficiaries served that has occurred during the last decade. Our 
rationale also indicates a desire for parity between hospices and home 
health agencies since nothing in our data analyses indicates that 
hospice labor costs differ substantially from home health labor costs. 
We believe that these data, in conjunction with the impact analysis, 
show that this unique methodology for achieving wage index budget 
neutrality has served its purpose and is no longer necessary. We will 
continue to monitor the impact of the BNAF phase-out for any 
unanticipated effects.
    Comment: A commenter stated that the BNAF phase-out discriminates 
against rural providers.
    Response: We disagree that the BNAF phase-out discriminates against 
rural providers. As noted in our impacts, providers with raw pre-floor, 
pre-reclassified hospital wage index values of 0.8 or more are affected 
equally. These providers are estimated to experience a 1.1 percent 
reduction in payments in FY 2009. Providers with raw pre-floor, pre-
reclassified wage index values <0.8 are protected by the hospice floor 
calculation and will either be less affected, or totally unaffected by 
the BNAF phase-out. Since many rural providers have lower raw pre-
floor, pre-reclassified hospital wage index values, and therefore are 
eligible for the hospice floor calculation, we disagree that those 
rural providers eligible for the floor are actually less impacted on 
net.
    Comment: A commenter stated that CMS was ``phasing out of the 
hospice wage index''.
    Response: We appreciate this comment, as it provides the 
opportunity to clear up a misunderstanding. We are not phasing out the 
wage index, but rather are phasing out the BNAF, which is an adjustment 
that increases the wage index values.
    Comment: A commenter stated that CMS is focusing on that small 
percentage of hospices that have long lengths of stay and a surplus of 
reimbursement over expense.
    Response: The BNAF reduction is applied equally to every wage index 
value not subject to the hospice floor. It does not disproportionately 
affect hospices with long lengths of stay or with high margins. While 
there were good reasons for putting the adjustment into place, those 
reasons are no longer valid (see the proposed rule (72 FR 24006) for a 
discussion of the rationale behind phasing out the BNAF).
    Comment: A few commenters stated that Congress has rejected the 
Administration's request to reduce the hospice reimbursement rate, 
understanding correctly that any reduction in rate must necessarily 
reduce either quality of care or access to care.
    Response: We are unclear about what the commenter is referring to. 
Congress has reduced hospice reimbursements in the past, cutting market 
basket updates by as much as 2.5 percent.
    Comment: A commenter stated that the budget neutrality does not 
take into account the market basket update.
    Response: We appreciate this comment, as it allows us to clarify 
the above statement. The calculation to derive the BNAF takes the 
market basket update into account as it uses updated payment rates to 
calculate aggregate payments. Since we calculate aggregate payments 
using the same payment rates and the same utilization, and only vary 
the wage index used (the 1983 BLS-based wage index or the current raw 
pre-floor, pre-reclassified hospital wage index), the market basket 
update has no effect on the BNAF that results.
    Comment: A commenter recommended that CMS consider an alternative 
to the BNAF phase-out. The commenter recommended that CMS establish 
minimum staffing patterns, as a better staffing ratio would lead to a 
reduction in patient pain, symptom crises, after-hours calls, 911 
calls, trips to the emergency room, and revocations. In addition, the 
commenter stated that it would reduce staff turnover and improve 
retention.
    Response: We thank the commenter for this recommendation. The new 
data reporting requirements from CR 5567, which began July 1, 2008, 
will enable us to investigate staffing patterns as part of any future 
hospice payment refinements analysis. However, we are not considering 
establishing minimum staffing patterns as an alternative to the BNAF 
phase-out.
    Comment: A commenter stated that reporting for CR 5567 does not 
include all disciplines. In addition, the commenter stated that 
promoting quality hinges on recognizing differences between routine 
home care and hospice care, which CR 5567 seems to question. The 
episodic nature of home care lends itself to per-visit reimbursement, 
while the holistic hospice approach is better suited to the current per 
diem reimbursement.
    Response: We appreciate the comment, but it is outside the scope of 
this final rule. We will, however, consider the comment when examining

[[Page 46482]]

visit reporting requirements in the future.
    Comment: A commenter stated that phasing out the BNAF amounted to 
``taxation without representation''.
    Response: We followed the requirements of the Administrative 
Procedures Act in proposing and finalizing this policy change, 
including providing rationale for the BNAF phase-out and the 
opportunity for public comment (73 FR 24006).
    Comment: A commenter did not want CMS to cut hospice payments. The 
commenter stated that Medicare was to help those without other sources 
of income.
    Response: We thank the commenter for his or her input. Medicare is 
a health insurance benefit available to people 65 and older, some 
disabled people under age 65, and people of all ages with End Stage 
Renal Disease. While Medicare is certainly a help to those without much 
income, eligibility for Medicare is not related to income. Those who 
are Medicare beneficiaries fall into all income categories, from the 
lowest to the highest.
    Comment: A commenter stated that non-hospice care is given at end-
of-life, and asked that CMS change physician practice and enhance 
public awareness rather than reducing hospice payments. The commenter 
suggested that we allow only the attending physician to order non-
emergency tests and treatments in hospitals; that we increase physician 
oversight of hospice patients; that we publicize actual success rates 
for various technologies; and that we restructure the physician payment 
system so that doctors are paid by diagnosis rather than by days in 
hospital or by procedures done.
    Another commenter stated that CMS should evaluate the skilled 
benefits, as people that are hospice-appropriate are being sent to 
skilled facilities first, even though they are not rehab potentials.
    One commenter stated that the federal government recognizes and 
uses a wage index in determining the salaries of their employees.
    A different commenter recommended that CMS seek to limit the growth 
in the hospice benefit by requiring survey agencies to establish or 
enhance needs methodologies.
    Several comments recommended other methods of saving federal 
dollars rather than phasing out the BNAF. One commenter stated that CMS 
should cut extreme farm subsidies. Another commenter stated that CMS 
should cut programs that reward illegal status in the U.S. A third 
commenter stated that CMS should stop those who are using Medicare 
dollars to buy expensive vehicles.
    A commenter also stated that since Medicaid payments for hospice 
services are based on the Medicare payment methodology and rates, the 
BNAF phase-out will have an even greater effect on, and impinge on the 
provision of hospice services to Medicaid recipients.
    Response: We appreciate these comments, but they are outside the 
scope of this final rule. References to literature cited in this 
section: Medicare Payment Advisory Commission (MedPAC), Report to 
Congress: Reforming the Delivery System, June 2008: 203-237.

III. Provisions of the Final Regulations

    This final rule incorporates the provisions of the proposed rule. 
None of the provisions of this final rule differs from the proposed 
rule.

IV. 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).

V. 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 
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 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 final rule is an economically significant 
rule under this Executive Order.
    Column 4 of Table 2 shows the combined effects of the 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 the FY 2009 market basket update, which is 3.6 percent, and 
which will be communicated through an administrative instruction. The 
estimated impact of a 3.6 percent FY 2009 market basket update on 
payments to hospices is approximately $330 million. If we were to take 
into account the 3.6 percent FY 2009 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 $230 
million ($330 million - $100 million = $230 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 FY 2009 
market basket update of 3.6 percent is reflected in column 5 of the 
impact table (Table 2).
    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 1 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 2 below, 
there are 3,111 hospices. Approximately 50.9 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

[[Page 46483]]

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 2, 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 
FY 2009 market basket update of 3.6 percent into these figures, the 
combined effects of Medicare payment changes to all hospices will 
result in an increase of approximately 2.5 percent. Overall average 
hospice revenue effects will be slightly less than these estimates 
since according to 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 final 
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 final 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 final rule will not 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 final 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 final rule, including the 
estimated effects of the 3.6 percent FY 2009 market basket update that 
will be communicated separately through an administrative instruction. 
The final rule includes continuing to use the CBSA-based raw 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 data are treated in the creation of the raw 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 final FY 2009 hospice wage index is based 
upon the 2008 raw pre-floor, pre-reclassified hospital wage index and 
the most complete claims data available (FY 2007 as of March 2008) with 
a 25 percent reduction in the BNAF.
    For the purposes of our impacts, our baseline is estimated FY 2008 
payments using the 2007 raw pre-floor, pre-reclassified hospital wage 
index. Our first comparison (column 3, Table 2) compares our baseline 
to estimated FY 2009 payments (holding payment rates constant) using 
the updated wage data (2008 raw pre-floor, pre-reclassified hospital 
wage index). Consequently, the estimated effects illustrated in column 
3 of Table 2 are for the updated wage data only. The effects of using 
the updated raw pre-floor, pre-reclassified hospital wage index data 
combined with the 25 percent reduction in the BNAF are illustrated in 
column 4 of Table 2.
    Even though the market basket update is not part of this final 
rule, we have included a comparison of the combined effects of the 25 
percent BNAF reduction, the updated raw pre-floor, pre-reclassified 
hospital wage index, and the 3.6 percent FY 2009 market basket increase 
for FY 2009 (Table 2, column 5). Presenting these data gives the 
hospice industry a more complete picture of the effects of the proposed 
changes in this rule and of 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 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.

[[Page 46484]]



 Table 2--Anticipated Impact on Medicare Hospice Payments of Reducing the BNAF, Updating the Raw Pre-Floor, Pre-
  Reclassified Hospital Wage Index Data, and Applying a 3.6 Percent Market Basket Update for the Final FY 2009
                 Hospice Wage Index, Compared to the Published Final FY 2008 Hospice Wage Index
----------------------------------------------------------------------------------------------------------------
                                                                                                  Percent change
                                                                                  Percent change    in hospice
                                                                                    in hospice     payments due
                                                                  Percent change   payments due    to wage index
                                                     Number of      in hospice     to wage index    change, 25%
                                     Number of     routine home    payments due   change and 25%   reduction in
                                    hospices *     care days in     to FY 2009     reduction in       budget
                                                     thousands      wage index        budget        neutrality
                                                                      change        neutrality      adjustment
                                                                                    adjustment      factor and
                                                                                      factor       market basket
                                                                                                      update
                                             (1)             (2)             (3)             (4)             (5)
----------------------------------------------------------------------------------------------------------------
ALL HOSPICES....................           3,111          67,239             0.0            -1.1             2.5
    URBAN HOSPICES..............           2,098          57,893             0.0            -1.1             2.5
    RURAL HOSPICES..............           1,013           9,346            -0.1            -0.9             2.7
BY REGION--URBAN **:
    NEW ENGLAND.................             119           2,074             0.4            -0.7             2.9
    MIDDLE ATLANTIC.............             209           5,971            -0.5            -1.5             2.0
    SOUTH ATLANTIC..............             310          12,950             0.0            -1.1             2.5
    EAST NORTH CENTRAL..........             307           8,324            -0.2            -1.3             2.3
    EAST SOUTH CENTRAL..........             170           4,506            -0.4            -1.3             2.3
    WEST NORTH CENTRAL..........             166           3,783             0.1            -1.0             2.6
    WEST SOUTH CENTRAL..........             348           7,588            -0.1            -1.2             2.4
    MOUNTAIN....................             201           5,054             0.0            -1.1             2.5
    PACIFIC.....................             234           6,692             0.8            -0.3             3.3
    OUTLYING....................              34             952            -1.1            -1.1             2.4
BY REGION--RURAL **:
    NEW ENGLAND.................              26             175            -0.4            -1.4             2.1
    MIDDLE ATLANTIC.............              44             462             0.4            -0.6             2.9
    SOUTH ATLANTIC..............             128           1,915             0.1            -0.9             2.7
    EAST NORTH CENTRAL..........             144           1,317             0.0            -1.0             2.5
    EAST SOUTH CENTRAL..........             152           2,051            -0.4            -1.1             2.4
    WEST NORTH CENTRAL..........             192           1,030            -0.2            -1.2             2.3
    WEST SOUTH CENTRAL..........             168           1,388            -0.5            -0.8             2.8
    MOUNTAIN....................             106             601             0.2            -0.8             2.8
    PACIFIC.....................              52             397             1.6             0.5             4.1
    OUTLYING....................               1               9             0.0             0.0             3.6
ROUTINE HOME CARE DAYS:
    0-3,499 DAYS (small)........             607           1,044             0.1            -0.8             2.7
    3,500-19,999 DAYS (medium)..           1,506          15,071            -0.1            -1.1             2.5
    20,000+ DAYS (large)........             998          51,123             0.0            -1.1             2.5
TYPE OF OWNERSHIP:
    VOLUNTARY...................           1,198          29,597            -0.1            -1.2             2.4
    PROPRIETARY.................           1,528          32,903             0.0            -1.0             2.6
    GOVERNMENT..................             192           1,049             0.2            -0.8             2.8
    OTHER [dagger]..............             193           3,690             0.1            -1.0             2.6
HOSPICE BASE:
    FREESTANDING................           1,918          49,843             0.0            -1.1             2.5
    HOME HEALTH AGENCY..........             609           9,816             0.1            -1.0             2.6
    HOSPITAL....................             567           7,329             0.1            -1.0             2.6
    SKILLED NURSING FACILITY....              17             251            -0.5            -1.6            2.0
----------------------------------------------------------------------------------------------------------------
* As of February, 2008; for this final rule, used FY 2007 claims as of March 2008.
** New England = Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont; Middle Atlantic =
  Pennsylvania, New Jersey, New York; South Atlantic = Delaware, District of Columbia, Florida, Georgia,
  Maryland, North Carolina, South Carolina, Virginia, West Virginia; East North Central = Illinois, Indiana,
  Michigan, Ohio, Wisconsin; East South Central = Alabama, Kentucky, Mississippi, Tennessee; West North Central
  = Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota; West South Central = Arkansas,
  Louisiana, Oklahoma, Texas; Mountain = Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming;
  Pacific = Alaska, California, Hawaii, Oregon, Washington; Outlying = Guam, Puerto Rico, Virgin Islands.
[dagger] This category refers to other government hospices.

    Table 2 shows the results of our analysis. In column 1 we indicate 
the number of hospices included in our analysis as of February 2008 
which had claims in FY 2007. 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 raw pre-floor, pre-
reclassified hospital wage index and

[[Page 46485]]

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 the 3.6 percent FY 2009 market basket update.
    Table 2 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 2,098 hospices located in urban areas and 1,013 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 2007. 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 2, there are 3,111 hospices. Approximately 
50.9 percent of Medicare-certified hospices are identified as 
voluntary, government, or other government 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 are now 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 raw 
pre-floor, pre-reclassified hospital wage indexes as well as the most 
complete claims data available (FY 2007 as of March 2008) in developing 
the impact analysis. The FY 2009 payment rates were adjusted to reflect 
the full 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 is 3.6 percent. 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 2 shows the combined impacts of the 25 percent BNAF 
reduction, the updated wage index, and a 3.6 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 followed by large 
hospices. Hospices are almost equal in numbers by ownership with 1,583 
designated as non-profit and 1,528 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 final FY 2009 wage index values without the BNAF reduction 
are anticipated to have a 0.1 percent increase on small hospice 
providers, a 0.1 percent decrease anticipated for medium hospices, and 
no change anticipated for large hospices (column 3); the final FY 2009 
wage index values with the 25 percent BNAF reduction and the updated 
wage data are anticipated to decrease estimated payments by 0.8 percent 
to small hospices and by 1.1 percent to medium and large hospices 
(column 4); and finally, the final FY 2009 wage index values with the 
25 percent BNAF reduction, the updated wage data, and the 3.6 percent 
FY 2009 market basket update are projected to increase estimated 
payments by 2.7 percent for small hospices and by 2.5 percent for 
medium and large hospices (column 5).
2. Geographic Location
    Column 3 of Table 2 shows that FY 2009 wage index values without 
the BNAF reduction will result in little change in estimated payments 
with no anticipated change for urban hospices and an anticipated 
decrease of 0.1 percent for rural hospices. 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 0.4 
percent, an increase of 0.1 percent for West North Central, and no 
change for the South Atlantic and Mountain regions. The remaining urban 
regions are anticipated to experience a decrease ranging from 0.1 
percent in the West South Central region to 1.1 percent in Puerto Rico.
    Column 3 shows that for rural hospices, Puerto Rico and the East 
North Central regions are anticipated to experience no change. Four 
regions are anticipated to experience a decrease ranging from 0.2 
percent for the West North Central region to 0.5 percent for West South 
Central region. The remaining regions are anticipated to experience an 
increase ranging from 0.1 percent for the South Atlantic region to 1.6 
percent for the Pacific region.
    Column 4 shows the combined effect of the 25 percent BNAF reduction 
and the updated raw pre-floor, pre-reclassified hospital wage index 
values on estimated payments, as compared to the published FY 2008 
payments.

[[Page 46486]]

Overall urban hospices are anticipated to experience a 1.1 percent 
decrease in payments, while rural hospices can expect a 0.9 percent 
decrease. The estimated percent decrease in payment for urban hospices 
ranged from 0.3 percent for Pacific hospices to 1.5 percent for Middle 
Atlantic hospices.
    The estimated percent decrease in payment for rural hospices ranged 
from 0.6 percent for Middle Atlantic hospices to 1.4 percent for New 
England hospices. Rural Puerto Rico's estimated payments were 
unaffected, and the Pacific region saw a 0.5 percent increase in 
estimated payments.
    Column 5 shows the combined effects of the final FY 2009 wage index 
values with the 25 percent BNAF reduction, the updated wage data, and 
the 3.6 percent FY 2009 market basket update on estimated payments as 
compared to the published FY 2008 payments. Overall, urban hospices are 
anticipated to experience a 2.5 percent increase in payments while 
rural hospices should experience a 2.7 percent increase in payments. 
Urban hospices are anticipated to see an increase in estimated payments 
ranging from 2.0 percent for the Middle Atlantic region to 3.3 percent 
for the Pacific region. Rural hospices are estimated to see an increase 
in estimated payments ranging from 2.1 percent for the New England 
region to 4.1 percent for the Pacific region.
 3. Type of Ownership
    Column 3 demonstrates the effect of the updated raw pre-floor, pre-
reclassified hospital wage index on FY 2009 estimated payments versus 
FY 2008 estimated payments. We anticipate that using the updated raw 
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 (0.1 percent), 
other hospices are expected to experience an increase of 0.1 percent, 
and government hospices are expected to experience an increase of 0.2 
percent.
    Column 4 demonstrates the combined effects of using updated raw 
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), government, and other hospices are anticipated 
to experience decreases of 1.2 percent, 0.8 percent, and 1.0 percent, 
respectively.
    Column 5 shows the combined effects of the updated raw pre-floor, 
pre-reclassified hospital wage index values with the 25 percent BNAF 
reduction, the updated wage data, and the 3.6 percent FY 2009 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 2.4 percent for voluntary hospices to 2.8 percent for 
government hospices.
4. Hospice Base
    Column 3 demonstrates the effect of using the updated raw pre-
floor, pre-reclassified hospital wage index values, comparing estimated 
payments for FY 2009 to FY 2008. Estimated payments are anticipated to 
decrease by 0.5 percent for skilled nursing facilities, but to increase 
for home health agency and hospital based facilities. Freestanding 
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 raw 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 1.6 percent 
decline, while hospital based hospices and home health agency based 
hospices are each anticipated to experience a 1.0 percent decrease in 
payments. Freestanding hospices are expected to experience a 1.1 
percent decrease.
    Column 5 shows the combined effects of the 25 percent BNAF 
reduction, the updated raw pre-floor, pre-reclassified hospital wage 
index, and the 3.6 percent FY 2009 market basket update on estimated 
payments, comparing FY 2009 to FY 2008. Estimated increases in payments 
range from 2.0 percent for skilled nursing facility based hospices to 
2.6 percent for home health agency based hospices and hospital 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 2 in this final rule, which include the effects of a 
3.6 percent FY 2009 market basket update, would need to change 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 3 below, we 
have prepared an accounting statement showing the classification of the 
expenditures associated with the final 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 
final rule on data for 3,111 hospices in our database. All expenditures 
are classified as transfers to Medicare providers (that is, hospices).

Table 3--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 of 3.6 percent.

    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.

0
For the reasons set forth in the preamble, the Centers for Medicare and 
Medicare Services amends 42 CFR chapter IV as set forth below:

PART 418--HOSPICE CARE

0
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

0
2. Section Sec.  418.306 is amended by revising paragraph (c) to read 
as follows:


Sec.  418.306  Determination of payment rates.

* * * * *
    (c) Adjustment for wage differences. 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

[[Page 46487]]

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)

    Dated: July 18, 2008.
Kerry Weems,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Approved: July 24, 2008.
Michael O. Leavitt,
Secretary.

    Note: The following Addenda will not appear in the Code of 
Federal Regulations.


  Addendum A--Final Hospice Wage Index for Urban Areas by CBSA--FY 2009
------------------------------------------------------------------------
                                Urban area (constituent       Wage index
        CBSA code                    counties) \2\               \1\
------------------------------------------------------------------------
10180....................  Abilene, TX.....................       0.8352
                             Callahan County, TX
                             Jones County, TX
                             Taylor County, TX
10380....................  Aguadilla-Isabela-San                  0.3965
                            Sebasti[aacute]n, PR.
                             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.......................       0.9231
                             Portage County, OH
                             Summit County, OH
10500....................  Albany, GA......................       0.8937
                             Baker County, GA
                             Dougherty County, GA
                             Lee County, GA
                             Terrell County, GA
                             Worth County, GA
10580....................  Albany-Schenectady-Troy, NY.....       0.9015
                             Albany County, NY
                             Rensselaer County, NY
                             Saratoga County, NY
                             Schenectady County, NY
                             Schoharie County, NY
10740....................  Albuquerque, NM.................       1.0029
                             Bernalillo County, NM
                             Sandoval County, NM
                             Torrance County, NM
                             Valencia County, NM
10780....................  Alexandria, LA..................       0.8375
                             Grant Parish, LA
                             Rapides Parish, LA
10900....................  Allentown-Bethlehem-Easton, PA-        1.0355
                            NJ.
                             Warren County, NJ
                             Carbon County, PA
                             Lehigh County, PA
                             Northampton County, PA
11020....................  Altoona, PA.....................       0.9046
                             Blair County, PA
11100....................  Amarillo, TX....................       0.9569
                             Armstrong County, TX
                             Carson County, TX
                             Potter County, TX
                             Randall County, TX
11180....................  Ames, IA........................       1.0545
                             Story County, IA
11260....................  Anchorage, AK...................       1.2505
                             Anchorage Municipality, AK
                             Matanuska-Susitna Borough, AK
11300....................  Anderson, IN....................       0.9266
                             Madison County, IN
11340....................  Anderson, SC....................       0.9537
                             Anderson County, SC
11460....................  Ann Arbor, MI...................       1.1063
                             Washtenaw County, MI
11500....................  Anniston-Oxford, AL.............       0.8320

[[Page 46488]]

 
                             Calhoun County, AL
11540....................  Appleton, WI....................       1.0075
                             Calumet County, WI
                             Outagamie County, WI
11700....................  Asheville, NC...................       0.9641
                             Buncombe County, NC
                             Haywood County, NC
                             Henderson County, NC
                             Madison County, NC
12020....................  Athens-Clarke County, GA........       1.1040
                             Clarke County, GA
                             Madison County, GA
                             Oconee County, GA
                             Oglethorpe County, GA
12060....................  Atlanta-Sandy Springs-Marietta,        1.0316
                            GA.
                             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
                             Pickens County, GA
                             Pike County, GA
                             Rockdale County, GA
                             Spalding County, GA
                             Walton County, GA
12100....................  Atlantic City, NJ...............       1.2804
                             Atlantic County, NJ
12220....................  Auburn-Opelika, AL..............       0.8492
                             Lee County, AL
12260....................  Augusta-Richmond County, GA-SC..       1.0124
                             Burke County, GA
                             Columbia County, GA
                             McDuffie County, GA
                             Richmond County, GA
                             Aiken County, SC
                             Edgefield County, SC
12420....................  Austin-Round Rock, TX...........       1.0018
                             Bastrop County, TX
                             Caldwell County, TX
                             Hays County, TX
                             Travis County, TX
                             Williamson County, TX
12540....................  Bakersfield, CA.................       1.1600
                             Kern County, CA
12580....................  Baltimore-Towson, MD............       1.0638
                             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......................       1.0474

[[Page 46489]]

 
                             Penobscot County, ME
12700....................  Barnstable Town, MA.............       1.3229
                             Barnstable County, MA
12940....................  Baton Rouge, LA.................       0.8433
                             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................       1.0685
                             Calhoun County, MI
13020....................  Bay City, MI....................       0.9339
                             Bay County, MI
13140....................  Beaumont-Port Arthur, TX........       0.8955
                             Hardin County, TX
                             Jefferson County, TX
                             Orange County, TX
13380....................  Bellingham, WA..................       1.2044
                             Whatcom County, WA
13460....................  Bend, OR........................       1.1486
                             Deschutes County, OR
13644....................  Bethesda-Frederick-Gaithersburg,       1.1033
                            MD.
                             Frederick County, MD
                             Montgomery County, MD
13740....................  Billings, MT....................       0.9097
                             Carbon County, MT
                             Yellowstone County, MT
13780....................  Binghamton, NY..................       0.9394
                             Broome County, NY
                             Tioga County, NY
13820....................  Birmingham-Hoover, AL...........       0.9340
                             Bibb County, AL
                             Blount County, AL
                             Chilton County, AL
                             Jefferson County, AL
                             St. Clair County, AL
                             Shelby County, AL
                             Walker County, AL
13900....................  Bismarck, ND....................       0.8000
                             Burleigh County, ND
                             Morton County, ND
13980....................  Blacksburg-Christiansburg-             0.8599
                            Radford, VA.
                             Giles County, VA
                             Montgomery County, VA
                             Pulaski County, VA
                             Radford City, VA
14020....................  Bloomington, IN.................       0.9358
                             Greene County, IN
                             Monroe County, IN
                             Owen County, IN
14060....................  Bloomington-Normal, IL..........       0.9788
                             McLean County, IL
14260....................  Boise City-Nampa, ID............       0.9935
                             Ada County, ID
                             Boise County, ID
                             Canyon County, ID
                             Gem County, ID
                             Owyhee County, ID
14484....................  Boston-Quincy, MA...............       1.2378
                             Norfolk County, MA
                             Plymouth County, MA
                             Suffolk County, MA
14500....................  Boulder, CO.....................       1.0944
                             Boulder County, CO
14540....................  Bowling Green, KY...............       0.8564
                             Edmonson County, KY
                             Warren County, KY

[[Page 46490]]

 
14740....................  Bremerton-Silverdale, WA........       1.1446
                             Kitsap County, WA
14860....................  Bridgeport-Stamford-Norwalk, CT.       1.3368
                             Fairfield County, CT
15180....................  Brownsville-Harlingen, TX.......       0.9357
                             Cameron County, TX
15260....................  Brunswick, GA...................       0.9946
                             Brantley County, GA
                             Glynn County, GA
                             McIntosh County, GA
15380....................  Buffalo-Niagara Falls, NY.......       1.0043
                             Erie County, NY
                             Niagara County, NY
15500....................  Burlington, NC..................       0.9182
                             Alamance County, NC
15540....................  Burlington-South Burlington, VT.       1.0140
                             Chittenden County, VT
                             Franklin County, VT
                             Grand Isle County, VT
15764....................  Cambridge-Newton-Framingham, MA.       1.1772
                             Middlesex County, MA
15804....................  Camden, NJ......................       1.0928
                             Burlington County, NJ
                             Camden County, NJ
                             Gloucester County, NJ
15940....................  Canton-Massillon, OH............       0.9379
                             Carroll County, OH
                             Stark County, OH
15980....................  Cape Coral-Fort Myers, FL.......       0.9863
                             Lee County, FL
16180....................  Carson City, NV.................       1.0500
16220....................  Casper, WY......................       0.9851
                             Natrona County, WY
16300....................  Cedar Rapids, IA................       0.9292
                             Benton County, IA
                             Jones County, IA
                             Linn County, IA
16580....................  Champaign-Urbana, IL............       0.9859
                             Champaign County, IL
                             Ford County, IL
                             Piatt County, IL
16620....................  Charleston, WV..................       0.8701
                             Boone County, WV
                             Clay County, WV
                             Kanawha County, WV
                             Lincoln County, WV
                             Putnam County, WV
16700....................  Charleston-North Charleston, SC.       0.9577
                             Berkeley County, SC
                             Charleston County, SC
                             Dorchester County, SC
16740....................  Charlotte-Gastonia-Concord, NC-        0.9993
                            SC.
                             Anson County, NC
                             Cabarrus County, NC
                             Gaston County, NC
                             Mecklenburg County, NC
                             Union County, NC
                             York County, SC
16820....................  Charlottesville, VA.............       0.9738
                             Albemarle County, VA
                             Fluvanna County, VA
                             Greene County, VA
                             Nelson County, VA
                             Charlottesville City, VA
16860....................  Chattanooga, TN-GA..............       0.9441
                             Catoosa County, GA
                             Dade County, GA
                             Walker County, GA
                             Hamilton County, TN
                             Marion County, TN
                             Sequatchie County, TN

[[Page 46491]]

 
16940....................  Cheyenne, WY....................       0.9771
                             Laramie County, WY
16974....................  Chicago-Naperville-Joliet, IL...       1.1247
                             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.......................       1.1851
                             Butte County, CA
17140....................  Cincinnati-Middletown, OH-KY-IN.       1.0270
                             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..............       0.8661
                             Christian County, KY
                             Trigg County, KY
                             Montgomery County, TN
                             Stewart County, TN
17420....................  Cleveland, TN...................       0.8452
                             Bradley County, TN
                             Polk County, TN
17460....................  Cleveland-Elyria-Mentor, OH.....       0.9803
                             Cuyahoga County, OH
                             Geauga County, OH
                             Lake County, OH
                             Lorain County, OH
                             Medina County, OH
17660....................  Coeur d'Alene, ID...............       1.0006
                             Kootenai County, ID
17780....................  College Station-Bryan, TX.......       0.9823
                             Brazos County, TX
                             Burleson County, TX
                             Robertson County, TX
17820....................  Colorado Springs, CO............       1.0202
                             El Paso County, CO
                             Teller County, CO
17860....................  Columbia, MO....................       0.9088
                             Boone County, MO
                             Howard County, MO
17900....................  Columbia, SC....................       0.9237
                             Calhoun County, SC
                             Fairfield County, SC
                             Kershaw County, SC
                             Lexington County, SC
                             Richland County, SC
                             Saluda County, SC
17980....................  Columbus, GA-AL.................       0.9163
                             Russell County, AL
                             Chattahoochee County, GA
                             Harris County, GA
                             Marion County, GA
                             Muscogee County, GA
18020....................  Columbus, IN....................       1.0011
                             Bartholomew County, IN
18140....................  Columbus, OH....................       1.0586

[[Page 46492]]

 
                             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..............       0.9015
                             Aransas County, TX
                             Nueces County, TX
                             San Patricio County, TX
18700....................  Corvallis, OR...................       1.1504
                             Benton County, OR
19060....................  Cumberland, MD-WV...............       0.8706
                             Allegany County, MD
                             Mineral County, WV
19124....................  Dallas-Plano-Irving, TX.........       1.0408
                             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......................       0.9195
                             Murray County, GA
                             Whitfield County, GA
19180....................  Danville, IL....................       0.9402
                             Vermilion County, IL
19260....................  Danville, VA....................       0.8649
                             Pittsylvania County, VA
                             Danville City, VA
19340....................  Davenport-Moline-Rock Island, IA-      0.9269
                            IL.
                             Henry County, IL
                             Mercer County, IL
                             Rock Island County, IL
                             Scott County, IA
19380....................  Dayton, OH......................       0.9647
                             Greene County, OH
                             Miami County, OH
                             Montgomery County, OH
                             Preble County, OH
19460....................  Decatur, AL.....................       0.8277
                             Lawrence County, AL
                             Morgan County, AL
19500....................  Decatur, IL.....................       0.8475
                             Macon County, IL
19660....................  Deltona-Daytona Beach-Ormond           0.9480
                            Beach, FL.
                             Volusia County, FL
19740....................  Denver-Aurora, CO...............       1.1251
                             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..       0.9684
                             Dallas County, IA
                             Guthrie County, IA
                             Madison County, IA
                             Polk County, IA
                             Warren County, IA
19804....................  Detroit-Livonia-Dearborn, MI....       1.0496
                             Wayne County, MI
20020....................  Dothan, AL......................       0.8000

[[Page 46493]]

 
                             Geneva County, AL
                             Henry County, AL
                             Houston County, AL
20100....................  Dover, DE.......................       1.0601
                             Kent County, DE
20220....................  Dubuque, IA.....................       0.9508
                             Dubuque County, IA
20260....................  Duluth, MN-WI...................       1.0471
                             Carlton County, MN
                             St. Louis County, MN
                             Douglas County, WI
20500....................  Durham, NC......................       1.0304
                             Chatham County, NC
                             Durham County, NC
                             Orange County, NC
                             Person County, NC
20740....................  Eau Claire, WI..................       0.9946
                             Chippewa County, WI
                             Eau Claire County, WI
20764....................  Edison, NJ......................       1.1737
                             Middlesex County, NJ
                             Monmouth County, NJ
                             Ocean County, NJ
                             Somerset County, NJ
20940....................  El Centro, CA...................       0.9357
                             Imperial County, CA
21060....................  Elizabethtown, KY...............       0.9144
                             Hardin County, KY
                             Larue County, KY
21140....................  Elkhart-Goshen, IN..............       1.0089
                             Elkhart County, IN
21300....................  Elmira, NY......................       0.8675
                             Chemung County, NY
21340....................  El Paso, TX.....................       0.9436
                             El Paso County, TX
21500....................  Erie, PA........................       0.8917
                             Erie County, PA
21660....................  Eugene-Springfield, OR..........       1.1475
                             Lane County, OR
21780....................  Evansville, IN-KY...............       0.9092
                             Gibson County, IN
                             Posey County, IN
                             Vanderburgh County, IN
                             Warrick County, IN
                             Henderson County, KY
                             Webster County, KY
21820....................  Fairbanks, AK...................       1.1599
                             Fairbanks North Star Borough,
                           AK
21940....................  Fajardo, PR.....................       0.5031
                             Ceiba Municipio, PR
                             Fajardo Municipio, PR
                             Luquillo Municipio, PR
22020....................  Fargo, ND-MN....................       0.8442
                             Cass County, ND
                             Clay County, MN
22140....................  Farmington, NM..................       1.0063
                             San Juan County, NM
22180....................  Fayetteville, NC................       0.9834
                             Cumberland County, NC
                             Hoke County, NC
22220....................  Fayetteville-Springdale-Rogers,        0.9176
                            AR-MO.
                             Benton County, AR
                             Madison County, AR
                             Washington County, AR
                             McDonald County, MO
22380....................  Flagstaff, AZ...................       1.2268
                             Coconino County, AZ
22420....................  Flint, MI.......................       1.1778
                             Genesee County, MI
22500....................  Florence, SC....................       0.8659
                             Darlington County, SC

[[Page 46494]]

 
                             Florence County, SC
22520....................  Florence-Muscle Shoals, AL......       0.8062
                             Colbert County, AL
                             Lauderdale County, AL
22540....................  Fond du Lac, WI.................       1.0147
                             Fond du Lac County, WI
22660....................  Fort Collins-Loveland, CO.......       1.0389
                             Larimer County, CO
22744....................  Fort Lauderdale-Pompano Beach-         1.0737
                            Deerfield Beach, FL.
                             Broward County, FL
22900....................  Fort Smith, AR-OK...............       0.8327
                             Crawford County, AR
                             Franklin County, AR
                             Sebastian County, AR
                             Le Flore County, OK
                             Sequoyah County, OK
23020....................  Fort Walton Beach-Crestview-           0.9177
                            Destin, FL.
                             Okaloosa County, FL
23060....................  Fort Wayne, IN..................       0.9745
                             Allen County, IN
                             Wells County, IN
                             Whitley County, IN
23104....................  Fort Worth-Arlington, TX........       1.0175
                             Johnson County, TX
                             Parker County, TX
                             Tarrant County, TX
                             Wise County, TX
23420....................  Fresno, CA......................       1.1539
                             Fresno County, CA
23460....................  Gadsden, AL.....................       0.8564
                             Etowah County, AL
23540....................  Gainesville, FL.................       0.9653
                             Alachua County, FL
                             Gilchrist County, FL
23580....................  Gainesville, GA.................       0.9674
                             Hall County, GA
23844....................  Gary, IN........................       0.9682
                             Jasper County, IN
                             Lake County, IN
                             Newton County, IN
                             Porter County, IN
24020....................  Glens Falls, NY.................       0.8666
                             Warren County, NY
                             Washington County, NY
24140....................  Goldsboro, NC...................       0.9750
                             Wayne County, NC
24220....................  Grand Forks, ND-MN..............       0.8273
                             Polk County, MN
                             Grand Forks County, ND
24300....................  Grand Junction, CO..............       1.0354
                             Mesa County, CO
24340....................  Grand Rapids-Wyoming, MI........       0.9778
                             Barry County, MI
                             Ionia County, MI
                             Kent County, MI
                             Newaygo County, MI
24500....................  Great Falls, MT.................       0.9106
                             Cascade County, MT
24540....................  Greeley, CO.....................       1.0138
                             Weld County, CO
24580....................  Green Bay, WI...................       1.0210
                             Brown County, WI
                             Kewaunee County, WI
                             Oconto County, WI
24660....................  Greensboro-High Point, NC.......       0.9458
                             Guilford County, NC
                             Randolph County, NC
                             Rockingham County, NC
24780....................  Greenville, NC..................       0.9869
                             Greene County, NC
                             Pitt County, NC

[[Page 46495]]

 
24860....................  Greenville-Mauldin-Easley, SC...       1.0350
                             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.............       0.9209
                             Hancock County, MS
                             Harrison County, MS
                             Stone County, MS
25180....................  Hagerstown-Martinsburg, MD-WV...       0.9461
                             Washington County, MD
                             Berkeley County, WV
                             Morgan County, WV
25260....................  Hanford-Corcoran, CA............       1.1021
                             Kings County, CA
25420....................  Harrisburg-Carlisle, PA.........       0.9741
                             Cumberland County, PA
                             Dauphin County, PA
                             Perry County, PA
25500....................  Harrisonburg, VA................       0.9308
                             Rockingham County, VA
                             Harrisonburg City, VA
25540....................  Hartford-West Hartford-East            1.1504
                            Hartford, CT.
                             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....       0.9477
                             Alexander County, NC
                             Burke County, NC
                             Caldwell County, NC
                             Catawba County, NC
25980....................  Hinesville-Fort Stewart, GA \3\.       0.9644
                             Liberty County, GA
                             Long County, GA
26100....................  Holland-Grand Haven, MI.........       0.9454
                             Ottawa County, MI
26180....................  Honolulu, HI....................       1.2130
                             Honolulu County, HI
26300....................  Hot Springs, AR.................       0.9562
                             Garland County, AR
26380....................  Houma-Bayou Cane-Thibodaux, LA..       0.8284
                             Lafourche Parish, LA
                             Terrebonne Parish, LA
26420....................  Houston-Sugar Land-Baytown, TX..       1.0433
                             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....       0.9490
                             Boyd County, KY
                             Greenup County, KY
                             Lawrence County, OH
                             Cabell County, WV
                             Wayne County, WV
26620....................  Huntsville, AL..................       0.9600
                             Limestone County, AL
                             Madison County, AL
26820....................  Idaho Falls, ID.................       0.9724

[[Page 46496]]

 
                             Bonneville County, ID
                             Jefferson County, ID
26900....................  Indianapolis-Carmel, IN.........       1.0333
                             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...................       1.0043
                             Johnson County, IA
                             Washington County, IA
27060....................  Ithaca, NY......................       1.0109
                             Tompkins County, NY
27100....................  Jackson, MI.....................       0.9793
                             Jackson County, MI
27140....................  Jackson, MS.....................       0.8409
                             Copiah County, MS
                             Hinds County, MS
                             Madison County, MS
                             Rankin County, MS
                             Simpson County, MS
27180....................  Jackson, TN.....................       0.9107
                             Chester County, TN
                             Madison County, TN
27260....................  Jacksonville, FL................       0.9469
                             Baker County, FL
                             Clay County, FL
                             Duval County, FL
                             Nassau County, FL
                             St. Johns County, FL
27340....................  Jacksonville, NC................       0.8480
                             Onslow County, NC
27500....................  Janesville, WI..................       1.0184
                             Rock County, WI
27620....................  Jefferson City, MO..............       0.8899
                             Callaway County, MO
                             Cole County, MO
                             Moniteau County, MO
                             Osage County, MO
27740....................  Johnson City, TN................       0.8058
                             Carter County, TN
                             Unicoi County, TN
                             Washington County, TN
27780....................  Johnstown, PA...................       0.8000
                             Cambria County, PA
27860....................  Jonesboro, AR...................       0.8177
                             Craighead County, AR
                             Poinsett County, AR
27900....................  Joplin, MO......................       0.9396
                             Jasper County, MO
                             Newton County, MO
28020....................  Kalamazoo-Portage, MI...........       1.0951
                             Kalamazoo County, MI
                             Van Buren County, MI
28100....................  Kankakee-Bradley, IL............       1.0747
                             Kankakee County, IL
28140....................  Kansas City, MO-KS..............       0.9976
                             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

[[Page 46497]]

 
                             Clay County, MO
                             Clinton County, MO
                             Jackson County, MO
                             Lafayette County, MO
                             Platte County, MO
                             Ray County, MO
28420....................  Kennewick-Richland-Pasco, WA....       1.0576
                             Benton County, WA
                             Franklin County, WA
28660....................  Killeen-Temple-Fort Hood, TX....       0.8659
                             Bell County, TX
                             Coryell County, TX
                             Lampasas County, TX
28700....................  Kingsport-Bristol-Bristol, TN-VA       0.8039
                             Hawkins County, TN
                             Sullivan County, TN
                             Bristol City, VA
                             Scott County, VA
                             Washington County, VA
28740....................  Kingston, NY....................       1.0031
                             Ulster County, NY
28940....................  Knoxville, TN...................       0.8435
                             Anderson County, TN
                             Blount County, TN
                             Knox County, TN
                             Loudon County, TN
                             Union County, TN
29020....................  Kokomo, IN......................       1.0068
                             Howard County, IN
                             Tipton County, IN
29100....................  La Crosse, WI-MN................       1.0166
                             Houston County, MN
                             La Crosse County, WI
29140....................  Lafayette, IN...................       0.9310
                             Benton County, IN
                             Carroll County, IN
                             Tippecanoe County, IN
29180....................  Lafayette, LA...................       0.8657
                             Lafayette Parish, LA
                             St. Martin Parish, LA
29340....................  Lake Charles, LA................       0.8163
                             Calcasieu Parish, LA
                             Cameron Parish, LA
29404....................  Lake County-Kenosha County, IL-        1.1130
                            WI.
                             Lake County, IL
                             Kenosha County, WI
29420....................  Lake Havasu City-Kingman, AZ....       0.9797
                             Mohave County, AZ
29460....................  Lakeland, FL....................       0.9091
                             Polk County, FL
29540....................  Lancaster, PA...................       0.9712
                             Lancaster County, PA
29620....................  Lansing-East Lansing, MI........       1.0622
                             Clinton County, MI
                             Eaton County, MI
                             Ingham County, MI
29700....................  Laredo, TX......................       0.8495
                             Webb County, TX
29740....................  Las Cruces, NM..................       0.9107
                             Dona Ana County, NM
29820....................  Las Vegas-Paradise, NV..........       1.2385
                             Clark County, NV
29940....................  Lawrence, KS....................       0.8636
                             Douglas County, KS
30020....................  Lawton, OK......................       0.8424
                             Comanche County, OK
30140....................  Lebanon, PA.....................       0.8599
                             Lebanon County, PA
30300....................  Lewiston, ID-WA.................       0.9924
                             Nez Perce County, ID
                             Asotin County, WA

[[Page 46498]]

 
30340....................  Lewiston-Auburn, ME.............       0.9650
                             Androscoggin County, ME
30460....................  Lexington-Fayette, KY...........       0.9648
                             Bourbon County, KY
                             Clark County, KY
                             Fayette County, KY
                             Jessamine County, KY
                             Scott County, KY
                             Woodford County, KY
30620....................  Lima, OH........................       0.9892
                             Allen County, OH
30700....................  Lincoln, NE.....................       1.0550
                             Lancaster County, NE
                             Seward County, NE
30780....................  Little Rock-North Little Rock-         0.9303
                            Conway, AR.
                             Faulkner County, AR
                             Grant County, AR
                             Lonoke County, AR
                             Perry County, AR
                             Pulaski County, AR
                             Saline County, AR
30860....................  Logan, UT-ID....................       0.9639
                             Franklin County, ID
                             Cache County, UT
30980....................  Longview, TX....................       0.9150
                             Gregg County, TX
                             Rusk County, TX
                             Upshur County, TX
31020....................  Longview, WA....................       1.1365
                             Cowlitz County, WA
31084....................  Los Angeles-Long Beach-Glendale,       1.2356
                            CA.
                             Los Angeles County, CA
31140....................  Louisville, KY-IN...............       0.9515
                             Clark County, IN
                             Floyd County, IN
                             Harrison County, IN
                             Washington County, IN
                             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.....................       0.9111
                             Crosby County, TX
                             Lubbock County, TX
31340....................  Lynchburg, VA...................       0.9166
                             Amherst County, VA
                             Appomattox County, VA
                             Bedford County, VA
                             Campbell County, VA
                             Bedford City, VA
                             Lynchburg City, VA
31420....................  Macon, GA.......................       1.0015
                             Bibb County, GA
                             Crawford County, GA
                             Jones County, GA
                             Monroe County, GA
                             Twiggs County, GA
31460....................  Madera, CA......................       0.8470
                             Madera County, CA
31540....................  Madison, WI.....................       1.1478
                             Columbia County, WI
                             Dane County, WI
                             Iowa County, WI
31700....................  Manchester-Nashua, NH...........       1.0783
                             Hillsborough County, NH
31900....................  Mansfield, OH...................       0.9732

[[Page 46499]]

 
                             Richland County, OH
32420....................  Mayag[uuml]ez, PR...............       0.4268
                             Hormigueros Municipio, PR
                             Mayag[uuml]ez Municipio, PR
32580....................  McAllen-Edinburg-Pharr, TX......       0.9576
                             Hidalgo County, TX
32780....................  Medford, OR.....................       1.0831
                             Jackson County, OR
32820....................  Memphis, TN-MS-AR...............       0.9710
                             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......................       1.2722
                             Merced County, CA
33124....................  Miami-Miami Beach-Kendall, FL...       1.0499
                             Miami-Dade County, FL
33140....................  Michigan City-La Porte, IN......       0.9357
                             LaPorte County, IN
33260....................  Midland, TX.....................       1.0515
                             Midland County, TX
33340....................  Milwaukee-Waukesha-West Allis,         1.0722
                            WI.
                             Milwaukee County, WI
                             Ozaukee County, WI
                             Washington County, WI
                             Waukesha County, WI
33460....................  Minneapolis-St. Paul-                  1.1644
                            Bloomington, MN-WI.
                             Anoka County, MN
                             Carver County, MN
                             Chisago County, MN
                             Dakota County, MN
                             Hennepin County, MN
                             Isanti County, MN
                             Ramsey County, MN
                             Scott County, MN
                             Sherburne County, MN
                             Washington County, MN
                             Wright County, MN
                             Pierce County, WI
                             St. Croix County, WI
33540....................  Missoula, MT....................       0.9398
                             Missoula County, MT
33660....................  Mobile, AL......................       0.8432
                             Mobile County, AL
33700....................  Modesto, CA.....................       1.2556
                             Stanislaus County, CA
33740....................  Monroe, LA......................       0.8221
                             Ouachita Parish, LA
                             Union Parish, LA
33780....................  Monroe, MI......................       0.9882
                             Monroe County, MI
33860....................  Montgomery, AL..................       0.8490
                             Autauga County, AL
                             Elmore County, AL
                             Lowndes County, AL
                             Montgomery County, AL
34060....................  Morgantown, WV..................       0.8734
                             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......       1.1052
                             Skagit County, WA
34620....................  Muncie, IN......................       0.8622
                             Delaware County, IN

[[Page 46500]]

 
34740....................  Muskegon-Norton Shores, MI......       1.0325
                             Muskegon County, MI
34820....................  Myrtle Beach-Conway-North Myrtle       0.9063
                            Beach, SC.
                             Horry County, SC
34900....................  Napa, CA........................       1.5195
                             Napa County, CA
34940....................  Naples-Marco Island, FL.........       0.9958
                             Collier County, FL
34980....................  Nashville-Davidson-Murfreesboro-       1.0170
                            Franklin, TN.
                             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..............       1.3268
                             Nassau County, NY
                             Suffolk County, NY
35084....................  Newark-Union, NJ-PA.............       1.2451
                             Essex County, NJ
                             Hunterdon County, NJ
                             Morris County, NJ
                             Sussex County, NJ
                             Union County, NJ
                             Pike County, PA
35300....................  New Haven-Milford, CT...........       1.2461
                             New Haven County, CT
35380....................  New Orleans-Metairie-Kenner, LA.       0.9339
                             Jefferson Parish, LA
                             Orleans Parish, LA
                             Plaquemines Parish, LA
                             St. Bernard Parish, LA
                             St. Charles Parish, LA
                             St. John the Baptist Parish,
                           LA
                             St. Tammany Parish, LA
35644....................  New York-Wayne-White Plains, NY-       1.3767
                            NJ.
                             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.........       0.9595
                             Berrien County, MI
35980....................  Norwich-New London, CT..........       1.2000
                             New London County, CT
36084....................  Oakland-Fremont-Hayward, CA.....       1.6464
                             Alameda County, CA
                             Contra Costa County, CA
36100....................  Ocala, FL.......................       0.9056
                             Marion County, FL
36140....................  Ocean City, NJ..................       1.1534
                             Cape May County, NJ
36220....................  Odessa, TX......................       1.0541
                             Ector County, TX
36260....................  Ogden-Clearfield, UT............       0.9447
                             Davis County, UT
                             Morgan County, UT
                             Weber County, UT

[[Page 46501]]

 
36420....................  Oklahoma City, OK...............       0.9253
                             Canadian County, OK
                             Cleveland County, OK
                             Grady County, OK
                             Lincoln County, OK
                             Logan County, OK
                             McClain County, OK
                             Oklahoma County, OK
36500....................  Olympia, WA.....................       1.2084
                             Thurston County, WA
36540....................  Omaha-Council Bluffs, NE-IA.....       1.0036
                             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.....................       0.9684
                             Lake County, FL
                             Orange County, FL
                             Osceola County, FL
                             Seminole County, FL
36780....................  Oshkosh-Neenah, WI..............       1.0026
                             Winnebago County, WI
36980....................  Owensboro, KY...................       0.9082
                             Daviess County, KY
                             Hancock County, KY
                             McLean County, KY
37100....................  Oxnard-Thousand Oaks-Ventura, CA       1.2441
                             Ventura County, CA
37340....................  Palm Bay-Melbourne-Titusville,         0.9788
                            FL.
                             Brevard County, FL
37380....................  Palm Coast, FL..................       0.9389
                             Flagler County, FL
37460....................  Panama City-Lynn Haven, FL......       0.8726
                             Bay County, FL
37620....................  Parkersburg-Marietta, WV-OH.....       0.8508
                             Washington County, OH
                             Pleasants County, WV
                             Wirt County, WV
                             Wood County, WV
37700....................  Pascagoula, MS..................       0.9077
                             George County, MS
                             Jackson County, MS
37764....................  Peabody, MA.....................       1.1179
                             Essex County, MA
37860....................  Pensacola-Ferry Pass-Brent, FL..       0.8692
                             Escambia County, FL
                             Santa Rosa County, FL
37900....................  Peoria, IL......................       0.9761
                             Marshall County, IL
                             Peoria County, IL
                             Stark County, IL
                             Tazewell County, IL
                             Woodford County, IL
37964....................  Philadelphia, PA................       1.1468
                             Bucks County, PA
                             Chester County, PA
                             Delaware County, PA
                             Montgomery County, PA
                             Philadelphia County, PA
38060....................  Phoenix-Mesa-Scottsdale, AZ.....       1.0774
                             Maricopa County, AZ
                             Pinal County, AZ
38220....................  Pine Bluff, AR..................       0.8229
                             Cleveland County, AR
                             Jefferson County, AR
                             Lincoln County, AR
38300....................  Pittsburgh, PA..................       0.8949

[[Page 46502]]

 
                             Allegheny County, PA
                             Armstrong County, PA
                             Beaver County, PA
                             Butler County, PA
                             Fayette County, PA
                             Washington County, PA
                             Westmoreland County, PA
38340....................  Pittsfield, MA..................       1.0592
                             Berkshire County, MA
38540....................  Pocatello, ID...................       0.9935
                             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-               1.0541
                            Biddeford, ME.
                             Cumberland County, ME
                             Sagadahoc County, ME
                             York County, ME
38900....................  Portland-Vancouver-Beaverton, OR-      1.2069
                            WA.
                             Clackamas County, OR
                             Columbia County, OR
                             Multnomah County, OR
                             Washington County, OR
                             Yamhill County, OR
                             Clark County, WA
                             Skamania County, WA
38940....................  Port St. Lucie, FL..............       1.0514
                             Martin County, FL
                             St. Lucie County, FL
39100....................  Poughkeepsie-Newburgh-                 1.1528
                            Middletown, NY.
                             Dutchess County, NY
                             Orange County, NY
39140....................  Prescott, AZ....................       1.0518
                             Yavapai County, AZ
39300....................  Providence-New Bedford-Fall            1.1099
                            River, RI-MA.
                             Bristol County, MA
                             Bristol County, RI
                             Kent County, RI
                             Newport County, RI
                             Providence County, RI
                             Washington County, RI
39340....................  Provo-Orem, UT..................       1.0032
                             Juab County, UT
                             Utah County, UT
39380....................  Pueblo, CO......................       0.9291
                             Pueblo County, CO
39460....................  Punta Gorda, FL.................       0.9714
                             Charlotte County, FL
39540....................  Racine, WI......................       0.9970
                             Racine County, WI
39580....................  Raleigh-Cary, NC................       1.0328
                             Franklin County, NC
                             Johnston County, NC
                             Wake County, NC
39660....................  Rapid City, SD..................       0.9249
                             Meade County, SD
                             Pennington County, SD
39740....................  Reading, PA.....................       0.9821
                             Berks County, PA
39820....................  Redding, CA.....................       1.4214
                             Shasta County, CA
39900....................  Reno-Sparks, NV.................       1.1247
                             Storey County, NV
                             Washoe County, NV
40060....................  Richmond, VA....................       0.9893
                             Amelia County, VA
                             Caroline County, VA
                             Charles City County, VA
                             Chesterfield County, VA

[[Page 46503]]

 
                             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-              1.1652
                            Ontario, CA.
                             Riverside County, CA
                             San Bernardino County, CA
40220....................  Roanoke, VA.....................       0.9123
                             Botetourt County, VA
                             Craig County, VA
                             Franklin County, VA
                             Roanoke County, VA
                             Roanoke City, VA
                             Salem City, VA
40340....................  Rochester, MN...................       1.1289
                             Dodge County, MN
                             Olmsted County, MN
                             Wabasha County, MN
40380....................  Rochester, NY...................       0.9298
                             Livingston County, NY
                             Monroe County, NY
                             Ontario County, NY
                             Orleans County, NY
                             Wayne County, NY
40420....................  Rockford, IL....................       1.0302
                             Boone County, IL
                             Winnebago County, IL
40484....................  Rockingham County-Strafford            1.0613
                            County, NH.
                             Rockingham County, NH
                             Strafford County, NH
40580....................  Rocky Mount, NC.................       0.9448
                             Edgecombe County, NC
                             Nash County, NC
40660....................  Rome, GA........................       0.9491
                             Floyd County, GA
40900....................  Sacramento--Arden-Arcade--             1.4176
                            Roseville, CA.
                             El Dorado County, CA
                             Placer County, CA
                             Sacramento County, CA
                             Yolo County, CA
40980....................  Saginaw-Saginaw Township North,        0.9250
                            MI.
                             Saginaw County, MI
41060....................  St. Cloud, MN...................       1.1073
                             Benton County, MN
                             Stearns County, MN
41100....................  St. George, UT..................       0.9823
                             Washington County, UT
41140....................  St. Joseph, MO-KS...............       0.9197
                             Doniphan County, KS
                             Andrew County, MO
                             Buchanan County, MO
                             DeKalb County, MO
41180....................  St. Louis, MO-IL................       0.9472
                             Bond County, IL
                             Calhoun County, IL
                             Clinton County, IL
                             Jersey County, IL
                             Macoupin County, IL
                             Madison County, IL

[[Page 46504]]

 
                             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.......................       1.1097
                             Marion County, OR
                             Polk County, OR
41500....................  Salinas, CA.....................       1.5509
                             Monterey County, CA
41540....................  Salisbury, MD...................       0.9441
                             Somerset County, MD
                             Wicomico County, MD
41620....................  Salt Lake City, UT..............       0.9866
                             Salt Lake County, UT
                             Summit County, UT
                             Tooele County, UT
41660....................  San Angelo, TX..................       0.9005
                             Irion County, TX
                             Tom Green County, TX
41700....................  San Antonio, TX.................       0.9273
                             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,         1.2063
                            CA.
                             San Diego County, CA
41780....................  Sandusky, OH....................       0.9260
                             Erie County, OH
41884....................  San Francisco-San Mateo-Redwood        1.5950
                            City, CA.
                             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,        1.6517
                            CA.
                             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

[[Page 46505]]

 
                             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.       1.3109
                             San Luis Obispo County, CA
42044....................  Santa Ana-Anaheim-Irvine, CA....       1.2351
                             Orange County, CA
42060....................  Santa Barbara-Santa Maria-             1.2296
                            Goleta, CA.
                             Santa Barbara County, CA
42100....................  Santa Cruz-Watsonville, CA......       1.6923
                             Santa Cruz County, CA
42140....................  Santa Fe, NM....................       1.1267
                             Santa Fe County, NM
42220....................  Santa Rosa-Petaluma, CA.........       1.5426
                             Sonoma County, CA
42260....................  Sarasota-Bradenton-Venice, FL...       1.0427
                             Manatee County, FL
                             Sarasota County, FL
42340....................  Savannah, GA....................       0.9585
                             Bryan County, GA
                             Chatham County, GA
                             Effingham County, GA
42540....................  Scranton--Wilkes-Barre, PA......       0.8877
                             Lackawanna County, PA
                             Luzerne County, PA
                             Wyoming County, PA
42644....................  Seattle-Bellevue-Everett, WA....       1.2147
                             King County, WA
                             Snohomish County, WA
42680....................  Sebastian-Vero Beach, FL........       0.9880
                             Indian River County, FL
43100....................  Sheboygan, WI...................       0.9421
                             Sheboygan County, WI
43300....................  Sherman-Denison, TX.............       0.8733
                             Grayson County, TX
43340....................  Shreveport-Bossier City, LA.....       0.8897
                             Bossier Parish, LA
                             Caddo Parish, LA
                             De Soto Parish, LA
43580....................  Sioux City, IA-NE-SD............       0.9711
                             Woodbury County, IA
                             Dakota County, NE
                             Dixon County, NE
                             Union County, SD
43620....................  Sioux Falls, SD.................       1.0038
                             Lincoln County, SD
                             McCook County, SD
                             Minnehaha County, SD
                             Turner County, SD
43780....................  South Bend-Mishawaka, IN-MI.....       1.0095
                             St. Joseph County, IN
                             Cass County, MI

[[Page 46506]]

 
43900....................  Spartanburg, SC.................       0.9890
                             Spartanburg County, SC
44060....................  Spokane, WA.....................       1.0975
                             Spokane County, WA
44100....................  Springfield, IL.................       0.9388
                             Menard County, IL
                             Sangamon County, IL
44140....................  Springfield, MA.................       1.0881
                             Franklin County, MA
                             Hampden County, MA
                             Hampshire County, MA
44180....................  Springfield, MO.................       0.9127
                             Christian County, MO
                             Dallas County, MO
                             Greene County, MO
                             Polk County, MO
                             Webster County, MO
44220....................  Springfield, OH.................       0.9126
                             Clark County, OH
44300....................  State College, PA...............       0.9204
                             Centre County, PA
44700....................  Stockton, CA....................       1.2444
                             San Joaquin County, CA
44940....................  Sumter, SC......................       0.9026
                             Sumter County, SC
45060....................  Syracuse, NY....................       1.0402
                             Madison County, NY
                             Onondaga County, NY
                             Oswego County, NY
45104....................  Tacoma, WA......................       1.1604
                             Pierce County, WA
45220....................  Tallahassee, FL.................       0.9473
                             Gadsden County, FL
                             Jefferson County, FL
                             Leon County, FL
                             Wakulla County, FL
45300....................  Tampa-St. Petersburg-Clearwater,       0.9468
                            FL.
                             Hernando County, FL
                             Hillsborough County, FL
                             Pasco County, FL
                             Pinellas County, FL
45460....................  Terre Haute, IN.................       0.9243
                             Clay County, IN
                             Sullivan County, IN
                             Vermillion County, IN
                             Vigo County, IN
45500....................  Texarkana, TX-Texarkana, AR.....       0.8156
                             Miller County, AR
                             Bowie County, TX
45780....................  Toledo, OH......................       0.9900
                             Fulton County, OH
                             Lucas County, OH
                             Ottawa County, OH
                             Wood County, OH
45820....................  Topeka, KS......................       0.8962
                             Jackson County, KS
                             Jefferson County, KS
                             Osage County, KS
                             Shawnee County, KS
                             Wabaunsee County, KS
45940....................  Trenton-Ewing, NJ...............       1.1231
                             Mercer County, NJ
46060....................  Tucson, AZ......................       0.9704
                             Pima County, AZ
46140....................  Tulsa, OK.......................       0.8754
                             Creek County, OK
                             Okmulgee County, OK
                             Osage County, OK
                             Pawnee County, OK
                             Rogers County, OK
                             Tulsa County, OK

[[Page 46507]]

 
                             Wagoner County, OK
46220....................  Tuscaloosa, AL..................       0.8716
                             Greene County, AL
                             Hale County, AL
                             Tuscaloosa County, AL
46340....................  Tyler, TX.......................       0.9567
                             Smith County, TX
46540....................  Utica-Rome, NY..................       0.8908
                             Herkimer County, NY
                             Oneida County, NY
46660....................  Valdosta, GA....................       0.8500
                             Brooks County, GA
                             Echols County, GA
                             Lanier County, GA
                             Lowndes County, GA
46700....................  Vallejo-Fairfield, CA...........       1.5395
                             Solano County, CA
47020....................  Victoria, TX....................       0.8715
                             Calhoun County, TX
                             Goliad County, TX
                             Victoria County, TX
47220....................  Vineland-Millville-Bridgeton, NJ       1.0637
                             Cumberland County, NJ
47260....................  Virginia Beach-Norfolk-Newport         0.9256
                            News, VA-NC.
                             Currituck County, NC
                             Gloucester County, VA
                             Isle of Wight County, VA
                             James City County, VA
                             Mathews County, VA
                             Surry County, VA
                             York County, VA
                             Chesapeake City, VA
                             Hampton City, VA
                             Newport News City, VA
                             Norfolk City, VA
                             Poquoson City, VA
                             Portsmouth City, VA
                             Suffolk City, VA
                             Virginia Beach City, VA
                             Williamsburg City, VA
47300....................  Visalia-Porterville, CA.........       1.0592
                             Tulare County, CA
47380....................  Waco, TX........................       0.8941
                             McLennan County, TX
47580....................  Warner Robins, GA...............       0.9582
                             Houston County, GA
47644....................  Warren-Troy-Farmington Hills, MI       1.0498
                             Lapeer County, MI
                             Livingston County, MI
                             Macomb County, MI
                             Oakland County, MI
                             St. Clair County, MI
47894....................  Washington-Arlington-Alexandria,       1.1394
                            DC-VA-MD-WV.
                             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

[[Page 46508]]

 
                             Manassas Park City, VA
                             Jefferson County, WV
47940....................  Waterloo-Cedar Falls, IA........       0.8942
                             Black Hawk County, IA
                             Bremer County, IA
                             Grundy County, IA
48140....................  Wausau, WI......................       1.0160
                             Marathon County, WI
48260....................  Weirton-Steubenville, WV-OH.....       0.8318
                             Jefferson County, OH
                             Brooke County, WV
                             Hancock County, WV
48300....................  Wenatchee, WA...................       1.2039
                             Chelan County, WA
                             Douglas County, WA
48424....................  West Palm Beach-Boca Raton-            1.0211
                            Boynton Beach, FL.
                             Palm Beach County, FL
48540....................  Wheeling, WV-OH.................       0.8000
                             Belmont County, OH
                             Marshall County, WV
                             Ohio County, WV
48620....................  Wichita, KS.....................       0.9512
                             Butler County, KS
                             Harvey County, KS
                             Sedgwick County, KS
                             Sumner County, KS
48660....................  Wichita Falls, TX...............       0.8314
                             Archer County, TX
                             Clay County, TX
                             Wichita County, TX
48700....................  Williamsport, PA................       0.8443
                             Lycoming County, PA
48864....................  Wilmington, DE-MD-NJ............       1.1362
                             New Castle County, DE
                             Cecil County, MD
                             Salem County, NJ
48900....................  Wilmington, NC..................       0.9878
                             Brunswick County, NC
                             New Hanover County, NC
                             Pender County, NC
49020....................  Winchester, VA-WV...............       1.0406
                             Frederick County, VA
                             Winchester City, VA
                             Hampshire County, WV
49180....................  Winston-Salem, NC...............       0.9571
                             Davie County, NC
                             Forsyth County, NC
                             Stokes County, NC
                             Yadkin County, NC
49340....................  Worcester, MA...................       1.1848
                             Worcester County, MA
49420....................  Yakima, WA......................       1.0777
                             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................       0.9824
                             York County, PA
49660....................  Youngstown-Warren-Boardman, OH-        0.9449
                            PA.
                             Mahoning County, OH
                             Trumbull County, OH
                             Mercer County, PA
49700....................  Yuba City, CA...................       1.1290
                             Sutter County, CA
                             Yuba County, CA
49740....................  Yuma, AZ........................       0.9959

[[Page 46509]]

 
                             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 raw pre-
  floor, pre-reclassified hospital wage index. The budget neutrality
  adjustment or the hospice floor is then applied to the raw 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
  (a) the 25 percent reduced budget neutrality adjustment OR (b) the
  minimum of the raw pre-floor, pre-reclassified hospital wage index
  value x 1.15, or 0.8000. For the final 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 rural 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--Final Hospice Wage Index for Rural Areas by CBSA--FY 2009
------------------------------------------------------------------------
                                                                  Wage
         CBSA code                    Nonurban area              index
------------------------------------------------------------------------
1.........................  Alabama..........................     0.8000
2.........................  Alaska...........................     1.2711
3.........................  Arizona..........................     0.8900
4.........................  Arkansas.........................     0.8000
5.........................  California.......................     1.2620
6.........................  Colorado.........................     1.0186
7.........................  Connecticut......................     1.1672
8.........................  Delaware.........................     1.0210
10........................  Florida..........................     0.8886
11........................  Georgia..........................     0.8040
12........................  Hawaii...........................     1.1139
13........................  Idaho............................     0.8314
14........................  Illinois.........................     0.8749
15........................  Indiana..........................     0.9002
16........................  Iowa.............................     0.8992
17........................  Kansas...........................     0.8378
18........................  Kentucky.........................     0.8180
19........................  Louisiana........................     0.8000
20........................  Maine............................     0.8897
21........................  Maryland.........................     0.9483
22........................  Massachusetts \1\................     1.2164
23........................  Michigan.........................     0.9398
24........................  Minnesota........................     0.9530
25........................  Mississippi......................     0.8083
26........................  Missouri.........................     0.8324
27........................  Montana..........................     0.8795
28........................  Nebraska.........................     0.9289
29........................  Nevada...........................     0.9733
30........................  New Hampshire....................     1.0990
31........................  New Jersey \2\...................  .........
32........................  New Mexico.......................     0.9384
33........................  New York.........................     0.8679
34........................  North Carolina...................     0.9030
35........................  North Dakota.....................     0.8000
36........................  Ohio.............................     0.9147
37........................  Oklahoma.........................     0.8000
38........................  Oregon...........................     1.0398
39........................  Pennsylvania.....................     0.8802
40........................  Puerto Rico \3\..................     0.4654
41........................  Rhode Island \2\.................  .........
42........................  South Carolina...................     0.9086
43........................  South Dakota.....................     0.8974
44........................  Tennessee........................     0.8107
45........................  Texas............................     0.8364
46........................  Utah.............................     0.8519
47........................  Vermont..........................     1.0412
48........................  Virgin Islands...................     0.7855
49........................  Virginia.........................     0.8288
50........................  Washington.......................     1.0769
51........................  West Virginia....................     0.8000
52........................  Wisconsin........................     1.0147
53........................  Wyoming..........................     0.9748
65........................  Guam.............................    1.0089
------------------------------------------------------------------------
\1\ There are no hospitals in the rural areas of Massachusetts, so the
  wage index value used is the average wage index value for the
  contiguous counties.
\2\ There are no rural areas in this state.
\3\ Wage index values are obtained using the methodology described in
  the rule.


  Addendum C--Comparison of Raw Pre-Floor, Pre-Reclassified Hospital Wage Index Values Used as Input Values To
                               Derive the FY 2008 and FY 2009 Hospice Wage Indices
                                        [For illustrative purposes only]
----------------------------------------------------------------------------------------------------------------
                                                                                                        Percent
                                                                        FY2008     FY2009   FY09-FY08     chng
----------------------------------------------------------------------------------------------------------------
                                                   Rural Area
----------------------------------------------------------------------------------------------------------------
1....................................  Alabama......................     0.7591     0.7533    -0.0058      -0.76
2....................................  Alaska.......................     1.0661     1.2109     0.1448      13.58
3....................................  Arizona......................     0.8908     0.8479    -0.0429      -4.82
4....................................  Arkansas.....................     0.7307     0.7371     0.0064       0.88
5....................................  California...................     1.1454     1.2023     0.0569       4.97
6....................................  Colorado.....................     0.9325     0.9704     0.0379       4.06
7....................................  Connecticut..................     1.1709     1.1119    -0.0590      -5.04
8....................................  Delaware.....................     0.9705     0.9727     0.0022       0.23
10...................................  Florida......................     0.8594     0.8465    -0.0129      -1.50
11...................................  Georgia......................     0.7593     0.7659     0.0066       0.87
12...................................  Hawaii.......................     1.0448     1.0612     0.0164       1.57
13...................................  Idaho........................     0.8120     0.7920    -0.0200      -2.46
14...................................  Illinois.....................     0.8320     0.8335     0.0015       0.18
15...................................  Indiana......................     0.8538     0.8576     0.0038       0.45
16...................................  Iowa.........................     0.8681     0.8566    -0.0115      -1.32
17...................................  Kansas.......................     0.7998     0.7981    -0.0017      -0.21
18...................................  Kentucky.....................     0.7768     0.7793     0.0025       0.32
19...................................  Louisiana....................     0.7438     0.7373    -0.0065      -0.87
20...................................  Maine........................     0.8443     0.8476     0.0033       0.39
21...................................  Maryland.....................     0.8926     0.9034     0.0108       1.21
22...................................  Massachusetts................     1.1661     1.1589    -0.0072      -0.62
23...................................  Michigan.....................     0.9062     0.8953    -0.0109      -1.20

[[Page 46510]]

 
24...................................  Minnesota....................     0.9153     0.9079    -0.0074      -0.81
25...................................  Mississippi..................     0.7738     0.7700    -0.0038      -0.49
26...................................  Missouri.....................     0.7927     0.7930     0.0003       0.04
27...................................  Montana......................     0.8590     0.8379    -0.0211      -2.46
28...................................  Nebraska.....................     0.8677     0.8849     0.0172       1.98
29...................................  Nevada.......................     0.8944     0.9272     0.0328       3.67
30...................................  New Hampshire................     1.0853     1.0470    -0.0383      -3.53
32...................................  New Mexico...................     0.8332     0.8940     0.0608       7.30
33...................................  New York.....................     0.8232     0.8268     0.0036       0.44
34...................................  North Carolina...............     0.8588     0.8603     0.0015       0.17
35...................................  North Dakota.................     0.7215     0.7182    -0.0033      -0.46
36...................................  Ohio.........................     0.8658     0.8714     0.0056       0.65
37...................................  Oklahoma.....................     0.7629     0.7492    -0.0137      -1.80
38...................................  Oregon.......................     0.9753     0.9906     0.0153       1.57
39...................................  Pennsylvania.................     0.8320     0.8385     0.0065       0.78
40...................................  Puerto Rico..................     0.4047     0.4047     0.0000       0.00
42...................................  South Carolina...............     0.8566     0.8656     0.0090       1.05
43...................................  South Dakota.................     0.8480     0.8549     0.0069       0.81
44...................................  Tennessee....................     0.7827     0.7723    -0.0104      -1.33
45...................................  Texas........................     0.7965     0.7968     0.0003       0.04
46...................................  Utah.........................     0.8140     0.8116    -0.0024      -0.29
47...................................  Vermont......................     0.9744     0.9919     0.0175       1.80
48...................................  Virgin Islands...............     0.8467     0.6830    -0.1637     -19.33
49...................................  Virginia.....................     0.7940     0.7896    -0.0044      -0.55
50...................................  Washington...................     1.0263     1.0259    -0.0004      -0.04
51...................................  West Virginia................     0.7607     0.7454    -0.0153      -2.01
52...................................  Wisconsin....................     0.9553     0.9667     0.0114       1.19
53...................................  Wyoming......................     0.9295     0.9287    -0.0008      -0.09
65...................................  Guam.........................     0.9611     0.9611     0.0000       0.00
----------------------------------------------------------------------------------------------------------------
CBSA.................................                                  Urban Area
----------------------------------------------------------------------------------------------------------------
10180................................  Abilene, TX..................     0.8000     0.7957    -0.0043      -0.54
10380................................  Aguadilla-Isabela-San             0.3915     0.3448    -0.0467     -11.93
                                        Sebasti[aacute]n, PR.
10420................................  Akron, OH....................     0.8654     0.8794     0.0140       1.62
10500................................  Albany, GA...................     0.8991     0.8514    -0.0477      -5.31
10580................................  Albany-Schenectady-Troy, NY..     0.8720     0.8588    -0.0132      -1.51
10740................................  Albuquerque, NM..............     0.9458     0.9554     0.0096       1.02
10780................................  Alexandria, LA...............     0.8006     0.7979    -0.0027      -0.34
10900................................  Allentown-Bethlehem-Easton,       0.9947     0.9865    -0.0082      -0.82
                                        PA-NJ.
11020................................  Altoona, PA..................     0.8812     0.8618    -0.0194      -2.20
11100................................  Amarillo, TX.................     0.9169     0.9116    -0.0053      -0.58
11180................................  Ames, IA.....................     0.9760     1.0046     0.0286       2.93
11260................................  Anchorage, AK................     1.2023     1.1913    -0.0110      -0.91
11300................................  Anderson, IN.................     0.8681     0.8827     0.0146       1.68
11340................................  Anderson, SC.................     0.9017     0.9086     0.0069       0.77
11460................................  Ann Arbor, MI................     1.0826     1.0539    -0.0287      -2.65
11500................................  Anniston-Oxford, AL..........     0.7770     0.7926     0.0156       2.01
11540................................  Appleton, WI.................     0.9455     0.9598     0.0143       1.51
11700................................  Asheville, NC................     0.9216     0.9185    -0.0031      -0.34
12020................................  Athens-Clarke County, GA.....     0.9856     1.0517     0.0661       6.71
12060................................  Atlanta-Sandy Springs-            0.9762     0.9828     0.0066       0.68
                                        Marietta, GA.
12100................................  Atlantic City, NJ............     1.1831     1.2198     0.0367       3.10
12220................................  Auburn-Opelika, AL...........     0.8096     0.8090    -0.0006      -0.07
12260................................  Augusta-Richmond County, GA-      0.9667     0.9645    -0.0022      -0.23
                                        SC.
12420................................  Austin-Round Rock, TX........     0.9344     0.9544     0.0200       2.14
12540................................  Bakersfield, CA..............     1.0725     1.1051     0.0326       3.04
12580................................  Baltimore-Towson, MD.........     1.0088     1.0134     0.0046       0.46
12620................................  Bangor, ME...................     0.9711     0.9978     0.0267       2.75
12700................................  Barnstable Town, MA..........     1.2539     1.2603     0.0064       0.51
12940................................  Baton Rouge, LA..............     0.8084     0.8034    -0.0050      -0.62
12980................................  Battle Creek, MI.............     0.9762     1.0179     0.0417       4.27
13020................................  Bay City, MI.................     0.9251     0.8897    -0.0354      -3.83
13140................................  Beaumont-Port Arthur, TX.....     0.8595     0.8531    -0.0064      -0.74
13380................................  Bellingham, WA...............     1.1104     1.1474     0.0370       3.33
13460................................  Bend, OR.....................     1.0743     1.0942     0.0199       1.85
13644................................  Bethesda-Gaithersburg-            1.0903     1.0511    -0.0392      -3.60
                                        Frederick, MD.
13740................................  Billings, MT.................     0.8712     0.8666    -0.0046      -0.53
13780................................  Binghamton, NY...............     0.8786     0.8949     0.0163       1.86

[[Page 46511]]

 
13820................................  Birmingham-Hoover, AL........     0.8894     0.8898     0.0004       0.04
13900................................  Bismarck, ND.................     0.7240     0.7225    -0.0015      -0.21
13980................................  Blacksburg-Christiansburg-        0.8213     0.8192    -0.0021      -0.26
                                        Radford, VA.
14020................................  Bloomington, IN..............     0.8533     0.8915     0.0382       4.48
14060................................  Bloomington-Normal, IL.......     0.8944     0.9325     0.0381       4.26
14260................................  Boise City-Nampa, ID.........     0.9401     0.9465     0.0064       0.68
14484................................  Boston-Quincy, MA............     1.1679     1.1792     0.0113       0.97
14500................................  Boulder, CO..................     1.0350     1.0426     0.0076       0.73
14540................................  Bowling Green, KY............     0.8148     0.8159     0.0011       0.14
14740................................  Bremerton-Silverdale, WA.....     1.0913     1.0904    -0.0009      -0.08
14860................................  Bridgeport-Stamford-Norwalk,      1.2659     1.2735     0.0076       0.60
                                        CT.
15180................................  Brownsville-Harlingen, TX....     0.9430     0.8914    -0.0516      -5.47
15260................................  Brunswick, GA................     1.0164     0.9475    -0.0689      -6.78
15380................................  Buffalo-Niagara Falls, NY....     0.9424     0.9568     0.0144       1.53
15500................................  Burlington, NC...............     0.8674     0.8747     0.0073       0.84
15540................................  Burlington-South Burlington,      0.9474     0.9660     0.0186       1.96
                                        VT.
15764................................  Cambridge-Newton-Framingham,      1.0970     1.1215     0.0245       2.23
                                        MA.
15804................................  Camden, NJ...................     1.0392     1.0411     0.0019       0.18
15940................................  Canton-Massillon, OH.........     0.9031     0.8935    -0.0096      -1.06
15980................................  Cape Coral-Fort Myers, FL....     0.9342     0.9396     0.0054       0.58
16180................................  Carson City, NV..............     1.0025     1.0003    -0.0022      -0.22
16220................................  Casper, WY...................     0.9145     0.9385     0.0240       2.62
16300................................  Cedar Rapids, IA.............     0.8888     0.8852    -0.0036      -0.41
16580................................  Champaign-Urbana, IL.........     0.9644     0.9392    -0.0252      -2.61
16620................................  Charleston, WV...............     0.8542     0.8289    -0.0253      -2.96
16700................................  Charleston-North Charleston,      0.9145     0.9124    -0.0021      -0.23
                                        SC.
16740................................  Charlotte-Gastonia-Concord,       0.9554     0.9520    -0.0034      -0.36
                                        NC-SC.
16820................................  Charlottesville, VA..........     1.0125     0.9277    -0.0848      -8.38
16860................................  Chattanooga, TN-GA...........     0.8948     0.8994     0.0046       0.51
16940................................  Cheyenne, WY.................     0.9060     0.9308     0.0248       2.74
16974................................  Chicago-Naperville-Joliet, IL     1.0751     1.0715    -0.0036      -0.33
17020................................  Chico, CA....................     1.1053     1.1290     0.0237       2.14
17140................................  Cincinnati-Middletown, OH-KY-     0.9601     0.9784     0.0183       1.91
                                        IN.
17300................................  Clarksville, TN-KY...........     0.8436     0.8251    -0.0185      -2.19
17420................................  Cleveland, TN................     0.8109     0.8052    -0.0057      -0.70
17460................................  Cleveland-Elyria-Mentor, OH..     0.9400     0.9339    -0.0061      -0.65
17660................................  Coeur d'Alene, ID............     0.9344     0.9532     0.0188       2.01
17780................................  College Station-Bryan, TX....     0.9045     0.9358     0.0313       3.46
17820................................  Colorado Springs, CO.........     0.9701     0.9719     0.0018       0.19
17860................................  Columbia, MO.................     0.8542     0.8658     0.0116       1.36
17900................................  Columbia, SC.................     0.8933     0.8800    -0.0133      -1.49
17980................................  Columbus, GA-AL..............     0.8239     0.8729     0.0490       5.95
18020................................  Columbus, IN.................     0.9318     0.9537     0.0219       2.35
18140................................  Columbus, OH.................     1.0107     1.0085    -0.0022      -0.22
18580................................  Corpus Christi, TX...........     0.8564     0.8588     0.0024       0.28
18700................................  Corvallis, OR................     1.1546     1.0959    -0.0587      -5.08
19060................................  Cumberland, MD-WV............     0.8446     0.8294    -0.0152      -1.80
19124................................  Dallas-Plano-Irving, TX......     1.0075     0.9915    -0.0160      -1.59
19140................................  Dalton, GA...................     0.9093     0.8760    -0.0333      -3.66
19180................................  Danville, IL.................     0.9266     0.8957    -0.0309      -3.33
19260................................  Danville, VA.................     0.8451     0.8240    -0.0211      -2.50
19340................................  Davenport-Moline-Rock Island,     0.8846     0.8830    -0.0016      -0.18
                                        IA-IL.
19380................................  Dayton, OH...................     0.9037     0.9190     0.0153       1.69
19460................................  Decatur, AL..................     0.8159     0.7885    -0.0274      -3.36
19500................................  Decatur, IL..................     0.8172     0.8074    -0.0098      -1.20
19660................................  Deltona-Daytona Beach-Ormond      0.9263     0.9031    -0.0232      -2.50
                                        Beach, FL.
19740................................  Denver-Aurora, CO............     1.0930     1.0718    -0.0212      -1.94
19780................................  Des Moines-West Des Moines,       0.9214     0.9226     0.0012       0.13
                                        IA.
19804................................  Detroit-Livonia-Dearborn, MI.     1.0281     0.9999    -0.0282      -2.74
20020................................  Dothan, AL...................     0.7381     0.7270    -0.0111      -1.50
20100................................  Dover, DE....................     0.9847     1.0099     0.0252       2.56
20220................................  Dubuque, IA..................     0.9133     0.9058    -0.0075      -0.82
20260................................  Duluth, MN-WI................     1.0042     0.9975    -0.0067      -0.67
20500................................  Durham, NC...................     0.9826     0.9816    -0.0010      -0.10
20740................................  Eau Claire, WI...............     0.9630     0.9475    -0.0155      -1.61
20764................................  Edison, NJ...................     1.1190     1.1181    -0.0009      -0.08
20940................................  El Centro, CA................     0.9076     0.8914    -0.0162      -1.78
21060................................  Elizabethtown, KY............     0.8697     0.8711     0.0014       0.16
21140................................  Elkhart-Goshen, IN...........     0.9426     0.9611     0.0185       1.96

[[Page 46512]]

 
21300................................  Elmira, NY...................     0.8240     0.8264     0.0024       0.29
21340................................  El Paso, TX..................     0.9053     0.8989    -0.0064      -0.71
21500................................  Erie, PA.....................     0.8827     0.8495    -0.0332      -3.76
21604................................  Essex County, MA.............     1.0418  .........  .........  .........
21660................................  Eugene-Springfield, OR.......     1.0876     1.0932     0.0056       0.51
21780................................  Evansville, IN-KY............     0.9071     0.8662    -0.0409      -4.51
21820................................  Fairbanks, AK................     1.1059     1.1050    -0.0009      -0.08
21940................................  Fajardo, PR..................     0.4036     0.4375     0.0339       8.40
22020................................  Fargo, ND-MN.................     0.8250     0.8042    -0.0208      -2.52
22140................................  Farmington, NM...............     0.8589     0.9587     0.0998      11.62
22180................................  Fayetteville, NC.............     0.8945     0.9368     0.0423       4.73
22220................................  Fayetteville-Springdale-          0.8865     0.8742    -0.0123      -1.39
                                        Rogers, AR-MO.
22380................................  Flagstaff, AZ................     1.1601     1.1687     0.0086       0.74
22420................................  Flint, MI....................     1.0969     1.1220     0.0251       2.29
22500................................  Florence, SC.................     0.8388     0.8249    -0.0139      -1.66
22520................................  Florence-Muscle Shoals, AL...     0.7843     0.7680    -0.0163      -2.08
22540................................  Fond du Lac, WI..............     1.0063     0.9667    -0.0396      -3.94
22660................................  Fort Collins-Loveland, CO....     0.9544     0.9897     0.0353       3.70
22744................................  Ft Lauderdale-Pompano Beach-      1.0133     1.0229     0.0096       0.95
                                        Deerfield, FL.
22900................................  Fort Smith, AR-OK............     0.7731     0.7933     0.0202       2.61
23020................................  Fort Walton Beach-Crestview-      0.8643     0.8743     0.0100       1.16
                                        Destin, FL.
23060................................  Fort Wayne, IN...............     0.9517     0.9284    -0.0233      -2.45
23104................................  Fort Worth-Arlington, TX.....     0.9569     0.9693     0.0124       1.30
23420................................  Fresno, CA...................     1.0943     1.0993     0.0050       0.46
23460................................  Gadsden, AL..................     0.8066     0.8159     0.0093       1.15
23540................................  Gainesville, FL..............     0.9277     0.9196    -0.0081      -0.87
23580................................  Gainesville, GA..............     0.8958     0.9216     0.0258       2.88
23844................................  Gary, IN.....................     0.9334     0.9224    -0.0110      -1.18
24020................................  Glens Falls, NY..............     0.8324     0.8256    -0.0068      -0.82
24140................................  Goldsboro, NC................     0.9171     0.9288     0.0117       1.28
24220................................  Grand Forks, ND-MN...........     0.7949     0.7881    -0.0068      -0.86
24300................................  Grand Junction, CO...........     0.9668     0.9864     0.0196       2.03
24340................................  Grand Rapids-Wyoming, MI.....     0.9455     0.9315    -0.0140      -1.48
24500................................  Great Falls, MT..............     0.8598     0.8675     0.0077       0.90
24540................................  Greeley, CO..................     0.9602     0.9658     0.0056       0.58
24580................................  Green Bay, WI................     0.9787     0.9727    -0.0060      -0.61
24660................................  Greensboro-High Point, NC....     0.8866     0.9010     0.0144       1.62
24780................................  Greenville, NC...............     0.9432     0.9402    -0.0030      -0.32
24860................................  Greenville, SC...............     0.9804     0.9860     0.0056       0.57
25020................................  Guayama, PR..................     0.3235     0.3064    -0.0171      -5.29
25060................................  Gulfport-Biloxi, MS..........     0.8915     0.8773    -0.0142      -1.59
25180................................  Hagerstown-Martinsburg, MD-WV     0.9038     0.9013    -0.0025      -0.28
25260................................  Hanford-Corcoran, CA.........     1.0282     1.0499     0.0217       2.11
25420................................  Harrisburg-Carlisle, PA......     0.9402     0.9280    -0.0122      -1.30
25500................................  Harrisonburg, VA.............     0.9073     0.8867    -0.0206      -2.27
25540................................  Hartford-West Hartford-East       1.0894     1.0959     0.0065       0.60
                                        Hartford, CT.
25620................................  Hattiesburg, MS..............     0.7430     0.7366    -0.0064      -0.86
25860................................  Hickory-Lenoir-Morganton, NC.     0.9010     0.9028     0.0018       0.20
25980................................  Hinesville-Fort Stewart, GA..     0.9178     0.9187     0.0009       0.10
26100................................  Holland-Grand Haven, MI......     0.9163     0.9006    -0.0157      -1.71
26180................................  Honolulu, HI.................     1.1096     1.1556     0.0460       4.15
26300................................  Hot Springs, AR..............     0.8782     0.9109     0.0327       3.72
26380................................  Houma-Bayou Cane-Thibodaux,       0.8082     0.7892    -0.0190      -2.35
                                        LA.
26420................................  Houston-Sugar Land-Baytown,       1.0008     0.9939    -0.0069      -0.69
                                        TX.
26580................................  Huntington-Ashland, WV-KY-OH.     0.8997     0.9041     0.0044       0.49
26620................................  Huntsville, AL...............     0.9007     0.9146     0.0139       1.54
26820................................  Idaho Falls, ID..............     0.9088     0.9264     0.0176       1.94
26900................................  Indianapolis-Carmel, IN......     0.9895     0.9844    -0.0051      -0.52
26980................................  Iowa City, IA................     0.9714     0.9568    -0.0146      -1.50
27060................................  Ithaca, NY...................     0.9928     0.9630    -0.0298      -3.00
27100................................  Jackson, MI..................     0.9560     0.9329    -0.0231      -2.42
27140................................  Jackson, MS..................     0.8271     0.8011    -0.0260      -3.14
27180................................  Jackson, TN..................     0.8853     0.8676    -0.0177      -2.00
27260................................  Jacksonville, FL.............     0.9165     0.9021    -0.0144      -1.57
27340................................  Jacksonville, NC.............     0.8231     0.8079    -0.0152      -1.85
27500................................  Janesville, WI...............     0.9655     0.9702     0.0047       0.49
27620................................  Jefferson City, MO...........     0.8332     0.8478     0.0146       1.75
27740................................  Johnson City, TN.............     0.8043     0.7677    -0.0366      -4.55
27780................................  Johnstown, PA................     0.8620     0.7543    -0.1077     -12.49

[[Page 46513]]

 
27860................................  Jonesboro, AR................     0.7662     0.7790     0.0128       1.67
27900................................  Joplin, MO...................     0.8605     0.8951     0.0346       4.02
28020................................  Kalamazoo-Portage, MI........     1.0704     1.0433    -0.0271      -2.53
28100................................  Kankakee-Bradley, IL.........     1.0083     1.0238     0.0155       1.54
28140................................  Kansas City, MO-KS...........     0.9495     0.9504     0.0009       0.09
28420................................  Kennewick-Richland-Pasco, WA.     1.0343     1.0075    -0.0268      -2.59
28660................................  Killeen-Temple-Fort Hood, TX.     0.8901     0.8249    -0.0652      -7.33
28700................................  Kingsport-Bristol, TN-VA.....     0.7985     0.7658    -0.0327      -4.10
28740................................  Kingston, NY.................     0.9367     0.9556     0.0189       2.02
28940................................  Knoxville, TN................     0.8249     0.8036    -0.0213      -2.58
29020................................  Kokomo, IN...................     0.9669     0.9591    -0.0078      -0.81
29100................................  La Crosse, WI-MN.............     0.9426     0.9685     0.0259       2.75
29140................................  Lafayette, IN................     0.8931     0.8869    -0.0062      -0.69
29180................................  Lafayette, LA................     0.8289     0.8247    -0.0042      -0.51
29340................................  Lake Charles, LA.............     0.7914     0.7777    -0.0137      -1.73
29404................................  Lake County-Kenosha County,       1.0570     1.0603     0.0033       0.31
                                        IL-WI.
29420................................  Lake Havasu City-Kingman, AZ.  .........     0.9333  .........  .........
29460................................  Lakeland, FL.................     0.8879     0.8661    -0.0218      -2.46
29540................................  Lancaster, PA................     0.9589     0.9252    -0.0337      -3.51
29620................................  Lansing-East Lansing, MI.....     1.0088     1.0119     0.0031       0.31
29700................................  Laredo, TX...................     0.7811     0.8093     0.0282       3.61
29740................................  Las Cruces, NM...............     0.9273     0.8676    -0.0597      -6.44
29820................................  Las Vegas-Paradise, NV.......     1.1430     1.1799     0.0369       3.23
29940................................  Lawrence, KS.................     0.8365     0.8227    -0.0138      -1.65
30020................................  Lawton, OK...................     0.8065     0.8025    -0.0040      -0.50
30140................................  Lebanon, PA..................     0.8679     0.8192    -0.0487      -5.61
30300................................  Lewiston, ID-WA..............     0.9853     0.9454    -0.0399      -4.05
30340................................  Lewiston-Auburn, ME..........     0.9126     0.9193     0.0067       0.73
30460................................  Lexington-Fayette, KY........     0.9181     0.9191     0.0010       0.11
30620................................  Lima, OH.....................     0.9042     0.9424     0.0382       4.22
30700................................  Lincoln, NE..................     1.0092     1.0051    -0.0041      -0.41
30780................................  Little Rock-North Little          0.8890     0.8863    -0.0027      -0.30
                                        Rock, AR.
30860................................  Logan, UT-ID.................     0.9022     0.9183     0.0161       1.78
30980................................  Longview, TX.................     0.8788     0.8717    -0.0071      -0.81
31020................................  Longview, WA.................     1.0011     1.0827     0.0816       8.15
31084................................  Los Angeles-Long Beach-Santa      1.1760     1.1771     0.0011       0.09
                                        Ana, CA.
31140................................  Louisville-Jefferson County,      0.9118     0.9065    -0.0053      -0.58
                                        KY-IN.
31180................................  Lubbock, TX..................     0.8613     0.8680     0.0067       0.78
31340................................  Lynchburg, VA................     0.8694     0.8732     0.0038       0.44
31420................................  Macon, GA....................     0.9519     0.9541     0.0022       0.23
31460................................  Madera, CA...................     0.8154     0.8069    -0.0085      -1.04
31540................................  Madison, WI..................     1.0840     1.0935     0.0095       0.88
31700................................  Manchester-Nashua, NH........     1.0243     1.0273     0.0030       0.29
31900................................  Mansfield, OH................     0.9271     0.9271     0.0000       0.00
32420................................  Mayag[uuml]ez, PR............     0.3848     0.3711    -0.0137      -3.56
32580................................  McAllen-Edinburg-Mission, TX.     0.8773     0.9123     0.0350       3.99
32780................................  Medford, OR..................     1.0818     1.0318    -0.0500      -4.62
32820................................  Memphis, TN-MS-AR............     0.9373     0.9250    -0.0123      -1.31
32900................................  Merced, CA...................     1.1471     1.2120     0.0649       5.66
33124................................  Miami-Miami Beach-Kendall, FL     0.9812     1.0002     0.0190       1.94
33140................................  Michigan City-La Porte, IN...     0.9118     0.8914    -0.0204      -2.24
33260................................  Midland, TX..................     0.9786     1.0017     0.0231       2.36
33340................................  Milwaukee-Waukesha-West           1.0218     1.0214    -0.0004      -0.04
                                        Allis, WI.
33460................................  Minneapolis-St. Paul-             1.0946     1.1093     0.0147       1.34
                                        Bloomington, MN-WI.
33540................................  Missoula, MT.................     0.8928     0.8953     0.0025       0.28
33660................................  Mobile, AL...................     0.7913     0.8033     0.0120       1.52
33700................................  Modesto, CA..................     1.1729     1.1962     0.0233       1.99
33740................................  Monroe, LA...................     0.7997     0.7832    -0.0165      -2.06
33780................................  Monroe, MI...................     0.9707     0.9414    -0.0293      -3.02
33860................................  Montgomery, AL...............     0.8009     0.8088     0.0079       0.99
34060................................  Morgantown, WV...............     0.8423     0.8321    -0.0102      -1.21
34100................................  Morristown, TN...............     0.7933     0.7388    -0.0545      -6.87
34580................................  Mount Vernon-Anacortes, WA...     1.0517     1.0529     0.0012       0.11
34620................................  Muncie, IN...................     0.8562     0.8214    -0.0348      -4.06
34740................................  Muskegon-Norton Shores, MI...     0.9941     0.9836    -0.0105      -1.06
34820................................  Myrtle Beach-Conway-North         0.8810     0.8634    -0.0176      -2.00
                                        Myrtle Beach, SC.
34900................................  Napa, CA.....................     1.3374     1.4476     0.1102       8.24
34940................................  Naples-Marco Island, FL......     0.9941     0.9487    -0.0454      -4.57
34980................................  Nashville-Davidson-               0.9847     0.9689    -0.0158      -1.60
                                        Murfreesboro, TN.

[[Page 46514]]

 
35004................................  Nassau-Suffolk, NY...........     1.2662     1.2640    -0.0022      -0.17
35084................................  Newark-Union, NJ-PA..........     1.1892     1.1862    -0.0030      -0.25
35300................................  New Haven-Milford, CT........     1.1953     1.1871    -0.0082      -0.69
35380................................  New Orleans-Metairie-Kenner,      0.8831     0.8897     0.0066       0.75
                                        LA.
35644................................  New York-White Plains-Wayne,      1.3177     1.3115    -0.0062      -0.47
                                        NY-NJ.
35660................................  Niles-Benton Harbor, MI......     0.8915     0.9141     0.0226       2.54
35980................................  Norwich-New London, CT.......     1.1932     1.1432    -0.0500      -4.19
36084................................  Oakland-Fremont-Hayward, CA..     1.5819     1.5685    -0.0134      -0.85
36100................................  Ocala, FL....................     0.8867     0.8627    -0.0240      -2.71
36140................................  Ocean City, NJ...............     1.0472     1.0988     0.0516       4.93
36220................................  Odessa, TX...................     1.0073     1.0042    -0.0031      -0.31
36260................................  Ogden-Clearfield, UT.........     0.8995     0.9000     0.0005       0.06
36420................................  Oklahoma City, OK............     0.8843     0.8815    -0.0028      -0.32
36500................................  Olympia, WA..................     1.1081     1.1512     0.0431       3.89
36540................................  Omaha-Council Bluffs, NE-IA..     0.9450     0.9561     0.0111       1.17
36740................................  Orlando-Kissimmee, FL........     0.9452     0.9226    -0.0226      -2.39
36780................................  Oshkosh-Neenah, WI...........     0.9315     0.9551     0.0236       2.53
36980................................  Owensboro, KY................     0.8748     0.8652    -0.0096      -1.10
37100................................  Oxnard-Thousand Oaks-Ventura,     1.1546     1.1852     0.0306       2.65
                                        CA.
37340................................  Palm Bay-Melbourne-               0.9443     0.9325    -0.0118      -1.25
                                        Titusville, FL.
37380................................  Palm Coast, FL...............  .........     0.8945  .........  .........
37460................................  Panama City-Lynn Haven, FL...     0.8027     0.8313     0.0286       3.56
37620................................  Parkersburg-Marietta-Vienna,      0.7977     0.8105     0.0128       1.60
                                        WV-OH.
37700................................  Pascagoula, MS...............     0.8215     0.8647     0.0432       5.26
37764................................  Peabody, MA..................  .........     1.0650  .........  .........
37860................................  Pensacola-Ferry Pass-Brent,       0.8000     0.8281     0.0281       3.51
                                        FL.
37900................................  Peoria, IL...................     0.8982     0.9299     0.0317       3.53
37964................................  Philadelphia, PA.............     1.0996     1.0925    -0.0071      -0.65
38060................................  Phoenix-Mesa-Scottsdale, AZ..     1.0287     1.0264    -0.0023      -0.22
38220................................  Pine Bluff, AR...............     0.8383     0.7839    -0.0544      -6.49
38300................................  Pittsburgh, PA...............     0.8674     0.8525    -0.0149      -1.72
38340................................  Pittsfield, MA...............     1.0266     1.0091    -0.0175      -1.70
38540................................  Pocatello, ID................     0.9400     0.9465     0.0065       0.69
38660................................  Ponce, PR....................     0.4842     0.4450    -0.0392      -8.10
38860................................  Portland-South Portland-          0.9908     1.0042     0.0134       1.35
                                        Biddeford, ME.
38900................................  Portland-Vancouver-Beaverton,     1.1416     1.1498     0.0082       0.72
                                        OR-WA.
38940................................  Port St. Lucie-Fort Pierce,       0.9833     1.0016     0.0183       1.86
                                        FL.
39100................................  Poughkeepsie-Newburgh-            1.0911     1.0982     0.0071       0.65
                                        Middletown, NY.
39140................................  Prescott, AZ.................     0.9836     1.0020     0.0184       1.87
39300................................  Providence-New Bedford-Fall       1.0783     1.0574    -0.0209      -1.94
                                        River, RI-MA.
39340................................  Provo-Orem, UT...............     0.9537     0.9557     0.0020       0.21
39380................................  Pueblo, CO...................     0.8753     0.8851     0.0098       1.12
39460................................  Punta Gorda, FL..............     0.9405     0.9254    -0.0151      -1.61
39540................................  Racine, WI...................     0.9356     0.9498     0.0142       1.52
39580................................  Raleigh-Cary, NC.............     0.9864     0.9839    -0.0025      -0.25
39660................................  Rapid City, SD...............     0.8833     0.8811    -0.0022      -0.25
39740................................  Reading, PA..................     0.9622     0.9356    -0.0266      -2.76
39820................................  Redding, CA..................     1.3198     1.3541     0.0343       2.60
39900................................  Reno-Sparks, NV..............     1.1963     1.0715    -0.1248     -10.43
40060................................  Richmond, VA.................     0.9177     0.9425     0.0248       2.70
40140................................  Riverside-San Bernardino-         1.0904     1.1100     0.0196       1.80
                                        Ontario, CA.
40220................................  Roanoke, VA..................     0.8647     0.8691     0.0044       0.51
40340................................  Rochester, MN................     1.1408     1.0755    -0.0653      -5.72
40380................................  Rochester, NY................     0.8994     0.8858    -0.0136      -1.51
40420................................  Rockford, IL.................     0.9989     0.9814    -0.0175      -1.75
40484................................  Rockingham County, NH........     1.0159     1.0111    -0.0048      -0.47
40580................................  Rocky Mount, NC..............     0.8854     0.9001     0.0147       1.66
40660................................  Rome, GA.....................     0.9193     0.9042    -0.0151      -1.64
40900................................  Sacramento--Arden-Arcade--        1.3372     1.3505     0.0133       0.99
                                        Roseville, CA.
40980................................  Saginaw-Saginaw Township          0.8874     0.8812    -0.0062      -0.70
                                        North, MI.
41060................................  St. Cloud, MN................     1.0362     1.0549     0.0187       1.80
41100................................  St. George, UT...............     0.9265     0.9358     0.0093       1.00
41140................................  St. Joseph, MO-KS............     1.0118     0.8762    -0.1356     -13.40
41180................................  St. Louis, MO-IL.............     0.9005     0.9024     0.0019       0.21
41420................................  Salem, OR....................     1.0438     1.0572     0.0134       1.28
41500................................  Salinas, CA..................     1.4337     1.4775     0.0438       3.06
41540................................  Salisbury, MD................     0.8953     0.8994     0.0041       0.46
41620................................  Salt Lake City, UT...........     0.9402     0.9399    -0.0003      -0.03
41660................................  San Angelo, TX...............     0.8362     0.8579     0.0217       2.60

[[Page 46515]]

 
41700................................  San Antonio, TX..............     0.8844     0.8834    -0.0010      -0.11
41740................................  San Diego-Carlsbad-San            1.1354     1.1492     0.0138       1.22
                                        Marcos, CA.
41780................................  Sandusky, OH.................     0.9302     0.8822    -0.0480      -5.16
41884................................  San Francisco-San Mateo-          1.5165     1.5195     0.0030       0.20
                                        Redwood City, CA.
41900................................  San Germ[aacute]n-Cabo Rojo,      0.4885     0.4729    -0.0156      -3.19
                                        PR.
41940................................  San Jose-Sunnyvale-Santa          1.5543     1.5735     0.0192       1.24
                                        Clara, CA.
41980................................  San Juan-Caguas-Guaynabo, PR.     0.4452     0.4528     0.0076       1.71
42020................................  San Luis Obispo-Paso Robles,      1.1598     1.2488     0.0890       7.67
                                        CA.
42044................................  Santa Ana-Anaheim-Irvine, CA.     1.1473     1.1766     0.0293       2.55
42060................................  Santa Barbara-Santa Maria, CA     1.1091     1.1714     0.0623       5.62
42100................................  Santa Cruz-Watsonville, CA...     1.5457     1.6122     0.0665       4.30
42140................................  Santa Fe, NM.................     1.0824     1.0734    -0.0090      -0.83
42220................................  Santa Rosa-Petaluma, CA......     1.4464     1.4696     0.0232       1.60
42260................................  Sarasota-Bradenton-Venice, FL     0.9868     0.9933     0.0065       0.66
42340................................  Savannah, GA.................     0.9351     0.9131    -0.0220      -2.35
42540................................  Scranton--Wilkes-Barre, PA...     0.8347     0.8457     0.0110       1.32
42644................................  Seattle-Bellevue-Everett, WA.     1.1434     1.1572     0.0138       1.21
42680................................  Sebastian-Vero Beach, FL.....     0.9573     0.9412    -0.0161      -1.68
43100................................  Sheboygan, WI................     0.9026     0.8975    -0.0051      -0.57
43300................................  Sherman-Denison, TX..........     0.8502     0.8320    -0.0182      -2.14
43340................................  Shreveport-Bossier City, LA..     0.8865     0.8476    -0.0389      -4.39
43580................................  Sioux City, IA-NE-SD.........     0.9200     0.9251     0.0051       0.55
43620................................  Sioux Falls, SD..............     0.9559     0.9563     0.0004       0.04
43780................................  South Bend-Mishawaka, IN-MI..     0.9842     0.9617    -0.0225      -2.29
43900................................  Spartanburg, SC..............     0.9174     0.9422     0.0248       2.70
44060................................  Spokane, WA..................     1.0447     1.0455     0.0008       0.08
44100................................  Springfield, IL..............     0.8890     0.8944     0.0054       0.61
44140................................  Springfield, MA..............     1.0079     1.0366     0.0287       2.85
44180................................  Springfield, MO..............     0.8469     0.8695     0.0226       2.67
44220................................  Springfield, OH..............     0.8593     0.8694     0.0101       1.18
44300................................  State College, PA............     0.8784     0.8768    -0.0016      -0.18
44700................................  Stockton, CA.................     1.1442     1.1855     0.0413       3.61
44940................................  Sumter, SC...................     0.8083     0.8599     0.0516       6.38
45060................................  Syracuse, NY.................     0.9691     0.9910     0.0219       2.26
45104................................  Tacoma, WA...................     1.0789     1.1055     0.0266       2.47
45220................................  Tallahassee, FL..............     0.8942     0.9025     0.0083       0.93
45300................................  Tampa-St. Petersburg-             0.9144     0.9020    -0.0124      -1.36
                                        Clearwater, FL.
45460................................  Terre Haute, IN..............     0.8765     0.8805     0.0040       0.46
45500................................  Texarkana, TX-Texarkana, AR..     0.8104     0.7770    -0.0334      -4.12
45780................................  Toledo, OH...................     0.9586     0.9431    -0.0155      -1.62
45820................................  Topeka, KS...................     0.8730     0.8538    -0.0192      -2.20
45940................................  Trenton-Ewing, NJ............     1.0835     1.0699    -0.0136      -1.26
46060................................  Tucson, AZ...................     0.9202     0.9245     0.0043       0.47
46140................................  Tulsa, OK....................     0.8103     0.8340     0.0237       2.92
46220................................  Tuscaloosa, AL...............     0.8542     0.8303    -0.0239      -2.80
46340................................  Tyler, TX....................     0.8811     0.9114     0.0303       3.44
46540................................  Utica-Rome, NY...............     0.8396     0.8486     0.0090       1.07
46660................................  Valdosta, GA.................     0.8369     0.8098    -0.0271      -3.24
46700................................  Vallejo-Fairfield, CA........     1.5137     1.4666    -0.0471      -3.11
47020................................  Victoria, TX.................     0.8560     0.8302    -0.0258      -3.01
47220................................  Vineland-Millville-Bridgeton,     0.9832     1.0133     0.0301       3.06
                                        NJ.
47260................................  Virginia Beach-Norfolk-           0.8790     0.8818     0.0028       0.32
                                        Newport News, VA.
47300................................  Visalia-Porterville, CA......     0.9968     1.0091     0.0123       1.23
47380................................  Waco, TX.....................     0.8633     0.8518    -0.0115      -1.33
47580................................  Warner Robins, GA............     0.8380     0.9128     0.0748       8.93
47644................................  Warren-Troy-Farmington Hills,     1.0054     1.0001    -0.0053      -0.53
                                        MI.
47894................................  Washington-Arlington-             1.1054     1.0855    -0.0199      -1.80
                                        Alexandria, DC-VA.
47940................................  Waterloo-Cedar Falls, IA.....     0.8408     0.8519     0.0111       1.32
48140................................  Wausau, WI...................     0.9722     0.9679    -0.0043      -0.44
48260................................  Weirton-Steubenville, WV-OH..     0.8063     0.7924    -0.0139      -1.72
48300................................  Wenatchee, WA................     1.0346     1.1469     0.1123      10.85
48424................................  West Palm Beach-Boca Raton-       0.9649     0.9728     0.0079       0.82
                                        Boynton, FL.
48540................................  Wheeling, WV-OH..............     0.7010     0.6961    -0.0049      -0.70
48620................................  Wichita, KS..................     0.9063     0.9062    -0.0001      -0.01
48660................................  Wichita Falls, TX............     0.8311     0.7920    -0.0391      -4.70
48700................................  Williamsport, PA.............     0.8139     0.8043    -0.0096      -1.18
48864................................  Wilmington, DE-MD-NJ.........     1.0684     1.0824     0.0140       1.31
48900................................  Wilmington, NC...............     0.9835     0.9410    -0.0425      -4.32
49020................................  Winchester, VA-WV............     1.0091     0.9913    -0.0178      -1.76

[[Page 46516]]

 
49180................................  Winston-Salem, NC............     0.9276     0.9118    -0.0158      -1.70
49340................................  Worcester, MA................     1.0722     1.1287     0.0565       5.27
49420................................  Yakima, WA...................     0.9847     1.0267     0.0420       4.27
49500................................  Yauco, PR....................     0.3854     0.3284    -0.0570     -14.79
49620................................  York-Hanover, PA.............     0.9397     0.9359    -0.0038      -0.40
49660................................  Youngstown-Warren-Boardman,       0.8802     0.9002     0.0200       2.27
                                        OH-PA.
49700................................  Yuba City, CA................     1.0730     1.0756     0.0026       0.24
49740................................  Yuma, AZ.....................     0.9109     0.9488     0.0379       4.16
----------------------------------------------------------------------------------------------------------------


  Addendum D--Comparison of Raw Pre-Floor, Pre-Reclassified Hospital Wage Index Values Used as Input Values to
                               Derive the FY 2007 and FY 2008 Hospice Wage Indices
                                        [For illustrative purposes only]
----------------------------------------------------------------------------------------------------------------
                                                                                                        Percent
                                                                        FY2007     FY2008   FY08-FY07     chng
----------------------------------------------------------------------------------------------------------------
                                                   Rural Area
----------------------------------------------------------------------------------------------------------------
1....................................  Alabama......................     0.7446     0.7591     0.0145       1.95
2....................................  Alaska.......................     1.1977     1.0661    -0.1316     -10.99
3....................................  Arizona......................     0.8768     0.8908     0.0140       1.60
4....................................  Arkansas.....................     0.7466     0.7307    -0.0159      -2.13
5....................................  California...................     1.1054     1.1454     0.0400       3.62
6....................................  Colorado.....................     0.9380     0.9325    -0.0055      -0.59
7....................................  Connecticut..................     1.1730     1.1709    -0.0021      -0.18
8....................................  Delaware.....................     0.9579     0.9705     0.0126       1.32
10...................................  Florida......................     0.8568     0.8594     0.0026       0.30
11...................................  Georgia......................     0.7662     0.7593    -0.0069      -0.90
12...................................  Hawaii.......................     1.0551     1.0448    -0.0103      -0.98
13...................................  Idaho........................     0.8037     0.8120     0.0083       1.03
14...................................  Illinois.....................     0.8271     0.8320     0.0049       0.59
15...................................  Indiana......................     0.8624     0.8538    -0.0086      -1.00
16...................................  Iowa.........................     0.8509     0.8681     0.0172       2.02
17...................................  Kansas.......................     0.8035     0.7998    -0.0037      -0.46
18...................................  Kentucky.....................     0.7766     0.7768     0.0002       0.03
19...................................  Louisiana....................     0.7411     0.7438     0.0027       0.36
20...................................  Maine........................     0.8843     0.8443    -0.0400      -4.52
21...................................  Maryland.....................     0.9353     0.8926    -0.0427      -4.57
22...................................  Massachusetts................     1.0216     1.1661     0.1445      14.14
23...................................  Michigan.....................     0.8895     0.9062     0.0167       1.88
24...................................  Minnesota....................     0.9132     0.9153     0.0021       0.23
25...................................  Mississippi..................     0.7674     0.7738     0.0064       0.83
26...................................  Missouri.....................     0.7900     0.7927     0.0027       0.34
27...................................  Montana......................     0.8762     0.8590    -0.0172      -1.96
28...................................  Nebraska.....................     0.8657     0.8677     0.0020       0.23
29...................................  Nevada.......................     0.9065     0.8944    -0.0121      -1.33
30...................................  New Hampshire................     1.0817     1.0853     0.0036       0.33
32...................................  New Mexico...................     0.8635     0.8332    -0.0303      -3.51
33...................................  New York.....................     0.8154     0.8232     0.0078       0.96
34...................................  North Carolina...............     0.8540     0.8588     0.0048       0.56
35...................................  North Dakota.................     0.7261     0.7215    -0.0046      -0.63
36...................................  Ohio.........................     0.8826     0.8658    -0.0168      -1.90
37...................................  Oklahoma.....................     0.7581     0.7629     0.0048       0.63
38...................................  Oregon.......................     0.9826     0.9753    -0.0073      -0.74
39...................................  Pennsylvania.................     0.8291     0.8320     0.0029       0.35
40...................................  Puerto Rico..................     0.4047     0.4047     0.0000       0.00
42...................................  South Carolina...............     0.8638     0.8566    -0.0072      -0.83
43...................................  South Dakota.................     0.8560     0.8480    -0.0080      -0.93
44...................................  Tennessee....................     0.7895     0.7827    -0.0068      -0.86
45...................................  Texas........................     0.8003     0.7965    -0.0038      -0.47
46...................................  Utah.........................     0.8118     0.8140     0.0022       0.27
47...................................  Vermont......................     0.9830     0.9744    -0.0086      -0.87
48...................................  Virgin Islands...............     0.7615     0.8467     0.0852      11.19
49...................................  Virginia.....................     0.8013     0.7940    -0.0073      -0.91
50...................................  Washington...................     1.0510     1.0263    -0.0247      -2.35
51...................................  West Virginia................     0.7717     0.7607    -0.0110      -1.43
52...................................  Wisconsin....................     0.9509     0.9553     0.0044       0.46

[[Page 46517]]

 
53...................................  Wyoming......................     0.9257     0.9295     0.0038       0.41
65...................................  Guam.........................     0.9611     0.9611     0.0000       0.00
----------------------------------------------------------------------------------------------------------------
CBSA.................................                                  Urban Area
----------------------------------------------------------------------------------------------------------------
10180................................  Abilene, TX..................     0.7896     0.8000     0.0104       1.32
10380................................  Aguadilla-Isabela-San             0.4738     0.3915    -0.0823     -17.37
                                        Sebasti[aacute]n, PR.
10420................................  Akron, OH....................     0.8982     0.8654    -0.0328      -3.65
10500................................  Albany, GA...................     0.8628     0.8991     0.0363       4.21
10580................................  Albany-Schenectady-Troy, NY..     0.8589     0.8720     0.0131       1.53
10740................................  Albuquerque, NM..............     0.9684     0.9458    -0.0226      -2.33
10780................................  Alexandria, LA...............     0.8033     0.8006    -0.0027      -0.34
10900................................  Allentown-Bethlehem-Easton,       0.9818     0.9947     0.0129       1.31
                                        PA-NJ.
11020................................  Altoona, PA..................     0.8944     0.8812    -0.0132      -1.48
11100................................  Amarillo, TX.................     0.9156     0.9169     0.0013       0.14
11180................................  Ames, IA.....................     0.9536     0.9760     0.0224       2.35
11260................................  Anchorage, AK................     1.1895     1.2023     0.0128       1.08
11300................................  Anderson, IN.................     0.8586     0.8681     0.0095       1.11
11340................................  Anderson, SC.................     0.8997     0.9017     0.0020       0.22
11460................................  Ann Arbor, MI................     1.0859     1.0826    -0.0033      -0.30
11500................................  Anniston-Oxford, AL..........     0.7682     0.7770     0.0088       1.15
11540................................  Appleton, WI.................     0.9288     0.9455     0.0167       1.80
11700................................  Asheville, NC................     0.9285     0.9216    -0.0069      -0.74
12020................................  Athens-Clarke County, GA.....     0.9855     0.9856     0.0001       0.01
12060................................  Atlanta-Sandy Springs-            0.9793     0.9762    -0.0031      -0.32
                                        Marietta, GA.
12100................................  Atlantic City, NJ............     1.1615     1.1831     0.0216       1.86
12220................................  Auburn-Opelika, AL...........     0.8100     0.8096    -0.0004      -0.05
12260................................  Augusta-Richmond County, GA-      0.9748     0.9667    -0.0081      -0.83
                                        SC.
12420................................  Austin-Round Rock, TX........     0.9437     0.9344    -0.0093      -0.99
12540................................  Bakersfield, CA..............     1.0470     1.0725     0.0255       2.44
12580................................  Baltimore-Towson, MD.........     0.9897     1.0088     0.0191       1.93
12620................................  Bangor, ME...................     0.9993     0.9711    -0.0282      -2.82
12700................................  Barnstable Town, MA..........     1.2600     1.2539    -0.0061      -0.48
12940................................  Baton Rouge, LA..............     0.8593     0.8084    -0.0509      -5.92
12980................................  Battle Creek, MI.............     0.9508     0.9762     0.0254       2.67
13020................................  Bay City, MI.................     0.9343     0.9251    -0.0092      -0.98
13140................................  Beaumont-Port Arthur, TX.....     0.8412     0.8595     0.0183       2.18
13380................................  Bellingham, WA...............     1.1731     1.1104    -0.0627      -5.34
13460................................  Bend, OR.....................     1.0786     1.0743    -0.0043      -0.40
13644................................  Bethesda-Gaithersburg-            1.1483     1.0903    -0.0580      -5.05
                                        Frederick, MD.
13740................................  Billings, MT.................     0.8834     0.8712    -0.0122      -1.38
13780................................  Binghamton, NY...............     0.8562     0.8786     0.0224       2.62
13820................................  Birmingham-Hoover, AL........     0.8959     0.8894    -0.0065      -0.73
13900................................  Bismarck, ND.................     0.7574     0.7240    -0.0334      -4.41
13980................................  Blacksburg-Christiansburg-        0.7954     0.8213     0.0259       3.26
                                        Radford, VA.
14020................................  Bloomington, IN..............     0.8447     0.8533     0.0086       1.02
14060................................  Bloomington-Normal, IL.......     0.9075     0.8944    -0.0131      -1.44
14260................................  Boise City-Nampa, ID.........     0.9052     0.9401     0.0349       3.86
14484................................  Boston-Quincy, MA............     1.1558     1.1679     0.0121       1.05
14500................................  Boulder, CO..................     0.9734     1.0350     0.0616       6.33
14540................................  Bowling Green, KY............     0.8211     0.8148    -0.0063      -0.77
14740................................  Bremerton-Silverdale, WA.....     1.0675     1.0913     0.0238       2.23
14860................................  Bridgeport-Stamford-Norwalk,      1.2592     1.2659     0.0067       0.53
                                        CT.
15180................................  Brownsville-Harlingen, TX....     0.9804     0.9430    -0.0374      -3.81
15260................................  Brunswick, GA................     0.9311     1.0164     0.0853       9.16
15380................................  Buffalo-Niagara Falls, NY....     0.9511     0.9424    -0.0087      -0.91
15500................................  Burlington, NC...............     0.8905     0.8674    -0.0231      -2.59
15540................................  Burlington-South Burlington,      0.9410     0.9474     0.0064       0.68
                                        VT.
15764................................  Cambridge-Newton-Framingham,      1.1172     1.0970    -0.0202      -1.81
                                        MA.
15804................................  Camden, NJ...................     1.0517     1.0392    -0.0125      -1.19
15940................................  Canton-Massillon, OH.........     0.8935     0.9031     0.0096       1.07
15980................................  Cape Coral-Fort Myers, FL....     0.9356     0.9342    -0.0014      -0.15
16180................................  Carson City, NV..............     1.0234     1.0025    -0.0209      -2.04
16220................................  Casper, WY...................     0.9026     0.9145     0.0119       1.32
16300................................  Cedar Rapids, IA.............     0.8825     0.8888     0.0063       0.71
16580................................  Champaign-Urbana, IL.........     0.9594     0.9644     0.0050       0.52
16620................................  Charleston, WV...............     0.8445     0.8542     0.0097       1.15
16700................................  Charleston-North Charleston,      0.9245     0.9145    -0.0100      -1.08
                                        SC.
16740................................  Charlotte-Gastonia-Concord,       0.9750     0.9554    -0.0196      -2.01
                                        NC-SC.

[[Page 46518]]

 
16820................................  Charlottesville, VA..........     1.0187     1.0125    -0.0062      -0.61
16860................................  Chattanooga, TN-GA...........     0.9088     0.8948    -0.0140      -1.54
16940................................  Cheyenne, WY.................     0.8775     0.9060     0.0285       3.25
16974................................  Chicago-Naperville-Joliet, IL     1.0790     1.0751    -0.0039      -0.36
17020................................  Chico, CA....................     1.0511     1.1053     0.0542       5.16
17140................................  Cincinnati-Middletown, OH-KY-     0.9615     0.9601    -0.0014      -0.15
                                        IN.
17300................................  Clarksville, TN-KY...........     0.8284     0.8436     0.0152       1.83
17420................................  Cleveland, TN................     0.8139     0.8109    -0.0030      -0.37
17460................................  Cleveland-Elyria-Mentor, OH..     0.9213     0.9400     0.0187       2.03
17660................................  Coeur d'Alene, ID............     0.9647     0.9344    -0.0303      -3.14
17780................................  College Station-Bryan, TX....     0.8900     0.9045     0.0145       1.63
17820................................  Colorado Springs, CO.........     0.9468     0.9701     0.0233       2.46
17860................................  Columbia, MO.................     0.8345     0.8542     0.0197       2.36
17900................................  Columbia, SC.................     0.9057     0.8933    -0.0124      -1.37
17980................................  Columbus, GA-AL..............     0.8560     0.8239    -0.0321      -3.75
18020................................  Columbus, IN.................     0.9588     0.9318    -0.0270      -2.82
18140................................  Columbus, OH.................     0.9860     1.0107     0.0247       2.51
18580................................  Corpus Christi, TX...........     0.8550     0.8564     0.0014       0.16
18700................................  Corvallis, OR................     1.0729     1.1546     0.0817       7.61
19060................................  Cumberland, MD-WV............     0.9317     0.8446    -0.0871      -9.35
19124................................  Dallas-Plano-Irving, TX......     1.0228     1.0075    -0.0153      -1.50
19140................................  Dalton, GA...................     0.9079     0.9093     0.0014       0.15
19180................................  Danville, IL.................     0.9028     0.9266     0.0238       2.64
19260................................  Danville, VA.................     0.8489     0.8451    -0.0038      -0.45
19340................................  Davenport-Moline-Rock Island,     0.8724     0.8846     0.0122       1.40
                                        IA-IL.
19380................................  Dayton, OH...................     0.9064     0.9037    -0.0027      -0.30
19460................................  Decatur, AL..................     0.8469     0.8159    -0.0310      -3.66
19500................................  Decatur, IL..................     0.8067     0.8172     0.0105       1.30
19660................................  Deltona-Daytona Beach-Ormond      0.9299     0.9263    -0.0036      -0.39
                                        Beach, FL.
19740................................  Denver-Aurora, CO............     1.0723     1.0930     0.0207       1.93
19780................................  Des Moines-West Des Moines,       0.9669     0.9214    -0.0455      -4.71
                                        IA.
19804................................  Detroit-Livonia-Dearborn, MI.     1.0424     1.0281    -0.0143      -1.37
20020................................  Dothan, AL...................     0.7721     0.7381    -0.0340      -4.40
20100................................  Dover, DE....................     0.9776     0.9847     0.0071       0.73
20220................................  Dubuque, IA..................     0.9024     0.9133     0.0109       1.21
20260................................  Duluth, MN-WI................     1.0213     1.0042    -0.0171      -1.67
20500................................  Durham, NC...................     1.0244     0.9826    -0.0418      -4.08
20740................................  Eau Claire, WI...............     0.9201     0.9630     0.0429       4.66
20764................................  Edison, NJ...................     1.1249     1.1190    -0.0059      -0.52
20940................................  El Centro, CA................     0.8906     0.9076     0.0170       1.91
21060................................  Elizabethtown, KY............     0.8802     0.8697    -0.0105      -1.19
21140................................  Elkhart-Goshen, IN...........     0.9627     0.9426    -0.0201      -2.09
21300................................  Elmira, NY...................     0.8250     0.8240    -0.0010      -0.12
21340................................  El Paso, TX..................     0.8977     0.9053     0.0076       0.85
21500................................  Erie, PA.....................     0.8737     0.8827     0.0090       1.03
21604................................  Essex County, MA.............     1.0538     1.0418    -0.0120      -1.14
21660................................  Eugene-Springfield, OR.......     1.0818     1.0876     0.0058       0.54
21780................................  Evansville, IN-KY............     0.8713     0.9071     0.0358       4.11
21820................................  Fairbanks, AK................     1.1408     1.1059    -0.0349      -3.06
21940................................  Fajardo, PR..................     0.4153     0.4036    -0.0117      -2.82
22020................................  Fargo, ND-MN.................     0.8486     0.8250    -0.0236      -2.78
22140................................  Farmington, NM...............     0.8509     0.8589     0.0080       0.94
22180................................  Fayetteville, NC.............     0.9416     0.8945    -0.0471      -5.00
22220................................  Fayetteville-Springdale-          0.8661     0.8865     0.0204       2.36
                                        Rogers, AR-MO.
22380................................  Flagstaff, AZ................     1.2092     1.1601    -0.0491      -4.06
22420................................  Flint, MI....................     1.0655     1.0969     0.0314       2.95
22500................................  Florence, SC.................     0.8947     0.8388    -0.0559      -6.25
22520................................  Florence-Muscle Shoals, AL...     0.8272     0.7843    -0.0429      -5.19
22540................................  Fond du Lac, WI..............     0.9640     1.0063     0.0423       4.39
22660................................  Fort Collins-Loveland, CO....     1.0122     0.9544    -0.0578      -5.71
22744................................  Ft Lauderdale-Pompano Beach-      1.0432     1.0133    -0.0299      -2.87
                                        Deerfield, FL.
22900................................  Fort Smith, AR-OK............     0.8230     0.7731    -0.0499      -6.06
23020................................  Fort Walton Beach-Crestview-      0.8872     0.8643    -0.0229      -2.58
                                        Destin, FL.
23060................................  Fort Wayne, IN...............     0.9793     0.9517    -0.0276      -2.82
23104................................  Fort Worth-Arlington, TX.....     0.9486     0.9569     0.0083       0.87
23420................................  Fresno, CA...................     1.0538     1.0943     0.0405       3.84
23460................................  Gadsden, AL..................     0.7938     0.8066     0.0128       1.61
23540................................  Gainesville, FL..............     0.9388     0.9277    -0.0111      -1.18
23580................................  Gainesville, GA..............     0.8874     0.8958     0.0084       0.95

[[Page 46519]]

 
23844................................  Gary, IN.....................     0.9395     0.9334    -0.0061      -0.65
24020................................  Glens Falls, NY..............     0.8559     0.8324    -0.0235      -2.75
24140................................  Goldsboro, NC................     0.8775     0.9171     0.0396       4.51
24220................................  Grand Forks, ND-MN...........     0.7901     0.7949     0.0048       0.61
24300................................  Grand Junction, CO...........     0.9550     0.9668     0.0118       1.24
24340................................  Grand Rapids-Wyoming, MI.....     0.9390     0.9455     0.0065       0.69
24500................................  Great Falls, MT..............     0.9052     0.8598    -0.0454      -5.02
24540................................  Greeley, CO..................     0.9570     0.9602     0.0032       0.33
24580................................  Green Bay, WI................     0.9483     0.9787     0.0304       3.21
24660................................  Greensboro-High Point, NC....     0.9104     0.8866    -0.0238      -2.61
24780................................  Greenville, NC...............     0.9425     0.9432     0.0007       0.07
24860................................  Greenville, SC...............     1.0027     0.9804    -0.0223      -2.22
25020................................  Guayama, PR..................     0.3181     0.3235     0.0054       1.70
25060................................  Gulfport-Biloxi, MS..........     0.8929     0.8915    -0.0014      -0.16
25180................................  Hagerstown-Martinsburg, MD-WV     0.9489     0.9038    -0.0451      -4.75
25260................................  Hanford-Corcoran, CA.........     1.0036     1.0282     0.0246       2.45
25420................................  Harrisburg-Carlisle, PA......     0.9313     0.9402     0.0089       0.96
25500................................  Harrisonburg, VA.............     0.9088     0.9073    -0.0015      -0.17
25540................................  Hartford-West Hartford-East       1.1073     1.0894    -0.0179      -1.62
                                        Hartford, CT.
25620................................  Hattiesburg, MS..............     0.7601     0.7430    -0.0171      -2.25
25860................................  Hickory-Lenoir-Morganton, NC.     0.8921     0.9010     0.0089       1.00
25980................................  Hinesville-Fort Stewart, GA..     0.9198     0.9178    -0.0020      -0.22
26100................................  Holland-Grand Haven, MI......     0.9055     0.9163     0.0108       1.19
26180................................  Honolulu, HI.................     1.1214     1.1096    -0.0118      -1.05
26300................................  Hot Springs, AR..............     0.9005     0.8782    -0.0223      -2.48
26380................................  Houma-Bayou Cane-Thibodaux,       0.7894     0.8082     0.0188       2.38
                                        LA.
26420................................  Houston-Sugar Land-Baytown,       0.9996     1.0008     0.0012       0.12
                                        TX.
26580................................  Huntington-Ashland, WV-KY-OH.     0.9477     0.8997    -0.0480      -5.06
26620................................  Huntsville, AL...............     0.9146     0.9007    -0.0139      -1.52
26820................................  Idaho Falls, ID..............     0.9420     0.9088    -0.0332      -3.52
26900................................  Indianapolis-Carmel, IN......     0.9920     0.9895    -0.0025      -0.25
26980................................  Iowa City, IA................     0.9747     0.9714    -0.0033      -0.34
27060................................  Ithaca, NY...................     0.9793     0.9928     0.0135       1.38
27100................................  Jackson, MI..................     0.9304     0.9560     0.0256       2.75
27140................................  Jackson, MS..................     0.8311     0.8271    -0.0040      -0.48
27180................................  Jackson, TN..................     0.8964     0.8853    -0.0111      -1.24
27260................................  Jacksonville, FL.............     0.9290     0.9165    -0.0125      -1.35
27340................................  Jacksonville, NC.............     0.8236     0.8231    -0.0005      -0.06
27500................................  Janesville, WI...............     0.9538     0.9655     0.0117       1.23
27620................................  Jefferson City, MO...........     0.8387     0.8332    -0.0055      -0.66
27740................................  Johnson City, TN.............     0.7937     0.8043     0.0106       1.34
27780................................  Johnstown, PA................     0.8354     0.8620     0.0266       3.18
27860................................  Jonesboro, AR................     0.7911     0.7662    -0.0249      -3.15
27900................................  Joplin, MO...................     0.8582     0.8605     0.0023       0.27
28020................................  Kalamazoo-Portage, MI........     1.0381     1.0704     0.0323       3.11
28100................................  Kankakee-Bradley, IL.........     1.0721     1.0083    -0.0638      -5.95
28140................................  Kansas City, MO-KS...........     0.9476     0.9495     0.0019       0.20
28420................................  Kennewick-Richland-Pasco, WA.     1.0619     1.0343    -0.0276      -2.60
28660................................  Killeen-Temple-Fort Hood, TX.     0.8526     0.8901     0.0375       4.40
28700................................  Kingsport-Bristol-Bristol, TN-    0.8054     0.7985    -0.0069      -0.86
                                        VA.
28740................................  Kingston, NY.................     0.9255     0.9367     0.0112       1.21
28940................................  Knoxville, TN................     0.8441     0.8249    -0.0192      -2.27
29020................................  Kokomo, IN...................     0.9508     0.9669     0.0161       1.69
29100................................  La Crosse, WI-MN.............     0.9564     0.9426    -0.0138      -1.44
29140................................  Lafayette, IN................     0.8736     0.8931     0.0195       2.23
29180................................  Lafayette, LA................     0.8428     0.8289    -0.0139      -1.65
29340................................  Lake Charles, LA.............     0.7833     0.7914     0.0081       1.03
29404................................  Lake County-Kenosha County,       1.0429     1.0570     0.0141       1.35
                                        IL-WI.
29460................................  Lakeland, FL.................     0.8912     0.8879    -0.0033      -0.37
29540................................  Lancaster, PA................     0.9694     0.9589    -0.0105      -1.08
29620................................  Lansing-East Lansing, MI.....     0.9794     1.0088     0.0294       3.00
29700................................  Laredo, TX...................     0.8068     0.7811    -0.0257      -3.19
29740................................  Las Cruces, NM...............     0.8467     0.9273     0.0806       9.52
29820................................  Las Vegas-Paradise, NV.......     1.1437     1.1430    -0.0007      -0.06
29940................................  Lawrence, KS.................     0.8537     0.8365    -0.0172      -2.01
30020................................  Lawton, OK...................     0.7872     0.8065     0.0193       2.45
30140................................  Lebanon, PA..................     0.8459     0.8679     0.0220       2.60
30300................................  Lewiston, ID-WA..............     0.9886     0.9853    -0.0033      -0.33
30340................................  Lewiston-Auburn, ME..........     0.9331     0.9126    -0.0205      -2.20

[[Page 46520]]

 
30460................................  Lexington-Fayette, KY........     0.9075     0.9181     0.0106       1.17
30620................................  Lima, OH.....................     0.9225     0.9042    -0.0183      -1.98
30700................................  Lincoln, NE..................     1.0214     1.0092    -0.0122      -1.19
30780................................  Little Rock-North Little          0.8747     0.8890     0.0143       1.63
                                        Rock, AR.
30860................................  Logan, UT-ID.................     0.9164     0.9022    -0.0142      -1.55
30980................................  Longview, TX.................     0.8730     0.8788     0.0058       0.66
31020................................  Longview, WA.................     0.9579     1.0011     0.0432       4.51
31084................................  Los Angeles-Long Beach-Santa      1.1783     1.1760    -0.0023      -0.20
                                        Ana, CA.
31140................................  Louisville-Jefferson County,      0.9251     0.9118    -0.0133      -1.44
                                        KY-IN.
31180................................  Lubbock, TX..................     0.8783     0.8613    -0.0170      -1.94
31340................................  Lynchburg, VA................     0.8691     0.8694     0.0003       0.03
31420................................  Macon, GA....................     0.9443     0.9519     0.0076       0.80
31460................................  Madera, CA...................     0.8713     0.8154    -0.0559      -6.42
31540................................  Madison, WI..................     1.0659     1.0840     0.0181       1.70
31700................................  Manchester-Nashua, NH........     1.0354     1.0243    -0.0111      -1.07
31900................................  Mansfield, OH................     0.9891     0.9271    -0.0620      -6.27
32420................................  Mayag[uuml]ez, PR............     0.4020     0.3848    -0.0172      -4.28
32580................................  McAllen-Edinburg-Mission, TX.     0.8934     0.8773    -0.0161      -1.80
32780................................  Medford, OR..................     1.0225     1.0818     0.0593       5.80
32820................................  Memphis, TN-MS-AR............     0.9397     0.9373    -0.0024      -0.26
32900................................  Merced, CA...................     1.1109     1.1471     0.0362       3.26
33124................................  Miami-Miami Beach-Kendall, FL     0.9750     0.9812     0.0062       0.64
33140................................  Michigan City-La Porte, IN...     0.9399     0.9118    -0.0281      -2.99
33260................................  Midland, TX..................     0.9514     0.9786     0.0272       2.86
33340................................  Milwaukee-Waukesha-West           1.0146     1.0218     0.0072       0.71
                                        Allis, WI.
33460................................  Minneapolis-St. Paul-             1.1075     1.0946    -0.0129      -1.16
                                        Bloomington, MN-WI.
33540................................  Missoula, MT.................     0.9473     0.8928    -0.0545      -5.75
33660................................  Mobile, AL...................     0.7891     0.7913     0.0022       0.28
33700................................  Modesto, CA..................     1.1885     1.1729    -0.0156      -1.31
33740................................  Monroe, LA...................     0.8031     0.7997    -0.0034      -0.42
33780................................  Monroe, MI...................     0.9468     0.9707     0.0239       2.52
33860................................  Montgomery, AL...............     0.8618     0.8009    -0.0609      -7.07
34060................................  Morgantown, WV...............     0.8420     0.8423     0.0003       0.04
34100................................  Morristown, TN...............     0.7961     0.7933    -0.0028      -0.35
34580................................  Mount Vernon-Anacortes, WA...     1.0454     1.0517     0.0063       0.60
34620................................  Muncie, IN...................     0.8930     0.8562    -0.0368      -4.12
34740................................  Muskegon-Norton Shores, MI...     0.9664     0.9941     0.0277       2.87
34820................................  Myrtle Beach-Conway-North         0.8934     0.8810    -0.0124      -1.39
                                        Myrtle Beach, SC.
34900................................  Napa, CA.....................     1.2643     1.3374     0.0731       5.78
34940................................  Naples-Marco Island, FL......     1.0139     0.9941    -0.0198      -1.95
34980................................  Nashville-Davidson--              0.9790     0.9847     0.0057       0.58
                                        Murfreesboro, TN.
35004................................  Nassau-Suffolk, NY...........     1.2719     1.2662    -0.0057      -0.45
35084................................  Newark-Union, NJ-PA..........     1.1883     1.1892     0.0009       0.08
35300................................  New Haven-Milford, CT........     1.1887     1.1953     0.0066       0.56
35380................................  New Orleans-Metairie-Kenner,      0.8995     0.8831    -0.0164      -1.82
                                        LA.
35644................................  New York-White Plains-Wayne,      1.3188     1.3177    -0.0011      -0.08
                                        NY-NJ.
35660................................  Niles-Benton Harbor, MI......     0.8879     0.8915     0.0036       0.41
35980................................  Norwich-New London, CT.......     1.1345     1.1932     0.0587       5.17
36084................................  Oakland-Fremont-Hayward, CA..     1.5346     1.5819     0.0473       3.08
36100................................  Ocala, FL....................     0.8925     0.8867    -0.0058      -0.65
36140................................  Ocean City, NJ...............     1.1011     1.0472    -0.0539      -4.90
36220................................  Odessa, TX...................     0.9884     1.0073     0.0189       1.91
36260................................  Ogden-Clearfield, UT.........     0.9029     0.8995    -0.0034      -0.38
36420................................  Oklahoma City, OK............     0.9031     0.8843    -0.0188      -2.08
36500................................  Olympia, WA..................     1.0927     1.1081     0.0154       1.41
36540................................  Omaha-Council Bluffs, NE-IA..     0.9560     0.9450    -0.0110      -1.15
36740................................  Orlando-Kissimmee, FL........     0.9464     0.9452    -0.0012      -0.13
36780................................  Oshkosh-Neenah, WI...........     0.9183     0.9315     0.0132       1.44
36980................................  Owensboro, KY................     0.8780     0.8748    -0.0032      -0.36
37100................................  Oxnard-Thousand Oaks-Ventura,     1.1622     1.1546    -0.0076      -0.65
                                        CA.
37340................................  Palm Bay-Melbourne-               0.9839     0.9443    -0.0396      -4.02
                                        Titusville, FL.
37460................................  Panama City-Lynn Haven, FL...     0.8005     0.8027     0.0022       0.27
37620................................  Parkersburg-Marietta-Vienna,      0.8270     0.7977    -0.0293      -3.54
                                        WV-OH.
37700................................  Pascagoula, MS...............     0.8156     0.8215     0.0059       0.72
37860................................  Pensacola-Ferry Pass-Brent,       0.8096     0.8000    -0.0096      -1.19
                                        FL.
37900................................  Peoria, IL...................     0.8870     0.8982     0.0112       1.26
37964................................  Philadelphia, PA.............     1.1038     1.0996    -0.0042      -0.38
38060................................  Phoenix-Mesa-Scottsdale, AZ..     1.0127     1.0287     0.0160       1.58
38220................................  Pine Bluff, AR...............     0.8680     0.8383    -0.0297      -3.42

[[Page 46521]]

 
38300................................  Pittsburgh, PA...............     0.8845     0.8674    -0.0171      -1.93
38340................................  Pittsfield, MA...............     1.0181     1.0266     0.0085       0.83
38540................................  Pocatello, ID................     0.9351     0.9400     0.0049       0.52
38660................................  Ponce, PR....................     0.4939     0.4842    -0.0097      -1.96
38860................................  Portland-South Portland-          1.0382     0.9908    -0.0474      -4.57
                                        Biddeford, ME.
38900................................  Portland-Vancouver-Beaverton,     1.1266     1.1416     0.0150       1.33
                                        OR-WA.
38940................................  Port St. Lucie-Fort Pierce,       1.0123     0.9833    -0.0290      -2.86
                                        FL.
39100................................  Poughkeepsie-Newburgh-            1.0891     1.0911     0.0020       0.18
                                        Middletown, NY.
39140................................  Prescott, AZ.................     0.9869     0.9836    -0.0033      -0.33
39300................................  Providence-New Bedford-Fall       1.0966     1.0783    -0.0183      -1.67
                                        River, RI-MA.
39340................................  Provo-Orem, UT...............     0.9500     0.9537     0.0037       0.39
39380................................  Pueblo, CO...................     0.8623     0.8753     0.0130       1.51
39460................................  Punta Gorda, FL..............     0.9255     0.9405     0.0150       1.62
39540................................  Racine, WI...................     0.8997     0.9356     0.0359       3.99
39580................................  Raleigh-Cary, NC.............     0.9691     0.9864     0.0173       1.79
39660................................  Rapid City, SD...............     0.8987     0.8833    -0.0154      -1.71
39740................................  Reading, PA..................     0.9686     0.9622    -0.0064      -0.66
39820................................  Redding, CA..................     1.2203     1.3198     0.0995       8.15
39900................................  Reno-Sparks, NV..............     1.0982     1.1963     0.0981       8.93
40060................................  Richmond, VA.................     0.9328     0.9177    -0.0151      -1.62
40140................................  Riverside-San Bernardino-         1.1027     1.0904    -0.0123      -1.12
                                        Ontario, CA.
40220................................  Roanoke, VA..................     0.8374     0.8647     0.0273       3.26
40340................................  Rochester, MN................     1.1131     1.1408     0.0277       2.49
40380................................  Rochester, NY................     0.9121     0.8994    -0.0127      -1.39
40420................................  Rockford, IL.................     0.9984     0.9989     0.0005       0.05
40484................................  Rockingham County, NH........     1.0374     1.0159    -0.0215      -2.07
40580................................  Rocky Mount, NC..............     0.8915     0.8854    -0.0061      -0.68
40660................................  Rome, GA.....................     0.9414     0.9193    -0.0221      -2.35
40900................................  Sacramento--Arden-Arcade--        1.2969     1.3372     0.0403       3.11
                                        Roseville, CA.
40980................................  Saginaw-Saginaw Township          0.9088     0.8874    -0.0214      -2.35
                                        North, MI.
41060................................  St. Cloud, MN................     0.9965     1.0362     0.0397       3.98
41100................................  St. George, UT...............     0.9392     0.9265    -0.0127      -1.35
41140................................  St. Joseph, MO-KS............     0.9519     1.0118     0.0599       6.29
41180................................  St. Louis, MO-IL.............     0.8954     0.9005     0.0051       0.57
41420................................  Salem, OR....................     1.0442     1.0438    -0.0004      -0.04
41500................................  Salinas, CA..................     1.4128     1.4337     0.0209       1.48
41540................................  Salisbury, MD................     0.9064     0.8953    -0.0111      -1.22
41620................................  Salt Lake City, UT...........     0.9421     0.9402    -0.0019      -0.20
41660................................  San Angelo, TX...............     0.8271     0.8362     0.0091       1.10
41700................................  San Antonio, TX..............     0.8980     0.8844    -0.0136      -1.51
41740................................  San Diego-Carlsbad-San            1.1413     1.1354    -0.0059      -0.52
                                        Marcos, CA.
41780................................  Sandusky, OH.................     0.9019     0.9302     0.0283       3.14
41884................................  San Francisco-San Mateo-          1.4994     1.5165     0.0171       1.14
                                        Redwood City,CA.
41900................................  San Germ[aacute]n-Cabo Rojo,      0.4650     0.4885     0.0235       5.05
                                        PR.
41940................................  San Jose-Sunnyvale-Santa          1.5099     1.5543     0.0444       2.94
                                        Clara, CA.
41980................................  San Juan-Caguas-Guaynabo, PR.     0.4621     0.4452    -0.0169      -3.66
42020................................  San Luis Obispo-Paso Robles,      1.1349     1.1598     0.0249       2.19
                                        CA.
42044................................  Santa Ana-Anaheim-Irvine, CA.     1.1559     1.1473    -0.0086      -0.74
42060................................  Santa Barbara-Santa Maria, CA     1.1694     1.1091    -0.0603      -5.16
42100................................  Santa Cruz-Watsonville, CA...     1.5166     1.5457     0.0291       1.92
42140................................  Santa Fe, NM.................     1.0920     1.0824    -0.0096      -0.88
42220................................  Santa Rosa-Petaluma, CA......     1.3493     1.4464     0.0971       7.20
42260................................  Sarasota-Bradenton-Venice, FL     0.9639     0.9868     0.0229       2.38
42340................................  Savannah, GA.................     0.9461     0.9351    -0.0110      -1.16
42540................................  Scranton--Wilkes-Barre, PA...     0.8540     0.8347    -0.0193      -2.26
42644................................  Seattle-Bellevue-Everett, WA.     1.1577     1.1434    -0.0143      -1.24
42680................................  Sebastian-Vero Beach, FL.....  .........     0.9573     0.9573  .........
43100................................  Sheboygan, WI................     0.8911     0.9026     0.0115       1.29
43300................................  Sherman-Denison, TX..........     0.9507     0.8502    -0.1005     -10.57
43340................................  Shreveport-Bossier City, LA..     0.8760     0.8865     0.0105       1.20
43580................................  Sioux City, IA-NE-SD.........     0.9381     0.9200    -0.0181      -1.93
43620................................  Sioux Falls, SD..............     0.9635     0.9559    -0.0076      -0.79
43780................................  South Bend-Mishawaka, IN-MI..     0.9788     0.9842     0.0054       0.55
43900................................  Spartanburg, SC..............     0.9172     0.9174     0.0002       0.02
44060................................  Spokane, WA..................     1.0905     1.0447    -0.0458      -4.20
44100................................  Springfield, IL..............     0.8792     0.8890     0.0098       1.11
44140................................  Springfield, MA..............     1.0248     1.0079    -0.0169      -1.65
44180................................  Springfield, MO..............     0.8237     0.8469     0.0232       2.82
44220................................  Springfield, OH..............     0.8396     0.8593     0.0197       2.35

[[Page 46522]]

 
44300................................  State College, PA............     0.8356     0.8784     0.0428       5.12
44700................................  Stockton, CA.................     1.1307     1.1442     0.0135       1.19
44940................................  Sumter, SC...................     0.8377     0.8083    -0.0294      -3.51
45060................................  Syracuse, NY.................     0.9574     0.9691     0.0117       1.22
45104................................  Tacoma, WA...................     1.0742     1.0789     0.0047       0.44
45220................................  Tallahassee, FL..............     0.8688     0.8942     0.0254       2.92
45300................................  Tampa-St. Petersburg-             0.9233     0.9144    -0.0089      -0.96
                                        Clearwater, FL.
45460................................  Terre Haute, IN..............     0.8304     0.8765     0.0461       5.55
45500................................  Texarkana, TX-Texarkana, AR..     0.8283     0.8104    -0.0179      -2.16
45780................................  Toledo, OH...................     0.9574     0.9586     0.0012       0.13
45820................................  Topeka, KS...................     0.8920     0.8730    -0.0190      -2.13
45940................................  Trenton-Ewing, NJ............     1.0834     1.0835     0.0001       0.01
46060................................  Tucson, AZ...................     0.9007     0.9202     0.0195       2.16
46140................................  Tulsa, OK....................     0.8543     0.8103    -0.0440      -5.15
46220................................  Tuscaloosa, AL...............     0.8645     0.8542    -0.0103      -1.19
46340................................  Tyler, TX....................     0.9168     0.8811    -0.0357      -3.89
46540................................  Utica-Rome, NY...............     0.8358     0.8396     0.0038       0.45
46660................................  Valdosta, GA.................     0.8866     0.8369    -0.0497      -5.61
46700................................  Vallejo-Fairfield, CA........     1.4936     1.5137     0.0201       1.35
46940................................  Vero Beach, FL...............     0.9434  .........    -0.9434  .........
47020................................  Victoria, TX.................     0.8160     0.8560     0.0400       4.90
47220................................  Vineland-Millville-Bridgeton,     0.9827     0.9832     0.0005       0.05
                                        NJ.
47260................................  Virginia Beach-Norfolk-           0.8799     0.8790    -0.0009      -0.10
                                        Newport News, VA.
47300................................  Visalia-Porterville, CA......     1.0123     0.9968    -0.0155      -1.53
47380................................  Waco, TX.....................     0.8518     0.8633     0.0115       1.35
47580................................  Warner Robins, GA............     0.8645     0.8380    -0.0265      -3.07
47644................................  Warren-Troy-Farmington Hills,     0.9871     1.0054     0.0183       1.85
                                        MI.
47894................................  Washington-Arlington-             1.0926     1.1054     0.0128       1.17
                                        Alexandria, DC-VA.
47940................................  Waterloo-Cedar Falls, IA.....     0.8557     0.8408    -0.0149      -1.74
48140................................  Wausau, WI...................     0.9590     0.9722     0.0132       1.38
48260................................  Weirton-Steubenville, WV-OH..     0.7819     0.8063     0.0244       3.12
48300................................  Wenatchee, WA................     1.0070     1.0346     0.0276       2.74
48424................................  West Palm Beach-Boca Raton-       1.0067     0.9649    -0.0418      -4.15
                                        Boynton, FL.
48540................................  Wheeling, WV-OH..............     0.7161     0.7010    -0.0151      -2.11
48620................................  Wichita, KS..................     0.9153     0.9063    -0.0090      -0.98
48660................................  Wichita Falls, TX............     0.8285     0.8311     0.0026       0.31
48700................................  Williamsport, PA.............     0.8364     0.8139    -0.0225      -2.69
48864................................  Wilmington, DE-MD-NJ.........     1.0471     1.0684     0.0213       2.03
48900................................  Wilmington, NC...............     0.9582     0.9835     0.0253       2.64
49020................................  Winchester, VA-WV............     1.0214     1.0091    -0.0123      -1.20
49180................................  Winston-Salem, NC............     0.8944     0.9276     0.0332       3.71
49340................................  Worcester, MA................     1.1028     1.0722    -0.0306      -2.77
49420................................  Yakima, WA...................     1.0155     0.9847    -0.0308      -3.03
49500................................  Yauco, PR....................     0.4408     0.3854    -0.0554     -12.57
49620................................  York-Hanover, PA.............     0.9347     0.9397     0.0050       0.53
49660................................  Youngstown-Warren-Boardman,       0.8603     0.8802     0.0199       2.31
                                        OH-PA.
49700................................  Yuba City, CA................     1.0921     1.0730    -0.0191      -1.75
49740................................  Yuma, AZ.....................     0.9126     0.9109    -0.0017      -0.19
----------------------------------------------------------------------------------------------------------------

[FR Doc. E8-17795 Filed 7-31-08; 4:15 pm]
BILLING CODE 4120-01-P