46370 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Part 412 

[CMS–1554–F] 

RIN 0938–AP19 

Medicare Program; Inpatient 

Rehabilitation Facility Prospective 

Payment System for Federal Fiscal 

Year 2009 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Final rule. 

SUMMARY: This final rule updates the 

prospective payment rates for inpatient 

rehabilitation facilities (IRFs) for 

Federal fiscal year (FY) 2009 (for 

discharges occurring on or after October 

1, 2008 and on or before September 30, 

2009) as required under section 

1886(j)(3)(C) of the Social Security Act 

(the Act). Section 1886(j)(5) of the Act 

requires the Secretary to publish in the 

Federal Register on or before the August 

1 that precedes the start of each fiscal 

year, the classification and weighting 

factors for the IRF prospective payment 

system’s (PPS) case-mix groups and a 

description of the methodology and data 

used in computing the prospective 

payment rates for that fiscal year. 

We are revising existing policies 

regarding the PPS within the authority 

granted under section 1886(j) of the Act. 

DATES: These regulations are effective 

October 1, 2008. The updated IRF 

prospective payment rates are 

applicable for discharges on or after 

October 1, 2008 and on or before 

September 30, 2009 (FY 2009). 

FOR FURTHER INFORMATION CONTACT: 

Susanne Seagrave, (410) 786–0044, for 

information regarding the payment 

policies. 

Jeanette Kranacs, (410) 786–9385, for 

information regarding the wage index. 

SUPPLEMENTARY INFORMATION: 

Table of Contents 

I. Background 

A. Historical Overview of the Inpatient 

Rehabilitation Facility Prospective 

Payment System (IRF PPS) 

B. Operational Overview of the Current IRF 

PPS 

II. Provisions of the Proposed Rule 

III. Analysis of and Responses to Public 

Comments 

IV. Update to the Case-Mix Group (CMG) 

Relative Weights and Average Length of 

Stay Values for FY 2009 

V. FY 2009 IRF PPS Federal Prospective 

Payment Rates 

A. Increase Factor and Labor-Related Share 

for FY 2009 

B. Area Wage Adjustment 

C. Description of the IRF Standard 

Payment Conversion Factor and Payment 

Rates for FY 2009 

D. Example of the Methodology for 

Adjusting the Federal Prospective 

Payment Rates 

VI. Update to Payments for High-Cost 

Outliers Under the IRF PPS 

A. Update to the Outlier Threshold 

Amount for FY 2009 

B. Update to the IRF Cost-to-Charge Ratio 

Ceilings 

VII. Revisions to the Regulation Text in 

Response to the Medicare, Medicaid, and 

SCHIP Extension Act of 2007 

VIII. Post Acute Care Payment Reform 

IX. Miscellaneous Comments 

X. Provisions of the Final Rule 

XI. Collection of Information Requirements 

XII. Regulatory Impact Statement 

Regulation Text 

Addendum 

Acronyms 

Because of the many terms to which 

we refer by acronym in this final rule, 

we are listing the acronyms used and 

their corresponding terms in 

alphabetical order below. 

ASCA Administrative Simplification 

Compliance Act, Public Law 107–105 

BBA Balanced Budget Act of 1997, Public 

Law 105–33 

BBRA Medicare, Medicaid, and SCHIP 

[State Children’s Health Insurance 

Program] Balanced Budget Refinement Act 

of 1999, Public Law 106–113 

BIPA Medicare, Medicaid, and SCHIP [State 

Children’s Health Insurance Program] 

Benefits Improvement and Protection Act 

of 2000, Public Law 106–554 

CBSA Core-Based Statistical Area 

CCR Cost-to-Charge Ratio 

CFR Code of Federal Regulations 

CMG Case-Mix Group 

DRA Deficit Reduction Act of 2005, Public 

Law 109–171 

DSH Disproportionate Share Hospital 

ECI Employment Cost Index 

FI Fiscal Intermediary 

FR Federal Register 

FY Federal Fiscal Year 

GDP Gross Domestic Product 

HHH Hubert H. Humphrey Building 

HIPAA Health Insurance Portability and 

Accountability Act, Public Law 104–191 

IFMC Iowa Foundation for Medical Care 

IPF Inpatient Psychiatric Facility 

IPPS Inpatient Prospective Payment System 

IRF Inpatient Rehabilitation Facility 

IRF–PAI Inpatient Rehabilitation FacilityPatient Assessment Instrument 

IRF PPS Inpatient Rehabilitation Facility 

Prospective Payment System 

IRVEN Inpatient Rehabilitation Validation 

and Entry 

LIP Low-Income Percentage 

LTCH Long-Term Care Hospital 

MAC Medicare Administrative Contractor 

MEDPAR Medicare Provider Analysis and 

Review 

MMA Medicare Prescription Drug, 

Improvement, and Modernization Act of 

2003, Public Law 108–173 

MMSEA Medicare, Medicaid, and SCHIP 

Extension Act of 2007, Public Law 110–173 

MSA Metropolitan Statistical Area 

NAICS North American Industrial 

Classification System 

OMB Office of Management and Budget 

PAI Patient Assessment Instrument 

PPS Prospective Payment System 

RAND RAND Corporation 

RFA Regulatory Flexibility Act, Public Law 

96–354 

RIA Regulatory Impact Analysis 

RIC Rehabilitation Impairment Category 

RPL Rehabilitation, Psychiatric, and LongTerm Care Hospital Market Basket 

SCHIP State Children’s Health Insurance 

Program 

SIC Standard Industrial Code 

TEFRA Tax Equity and Fiscal 

Responsibility Act of 1982, Public Law 97– 

248 

I. Background 

A. Historical Overview of the Inpatient 

Rehabilitation Facility Prospective 

Payment System (IRF PPS) 

Section 4421 of the Balanced Budget 

Act of 1997 (BBA), Public Law 105–33, 

as amended by section 125 of the 

Medicare, Medicaid, and SCHIP (State 

Children’s Health Insurance Program) 

Balanced Budget Refinement Act of 

1999 (BBRA), Public Law 106–113, and 

by section 305 of the Medicare, 

Medicaid, and SCHIP Benefits 

Improvement and Protection Act of 

2000 (BIPA), Public Law 106–554, 

provides for the implementation of a per 

discharge prospective payment system 

(PPS) under section 1886(j) of the Social 

Security Act (the Act) for inpatient 

rehabilitation hospitals and inpatient 

rehabilitation units of a hospital 

(hereinafter referred to as IRFs). 

Payments under the IRF PPS 

encompass inpatient operating and 

capital costs of furnishing covered 

rehabilitation services (that is, routine, 

ancillary, and capital costs) but not 

direct graduate medical education costs, 

costs of approved nursing and allied 

health education activities, bad debts, 

and other services or items outside the 

scope of the IRF PPS. Although a 

complete discussion of the IRF PPS 

provisions appears in the original FY 

2002 IRF PPS final rule (66 FR 41316) 

and the FY 2006 IRF PPS final rule (70 

FR 47880), we are providing below a 

general description of the IRF PPS for 

fiscal years (FYs) 2002 through 2008. 

Under the IRF PPS from FY 2002 

through FY 2005, as described in the FY 

2002 IRF PPS final rule (66 FR 41316), 

the Federal prospective payment rates 

were computed across 100 distinct casemix groups (CMGs). We constructed 95 

CMGs using rehabilitation impairment 


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categories (RICs), functional status (both 

motor and cognitive), and age (in some 

cases, cognitive status and age may not 

be a factor in defining a CMG). In 

addition, we constructed five special 

CMGs to account for very short stays 

and for patients who expire in the IRF. 

For each of the CMGs, we developed 

relative weighting factors to account for 

a patient’s clinical characteristics and 

expected resource needs. Thus, the 

weighting factors accounted for the 

relative difference in resource use across 

all CMGs. Within each CMG, we created 

tiers based on the estimated effects that 

certain comorbidities would have on 

resource use. 

We established the Federal PPS rates 

using a standardized payment 

conversion factor (formerly referred to 

as the budget neutral conversion factor). 

For a detailed discussion of the budget 

neutral conversion factor, please refer to 

our FY 2004 IRF PPS final rule (68 FR 

45684 through 45685). In the FY 2006 

IRF PPS final rule (70 FR 47880), we 

discussed in detail the methodology for 

determining the standard payment 

conversion factor. 

We applied the relative weighting 

factors to the standard payment 

conversion factor to compute the 

unadjusted Federal prospective 

payment rates under the IRF PPS from 

FYs 2002 through 2005. Within the 

structure of the payment system, we 

then made adjustments to account for 

interrupted stays, transfers, short stays, 

and deaths. Finally, we applied the 

applicable adjustments to account for 

geographic variations in wages (wage 

index), the percentage of low-income 

patients, location in a rural area (if 

applicable), and outlier payments (if 

applicable) to the IRF’s unadjusted 

Federal prospective payment rates. 

For cost reporting periods that began 

on or after January 1, 2002 and before 

October 1, 2002, we determined the 

final prospective payment amounts 

using the transition methodology 

prescribed in section 1886(j)(1) of the 

Act. Under this provision, IRFs 

transitioning into the PPS were paid a 

blend of the Federal IRF PPS rate and 

the payment that the IRF would have 

received had the IRF PPS not been 

implemented. This provision also 

allowed IRFs to elect to bypass this 

blended payment and immediately be 

paid 100 percent of the Federal IRF PPS 

rate. The transition methodology 

expired as of cost reporting periods 

beginning on or after October 1, 2002 

(FY 2003), and payments for all IRFs 

now consist of 100 percent of the 

Federal IRF PPS rate. 

We established a CMS Web site as a 

primary information resource for the 

IRF PPS. The Web site URL is http:// 

www.cms.hhs.gov/ 

InpatientRehabFacPPS/ and may be 

accessed to download or view 

publications, software, data 

specifications, educational materials, 

and other information pertinent to the 

IRF PPS. 

Section 1886(j) of the Act confers 

broad statutory authority upon the 

Secretary to propose refinements to the 

IRF PPS. In the FY 2006 IRF PPS final 

rule (70 FR 47880) and in correcting 

amendments to the FY 2006 IRF PPS 

final rule (70 FR 57166) that we 

published on September 30, 2005, we 

finalized a number of refinements to the 

IRF PPS case-mix classification system 

(the CMGs and the corresponding 

relative weights) and the case-level and 

facility-level adjustments. These 

refinements included the adoption of 

OMB’s Core-Based Statistical Area 

(CBSA) market definitions, 

modifications to the CMGs, tier 

comorbidities, and CMG relative 

weights, implementation of a new 

teaching status adjustment for IRFs, 

revision and rebasing of the IRF market 

basket, and updates to the rural, lowincome percentage (LIP), and high-cost 

outlier adjustments. Any reference to 

the FY 2006 IRF PPS final rule in this 

final rule also includes the provisions 

effective in the correcting amendments. 

For a detailed discussion of the final key 

policy changes for FY 2006, please refer 

to the FY 2006 IRF PPS final rule (70 FR 

47880 and 70 FR 57166). 

In the FY 2007 IRF PPS final rule (71 

FR 48354), we further refined the IRF 

PPS case-mix classification system (the 

CMG relative weights) and the caselevel adjustments, to ensure that IRF 

PPS payments continue to reflect as 

accurately as possible the costs of care. 

For a detailed discussion of the FY 2007 

policy revisions, please refer to the FY 

2007 IRF PPS final rule (71 FR 48354). 

In the FY 2008 IRF PPS final rule (72 

FR 44284), we updated the Federal 

prospective payment rates and the 

outlier threshold, revised the IRF wage 

index policy, and clarified how we 

determine high-cost outlier payments 

for transfer cases. For more information 

on the policy changes implemented for 

FY 2008, please refer to the FY 2008 IRF 

PPS final rule (72 FR 44284), in which 

we published the final FY 2008 IRF 

Federal prospective payment rates. 

After publication of the FY 2008 IRF 

PPS final rule (72 FR 44284), section 

115 of the Medicare, Medicaid, and 

SCHIP Extension Act of 2007, Public 

Law 110–173 (MMSEA), amended 

section 1886(j)(3)(C) of the Act to apply 

a zero percent increase factor for FYs 

2008 and 2009, effective for IRF 

discharges occurring on or after April 1, 

2008. Section 1886(j)(3)(C) of the Act 

requires the Secretary to develop an 

increase factor to update the IRF Federal 

prospective payment rates for each FY. 

Based on the legislative change to the 

increase factor, we revised the FY 2008 

Federal prospective payment rates for 

IRF discharges occurring on or after 

April 1, 2008. Thus, the final FY 2008 

IRF Federal prospective payment rates 

that were published in the FY 2008 IRF 

PPS final rule (72 FR 44284) were 

effective for discharges occurring on or 

after October 1, 2007 and on or before 

March 31, 2008; and the revised FY 

2008 IRF Federal prospective payment 

rates are effective for discharges 

occurring on or after April 1, 2008 and 

on or before September 30, 2008. The 

revised FY 2008 Federal prospective 

payment rates are available on the CMS 

Web site at http://www.cms.hhs.gov/ 

InpatientRehabFacPPS/ 

07_DataFiles.asp#TopOfPage. 

B. Operational Overview of the Current 

IRF PPS 

As described in the FY 2002 IRF PPS 

final rule, upon the admission and 

discharge of a Medicare Part A fee-forservice patient, the IRF is required to 

complete the appropriate sections of a 

patient assessment instrument, the 

Inpatient Rehabilitation Facility-Patient 

Assessment Instrument (IRF–PAI). All 

required data must be electronically 

encoded into the IRF–PAI software 

product. Generally, the software product 

includes patient classification 

programming called the GROUPER 

software. The GROUPER software uses 

specific IRF-PAI data elements to 

classify (or group) patients into distinct 

CMGs and account for the existence of 

any relevant comorbidities. 

The GROUPER software produces a 

five-digit CMG number. The first digit is 

an alpha-character that indicates the 

comorbidity tier. The last four digits 

represent the distinct CMG number. 

Free downloads of the Inpatient 

Rehabilitation Validation and Entry 

(IRVEN) software product, including the 

GROUPER software, are available on the 

CMS Web site at http:// 

www.cms.hhs.gov/ 

InpatientRehabFacPPS/ 

06_Software.asp. 

Once a patient is discharged, the IRF 

submits a Medicare claim as a Health 

Insurance Portability and 

Accountability Act (HIPAA), Public Law 

104–191, compliant electronic claim or, 

if the Administrative Compliance Act 

(ASCA), Public Law 107–105, permits, a 

paper claim, a UB–04 or a CMS–1450, 

(as appropriate) using the five-digit 

CMG number and sends it to the 


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appropriate Medicare fiscal 

intermediary (FI) or Medicare 

Administrative Contractor (MAC). 

Claims submitted to Medicare must 

comply with both ASCA and HIPAA. 

Section 3 of the ASCA amends section 

1862(a) of the Act by adding paragraph 

(22) which requires the Medicare 

program, subject to section 1862(h) of 

the Act, to deny payment under Part A 

or Part B for any expenses for items or 

services ‘‘for which a claim is submitted 

other than in an electronic form 

specified by the Secretary.’’ Section 

1862(h) of the Act, in turn, provides that 

the Secretary shall waive such denial in 

situations in which there is no method 

available for the submission of claims in 

an electronic form or the entity 

submitting the claim is a small provider. 

In addition, the Secretary also has the 

authority to waive such denial ‘‘in such 

unusual cases as the Secretary finds 

appropriate.’’ We refer the reader to the 

final rule, ‘‘Medicare Program; 

Electronic Submission of Medicare 

Claims’’ (70 FR 71008, November 25, 

2005). Section 3 of the ASCA operates 

in the context of the administrative 

simplification provisions of HIPAA, 

which include, among others, the 

requirements for transaction standards 

and code sets codified in 45 CFR, parts 

160 and 162, subparts A and I through 

R (generally known as the Transactions 

Rule). The Transactions Rule requires 

covered entities, including covered 

healthcare providers, to conduct 

covered electronic transactions 

according to the applicable transaction 

standards. (See the program claim 

memoranda issued and published by 

CMS at: http://www.cms.hhs.gov/ 

ElectronicBillingEDITrans/ and listed in 

the addenda to the Medicare 

Intermediary Manual, Part 3, section 

3600. CMS instructions for the limited 

number of Medicare claims submitted 

on paper are available at: http:// 

www.cms.hhs.gov/manuals/downloads/ 

clm104c25.pdf.) 

The Medicare FI or MAC processes 

the claim through its software system. 

This software system includes pricing 

programming called the ‘‘PRICER’’

software. The PRICER software uses the 

CMG number, along with other specific 

claim data elements and providerspecific data, to adjust the IRF’s 

prospective payment for interrupted 

stays, transfers, short stays, and deaths, 

and then applies the applicable 

adjustments to account for the IRF’s 

wage index, percentage of low-income 

patients, rural location, and outlier 

payments. For discharges occurring on 

or after October 1, 2005, the IRF PPS 

payment also reflects the new teaching 

status adjustment that became effective 

as of FY 2006, as discussed in the FY 

2006 IRF PPS final rule (70 FR 47880). 

II. Provisions of the Proposed Rule 

As discussed in the FY 2009 IRF PPS 

proposed rule (73 FR 22674), we 

proposed to make revisions to the 

regulation text in response to section 

115 of the MMSEA. Specifically, we 

proposed to revise 42 CFR part 412. We 

discuss these proposed revisions and 

others in detail below. 

A. Section 412.23 Excluded Hospitals: 

Classifications 

We proposed to revise the regulation 

text in paragraph (b)(2)(i) and remove 

paragraph (b)(2)(ii) in response to 

section 115 of the MMSEA. To 

summarize, for cost reporting periods—

(1) Beginning on or after July 1, 2005, 

the hospital has served an inpatient 

population of whom at least 60 percent 

require intensive rehabilitation services 

for treatment of one or more of the 

conditions specified at paragraph 

(b)(2)(ii) of this section (as amended by 

removing former (b)(2)(ii) and 

redesignating former (b)(2)(iii) as the 

new (b)(2)(ii)). 

(2) A comorbidity that meets the 

criteria as specified in § 412.23(b)(2)(i) 

may continue to be used to determine 

the compliance threshold. 

B. Additional Proposed Changes 

• Update the FY 2009 IRF PPS 

relative weights and average length of 

stay values using the most current and 

complete Medicare claims and cost 

report data, as discussed in section II of 

the FY 2009 IRF PPS proposed rule (73 

FR 22674, 22676 through 22680). 

• Update the FY 2009 IRF PPS 

payment rates by the proposed wage 

index and labor related share in a 

budget neutral manner, as discussed in 

sections III.A and B of the FY 2009 IRF 

PPS proposed rule (73 FR 22674, 22680 

through 22686). 

• Update the outlier threshold 

amount for FY 2009, as discussed in 

section IV.A of the FY 2009 IRF PPS 

proposed rule (73 FR 22674, 22686 

through 22687). 

• Update the cost-to-charge ratio 

ceiling and the national average urban 

and rural cost-to-charge ratios for 

purposes of determining outlier 

payments under the IRF PPS, as 

discussed in section IV.B of the FY 2009 

IRF PPS proposed rule (73 FR 22674 at 

22687). 

III. Analysis of and Responses to Public 

Comments 

We received approximately 17 timely 

items of correspondence containing 

multiple comments on the FY 2009 IRF 

PPS proposed rule (73 FR 22674) from 

the public. We received comments from 

various trade associations, inpatient 

rehabilitation facilities, health care 

industry organizations, and health care 

consulting firms. The following 

discussion, arranged by subject area, 

includes a summary of the public 

comments that we received, and our 

responses to the comments appear 

under the appropriate subject heading. 

IV. Update to the CMG Relative 

Weights and Average Length of Stay 

Values for FY 2009 

As specified in 42 CFR 412.620(b)(1), 

we calculate a relative weight for each 

CMG that is proportional to the 

resources needed by an average 

inpatient rehabilitation case in that 

CMG. For example, cases in a CMG with 

a relative weight of 2, on average, will 

cost twice as much as cases in a CMG 

with a relative weight of 1. Relative 

weights account for the variance in cost 

per discharge due to the variance in 

resource utilization among the payment 

groups, and their use helps to ensure 

that IRF PPS payments support 

beneficiary access to care as well as 

provider efficiency. 

In the FY 2009 IRF PPS proposed rule 

(73 FR 22674, 22676 through 22680), we 

proposed updates to the CMG relative 

weights and average length of stay 

values using the most recent available 

data (FY 2006 IRF claims, FY 2006 IRFPAI, and FY 2006 IRF cost report data) 

to ensure that IRF PPS payments 

continue to reflect as accurately as 

possible the costs of care in IRFs. We 

proposed to do this using the same 

methodology, with one change, that was 

described in the original, FY 2002 IRF 

PPS final rule (66 FR 41316) and the FY 

2006 IRF PPS final rule (70 FR 47880, 

47887 through 47888). The proposed 

change to the methodology involves 

using new, more detailed cost-to-charge 

ratio (CCR) data from the cost reports of 

IRF subprovider units of primary acute 

care hospitals, instead of CCR data from 

the associated primary acute care 

hospitals, to calculate IRFs’ average 

costs per case. In general, we proposed 

to make this change in the methodology 

because the more detailed CCR data 

from the IRF subprovider cost reports 

are now available in sufficient detail, 

and the relationship between costs and 

charge in the primary acute care 

hospital could differ from the 

relationship between costs and charges 

in the IRF subprovider units, making the 

data from the IRF subprovider units 

potentially more accurate for estimating 

the average costs per case in these units. 

For freestanding IRFs, we proposed to 

continue using CCR data from the 


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freestanding IRF’s cost report. We also 

noted that in future years we would 

continue to estimate the CMG relative 

weights using both the primary acute 

care hospital CCRs and the IRF 

subprovider unit CCRs to ensure that we 

continue to use the most appropriate 

data in updating the CMG relative 

weights. 

In addition, we proposed to make 

changes to the CMG relative weights for 

FY 2009 in such a way that total 

estimated aggregate payments to IRFs 

for FY 2009 would be the same with or 

without the proposed changes (that is, 

in a budget neutral manner) by applying 

a budget neutrality factor to the 

standard payment amount, as described 

in section II of the FY 2009 IRF PPS 

proposed rule (73 FR 22674 at 22677). 

To compute the budget neutrality factor 

used to update the CMG relative 

weights, we proposed to use the 

following steps: 

Step 1. Calculate the estimated total 

amount of IRF PPS payments for FY 

2009 (with no proposed changes to the 

CMG relative weights). 

Step 2. Apply the proposed changes 

to the CMG relative weights (as 

discussed above) to calculate the 

estimated total amount of IRF PPS 

payments for FY 2009. 

Step 3. Divide the amount calculated 

in step 1 by the amount calculated in 

step 2 to determine the budget 

neutrality factor that would maintain 

the same total estimated aggregate 

payments in FY 2009 with and without 

the proposed changes to the CMG 

relative weights. 

Step 4. Apply the proposed budget 

neutrality factor to the FY 2008 IRF PPS 

standard payment amount after the 

application of the budget-neutral wage 

adjustment factor. 

Note that the budget neutrality factor 

that we use to update the CMG relative 

weights for FY 2009 changed from 

0.9969 in the proposed rule to 0.9939 in 

this final rule due to the use of updated 

FY 2007 IRF claims data in this final 

rule. 

We received five comments on the 

proposed updates to the CMG relative 

weights and average length of stay 

values, which are summarized below. 

Comment: Several commenters 

supported the proposed update to the 

CMG relative weights for FY 2009, with 

one commenter referring to the 

proposed update as a ‘‘step in the right 

direction.’’ However, several 

commenters specifically suggested that 

we analyze the FY 2007 IRF claims and 

cost report data in computing the CMG 

relative weights for FY 2009, as these 

data would reflect more of the impact of 

recent changes in the 75 percent rule 

and the IRF medical necessity reviews 

than the FY 2006 IRF claims and cost 

report data. Further, one commenter 

recommended that we seek additional 

cost information to use to compute the 

CMG relative weights, including nursing 

staff time data, ancillary cost data, and 

other alternatives to the IRF claims and 

cost report data that we currently use to 

compute the CMG relative weights. 

Finally, a couple of commenters 

recommended that we recalibrate the 

CMG relative weights more frequently, 

with one commenter specifically asking 

that we recalibrate the CMG relative 

weights again next year (for FY 2010) 

using the most recent available data. 

Response: We agree with the 

commenters that we should analyze the 

most recent available IRF data to 

compute the CMG relative weights for 

FY 2009 in order to ensure that IRF PPS 

payments continue to reflect as 

accurately as possible the costs of care 

in IRFs. For the proposed rule, we used 

data from FY 2006 IRF claims, FY 2006 

IRF-PAI, and FY 2006 IRF cost reports 

because that was the best available data 

at the time. For this final rule, we have 

updated the IRF claims data used in our 

analysis of the CMG relative weights 

and average length of stay values from 

FY 2006 to FY 2007. 

We note that we used FY 2006 IRFPAI data for analyzing the CMG relative 

weights in the proposed rule because we 

implemented some minor adjustments 

to the classification system for FY 2007 

in the FY 2007 IRF PPS final rule (71 

FR 48354, 48360 through 48370). 

Accordingly, some of the CMGs that 

appeared on the FY 2006 IRF claims 

data would not be the same CMGs that 

would be assigned under the current, 

post-FY 2007 IRF classification system. 

We therefore used the FY 2006 IRF–PAI 

data for the proposed rule to ensure that 

the appropriate current CMG was 

assigned for all of the FY 2006 claims. 

However, use of the IRF–PAI data was 

no longer necessary when we used the 

FY 2007 IRF claims data for this final 

rule because the CMG information on 

the FY 2007 IRF claims data 

incorporated all of the changes to the 

IRF classification system that were 

implemented in the FY 2007 IRF PPS 

final rule (71 FR 48354, 48360 through 

48370). We did not implement any 

changes to the IRF classification system 

in the FY 2008 IRF PPS final rule (72 

FR 44284). The results of our analysis of 

the FY 2007 IRF claims data are 

reflected in the CMG relative weights 

and average length of stay values 

presented in Table 1 in this final rule. 

We further note that we have not 

updated the IRF cost report data used in 

this final rule. Although we agree with 

the commenter that it is important to 

analyze the most recent available cost 

report data to reflect as fully as possible 

the changes in IRF patient populations 

that may have occurred as a result of 

changes in the 75 percent rule and the 

IRF medical necessity reviews, only a 

small portion of the FY 2007 IRF cost 

reports are available for analysis at this 

time. Accordingly, we have continued 

to use the FY 2006 cost report data for 

analyzing IRFs’ costs per case in this 

final rule because these are the most 

complete IRF cost report data available 

at this time. However, we will continue 

to evaluate the need for further updates 

and refinements to the CMG relative 

weights and average length of stay 

values in future years and would update 

the cost report data, as appropriate, 

when the data become available. 

We appreciate the commenter’s 

suggestions regarding alternative data to 

use in analyzing the costs of caring for 

IRF patients, and we will carefully 

consider the commenter’s suggestions 

for future refinements to the 

methodology for computing the CMG 

relative weights. 

Finally, we agree with the 

commenters that we may need to update 

the CMG relative weight and average 

length of stay analysis frequently to 

ensure that IRF payments continue to 

reflect the costs of caring for IRF 

patients, especially in light of recent 

changes resulting from changes to the 75 

percent rule and the IRF medical 

necessity reviews. We intend to 

continue analyzing the most recent 

available data, and will propose future 

refinements to the IRF classification and 

weighting system based on that analysis, 

as appropriate. 

Comment: One commenter stated a 

concern that the methodology used to 

revise the IRF classification system in 

the FY 2006 IRF PPS final rule (70 FR 

47880) may have reduced the overall 

IRF case mix weights. This commenter 

asked CMS to re-examine this issue. 

Response: As discussed in the FY 

2006 IRF PPS final rule (70 FR 47880, 

47886 through 47904), the FY 2007 IRF 

PPS final rule (71 FR 48354, 48373 

through 48374), and the FY 2008 IRF 

PPS final rule (72 FR 44284 at 44293), 

we have analyzed the data and it 

continues to show that the FY 2006 

refinements to the IRF classification 

system did not cause a reduction in the 

overall IRF case mix weights or in 

aggregate IRF payments. We have met 

with industry representatives several 

times in order to understand their 

concerns. We have also discussed the 

results of our analysis with them, which 

continues to show that we implemented 

the FY 2006 refinements to the IRF 


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classification system in a budget neutral 

manner, so that estimated aggregate 

payments to providers would not 

increase or decrease as a result of these 

refinements. 

Comment: One commenter questioned 

why only 141 (40 percent) of the 

proposed FY 2009 CMG relative weight 

values increased compared with the FY 

2008 CMG relative weight values, while 

212 (60 percent) of the proposed FY 

2009 CMG relative weight values 

decreased compared with the FY 2008 

CMG relative weight values. This 

commenter generally expressed surprise 

at the proposed FY 2009 CMG relative 

weights values, but indicated that 

certain changes appeared to be correct, 

particularly the increases in the CMG 

relative weights for some of the 

orthopedic conditions. However, the 

commenter questioned why the CMG 

relative weight values for other types of 

cases decreased. 

Response: As we discussed in the 

proposed rule (73 FR 22674 at 22680), 

updates to the CMG relative weights 

will result in some increases and some 

decreases to the CMG relative weight 

values. This is due to the distributional 

nature of CMG relative weight changes. 

However, our updated analysis of the 

CMG relative weight values presented in 

Table 1 of this final rule (which is based 

on more recent data than that used in 

the proposed rule, as explained 

previously in this section) now shows 

that more than half of the CMG relative 

weights will increase and, further, that 

more than half of beneficiaries are in 

payment groups for which the CMG 

relative weight will increase between 

FY 2008 and FY 2009. Specifically, our 

analysis shows that 57 percent of 

patients are classified into one of the 

177 payment groups (that is, the 

combination of CMG and tier) that will 

experience an increase in the CMG 

relative weight value between FYs 2008 

and 2009, and 43 percent of patients are 

classified into one of the 176 

classification groups that will 

experience a decrease in the CMG 

relative weight value between FYs 2008 

and 2009. 

Final Decision: We received only 

positive comments in support of the 

proposal to change the methodology for 

determining IRFs’ average costs per case 

by using more detailed cost-to-charge 

ratio (CCR) data from the cost reports of 

IRF subprovider units of primary acute 

care hospitals to calculate the IRF 

subprovider units’ average costs per 

case. Thus, after carefully considering 

all of the comments that we received on 

the proposed updates to the CMG 

relative weights and average length of 

stay values, we are finalizing this 

change to the methodology for the 

reasons explained previously and as 

described in more detail in the proposed 

rule (73 FR 22674, 22676 through 

22677). For freestanding IRFs, we will 

continue to use the CCR data from the 

freestanding IRFs’ cost reports. 

Consistent with the methodology that 

we used to compute the CMG relative 

weights for FYs 2002 through 2008, 

with the one change described above, 

we are implementing the updates to the 

CMG relative weights and average 

length of stay values presented in Table 

1 below. As recommended by the 

commenters, we have updated the CMG 

relative weights and average length of 

stay values in Table 1 using FY 2007 

IRF claims data for this final rule. 

Further, as noted previously, we have 

continued to use FY 2006 IRF cost 

report data for this final rule because it 

is the best available cost report data at 

this time. 

TABLE 1—RELATIVE WEIGHTS AND AVERAGE LENGTHS OF STAY FOR CASE-MIX GROUPS

CMG 

CMG 

description 

(M=motor, 

C=cognitive, 

A=age) 

Relative weight Average length of stay 

Tier 1 Tier 2 Tier 3 None Tier 1 Tier 2 Tier 3 None 

0101 ............... Stroke: M>51.05 ................... 0.7712 0.7108 0.6381 0.6059 9 10 9 8 

0102 ............... Stroke: M>44.45 and 

M<51.05 and C>18.5.

0.9694 0.8936 0.8021 0.7617 11 11 11 10 

0103 ............... Stroke: M>44.45 and 

M<51.05 and C<18.5.

1.1478 1.0580 0.9496 0.9018 14 14 12 12 

0104 ............... Stroke: M>38.85 and 

M<44.45.

1.2192 1.1238 1.0087 0.9579 13 14 13 13 

0105 ............... Stroke: M>34.25 and 

M<38.85.

1.4320 1.3199 1.1848 1.1251 16 18 15 15 

0106 ............... Stroke: M>30.05 and 

M<34.25.

1.6632 1.5330 1.3761 1.3067 19 19 17 17 

0107 ............... Stroke: M>26.15 and 

M<30.05.

1.8970 1.7485 1.5695 1.4904 20 21 19 19 

0108 ............... Stroke: M<26.15 and A>84.5 2.2795 2.1011 1.8860 1.7910 27 26 23 22 

0109 ............... Stroke: M>22.35 and 

M<26.15 and A<84.5.

2.1786 2.0081 1.8025 1.7117 22 23 21 22 

0110 ............... Stroke: M<22.35 and A<84.5 2.7217 2.5087 2.2518 2.1384 30 30 27 26 

0201 ............... Traumatic brain injury: 

M>53.35 and C>23.5.

0.7556 0.6464 0.5818 0.5295 10 10 8 8 

0202 ............... Traumatic brain injury: 

M>44.25 and M<53.35 

and C>23.5.

1.0305 0.8817 0.7935 0.7222 13 11 10 10 

0203 ............... Traumatic brain injury: 

M>44.25 and C<23.5.

1.1487 0.9828 0.8846 0.8051 12 13 12 11 

0204 ............... Traumatic brain injury: 

M>40.65 and M<44.25.

1.2934 1.1066 0.9959 0.9064 15 14 13 12 

0205 ............... Traumatic brain injury: 

M>28.75 and M<40.65.

1.5739 1.3466 1.2119 1.1030 17 17 16 14 

0206 ............... Traumatic brain injury: 

M>22.05 and M<28.75.

1.9530 1.6709 1.5039 1.3687 21 21 18 18 

0207 ............... Traumatic brain injury: 

M<22.05.

2.6307 2.2508 2.0257 1.8437 36 28 24 22 


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TABLE 1—RELATIVE WEIGHTS AND AVERAGE LENGTHS OF STAY FOR CASE-MIX GROUPS—Continued 

CMG 

CMG 

description 

(M=motor, 

C=cognitive, 

A=age) 

Relative weight Average length of stay 

Tier 1 Tier 2 Tier 3 None Tier 1 Tier 2 Tier 3 None 

0301 ............... Non-traumatic brain injury: 

M>41.05.

1.1084 0.9308 0.8358 0.7650 12 12 11 10 

0302 ............... Non-traumatic brain injury: 

M>35.05 and M<41.05.

1.4120 1.1857 1.0647 0.9746 14 15 13 13 

0303 ............... Non-traumatic brain injury: 

M>26.15 and M<35.05.

1.6938 1.4224 1.2772 1.1691 17 17 16 15 

0304 ............... Non-traumatic brain injury: 

M<26.15.

2.3130 1.9424 1.7441 1.5966 27 23 21 20 

0401 ............... Traumatic spinal cord injury: 

M>48.45.

0.9255 0.7883 0.7732 0.6566 12 12 11 9 

0402 ............... Traumatic spinal cord injury: 

M>30.35 and M<48.45.

1.3933 1.1868 1.1640 0.9886 17 15 16 13 

0403 ............... Traumatic spinal cord injury: 

M>16.05 and M<30.35.

2.2823 1.9440 1.9067 1.6194 28 23 23 21 

0404 ............... Traumatic spinal cord injury: 

M<16.05 and A>63.5.

3.9766 3.3872 3.3222 2.8215 53 40 37 34 

0405 ............... Traumatic spinal cord injury: 

M<16.05 and A<63.5.

.0347 2.5850 2.5354 2.1532 42 30 29 27 

0501 ............... Non-traumatic spinal cord injury: M>51.35.0.8107 0.6397 0.5945 0.5245 9 9 8 8 

0502 ............... Non-traumatic spinal cord injury: M>40.15 and 

M<51.35.

1.0994 0.8675 0.8062 0.7113 13 11 11 10 

0503 ............... Non-traumatic spinal cord injury: M>31.25 and 

M<40.15.

1.4315 1.1296 1.0497 0.9261 16 14 13 13 

0504 ............... Non-traumatic spinal cord injury: M>29.25 and 

M<31.25.

1.7229 1.3596 1.2634 1.1147 21 17 16 15 

0505 ............... Non-traumatic spinal cord injury: M>23.75 and 

M<29.25.

2.0360 1.6066 1.4930 1.3173 23 21 19 17 

0506 ............... Non-traumatic spinal cord injury: M<23.75.2.8325 2.2351 2.0770 1.8325 32 27 25 23 

0601 ............... Neurological: M>47.75 ......... 0.9245 0.7546 0.7174 0.6542 11 9 10 9 

0602 ............... Neurological: M>37.35 and 

M<47.75.

1.2366 1.0094 0.9596 0.8750 12 13 12 12 

0603 ............... Neurological: M>25.85 and 

M<37.35.

1.5763 1.2866 1.2232 1.1154 16 16 15 14 

0604 ............... Neurological: M<25.85 ......... 2.0887 1.7049 1.6208 1.4780 24 21 20 18 

0701 ............... Fracture of lower extremity: 

M>42.15.

0.9187 0.7742 0.7300 0.6563 11 10 10 9 

0702 ............... Fracture of lower extremity: 

M>34.15 and M<42.15.

1.2116 1.0209 0.9627 0.8655 14 14 12 12 

0703 ............... Fracture of lower extremity: 

M>28.15 and M<34.15.

1.4846 1.2510 1.1797 1.0606 16 16 15 14 

0704 ............... Fracture of lower extremity: 

M<28.15.

1.8994 1.6005 1.5093 1.3569 20 20 19 17 

0801 ............... Replacement of lower extremity joint: M>49.55.0.7000 0.5704 0.5172 0.4714 8 7 8 7 

0802 ............... Replacement of lower extremity joint: M>37.05 and 

M<49.55.

0.9380 0.7643 0.6931 0.6317 10 10 9 9 

0803 ............... Replacement of lower extremity joint: M>28.65 and 

M<37.05 and A>83.5.

1.3383 1.0905 0.9889 0.9013 14 13 13 12 

0804 ............... Replacement of lower extremity joint: M>28.65 and 

M<37.05 and A<83.5.

1.1745 0.9571 0.8679 0.7910 13 12 11 10 

0805 ............... Replacement of lower extremity joint: M>22.05 and 

M<28.65.

1.4661 1.1947 1.0833 0.9874 16 16 13 13 

0806 ............... Replacement of lower extremity joint: M<22.05.1.8139 1.4780 1.3403 1.2215 18 18 17 15 

0901 ............... Other orthopedic: M>44.75 .. 0.8584 0.7574 0.6829 0.6041 10 10 9 9 

0902 ............... Other orthopedic: M>34.35 

and M<44.75.

1.1473 1.0122 0.9127 0.8074 13 13 12 11 


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TABLE 1—RELATIVE WEIGHTS AND AVERAGE LENGTHS OF STAY FOR CASE-MIX GROUPS—Continued 

CMG 

CMG 

description 

(M=motor, 

C=cognitive, 

A=age) 

Relative weight Average length of stay 

Tier 1 Tier 2 Tier 3 None Tier 1 Tier 2 Tier 3 None 

0903 ............... Other orthopedic: M>24.15 

and M<34.35.

1.4840 1.3093 1.1806 1.0443 16 16 15 14 

0904 ............... Other orthopedic: M<24.15 .. 1.9620 1.7310 1.5608 1.3807 22 22 19 18 

1001 ............... Amputation, lower extremity: 

M>47.65.

0.9356 0.9061 0.7797 0.7137 11 12 11 10 

1002 ............... Amputation, lower extremity: 

M>36.25 and M<47.65.

1.2522 1.2127 1.0435 0.9552 14 15 13 12 

1003 ............... Amputation, lower extremity: 

M<36.25.

1.8193 1.7619 1.5161 1.3877 19 21 19 17 

1101 ............... Amputation, non-lower extremity: M>36.35.1.1846 0.9851 0.9851 0.8558 12 12 13 11 

1102 ............... Amputation, non-lower extremity: M<36.35.1.7288 1.4377 1.4377 1.2490 17 18 17 15 

1201 ............... Osteoarthritis: M>37.65 ........ 1.0319 0.9668 0.8483 0.7541 11 12 11 10 

1202 ............... Osteoarthritis: M>30.75 and 

M<37.65.

1.3034 1.2212 1.0715 0.9525 14 15 13 13 

1203 ............... Osteoarthritis: M<30.75 ........ 1.6379 1.5346 1.3465 1.1969 16 18 17 15 

1301 ............... Rheumatoid, other arthritis: 

M>36.35.

1.0983 0.9874 0.8499 0.7648 12 12 11 10 

1302 ............... Rheumatoid, other arthritis: 

M>26.15 and M<36.35.

1.4790 1.3296 1.1445 1.0299 15 16 14 13 

1303 ............... Rheumatoid, other arthritis: 

M<26.15.

1.9140 1.7208 1.4812 1.3329 24 22 18 17 

1401 ............... Cardiac: M>48.85 ................. 0.8003 0.7221 0.6388 0.5667 10 11 9 8 

1402 ............... Cardiac: M>38.55 and 

M<48.85.

1.1095 1.0010 0.8856 0.7856 13 13 12 11 

1403 ............... Cardiac: M>31.15 and 

M<38.55.

1.3578 1.2251 1.0838 0.9615 15 15 13 13 

1404 ............... Cardiac: M<31.15 ................. 1.7628 1.5905 1.4071 1.2483 20 20 17 16 

1501 ............... Pulmonary: M>49.25 ............ 0.9603 0.8386 0.7413 0.7038 11 12 10 9 

1502 ............... Pulmonary: M>39.05 and 

M<49.25.

1.2297 1.0739 0.9494 0.9013 13 13 12 11 

1503 ............... Pulmonary: M>29.15 and 

M<39.05.

1.5640 1.3658 1.2074 1.1463 16 17 14 14 

1504 ............... Pulmonary: M<29.15 ............ 1.9525 1.7051 1.5073 1.4310 22 19 17 17 

1601 ............... Pain syndrome: M>37.15 ..... 1.1094 0.8968 0.7667 0.7068 13 13 10 10 

1602 ............... Pain syndrome: M>26.75 

and M<37.15.

1.4978 1.2108 1.0351 0.9543 16 16 13 13 

1603 ............... Pain syndrome: M<26.75 ..... 1.9287 1.5590 1.3328 1.2287 22 19 17 16 

1701 ............... Major multiple trauma without brain or spinal cord injury: M>39.25.1.0454 0.9189 0.8461 0.7419 11 12 11 10 

1702 ............... Major multiple trauma without brain or spinal cord injury: M>31.05 and 

M<39.25.

1.3777 1.2110 1.1151 0.9778 14 15 14 13 

1703 ............... Major multiple trauma without brain or spinal cord injury: M>25.55 and 

M<31.05.

1.6566 1.4561 1.3408 1.1757 18 17 16 15 

1704 ............... Major multiple trauma without brain or spinal cord injury: M<25.55.2.0776 1.8261 1.6815 1.4744 23 24 21 19 

1801 ............... Major multiple trauma with 

brain or spinal cord injury: 

M>40.85.

1.2189 0.9629 0.9044 0.7757 15 13 13 10 

1802 ............... Major multiple trauma with 

brain or spinal cord injury: 

M>23.05 and M<40.85.

1.8398 1.4533 1.3651 1.1708 19 17 16 15 

1803 ............... Major multiple trauma with 

brain or spinal cord injury: 

M<23.05.

3.1442 2.4838 2.3329 2.0009 37 31 26 24 

1901 ............... Guillian Barre: M>35.95 ....... 1.1582 0.9288 0.9288 0.8782 15 11 11 12 

1902 ............... Guillian Barre: M>18.05 and 

M<35.95.

2.3408 1.8772 1.8772 1.7749 26 22 25 22 

1903 ............... Guillian Barre: M<18.05 ....... 3.5944 2.8825 2.8825 2.7254 33 35 41 31 

2001 ............... Miscellaneous: M>49.15 ...... 0.8820 0.7282 0.6614 0.5928 11 9 9 8 


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TABLE 1—RELATIVE WEIGHTS AND AVERAGE LENGTHS OF STAY FOR CASE-MIX GROUPS—Continued 

CMG 

CMG 

description 

(M=motor, 

C=cognitive, 

A=age) 

Relative weight Average length of stay 

Tier 1 Tier 2 Tier 3 None Tier 1 Tier 2 Tier 3 None 

2002 ............... Miscellaneous: M>38.75 and 

M<49.15.

1.1873 0.9803 0.8904 0.7980 12 13 11 11 

2003 ............... Miscellaneous: M>27.85 and 

M<38.75.

1.5231 1.2575 1.1422 1.0237 16 16 14 13 

2004 ............... Miscellaneous: M<27.85 ...... 2.0363 1.6812 1.5271 1.3686 22 20 19 17 

2101 ............... Burns: M>0 ........................... 2.3666 2.3666 2.1481 1.7454 25 25 25 17 

5001 ............... Short-stay cases, length of 

stay is 3 days or fewer.

................ ................ ................ 0.1476 ................ ................ ................ 3 

5101 ............... Expired, orthopedic, length 

of stay is 13 days or fewer.

................ ................ ................ 0.6783 ................ ................ ................ 8 

5102 ............... Expired, orthopedic, length 

of stay is 14 days or more.

................ ................ ................ 1.5432 ................ ................ ................ 19 

5103 ............... Expired, not orthopedic, 

length of stay is 15 days 

or fewer.

................ ................ ................ 0.7086 ................ ................ ................ 9 

5104 ............... Expired, not orthopedic, 

length of stay is 16 days 

or more.

................ ................ ................ 1.9586 ................ ................ ................ 23 

V. FY 2009 IRF PPS Federal 

Prospective Payment Rates 

A. Increase Factor and Labor-Related 

Share for FY 2009 

Section 1886(j)(3)(C) of the Act 

requires the Secretary to establish an 

increase factor that reflects changes over 

time in the prices of an appropriate mix 

of goods and services included in the 

covered IRF services, which is referred 

to as a market basket index. According 

to section 1886(j)(3)(A)(i) of the Act, the 

increase factor shall be used to update 

the IRF Federal prospective payment 

rates for each FY. However, section 115 

of the MMSEA, amended section 

1886(j)(3)(C) of the Act to apply a zero 

percent increase factor for FYs 2008 and 

2009, effective for IRF discharges 

occurring on or after April 1, 2008. 

Thus, we are applying an increase factor 

of zero percent to update the IRF 

Federal prospective payment rates for 

FY 2009 in this final rule. 

We continue to use the methodology 

described in the FY 2006 IRF PPS final 

rule to update the IRF labor-related 

share for FY 2009 (70 FR 47880, 47908 

through 47917). The IRF labor-related 

share for FY 2009 is the sum of the FY 

2009 relative importance of each laborrelated cost category, and reflects the 

different rates of price change for these 

cost categories between the base year 

(FY 2002) and FY 2009. Consistent with 

our proposal to update the labor-related 

share with the most recent available 

data, the labor-related share for this 

final rule reflects Global Insight’s 

second quarter 2008 forecast. (Global 

Insight is a nationally recognized 

economic and financial forecasting firm 

that contracts with CMS to forecast the 

components of providers’ market 

baskets.) As shown in Table 2, the total 

FY 2009 Rehabilitation, Psychiatric, and 

Long-Term Care Hospital Market Basket 

(RPL) labor-related share in this final 

rule is 75.464 percent. 

TABLE 2—FY 2009 IRF RPL LABORRELATED SHARE RELATIVE IMPORTANCE

Cost category 

FY 2009 IRF 

labor-related 

share relative 

importance 

Wages and salaries .......... 52.552 

Employee benefits ............ 13.982 

Professional fees .............. 2.890 

All other labor intensive 

services ......................... 2.120 

Subtotal ..................... 71.544 

Labor-related share of 

capital costs (.46) .......... 3.920 

Total ................... 75.464 

SOURCE: GLOBAL INSIGHT, INC, 2nd 

QTR, 2008; @USMACRO/CONTROL0508 

@CISSIM/TL0508.SIM Historical Data through 

1st QTR, 2008. 

We received five comments on the 

increase factor and labor-related share 

for FY 2009, which are summarized 

below. 

Comment: Two commenters 

expressed concern that the zero percent 

increase factor that we are applying to 

the IRF Federal prospective payment 

rates for FY 2009, would impose a 

financial burden on IRFs. These 

commenters noted that the zero percent 

increase factor for FY 2009 was required 

by section 115 of the MMSEA, which 

also made revisions to the 60 percent 

rule. The commenters requested that 

any future legislative changes to the 60 

percent rule also be considered in 

combination with updates to the IRF 

Federal prospective payment rates. 

Response: As we discussed in the FY 

2009 IRF PPS proposed rule (73 FR 

22674, 22680 through 22681), section 

115 of the MMSEA amended section 

1886(j)(3)(C) of the Act to apply a zero 

percent increase factor for FYs 2008 and 

2009, effective for IRF discharges 

occurring on or after April 1, 2008. 

While we understand that the effect of 

the zero percent increase factor is to 

maintain FY 2009 IRF PPS payment 

rates at FY 2008 levels, the statute does 

not give CMS the discretion to 

implement an increase factor other than 

zero percent for FY 2009. We will 

respond to any future legislative 

changes to the 60 percent rule 

accordingly. 

Comment: One commenter requested 

that CMS calculate the IRF PPS market 

basket estimates using more current 

market basket data. This commenter 

stated that the FY 2009 market basket 

estimate is based on data from FY 2002, 

and that the FY 2002 data underestimate 

the increase in costs, especially labor 

costs, that IRFs have experienced. The 

commenter suggested that CMS use 

Medicare cost report data to compute 

the market basket estimate, rather than 

data from the Bureau of Labor Statistics, 

in order to make the estimate more 

current. 

Response: The IRF PPS market basket, 

which is a fixed weight, Laspeyres-type 

price index, is constructed in three 


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46378 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

steps. First, a base period is selected (FY 

2002 in the current market basket) and 

total base period expenditures are 

estimated for a set of mutually exclusive 

and exhaustive spending categories 

based upon type of expenditure. The 

proportion of total operating costs that 

each category represents is called a cost 

or expenditure weight. 

Medicare Cost Report (MCR) data are 

used to derive the primary cost weights 

for the market basket. We monitor the 

stability of these cost weights and have 

determined that they do not tend to 

fluctuate over short periods of time 

(such as a period of less than 5 years). 

In general, we have typically rebased 

(recalculated market basket cost 

weights) approximately every 5 years. 

We note that we last revised and 

rebased the market basket in the FY 

2006 IRF PPS final rule (70 FR 47880, 

47915 through 47917). 

Second, the FY 2002 expenditure 

weight for each cost category is matched 

to an appropriate price or wage variable, 

referred to as a price proxy. These price 

proxies are selected to reflect the rateof-price change for each expenditure 

category and are primarily obtained 

from the Bureau of Labor Statistics 

(BLS). 

Finally, each FY 2002 cost weight is 

multiplied by the level of its respective 

price proxy. The sum of these products 

(that is, the expenditure weights 

multiplied by their price levels) for all 

cost categories yields the composite 

index level of the market basket in a 

given period. Repeating this step for 

other periods produces a series of 

market basket levels over time. 

The final IRF market basket update for 

FY 2009 is calculated using the market 

basket levels from the second quarter of 

2008 (2008Q2) forecast prepared by 

Global Insight, Inc. (GII). These levels 

reflect the most recent price data 

available (historical price data through 

2008Q1 and forecasted price data for 

2008Q2 and beyond). 

Given the methodology described 

above, the current market basket 

estimate is not based solely on FY 2002 

data, but rather is calculated by 

applying the most recent available price 

data for each quarter to the FY 2002 cost 

weights. Thus, the current FY 2009 

market basket estimate does in fact 

reflect recent price increases 

experienced by IRFs. 

Comment: Several commenters 

expressed concern about the 

methodology for computing the laborrelated share. One commenter requested 

that we begin updating the labor-related 

share more frequently using the most 

recent available data. The commenter 

stated that the current calculation of the 

labor-related share is based on 2002 

data. Another commenter said that the 

methodology does not adequately reflect 

the difficulty IRFs have in recruiting a 

skilled labor force. 

Response: The FY 2009 labor-related 

share is intended to reflect those costs 

that are related to, influenced by, or 

vary with the local labor market. 

Accordingly, the share is calculated as 

the sum of the relative importance of the 

appropriate categories which include 

wages and salaries, fringe benefits, 

professional fees, labor-intensive 

services, and a portion of capital costs. 

We calculate this share based on the 

RPL market basket, which we believe 

adequately captures the current cost 

structures of Medicare-participating 

IRFs. 

By following a four-step process to 

estimate the labor-related relative 

importance for FY 2009, we are making 

use of up-to-date data that reflect 

current trends. As a result, the laborrelated share appropriately reflects 

current labor market price pressures 

experienced by IRFs. The process is as 

follows: First, we compute the FY 2009 

price index level for the total market 

basket and each cost category of the 

market basket. Second, we calculate a 

ratio for each cost category by dividing 

the FY 2009 price index level for that 

cost category by the total market basket 

price index level. Third, we determine 

the FY 2009 relative importance for 

each cost category by multiplying this 

ratio by the base year (FY 2002) weight. 

Finally, we sum the FY 2009 relative 

importance for each of the labor-related 

categories to produce the FY 2009 laborrelated relative importance. 

The price proxies that move the 

different cost categories in the market 

basket do not necessarily change at the 

same rate, and the relative importance 

captures these potential differential 

growth rates. Accordingly, the relative 

importance figure more closely reflects 

the cost share weights for FY 2009 when 

compared to the base year weights from 

the 2002-based RPL market basket. We 

revised and rebased the market basket 

and labor-related share in FY 2006 and 

expect to conduct additional updates on 

a regular basis. 

Final Decision: We will continue to 

apply a zero percent increase factor to 

the IRF Federal prospective payment 

rates for FY 2009, in accordance with 

section 115 of the MMSEA. Further, we 

will continue to update the IRF laborrelated share using our current 

methodology, which reflects the most 

recent available data. Thus, for this final 

rule, the labor-related share is 75.464 

percent. This is based on the GII’s 

forecast for the second quarter of 2008 

(2008Q2) with historical data through 

the first quarter of 2008 (2008Q1). 

B. Area Wage Adjustment 

Section 1886(j)(6) of the Act requires 

the Secretary to adjust the proportion 

(as estimated by the Secretary from time 

to time) of rehabilitation facilities’ costs 

attributable to wages and wage-related 

costs by a factor (established by the 

Secretary) reflecting the relative hospital 

wage level in the geographic area of the 

rehabilitation facility compared to the 

national average wage level for those 

facilities. The Secretary is required to 

update the IRF PPS wage index on the 

basis of information available to the 

Secretary on the wages and wage-related 

costs to furnish rehabilitation services. 

Any adjustments or updates made under 

section 1886(j)(6) of the Act for a FY are 

made in a budget neutral manner. 

In the FY 2008 IRF PPS final rule (72 

FR 44284 at 44299), we maintained the 

methodology described in the FY 2006 

IRF PPS final rule to determine the wage 

index, labor market area definitions, and 

hold harmless policy consistent with 

the rationale outlined in the FY 2006 

IRF PPS final rule (70 FR 47880, 47917 

through 47933). 

For FY 2009, we proposed to and will 

maintain the policies and 

methodologies described in the FY 2008 

IRF PPS final rule relating to the labor 

market area definitions and the wage 

index methodology for areas with wage 

data. Therefore, this final rule continues 

to use the Core-Based Statistical Area 

(CBSA) labor market area definitions 

and the pre-reclassification and prefloor hospital wage index data based on 

2004 cost report data. 

When adopting new labor market 

designations made by the Office of 

Management and Budget (OMB), we 

identified some geographic areas where 

there were no hospitals and, thus, no 

hospital wage index data on which to 

base the calculation of the IRF PPS wage 

index. We continue to use the same 

methodology discussed in the FY 2008 

IRF PPS final rule (72 FR 44284 at 

44299) to address those geographic areas 

where there are no hospitals and, thus, 

no hospital wage index data on which 

to base the calculation of the FY 2009 

IRF PPS wage index. 

Additionally, this final rule 

incorporates the CBSA changes 

published in the most recent OMB 

bulletin that applies to the hospital 

wage data used to determine the current 

IRF PPS wage index. The changes were 

nomenclature and did not represent 

substantive changes to the CBSA-based 

designations. Specifically, OMB added 

or deleted certain CBSA numbers and 

revised certain titles. The OMB bulletins 


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Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46379 

are available online at http:// 

www.whitehouse.gov/omb/bulletins/ 

index.html. 

1. Clarification of New England Deemed 

Counties 

We are taking this opportunity to 

address the change in the treatment of 

‘‘New England deemed counties’’ (that 

is, those counties in New England listed 

in § 412.64(b)(1)(ii)(B) of the regulations 

that were deemed to be parts of urban 

areas under section 601(g) of the Social 

Security Amendments of 1983) that was 

made in the FY 2008 Inpatient 

Prospective Payment System (IPPS) 

final rule with comment period (72 FR 

47337). These counties include the 

following: Litchfield County, CT; York 

County, ME; Sagadahoc County, ME; 

Merrimack County, NH; and Newport 

County, RI. Of these five ‘‘New England 

deemed counties,’’ three (York County, 

ME, Sagadahoc County, ME, and 

Newport County, RI) are also included 

in metropolitan statistical areas (MSAs) 

defined by OMB and are considered 

urban under both the current IPPS and 

IRF PPS labor market area definitions in 

§ 412.64(b)(1)(ii)(A). The remaining two, 

Litchfield County, CT and Merrimack 

County, NH, are geographically located 

in areas that are considered rural under 

the current IPPS (and IRF PPS) labor 

market area definitions, but have been 

previously deemed urban under the 

IPPS in certain circumstances, as 

discussed below. 

In the FY 2008 IPPS final rule with 

comment period, (72 FR 47337 through 

47338), § 412.64(b)(1)(ii)(B) was revised 

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, and, therefore, are 

considered rural in accordance with 

§ 412.64(b)(1)(ii)(C). However, for 

purposes of payment under the IPPS, 

acute care hospitals located within 

those areas are treated as being 

reclassified to their deemed urban area 

effective for discharges occurring on or 

after October 1, 2007 (see 72 FR 47337 

through 47338). We note that the IRF 

PPS does not provide for geographic 

reclassification. Also, in the FY 2008 

IPPS final rule with comment period (72 

FR 47338), we explained that we limited 

this policy change for the ‘‘New England 

deemed counties’’ only to IPPS 

hospitals, and any change to non-IPPS 

provider wage indexes would be 

addressed in the respective payment 

system rules. 

Accordingly, as stated above, we are 

taking this opportunity to clarify the 

treatment of ‘‘New England deemed 

counties’’ under the IRF PPS in this 

final rule. 

As discussed above, the IRF PPS has 

consistently used the IPPS definition of 

‘‘urban’’ and ‘‘rural’’ with regard to the 

wage index used in the IRF PPS. Under 

existing § 412.602, an IRF’s wage index 

is determined based on the location of 

the IRF in an urban or rural area as 

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

(C). 

Historical changes to the labor market 

area/geographic classifications and 

annual updates to the wage index values 

under the IRF PPS are made effective 

October 1 each year. When we 

established the most recent IRF PPS 

payment rate update, effective for 

discharges occurring on or after October 

1, 2007 through September 30, 2008, we 

considered the ‘‘New England deemed 

counties’’ (including Litchfield County, 

CT and Merrimack County, NH) as 

urban for FY 2008, as evidenced by the 

inclusion of Litchfield County, CT as 

one of the constituent counties of urban 

CBSA 25540 (Hartford-West HartfordEast Hartford, CT), and the inclusion of 

Merrimack County, NH as one of the 

constituent counties of urban CBSA 

31700 (Manchester-Nashua, NH). 

As noted above, § 412.602 indicates 

that the terms ‘‘rural’’ and ‘‘urban’’ are 

defined according to the definitions of 

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

through (C). Applying the IPPS 

definitions, Litchfield County, CT and 

Merrimack County, NH are not 

considered ‘‘urban’’ under 

§§ 412.64(b)(1)(ii)(A) and (B) as revised 

under the FY 2008 IPPS final rule and, 

therefore, are considered ‘‘rural’’ under 

§ 412.64(b)(1)(ii)(C). Accordingly, 

reflecting our policy to use the IPPS 

definitions of ‘‘urban’’ and ‘‘rural’’, 

these two counties would be considered 

‘‘rural’’ under the IRF PPS effective with 

the next update of the IRF PPS payment 

rates, October 1, 2008, and would no 

longer be included in urban CBSA 

25540 (Hartford-West Hartford-East 

Hartford, CT) and urban CBSA 31700 

(Manchester-Nashua, NH), respectively. 

We note that this policy is consistent 

with our policy of not taking into 

account IPPS geographic 

reclassifications in determining 

payments under the IRF PPS. We do not 

need to make any changes to our 

regulations to effectuate this change. 

There is one IRF (in Merrimack 

County, NH) that greatly benefits from 

treating these counties as rural. This IRF 

would begin to receive a higher wage 

index value and the 21.3 percent 

adjustment that is applied to IRF PPS 

payments for rural facilities. Currently, 

there are no IRFs in the following areas: 

Litchfield County, CT; rural 

Connecticut; or rural New Hampshire. 

2. Multi-Campus Hospital Wage Index 

Data 

In the FY 2008 IRF PPS final rule (72 

FR 44284, August 7, 2007), we 

established IRF PPS wage index values 

for FY 2008 calculated from the same 

data (collected from cost reports 

submitted by hospitals for cost reporting 

periods beginning during FY 2003) used 

to compute the FY 2007 acute care 

hospital inpatient wage index, without 

taking into account geographic 

reclassification under sections 

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

IRF PPS wage index values applicable 

for discharges occurring on or after 

October 1, 2007 through September 30, 

2008 are shown in Table 1 (for urban 

areas) and Table 2 (for rural areas) in the 

addendum to the FY 2008 IRF PPS final 

rule (72 FR 44284, 44312 through 

44335). 

We are continuing to use IPPS wage 

data for the FY 2009 IRF PPS Wage 

Index, because we believe that using the 

hospital inpatient wage data is 

appropriate and reasonable for the IRF 

PPS. We note that the IPPS wage data 

used to determine the FY 2009 IRF wage 

index values reflect our policy that was 

adopted under the IPPS beginning in FY 

2008. The wage data for multi-campus 

hospitals located in different labor 

market areas (CBSAs) are apportioned to 

each CBSA where the campuses are 

located (see the FY 2008 IPPS final rule 

with comment period (72 FR 47317 

through 47320)). We computed the FY 

2009 IRF PPS wage index values 

presented in this final rule consistent 

with our pre-reclassified IPPS wage 

index policy (that is, our historical 

policy of not taking into account IPPS 

geographic reclassifications in 

determining payments under the IRF 

PPS). 

For the FY 2009 IRF PPS, we 

computed the wage index from IPPS 

wage data (submitted by hospitals for 

cost reporting periods beginning in FY 

2004 and used in the FY 2008 IPPS 

wage index), which allocated salaries 

and hours to the campuses of two multicampus hospitals with campuses that 

are located in different labor areas, one 

in Massachusetts and another in Illinois. 

Thus, the FY 2009 IRF PPS 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 CountyKenosha County, IL-WI (CBSA 29404) 

(please refer to Table 1 in the addendum 

of this final rule). 


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46380 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

3. Methodology for Applying the 

Revisions to the Area Wage Adjustment 

for FY 2009 in a Budget-Neutral Manner 

To calculate the wage-adjusted facility 

payment for the payment rates set forth 

in this final rule, we multiply the 

unadjusted Federal prospective 

payment by the FY 2009 RPL laborrelated share (75.464 percent) to 

determine the labor-related portion of 

the Federal prospective payments. We 

then multiply this labor-related portion 

by the applicable IRF wage index shown 

in Table 1 for urban areas and Table 2 

for rural areas in the addendum. 

Adjustments or updates to the IRF 

wage index made under section 

1886(j)(6) of the Act must be made in a 

budget neutral manner; therefore, we 

calculated a budget neutral wage 

adjustment factor as established in the 

FY 2004 IRF PPS final rule (68 FR 45674 

at 45689), codified at § 412.624(e)(1), 

and described in the steps below. We 

proposed to use (and have used for this 

final rule) the following steps to ensure 

that the FY 2009 IRF standard payment 

conversion factor reflects the update to 

the proposed wage indexes (based on 

the FY 2004 pre-reclassified and prefloor hospital wage data) and the laborrelated share in a budget neutral 

manner: 

Step 1. Determine the total amount of 

the estimated FY 2008 IRF PPS rates, 

using the FY 2008 standard payment 

conversion factor and the labor-related 

share and the wage indexes from FY 

2008 (as published in the FY 2008 IRF 

PPS final rule (72 FR 44284 at 44301, 

44298, and 44312 through 44335, 

respectively)). 

Step 2. Calculate the total amount of 

estimated IRF PPS payments, using the 

FY 2008 standard payment conversion 

factor and the FY 2009 labor-related 

share and CBSA urban and rural wage 

indexes. 

Step 3. Divide the amount calculated 

in step 1 by the amount calculated in 

step 2, which equals the final FY 2009 

budget neutral wage adjustment factor 

of 1.0003. (Note that this final budget 

neutral wage adjustment factor differs 

from the one we proposed in the 

proposed rule (1.0004) because of the 

use of updated data to calculate the 

labor-related share for this final rule and 

the use of updated FY 2007 IRF claims 

data for this final rule.) 

Step 4. Apply the FY 2009 budget 

neutral wage adjustment factor from 

step 3 to the FY 2008 IRF PPS standard 

payment conversion factor after the 

application of the estimated market 

basket update to determine the FY 2009 

standard payment conversion factor. 

We received 4 comments on the 

proposed FY 2009 IRF PPS wage index, 

which are summarized below. 

Comment: Several commenters 

recommended that we consider wage 

index policies under the acute IPPS 

because IRFs compete in a similar labor 

pool as acute care hospitals. The IPPS 

wage index policies would allow IRFs to 

benefit from the IPPS reclassification 

and/or floor policies. Several 

commenters also recommended that 

CMS conduct further analysis of the 

wage index methodology to ensure that 

fluctuations in the annual wage index 

for hospitals are minimized, that all 

future updates match the costs of labor 

in the market, that IRF’s occupational 

mix is appropriately recognized, and 

that payments are ‘‘smoothed’’ across 

geography and across time. Further, one 

provider requested that the same wage 

index policies be used for all healthcare 

providers, to maintain consistency. 

Response: We do not believe IPPS 

wage index policies should be applied 

to IRFs. We note the IRF PPS does not 

account for geographic reclassification 

under sections 1886(d)(8) and (d)(10) of 

the Act and does not apply the ‘‘rural 

floor’’ under section 4410 of Public Law 

105–33(BBA). Because we do not have 

an IRF specific wage index we are 

unable to determine at this time the 

degree, if any, to which a geographic 

reclassification adjustment under the 

IRF PPS is appropriate. Furthermore, we 

believe the ‘‘rural floor’’ is applicable 

only to the acute care hospital payment 

system. The rationale for our current 

wage index policies is fully described in 

the FY 2006 final rule (70 FR 47880, 

47926 through 47928). 

In addition, we reviewed the 

Medicare Payment Advisory 

Commission’s (MedPAC) wage index 

recommendations as discussed in 

MedPAC’s June 2007 report titled, 

‘‘Report to Congress: Promoting Greater 

Efficiency in Medicare.’’ Although some 

commenters recommended that we 

adopt the IPPS wage index policies such 

as reclassification and floor policies, we 

note that MedPAC’s June 2007 report to 

Congress recommends that Congress 

‘‘repeal the existing hospital wage index 

statute, including reclassification and 

exceptions, and give the Secretary 

authority to establish new wage index 

systems.’’ We believe that adopting the 

IPPS wage index policies, such as 

reclassification or floor, would not be 

prudent at this time because MedPAC 

suggests that the reclassification and 

exception policies in the IPPS wage 

index alters the wage index values for 

one-third of IPPS hospitals. In addition, 

MedPAC found that the exceptions may 

lead to anomalies in the wage index. By 

adopting the IPPS reclassification and 

exceptions at this time, the IRF PPS 

wage index may be vulnerable to similar 

issues that MedPAC identified in their 

June 2007 Report to Congress. However, 

we will continue to review and consider 

MedPAC’s recommendations on a 

refined or an alternative wage index 

methodology for the IRF PPS in future 

years. 

We would also like to inform the 

commenter about our current research 

with respect to wage index 

methodology, including the issues the 

commenter mentioned about ensuring 

that the wage index minimizes 

fluctuations, matches the costs of labor 

in the market, and provides for a single 

wage index policy. Section 106(b)(2) of 

the MIEA–TRHCA instructed the 

Secretary of Health and Human 

Services, to take into account MedPAC’s 

recommendations on the Medicare wage 

index classification system, to include 

in the FY 2009 IPPS proposed rule one 

or more proposals to revise the wage 

index adjustment applied under section 

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

the IPPS. The proposal (or proposals) 

must consider each of the following: 

• Problems associated with the 

definition of labor markets for the wage 

index adjustment. 

• The modification or elimination of 

geographic reclassifications and other 

adjustments. 

• The use of Bureau of Labor of 

Statistics data or other data or 

methodologies to calculate relative 

wages for each geographic area. 

• Minimizing variations in wage 

index adjustments between and within 

MSAs and statewide rural areas. 

• The feasibility of applying all 

components of CMS’s proposal to other 

settings. 

• Methods to minimize the volatility 

of wage index adjustments while 

maintaining the principle of budget 

neutrality. 

• The effect that the implementation 

of the proposal would have on health 

care providers on each region of the 

country. 

• Methods for implementing the 

proposal(s) including methods to phase 

in such implementations. 

• Issues relating to occupational mix 

such as staffing practices and any 

evidence on quality of care and patient 

safety including any recommendation 

for alternative calculations to the 

occupational mix. 

To assist us in meeting the 

requirements of section 106(b)(2) of 

Public Law 109–432, in February 2008, 

we awarded a Task Order under its 

Expedited Research and Demonstration 

Contract, to Acumen, LLC. A 


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Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46381 

comparison of the current IPPS wage 

index and MedPAC’s recommendations 

will be presented in the FY 2009 IPPS 

final rule. We plan to monitor these 

efforts and the impact or influence they 

may have to the IRF PPS wage index. 

Comment: One commenter requested 

that the IRF wage index values for FY 

2009 be capped at plus or minus 2 

percent of the IRF wage index values for 

FY 2008 to provide for more stable, and 

thus more predictable, changes in the 

IRF wage index between FY 2008 and 

FY 2009. 

Response: We will take the 

commenter’s suggestion into account for 

the future. However, we do not believe 

that the IRF wage index would 

accurately reflect geographic variations 

in the costs of labor, which is the 

purpose of the IRF wage index, if we 

were to constrain changes in the wage 

index adjustment from year to year. 

Thus, we believe it is best at this point 

to continue the analysis of the wage 

index methodology, as described above, 

and to consider developing wage index 

policies that are consistent across 

settings as noted in the previous 

response. 

Final Decision: We will continue to 

use the policies and methodologies 

described in the FY 2008 IRF PPS final 

rule relating to the labor market area 

definitions and the wage index 

methodology for areas with wage data. 

Therefore, this final rule continues to 

use the Core-Based Statistical Area 

(CBSA) labor market area definitions 

and the pre-reclassification and prefloor hospital wage index data based on 

2004 cost report data. We discuss the 

final standard payment conversion 

factor for FY 2009 in the next section 

below. 

C. Description of the IRF Standard 

Payment Conversion Factor and 

Payment Rates for FY 2009 

To calculate the standard payment 

conversion factor for FY 2009, as 

illustrated in Table 4 below, we begin 

with the standard payment conversion 

factor for FY 2008. To explain how we 

determined the standard payment 

conversion factor for FY 2008, we 

include Table 3 below. The final FY 

2008 IRF standard payment conversion 

factor that we show in Tables 3 and 4 

below is different than the IRF standard 

payment conversion factor that we 

published in the FY 2008 IRF PPS final 

rule (72 FR 44284 at 44301) due to a 

legislative change. We adjusted the IRF 

standard payment conversion factor for 

IRF discharges occurring on or after 

April 1, 2008 to reflect the changes 

codified in section 115 of the MMSEA 

that require the Secretary to apply a zero 

percent increase factor for FYs 2008 and 

2009, effective for discharges occurring 

on or after April 1, 2008. 

In the FY 2008 IRF PPS final rule (72 

FR 44284, 44300 through 44301), we 

used the RPL market basket estimate 

described in that final rule (3.2 percent) 

to update the IRF standard payment 

conversion factor. As shown in Table 3 

of the FY 2008 IRF PPS final rule (72 FR 

44284 at 44301), applying this market 

basket estimate to the standard payment 

amount resulted in a final standard 

payment conversion factor for FY 2008 

of $13,451. 

However, section 115 of the MMSEA 

had the effect of changing the increase 

factor for FY 2008 from 3.2 percent to 

zero percent for discharges occurring on 

or after April 1, 2008. This, in turn, had 

the effect of decreasing the IRF standard 

payment conversion factor for 

discharges occurring on or after April 1, 

2008. 

As shown in Table 3 below, to 

develop the FY 2008 standard payment 

conversion factor for discharges 

beginning on or after April 1, 2008, we 

started with the FY 2007 standard 

payment conversion factor that was 

finalized in the FY 2007 IRF PPS final 

rule (71 FR 48354 at 48378). We then 

multiplied this by the zero percent 

increase factor, as described above. 

Then, we applied the same FY 2008 

budget neutrality factor (1.0041) for the 

Wage Index, Labor-Related Share, and 

the Hold Harmless Provision that was 

published in the FY 2008 IRF PPS Final 

Rule (72 FR 44284 at 44301). This 

resulted in the final FY 2008 standard 

payment conversion factor, effective for 

discharges occurring on or after April 1, 

2008, of $13,034. 

TABLE 3—CALCULATIONS TO DETERMINE THE FY 2008 IRF STANDARD PAYMENT CONVERSION FACTOR FOR

DISCHARGES BEGINNING ON OR AFTER APRIL 1, 2008 

Explanation for adjustment Calculations 

FY 2007 Standard Payment Conversion Factor (published in the FY 2007 IRF PPS Final Rule (71 FR 48354)) ........................... $12,981 

Zero Percent Increase Factor for Discharges Occurring on or after April 1, 2008 ............................................................................ × 1.0000 

Budget Neutrality Factor for the Wage Index, Labor-Related Share, and the Hold Harmless Provision that was published in the 

FY 2008 IRF PPS Final Rule (72 FR 44284) .................................................................................................................................. × 1.0041 

Standard Payment Conversion Factor for Discharges Occurring on or after April 1, 2008 ............................................................... = $13,034 

As a result, the IRF standard payment 

conversion factor changed from $13,451 

for discharges occurring on or after 

October 1, 2007 to $13,034 for 

discharges occurring on or after April 1, 

2008. 

Further, as required by section 115 of 

the MMSEA, we apply an increase 

factor of zero percent to the standard 

payment conversion factor for FY 2009, 

meaning that it does not change from 

the current value of $13,034. Next, we 

apply the combined final budget 

neutrality factor for the FY 2009 wage 

index and labor related share of 1.0003, 

which results in a standard payment 

amount of $13,038. Finally, we apply 

the final budget neutrality factor for the 

revised CMG relative weights of 0.9939, 

which results in the final FY 2009 

standard payment conversion factor of 

$12,958. 

As stated previously, we note that the 

budget neutrality factor for the FY 2009 

wage index and labor related share 

changed from 1.0004 in the proposed 

rule to 1.0003 in this final rule due to 

the use of updated FY 2007 IRF claims 

data in this final rule and the update to 

the FY 2009 labor-related share for this 

final rule using the most recent 

available data. Similarly, the budget 

neutrality factor used to update the 

CMG relative weights and average 

length of stay values changed from 

0.9969 in the proposed rule to 0.9939 in 

this final rule due to the use of updated 

FY 2007 IRF claims data in this final 

rule. Furthermore, the methodology that 

we used to compute the final budget 

neutrality factors for this final rule is the 

same methodology (as discussed above 

and in section IV of this final rule) that 

we used to compute the proposed 

budget neutrality factors in the 

proposed rule (73 FR 22674 at 22677 

and 22683). 


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46382 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

TABLE 4—CALCULATIONS TO DETERMINE THE FY 2009 STANDARD PAYMENT CONVERSION FACTOR

Explanation for adjustment Calculations 

Standard Payment Conversion Factor for Discharges Occurring on or after April 1, 2008 ............................................................... $13,034 

Zero Percent Increase Factor for FY 2009 ......................................................................................................................................... × 1.0000 

Budget Neutrality Factor for the Wage Index and Labor-Related Share ............................................................................................ × 1.0003 

Budget Neutrality Factor for the Revisions to the CMG Relative Weights ......................................................................................... × 0.9939 

FY 2009 Standard Payment Conversion Factor ................................................................................................................................. = $12,958 

After the application of the CMG 

relative weights described in section IV 

of this final rule, the resulting 

unadjusted IRF prospective payment 

rates for FY 2009 are shown below in 

Table 5, ‘‘FY 2009 Payment Rates.’’

TABLE 5—FY 2009 PAYMENT RATES

CMG Payment rate 

tier 1 

Payment rate 

tier 2 

Payment rate 

tier 3 

Payment rate 

no comorbidity 

0101 ................................................................................................................. $9,993.21 $9,210.55 $8,268.50 $7,851.25 

0102 ................................................................................................................. 12,561.49 11,579.27 10,393.61 9,870.11 

0103 ................................................................................................................. 14,873.19 13,709.56 12,304.92 11,685.52 

0104 ................................................................................................................. 15,798.39 14,562.20 13,070.73 12,412.47 

0105 ................................................................................................................. 18,555.86 17,103.26 15,352.64 14,579.05 

0106 ................................................................................................................. 21,551.75 19,864.61 17,831.50 16,932.22 

0107 ................................................................................................................. 24,581.33 22,657.06 20,337.58 19,312.60 

0108 ................................................................................................................. 29,537.76 27,226.05 24,438.79 23,207.78 

0109 ................................................................................................................. 28,230.30 26,020.96 23,356.80 22,180.21 

0110 ................................................................................................................. 35,267.79 32,507.73 29,178.82 27,709.39 

0201 ................................................................................................................. 9,791.06 8,376.05 7,538.96 6,861.26 

0202 ................................................................................................................. 13,353.22 11,425.07 10,282.17 9,358.27 

0203 ................................................................................................................. 14,884.85 12,735.12 11,462.65 10,432.49 

0204 ................................................................................................................. 16,759.88 14,339.32 12,904.87 11,745.13 

0205 ................................................................................................................. 20,394.60 17,449.24 15,703.80 14,292.67 

0206 ................................................................................................................. 25,306.97 21,651.52 19,487.54 17,735.61 

0207 ................................................................................................................. 34,088.61 29,165.87 26,249.02 23,890.66 

0301 ................................................................................................................. 14,362.65 12,061.31 10,830.30 9,912.87 

0302 ................................................................................................................. 18,296.70 15,364.30 13,796.38 12,628.87 

0303 ................................................................................................................. 21,948.26 18,431.46 16,549.96 15,149.20 

0304 ................................................................................................................. 29,971.85 25,169.62 22,600.05 20,688.74 

0401 ................................................................................................................. 11,992.63 10,214.79 10,019.13 8,508.22 

0402 ................................................................................................................. 18,054.38 15,378.55 15,083.11 12,810.28 

0403 ................................................................................................................. 29,574.04 25,190.35 24,707.02 20,984.19 

0404 ................................................................................................................. 51,528.78 43,891.34 43,049.07 36,561.00 

0405 ................................................................................................................. 39,323.64 33,496.43 32,853.71 27,901.17 

0501 ................................................................................................................. 10,505.05 8,289.23 7,703.53 6,796.47 

0502 ................................................................................................................. 14,246.03 11,241.07 10,446.74 9,217.03 

0503 ................................................................................................................. 18,549.38 14,637.36 13,602.01 12,000.40 

0504 ................................................................................................................. 22,325.34 17,617.70 16,371.14 14,444.28 

0505 ................................................................................................................. 26,382.49 20,818.32 19,346.29 17,069.57 

0506 ................................................................................................................. 36,703.54 28,962.43 26,913.77 23,745.54 

0601 ................................................................................................................. 11,979.67 9,778.11 9,296.07 8,477.12 

0602 ................................................................................................................. 16,023.86 13,079.81 12,434.50 11,338.25 

0603 ................................................................................................................. 20,425.70 16,671.76 15,850.23 14,453.35 

0604 ................................................................................................................. 27,065.37 22,092.09 21,002.33 19,151.92 

0701 ................................................................................................................. 11,904.51 10,032.08 9,459.34 8,504.34 

0702 ................................................................................................................. 15,699.91 13,228.82 12,474.67 11,215.15 

0703 ................................................................................................................. 19,237.45 16,210.46 15,286.55 13,743.25 

0704 ................................................................................................................. 24,612.43 20,739.28 19,557.51 17,582.71 

0801 ................................................................................................................. 9,070.60 7,391.24 6,701.88 6,108.40 

0802 ................................................................................................................. 12,154.60 9,903.80 8,981.19 8,185.57 

0803 ................................................................................................................. 17,341.69 14,130.70 12,814.17 11,679.05 

0804 ................................................................................................................. 15,219.17 12,402.10 11,246.25 10,249.78 

0805 ................................................................................................................. 18,997.72 15,480.92 14,037.40 12,794.73 

0806 ................................................................................................................. 23,504.52 19,151.92 17,367.61 15,828.20 

0901 ................................................................................................................. 11,123.15 9,814.39 8,849.02 7,827.93 

0902 ................................................................................................................. 14,866.71 13,116.09 11,826.77 10,462.29 

0903 ................................................................................................................. 19,229.67 16,965.91 15,298.21 13,532.04 

0904 ................................................................................................................. 25,423.60 22,430.30 20,224.85 17,891.11 

1001 ................................................................................................................. 12,123.50 11,741.24 10,103.35 9,248.12 

1002 ................................................................................................................. 16,226.01 15,714.17 13,521.67 12,377.48 

1003 ................................................................................................................. 23,574.49 22,830.70 19,645.62 17,981.82 

1101 ................................................................................................................. 15,350.05 12,764.93 12,764.93 11,089.46 

1102 ................................................................................................................. 22,401.79 18,629.72 18,629.72 16,184.54 


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TABLE 5—FY 2009 PAYMENT RATES—Continued 

CMG Payment rate 

tier 1 

Payment rate 

tier 2 

Payment rate 

tier 3 

Payment rate 

no comorbidity 

1201 ................................................................................................................. 13,371.36 12,527.79 10,992.27 9,771.63 

1202 ................................................................................................................. 16,889.46 15,824.31 13,884.50 12,342.50 

1203 ................................................................................................................. 21,223.91 19,885.35 17,447.95 15,509.43 

1301 ................................................................................................................. 14,231.77 12,794.73 11,013.00 9,910.28 

1302 ................................................................................................................. 19,164.88 17,228.96 14,830.43 13,345.44 

1303 ................................................................................................................. 24,801.61 22,298.13 19,193.39 17,271.72 

1401 ................................................................................................................. 10,370.29 9,356.97 8,277.57 7,343.30 

1402 ................................................................................................................. 14,376.90 12,970.96 11,475.60 10,179.80 

1403 ................................................................................................................. 17,594.37 15,874.85 14,043.88 12,459.12 

1404 ................................................................................................................. 22,842.36 20,609.70 18,233.20 16,175.47 

1501 ................................................................................................................. 12,443.57 10,866.58 9,605.77 9,119.84 

1502 ................................................................................................................. 15,934.45 13,915.60 12,302.33 11,679.05 

1503 ................................................................................................................. 20,266.31 17,698.04 15,645.49 14,853.76 

1504 ................................................................................................................. 25,300.50 22,094.69 19,531.59 18,542.90 

1601 ................................................................................................................. 14,375.61 11,620.73 9,934.90 9,158.71 

1602 ................................................................................................................. 19,408.49 15,689.55 13,412.83 12,365.82 

1603 ................................................................................................................. 24,992.09 20,201.52 17,270.42 15,921.49 

1701 ................................................................................................................. 13,546.29 11,907.11 10,963.76 9,613.54 

1702 ................................................................................................................. 17,852.24 15,692.14 14,449.47 12,670.33 

1703 ................................................................................................................. 21,466.22 18,868.14 17,374.09 15,234.72 

1704 ................................................................................................................. 26,921.54 23,662.60 21,788.88 19,105.28 

1801 ................................................................................................................. 15,794.51 12,477.26 11,719.22 10,051.52 

1802 ................................................................................................................. 23,840.13 18,831.86 17,688.97 15,171.23 

1803 ................................................................................................................. 40,742.54 32,185.08 30,229.72 25,927.66 

1901 ................................................................................................................. 15,007.96 12,035.39 12,035.39 11,379.72 

1902 ................................................................................................................. 30,332.09 24,324.76 24,324.76 22,999.15 

1903 ................................................................................................................. 46,576.24 37,351.44 37,351.44 35,315.73 

2001 ................................................................................................................. 11,428.96 9,436.02 8,570.42 7,681.50 

2002 ................................................................................................................. 15,385.03 12,702.73 11,537.80 10,340.48 

2003 ................................................................................................................. 19,736.33 16,294.69 14,800.63 13,265.10 

2004 ................................................................................................................. 26,386.38 21,784.99 19,788.16 17,734.32 

2101 ................................................................................................................. 30,666.40 30,666.40 27,835.08 22,616.89 

5001 ................................................................................................................. 0.00 0.00 0.00 1,912.60 

5101 ................................................................................................................. 0.00 0.00 0.00 8,789.41 

5102 ................................................................................................................. 0.00 0.00 0.00 19,996.79 

5103 ................................................................................................................. 0.00 0.00 0.00 9,182.04 

5104 ................................................................................................................. 0.00 0.00 0.00 25,379.54 

We received 3 comments on the 

proposed standard payment conversion 

factor and the proposed unadjusted IRF 

prospective payment rates for FY 2009, 

which are summarized below. 

Comment: One commenter 

recommended that CMS use the most 

recent available data in computing the 

FY 2009 CMG relative weights, because 

these have an impact on the FY 2009 

IRF prospective payment rates and the 

budget neutrality factors used in 

computing the FY 2009 standard 

payment conversion factor. 

Response: We agree that we should 

use the most recent available data in 

computing the FY 2009 CMG relative 

weights. We typically update the data 

we use in our analysis each year 

between the proposed and final rules in 

order to ensure that we are using the 

most current available data. 

Specifically, in the proposed rule (73 FR 

22674 at 22677), we proposed to update 

our analysis for this final rule using 

more current data. Thus, we updated 

our data analysis using FY 2007 IRF 

claims data for the final rule, whereas 

we had used FY 2006 IRF claims data 

in conducting the analysis for the FY 

2009 IRF PPS proposed rule (73 FR 

22674 at 22677). As discussed in detail 

in section IV of this final rule, we did 

not use IRF-PAI data for this final rule 

because the CMG information on the FY 

2007 IRF claims data incorporated all of 

the most recent changes to the IRF 

classification system that were 

implemented in the FY 2007 IRF PPS 

final rule (71 FR 48354). Moreover, we 

did not implement any changes to the 

IRF classification system in the FY 2008 

IRF PPS final rule (72 FR 44284). 

The revised final budget neutrality 

factors for FY 2009 reflect the updated 

FY 2009 IRF labor-related share and the 

revised CMG relative weights and 

average length of stay values described 

above. 

Comment: Several commenters 

requested that we keep the same 

standard payment conversion factor of 

$13,034 for FY 2009 that was used for 

determining IRF PPS payments in FY 

2008, for discharges occurring on or 

after April 1, 2008. In effect, we believe 

that these commenters were asking us 

not to apply the combined budget 

neutrality factor for the wage index and 

labor-related share or the budget 

neutrality factor for the revisions to the 

CMG relative weights to the FY 2008 

standard payment conversion factor in 

determining the FY 2009 standard 

payment conversion factor. Another 

commenter asked us to provide a more 

extensive explanation of the 

methodology that we use to compute the 

budget neutrality factors, including any 

background studies on the methodology 

and calculations for the budget 

neutrality factors. 

Response: Section 1886(j)(6) of the 

Act requires CMS to make any 

adjustments or updates to the IRF wage 

index in a budget neutral manner. To do 

this, we ensure that estimated aggregate 

payments to IRFs in the FY are not 

greater or less than estimated aggregate 

payments would have been without 

such adjustments or updates to the wage 

index. Thus, in accordance with the 

statute and using the same general 

methodology that was described and 


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finalized in the FY 2004 IRF PPS final 

rule (68 FR 45674 at 45689), we are 

required to adjust the FY 2008 standard 

payment conversion factor of $13,034 by 

the combined final budget neutrality 

factor for the FY 2009 wage index and 

labor related share of 1.0003, which 

results in a standard payment amount of 

$13,038. 

Further, in accordance with the 

regulations at § 412.624(d)(4), as 

discussed in the FY 2006 IRF PPS final 

rule (70 FR 47880 at 47937), we apply 

an additional budget neutrality factor to 

make the updates to the CMG relative 

weights and average length of stay 

values budget neutral. The final budget 

neutrality factor used to update the 

CMG relative weights and average 

length of stay values for this final rule 

is 0.9939, which results in a standard 

payment amount of $12,958. As 

discussed above, the budget neutrality 

factor used to update the CMG relative 

weights and average length of stay 

values changed from 0.9969 in the 

proposed rule to 0.9939 in this final rule 

due to the use of updated FY 2007 IRF 

claims data in this final rule. Although 

the standard payment conversion factor 

for FY 2009 of $12,958 is lower than the 

standard payment conversion factor 

applicable for discharges occurring on 

or after April 1, 2008, of $13,034, 

estimated aggregate IRF payments for 

FY 2009, excluding outlier payments, 

are the same. This is because we 

estimate that aggregate IRF payments 

would have increased by about $37 

million, due to the update to the CMG 

relative weights for FY 2009, if we had 

not applied the budget-neutrality factor 

used to update the CMG relative weights 

and average length of stay values. 

We have consistently implemented 

any revisions to the IRF classification 

and weighting factors in a budgetneutral manner, such that estimated 

aggregate payments to IRFs remain the 

same with and without the revisions. 

The methodology for computing the 

budget neutrality factor is the same 

general methodology that we have 

consistently used to ensure that the 

changes to the classification and 

weighting factors that we implemented 

in the FY 2006 IRF PPS final rule (70 

FR 47880) and in the FY 2007 IRF PPS 

final rule (71 FR 48354) were done in 

a budget-neutral manner. (Note that we 

did not implement any changes to the 

IRF classification or weighting factors in 

the FY 2008 IRF PPS final rule (72 FR 

44284)). The methodology that we are 

using in this final rule to compute the 

budget neutrality factor for the updates 

to the CMG relative weights is the same 

general methodology that we have used 

to ensure that updates to the IRF wage 

index are implemented in a budgetneutral manner, as discussed above and 

as finalized in the FY 2004 IRF PPS 

final rule (68 FR 45674 at 45689). The 

methodology, as proposed in the FY 

2009 IRF PPS proposed rule (73 FR 

22674 at 22677) and finalized in this 

final rule, applied to the update to the 

CMG relative weights for FY 2009 

involves the following steps: 

Step 1. Calculate the estimated total 

amount of IRF PPS payments for FY 

2009 (with no changes to the CMG 

relative weights). 

Step 2. Apply the changes to the CMG 

relative weights (as discussed in section 

IV of this final rule) to calculate the 

estimated total amount of IRF PPS 

payments for FY 2009 (with the 

changes). 

Step 3. Divide the amount calculated 

in step 1 ($6,003,947,007) by the 

amount calculated in step 2 

($6,040,824,839) to determine the factor 

(0.9939) that maintains the same total 

estimated aggregate payments in FY 

2009 with and without the changes to 

the CMG relative weights. 

Step 4. Apply the final budget 

neutrality factor (0.9939) to the FY 2008 

IRF PPS standard payment amount after 

the application of the budget-neutral 

wage adjustment factor. 

The FY 2004 IRF PPS final rule (68 FR 

45674 at 45689) contains additional 

information on the methodology for 

computing the budget neutrality factor 

for the IRF wage index and labor-related 

share, and the FY 2006 IRF PPS final 

rule (70 FR 47880, 47937 through 

47938) contains additional information 

on the methodology for computing the 

budget neutrality factor for the updates 

to the CMG relative weights and average 

length of stay values. 

Final Decision: After reviewing the 

comments that we received on the 

proposed methodology for calculating 

the budget neutrality factors for the 

wage index and labor-related share and 

for the CMG relative weights and 

average length of stay values, we are 

finalizing the proposed methodology. 

We are also finalizing the FY 2009 

standard payment conversion factor at 

$12,958. This differs from the standard 

payment conversion factor of $12,999 

that we had proposed in the proposed 

rule because of the use of updated FY 

2007 IRF claims data for analyzing the 

final CMG relative weights and average 

length of stay values for this final rule, 

as discussed in section IV of this final 

rule. 

D. Example of the Methodology for 

Adjusting the Federal Prospective 

Payment Rates 

Table 6 illustrates the methodology 

for adjusting the Federal prospective 

payments (as described in sections III.A 

through III.C of the FY 2009 proposed 

rule (73 FR 22674, 22680 through 

22685)). The examples below are based 

on two hypothetical Medicare 

beneficiaries, both classified into CMG 

0110 (without comorbidities). The 

unadjusted Federal prospective 

payment rate for CMG 0110 (without 

comorbidities) appears in Table 5 above. 

One beneficiary is in Facility A, an 

IRF located in rural Spencer County, 

Indiana, and another beneficiary is in 

Facility B, an IRF located in urban 

Harrison County, Indiana. Facility A, a 

non-teaching hospital, has a 

disproportionate share hospital (DSH) 

percentage of 5 percent (which results 

in a low-income percentage (LIP) 

adjustment of 1.0309), a wage index of 

0.8576, and an applicable rural 

adjustment of 21.3 percent. Facility B, a 

teaching hospital, has a DSH percentage 

of 15 percent (which results in a LIP 

adjustment of 1.0910), a wage index of 

0.9065, and an applicable teaching 

status adjustment of 0.109. 

To calculate each IRF’s labor and nonlabor portion of the Federal prospective 

payment, we begin by taking the 

unadjusted Federal prospective 

payment rate for CMG 0110 (without 

comorbidities) from Table 5 above. 

Then, we multiply the estimated laborrelated share (75.464) described in 

section V.A of this final rule by the 

unadjusted Federal prospective 

payment rate. To determine the nonlabor portion of the Federal prospective 

payment rate, we subtract the labor 

portion of the Federal payment from the 

unadjusted Federal prospective 

payment. 

To compute the wage-adjusted 

Federal prospective payment, we 

multiply the result of the labor portion 

of the Federal payment by the 

appropriate wage index found in the 

addendum in Tables 1 and 2, which 

would result in the wage-adjusted 

amount. Next, we compute the wageadjusted Federal payment by adding the 

wage-adjusted amount to the non-labor 

portion. 

Adjusting the Federal prospective 

payment by the facility-level 

adjustments involves several steps. 

First, we take the wage-adjusted Federal 

prospective payment and multiply it by 

the appropriate rural and LIP 

adjustments (if applicable). Second, to 

determine the appropriate amount of 

additional payment for the teaching 


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status adjustment (if applicable), we 

multiply the teaching status adjustment 

(0.109, in this example) by the wageadjusted and rural-adjusted amount (if 

applicable). Finally, we add the 

additional teaching status payments (if 

applicable) to the wage, rural, and LIPadjusted Federal prospective payment 

rates. Table 6 illustrates the components 

of the adjusted payment calculation. 

TABLE 6—EXAMPLE OF COMPUTING AN IRF FY 2009 FEDERAL PROSPECTIVE PAYMENT

Steps 

Rural facility A 

(Spencer Co., 

IN) 

Urban Facility 

B (Harrison 

Co., IN) 

1. Unadjusted Federal Prospective Payment .......................................................................................................... $27,709.39 $27,709.39 

2. Labor Share ......................................................................................................................................................... × 0.75464 × 0.75464 

3. Labor Portion of Federal Payment ...................................................................................................................... = $20,910.61 = $20,910.61 

4. CBSA Based Wage Index (shown in the Addendum, Tables 1 and 2) .............................................................. × 0.8576 × 0.9065 

5. Wage-Adjusted Amount ....................................................................................................................................... = $17,932.94 = $18,955.47 

6. Non-labor Amount ............................................................................................................................................... + $6,798.78 + $6,798.78 

7. Wage-Adjusted Federal Payment ....................................................................................................................... = $24,731.72 = $25,754.25 

8. Rural Adjustment ................................................................................................................................................. × 1.213 × 1.000 

9. Wage- and Rural-Adjusted Federal Payment ..................................................................................................... = $29,999.57 = $25,754.25 

10. LIP Adjustment .................................................................................................................................................. × 1.0309 × 1.0910 

11. FY 2009 Wage-, Rural- and LIP-Adjusted Federal Prospective Payment Rate ............................................... = $30,926.56 = $28,097.88 

12. FY 2009 Wage- and Rural-Adjusted Federal Prospective Payment ................................................................ $29,999.57 $25,754.25 

13. Teaching Status Adjustment ............................................................................................................................. × 0.000 × 0.109 

14. Teaching Status Adjustment Amount ................................................................................................................ = $0.00 = $2,807.21 

15. FY 2009 Wage-, Rural-, and LIP-Adjusted Federal Prospective Payment Rate .............................................. + $30,926.56 + $28,097.88 

16. Total FY 2009 Adjusted Federal Prospective Payment .................................................................................... = $30,926.56 = $30,905.10 

Thus, the adjusted payment for 

Facility A would be $30,926.56 and the 

adjusted payment for Facility B would 

be $30,905.10. 

VI. Update to Payments for High-Cost 

Outliers Under the IRF PPS 

A. Update to the Outlier Threshold 

Amount for FY 2009 

Section 1886(j)(4) of the Act provides 

the Secretary with the authority to make 

payments in addition to the basic IRF 

prospective payments for cases 

incurring extraordinarily high costs. A 

case qualifies for an outlier payment if 

the estimated cost of the case exceeds 

the adjusted outlier threshold. We 

calculate the adjusted outlier threshold 

by adding the IRF PPS payment for the 

case (that is, the CMG payment adjusted 

by all of the relevant facility-level 

adjustments) and the adjusted threshold 

amount (also adjusted by all of the 

relevant facility-level adjustments). 

Then, we calculate the estimated cost of 

a case by multiplying the IRF’s overall 

CCR by the Medicare allowable covered 

charge. If the estimated cost of the case 

is higher than the adjusted outlier 

threshold, we make an outlier payment 

for the case equal to 80 percent of the 

difference between the estimated cost of 

the case and the outlier threshold. 

In the FY 2002 IRF PPS final rule (66 

FR 41316, 41362 through 41363), we 

discussed our rationale for setting the 

outlier threshold amount for the IRF 

PPS so that estimated outlier payments 

would equal 3 percent of total estimated 

payments. Subsequently, we updated 

the IRF outlier threshold amount in the 

FYs 2006, 2007, and 2008 IRF PPS final 

rules (70 FR 47880, 70 FR 57166, 71 FR 

48354, and 72 FR 44284, respectively) to 

maintain estimated outlier payments at 

3 percent of total estimated payments. 

We also stated that we would continue 

to analyze the estimated outlier 

payments for subsequent years and 

adjust the outlier threshold amount as 

appropriate to maintain the 3 percent 

target. 

As was proposed, for this final rule, 

we used updated data for calculating the 

high-cost outlier threshold amount. 

Specifically, we performed an updated 

analysis using FY 2007 claims data 

using the same methodology that we 

used to set the initial outlier threshold 

amount in the FY 2002 IRF PPS final 

rule (66 FR 41316, 41362 through 

41363), which is also the same 

methodology that we used to update the 

outlier threshold amounts for FYs 2006, 

2007, and 2008. (Note: the methodology 

that we use to calculate the appropriate 

outlier threshold amount for each FY 

requires us to simulate Medicare 

payments for that FY, using the most 

recent available IRF claims data from a 

previous FY. If the previous FY’s data 

that we are using for the analysis does 

not contain exactly the same CMGs as 

the future FY for which we are 

calculating the update to the outlier 

threshold, then we cannot rely on the 

CMGs from the previous FY’s IRF 

claims data and must instead use IRF–

PAI data to assign the appropriate CMG 

for each IRF claim.) The CMGs and tiers 

in effect for FY 2009 would be slightly 

different than those that were in effect 

for FY 2006, due to revisions that were 

implemented in the FY 2007 IRF PPS 

final rule (71 FR 48354, 48360 through 

48370). Use of the IRF–PAI data was no 

longer necessary when we used the 

updated FY 2007 IRF claims data for 

this final rule because the CMG 

information on the FY 2007 IRF claims 

data incorporated all of the changes to 

the IRF classification system that were 

implemented in the FY 2007 IRF PPS 

final rule (71 FR 48354, 48360 through 

48370). We did not implement any 

changes to the IRF classification system 

in the FY 2008 IRF PPS final rule (72 

FR 44284). 

For FY 2009, based on an analysis of 

updated FY 2007 claims data, we 

estimate that IRF outlier payments as a 

percentage of total estimated payments 

would be 4.2 percent without the 

change to the outlier threshold amount. 

The need to revise the high-cost outlier 


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threshold is discussed in detail in 

section IV.A of the FY 2009 proposed 

rule (73 FR 22674, 22686 through 

22687). Generally, we note that the zero 

percent IRF increase factor for FYs 2008 

and 2009, for discharges occurring on or 

after April 1, 2008, implemented by 

section 115 of the MMSEA resulted in 

lower IRF PPS payments for FYs 2008 

and 2009 than would otherwise have 

been implemented. In addition, IRF 

charges found in the FY 2007 IRF claims 

data were higher than those in the FY 

2006 IRF claims data, resulting in higher 

estimated outlier payments for FY 2009. 

Based on the updated analysis of FY 

2007 claims data (for the reasons 

discussed previously, IRF–PAI data was 

not needed in this analysis), we are 

updating the outlier threshold amount 

to $10,250 to maintain estimated outlier 

payments at 3 percent of total estimated 

aggregate IRF payments for FY 2009. 

B. Update to the IRF Cost-to-Charge 

Ratio Ceilings 

In accordance with the methodology 

stated in the FY 2004 IRF PPS final rule 

(68 FR 45674, 45692 through 45694), we 

apply a ceiling to IRFs’ CCRs. Using the 

methodology described in that final 

rule, as discussed in more detail in 

section IV.B of the FY 2009 proposed 

rule (73 FR 22674 at 22687), we are 

updating the national urban and rural 

CCRs for IRFs. As was proposed, the 

national average rural and urban CCRs 

and our estimate of the national CCR 

ceiling are changing in this final rule 

based on the analysis of updated data. 

We apply the national urban and rural 

CCRs in the following situations: 

• New IRFs that have not yet 

submitted their first Medicare cost 

report. 

• IRFs whose overall CCR is in excess 

of the national CCR ceiling for FY 2009, 

as discussed below. 

• Other IRFs for which accurate data 

to calculate an overall CCR are not 

available. 

Specifically, for FY 2009, we estimate 

a national average CCR of 0.619 for rural 

IRFs and 0.490 for urban IRFs based on 

the most recent available IRF cost report 

data. For this final rule, we have used 

FY 2006 IRF cost report data, updated 

through March 31, 2008. If, for any IRF, 

the FY 2006 cost report was missing or 

had an ‘‘as submitted’’ status, we use 

data from a previous fiscal year’s report 

for that IRF. However, we do not use 

cost report data from before FY 2003 for 

any IRF. For new IRFs, we use these 

national CCRs until the facility’s actual 

CCR can be computed using the first 

settled cost report (either tentative or 

final, whichever is earlier). 

In addition, we estimate the national 

CCR ceiling at 1.60 for FY 2009. This 

means that, if an individual IRF’s CCR 

exceeds this ceiling of 1.60 for FY 2009, 

we would replace the IRF’s CCR with 

the appropriate national average CCR 

(either rural or urban, depending on the 

geographic location of the IRF). For a 

complete description of the 

methodology used to calculate the 

national CCR ceiling for this final rule, 

see section IV.B of the FY 2009 

proposed rule (73 FR 22674 at 22687). 

We received seven comments on the 

proposed high-cost outlier updates 

under the IRF PPS, which are 

summarized below. 

Comment: Most commenters 

supported our proposal to increase the 

outlier threshold amount to maintain 

estimated outlier payments at 3 percent 

of total estimated payments. However, 

several other commenters expressed 

concerns that the change would mean 

that fewer cases would qualify for 

outlier payments and that it would 

affect IRFs’ ability to provide care to 

Medicare beneficiaries. Several 

commenters asked that we further 

explain the reasons behind the increase 

in the IRF outlier threshold amount and 

provide proof that we would be paying 

more than 3 percent in outliers without 

the change. Finally, one commenter said 

that the increases in the outlier 

threshold amount in recent years appear 

excessive and recommended that CMS 

look more closely to determine if there 

are anomalies in the IRF outlier data or 

institutional practices that may be 

causing the changes. 

Response: Based on our analysis of FY 

2007 IRF claims and FY 2006 IRF cost 

report data (as previously discussed, we 

did not need to use IRF–PAI data in 

conjunction with the FY 2007 IRF 

claims data), we need to increase the 

IRF outlier threshold amount to 

maintain estimated outlier payments at 

3 percent of total estimated payments 

for FY 2009 for the following reasons. 

First, as discussed in detail in the FY 

2009 IRF PPS proposed rule (73 FR 

22674, 22686 through 22687), section 

115 of the MMSEA, which amended 

section 1886(j)(3)(C) of the Social 

Security Act, required the Secretary to 

apply a zero percent increase factor for 

FYs 2008 and 2009, effective for 

discharges occurring on or after April 1, 

2008. The effect of this change was to 

decrease projected IRF PPS payments. 

As a direct result of a zero percent 

update, we would exceed our projected 

3 percent target for the proportion of 

estimated IRF outlier payment to 

estimated IRF total payments. 

Second, because the average charges 

per case in the FY 2007 data are 

significantly higher than the average 

charges per case in the FY 2006 data, we 

believe that our increase to the outlier 

threshold amount for FY 2009 is 

warranted. Specifically, higher charges 

directly result in more cases being 

estimated to qualify for outlier 

payments and higher estimated outlier 

payments, which in turn lead to higher 

estimates of outlier payments as a 

percentage of total estimated payments. 

In this case, higher charges result in 

estimated outlier payments as a 

percentage of total estimated payments 

in FY 2009 of 4.2 percent, well above 

the 3 percent target. To decrease 

estimated outlier payments as a 

percentage of total estimated payments 

from 4.2 percent to 3 percent, we must 

increase the outlier threshold. 

The higher charges in the FY 2007 

may be due to several factors, including 

the ‘‘75 percent’’ rule and the IRF 

medical review activities, which have 

led to declines in the number of IRF 

discharges and may have led to 

increases in the complexity of IRF cases. 

Thus, based on our analysis of updated 

data (that is, FY 2007 IRF claims data), 

we now project that estimated IRF 

outlier payments as a percentage of total 

estimated payments for FY 2008 

increased from 3.0 percent to 3.7 

percent. 

Thus, given the recent changes in IRF 

aggregate payments resulting from 

section 115 of the MMSEA and recent 

increases in IRFs’ charges that are being 

reflected in the IRF claims data for FY 

2007, we believe that it is necessary to 

adjust the outlier threshold amount for 

FY 2009 to maintain estimated IRF 

outlier payments equal to 3 percent of 

estimated total payments. 

As several of the commenters 

suggested, increasing the outlier 

threshold amount for FY 2009 would 

mean that fewer cases would qualify for 

IRF outlier payments. As discussed 

above, this is necessary to maintain 

estimated IRF outlier payments at 3 

percent of estimated total payments. 

However, we do not believe that this 

will affect IRFs’ ability to provide care 

to Medicare beneficiaries because the 

IRF outlier policy is designed to reduce 

the financial risk to IRFs, which could 

be substantial for many smaller IRFs, of 

admitting unusually high-cost cases. 

The additional IRF outlier payments 

reduce the financial losses caused by 

treating these patients and, therefore, 

reduce the incentives to underserve 

these patients. As discussed at length in 

the FY 2002 IRF PPS final rule (66 FR 

41316 at 41362), we considered various 

options for setting the target percentage 

of estimated outlier payments as a 

percentage of total payments. In that 


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final rule, we finalized our proposal to 

set an outlier policy of 3 percent of total 

estimated payments because we 

believed (and continue to believe) that 

this option optimizes the extent to 

which we protect vulnerable IRFs for 

treating unusually high-cost cases, 

while still providing adequate payment 

for all other IRF cases. If we were to 

increase the percentage of total 

estimated IRF payments that we paid in 

IRF outlier payments, then we would 

have to reduce IRF PPS payments for all 

other IRF cases in order to implement 

this change in a budget neutral manner. 

This could negatively affect the 

adequacy of IRF PPS payments for 

other, non-outlier IRF cases. Thus, we 

continue to believe that the 3 percent 

outlier policy ensures that all IRF cases, 

outlier and non-outlier, continue to be 

reimbursed appropriately. 

As one of the commenters suggested, 

we will continue to analyze IRF outliers 

to determine if there are any anomalies 

in the IRF outlier data or any 

institutional practices which may be 

affecting our analysis of IRF outliers. To 

the extent that we find any such 

anomalies, we would propose to 

implement future refinements to the IRF 

outlier policies to ensure that IRF 

outlier payments continue to fulfill their 

intended purpose of reducing the risks 

to IRFs of treating unusually high-cost 

cases and ensuring access to care for all 

patients who require and can benefit 

from an IRF level of care. 

Comment: One commenter 

recommended that we continue to refine 

our methodology for calculating the 

outlier threshold amount, and that we 

use the most accurate CCR data 

available. 

Response: The CCR data that we use 

in our analyses comes directly from the 

Medicare cost reports submitted to 

Medicare by IRFs and is continually 

updated each time a more recent cost 

report is tentatively settled. Therefore, 

we believe that it is the most accurate 

and most recent CCR data available. 

However, we agree with the commenter 

about the need to continually examine 

our methodology and the CCR data to 

ensure that we are setting the IRF outlier 

threshold at the appropriate level to 

maintain estimated outlier payments at 

3 percent of total estimated payments. 

Comment: One commenter requested 

that we conduct an analysis of IRF 

outlier payments to ensure that we are 

not rewarding IRFs with outlier 

payments for the ‘‘wrong’’ reasons, such 

as the cost effects of declines in patient 

volume. This commenter suggested that 

we should either ‘‘hold back’’ outlier 

payments from facilities if we find that 

the outlier payments were paid for the 

‘‘wrong’’ reasons, or that we should 

reduce the outlier pool from 3 percent 

to 1.5 percent. 

Response: We are continuing to 

analyze IRF outlier payments to ensure 

that they continue to compensate IRFs 

for treating unusually high-cost patients 

and promote access to care for patients 

who are likely to require unusually 

high-cost care. At this time, we do not 

have indications to suggest that any IRF 

outlier payments are being paid for the 

‘‘wrong’’ reasons. Further, we do not 

have indications to suggest that the 

outlier pool would be better set at 1.5 

percent than at 3 percent. However, we 

will carefully consider this commenter’s 

suggestions, and will consider 

proposing additional refinements to the 

IRF outlier policies in the future if we 

find that such refinements are 

necessary. 

Comment: Several commenters 

requested that CMS provide additional 

data and information to the public to 

allow the IRF industry and external 

researchers to conduct a more thorough 

review of CMS’s proposed updates to 

the outlier threshold amount and to 

verify our estimates of outlier payments 

as a percentage of total payments for FY 

2009. Specifically, one commenter 

asked that we provide information on 

actual charge increases and CCR 

declines that have been utilized in the 

outlier threshold calculation, a 

discussion of the data sources and time 

periods used in computing the outlier 

threshold, an IRF Medpar file (including 

total payments, outlier payments, and 

actual, estimated, and proposed CMGs), 

historical information on IRF facilitylevel payment factors (specifically 

CCRs), and actual levels and 

percentages of outlier payments. The 

commenter also asked that we provide 

data on actual outlier payments and the 

percentage of outlier payments by FY. 

Response: We will carefully consider 

all of the commenter’s suggestions in 

updating the IRF rate setting files that 

we post on the IRF PPS Web site in 

conjunction with each IRF PPS 

proposed and final rule. These files are 

available for download from the IRF 

PPS Web site at http:// 

www.cms.hhs.gov/ 

InpatientRehabFacPPS/ 

07_DataFiles.asp#TopOfPage. These 

files already contain much of the 

facility-level payment data requested by 

the commenter, including the CCRs 

used to compute the IRF outlier 

threshold amount. For this final rule, we 

used FY 2007 IRF claims data to 

conduct patient-level payment 

simulations to estimate the outlier 

threshold amount for FY 2009. This data 

file contains information that can be 

used to identify individual Medicare 

beneficiaries and is therefore not 

publicly available. We obtained the 

provider-level CCR data used in this 

analysis from the Provider-Specific 

Files, which contain historical CCR data 

and are available for download from the 

CMS Web site at http:// 

www.cms.hhs.gov/ 

ProspMedicareFeeSvcPmtGen/ 

03_psf.asp. 

The modified Medpar data files that 

CMS provides to IPPS hospitals already 

contain IRF stay data. However, we have 

recently discovered that these files do 

not include the CMGs, and we recognize 

that there may be other limitations to 

the usefulness of these files for 

analyzing IRF payments. Based on the 

commenters’ requests, we will carefully 

consider the usefulness and feasibility 

of including additional variables, such 

as actual IRF outlier payments and the 

percentage of outlier payments, on the 

Medpar file in the future to facilitate IRF 

analyses. 

Comment: One commenter suggested 

that CMS utilize the same concepts that 

the IPPS uses for modeling charge 

increases and cost-to-charge ratio (CCR) 

changes in estimating the outlier 

threshold amount, as noted in the 

methodology implemented for IPPS 

hospitals in the FY 2007 IPPS final rule 

(71 FR 47870, 48150 through 48151). 

Response: We considered proposing 

the same methodology described in the 

FY 2007 IPPS final rule (71 FR 47870, 

48150 through 48151) for projecting cost 

and charge growth in estimating the FY 

2008 and FY 2009 IRF outlier threshold 

amount. However, we discovered that 

the accuracy of the projections depends 

on the case mix of patients in the 

facilities remaining similar from year to 

year, as it does in IPPS hospitals. With 

the recent phase in of the enforcement 

of the 75 percent rule criteria and 

increases in IRF medical review 

activities, we find evidence of relatively 

large changes in the case mix of patients 

in IRFs, especially in recent years (FYs 

2004 through 2007). In performing our 

analysis, we noted that, if we based 

future projections of cost and charge 

growth on data from years in which 

IRFs were experiencing abnormal 

fluctuations in case mix, the results 

appeared dramatically skewed. Rather 

than implementing an outlier threshold 

amount for FY 2009 based on such 

skewed results, we thought a better 

approach would be to wait until we 

could further analyze the interactions 

between case mix changes and IRF cost 

and charge growth. 

We are encouraged that IRF case mix 

may stabilize in the near future now that 

the IRF compliance percentage is set at 


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60 percent for FY 2009. However, as 

recently as FY 2007, we are still 

observing large shifts in IRFs’ patient 

populations, and we believe it is 

prudent at this time to defer adopting a 

methodology for projecting cost and 

charge growth in IRFs until the patient 

populations have stabilized. 

Final Decision: Based on careful 

consideration of the comments that we 

received on the proposed update to the 

outlier threshold amount for FY 2009 

and based on updated analysis of the FY 

2007 data explained previously in this 

section and for the reasons explained in 

the proposed rule (73 FR 22674, 22686 

through 22687), we are finalizing our 

decision to update the outlier threshold 

amount for FY 2009. Based on our 

proposed policy, the outlier threshold 

amount for FY 2009 is $10,250. In 

addition, we did not receive any 

comments on the IRF cost-to-charge 

ratio ceiling. Based on our proposed 

policy and the reasons set forth in the 

proposed rule (73 FR 22674 at 22687), 

we are finalizing the national average 

urban CCR at 0.490 and the national 

average rural CCR at 0.619. We are also 

finalizing our estimate of the IRF 

national CCR ceiling at 1.60 for FY 

2009. 

VII. Revisions to the Regulation Text in 

Response to the Medicare, Medicaid, 

and SCHIP Extension Act of 2007 

Section 115 of the MMSEA amended 

section 5005 of the Deficit Reduction 

Act of 2005 (DRA, Pub. L. 109–171) to 

revise the following elements of the 75 

percent rule that are used to classify 

IRFs: 

• The compliance rate that IRFs must 

meet to be excluded from the IPPS and 

to be paid under the IRF PPS shall be 

no greater than the 60 percent 

compliance rate that became effective 

for cost reporting periods beginning on 

or after July 1, 2006. 

• Patient comorbidities that satisfy 

the criteria specified in 42 CFR 

412.23(b)(2)(i) shall be included in the 

calculations used to determine whether 

an IRF meets the 60 percent compliance 

percentage for cost reporting periods 

beginning on or after July 1, 2007. 

Although section 115 of the MMSEA 

grants the Secretary broad discretion to 

implement compliance criteria up to 60 

percent, we are setting the compliance 

rate at 60 percent, the highest level 

possible within current statutory 

authority, for the reasons discussed in 

detail in the proposed rule (73 FR 

22674, 22687 through 22688). Generally, 

we are setting the compliance rate at 60 

percent because we believe that it 

implements the provisions of the statute 

with minimal disruption to IRF 

operations, thus allowing us to more 

effectively analyze changes in IRF 

operations and admissions patterns over 

time as well as helping us to ensure that 

IRFs predominantly treat patients who 

benefit most from this level of care. 

Specifically, we proposed the 

following revisions to the regulation text 

in § 412.23(b). We proposed to remove 

the following phrases from the first 

sentence of § 412.23(b)(2)(i): 

• ‘‘and before July 1, 2007;’’ and 

• ‘‘and for cost reporting periods 

beginning on or after July 1, 2007 and 

before July 1, 2008, the hospital has 

served an inpatient population of whom 

at least 65 percent,’’

We also proposed to remove 

§ 412.23(b)(2)(ii) in its entirety, 

redesignate the existing 

§ 412.23(b)(2)(iii) to § 412.23(b)(2)(ii), 

and revise all references to the 

previously numbered § 412.23(b)(2)(iii) 

accordingly. 

We received 3 comments on the 

proposed revisions to the regulation text 

in response to section 115 of the 

MMSEA, which are summarized below. 

Comment: Although several 

commenters supported the revisions to 

the regulation text in response to section 

115 of the MMSEA, one commenter was 

concerned that CMS was confusing the 

75 percent rule policies, hereinafter 

referred to as the 60 percent rule 

policies, and the IRF medical necessity 

policies. 

Response: We agree with the 

commenter that the IRF 60 percent rule 

policies and the IRF medical necessity 

policies are different. 

While both policies relate to ensuring 

that patients who need the intensive 

rehabilitation services provided in IRFs 

have access to this level of care, the two 

policies serve different functions and 

are applied differently. 

The Medicare statute excludes 

payment for services that ‘‘* * * are not 

reasonable and necessary’’ (see section 

1862(a) of the Social Security Act). This 

applies to all Medicare settings of care, 

including IRFs, and it applies to all 

Medicare beneficiaries receiving 

treatment in those settings. Thus, all IRF 

discharges for which providers seek 

payment from Medicare must meet the 

criteria for establishing the medical 

necessity of the treatment, regardless of 

whether the patient’s condition is one of 

the conditions listed in 

§ 412.23(b)(2)(iii), herein redesignated 

as § 412.23(b)(2)(ii), or not. CMS has 

specifically instructed its contractors to 

make medical review determinations 

based on reviews of individual medical 

records by qualified clinicians, not on 

the basis of diagnosis alone. In addition, 

we do not believe that the 60 percent 

rule should be used to make individual 

medical review claim determinations. 

Conversely, the IRF 60 percent rule is 

intended to distinguish IRFs from other 

inpatient hospital settings of care, 

including acute care hospitals and 

traditional post-acute care settings (such 

as skilled nursing facilities). The 60 

percent rule specifies that an IRF’s 

patient population must consist of at 

least 60 percent of the patients who 

need intensive rehabilitation services 

for one or more of 13 specified 

conditions. The remaining 40 percent of 

patients in an IRF may be admitted for 

treatment of conditions not included on 

the list of qualifying conditions. We 

recognize that the list of 13 conditions 

does not identify all possible conditions 

for which it would generally be 

considered reasonable and necessary for 

a patient to be treated in an IRF, and 

thus we believe that it is appropriate to 

allow some percentage of an IRF’s 

patient population to be made up of 

patients with other conditions. 

However, every patient must meet the 

medical necessity criteria. 

We believe that it is particularly 

important to ensure that all patients 

being treated in IRFs meet the medical 

necessity criteria, so that the data on 

which we base IRF PPS payments is as 

accurate as possible. 

Comment: One commenter expressed 

a number of concerns about Medicare’s 

policies concerning IRF medical 

necessity. This commenter indicated 

that IRFs are confused about the 

interpretation of the medical necessity 

policies. The commenter also expressed 

concerns that the data that CMS uses to 

analyze and update IRF PPS payment 

rates may not be as accurate as it could 

be because it may include patients who 

do not meet medical necessity 

requirements for receiving care in IRFs. 

The commenter suggested that this 

could lead to inaccuracies in CMS’s rate 

setting for IRFs. 

Response: We note that we did not 

propose anything regarding the IRF 

medical necessity policies in the 

proposed rule. However, we will 

carefully consider the commenter’s 

concerns and suggestions and will 

consider refinements to the IRF medical 

necessity criteria in the future. 

Comment: Several commenters 

requested that CMS implement changes 

to the operational policies used in 

determining IRFs’ compliance with the 

60 percent rule, to correspond with the 

statutory changes to the compliance 

percentage and the continued use of 

comorbidites. For example, several 

commenters asked CMS to revise its 

policies to include Medicare Advantage 

patients in determining whether at least 


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50 percent of an IRF’s patient 

population is made up of Medicare 

patients. In addition, one commenter 

asked that CMS revise its policies to 

allow individual IRFs to view the same 

IRF–PAI database information that the 

fiscal intermediaries use in determining 

the IRFs’ compliance using the 

presumptive methodology. 

Response: We appreciate the 

suggestions provided by the 

commenters and are considering making 

future changes to some of the 

operational policies for determining 

compliance with the 60 percent rule, 

including changes to some of the 

policies mentioned by the commenters. 

We are currently evaluating whether we 

could include Medicare Advantage 

patients in determining whether 50 

percent of an IRF’s patient population is 

made up of Medicare patients, including 

our statutory authority for doing so. We 

are also currently evaluating whether 

modifications to the current system for 

collecting and compiling IRF–PAI data 

could be made to allow individual IRFs 

to view copies of the reports that the 

Medicare contractors use in determining 

the individual IRF’s compliance using 

the presumptive methodology. Our goal 

is to continue to ensure that the 60 

percent rule compliance determinations 

are as transparent and equitable as 

possible both for providers and for 

Medicare contractors. We are continuing 

to work toward this end. 

Comment: One commenter suggested 

that we remove the phrase ‘‘(b)(2)(ii)’’

from the end of the paragraph in the 

regulations at § 412.23(b)(2), as the 

original § 412.23(b)(2)(ii) to which the 

paragraph referred will no longer exist. 

Response: We agree with the 

commenter’s suggestion and will make 

the suggested revision. 

Final Decision: As all of the 

commenters supported the proposed 

revisions to the regulation text, we are 

finalizing our revisions to the regulation 

text at § 412.23(b) by removing the 

following phrases from the first 

sentence of § 412.23(b)(2)(i): 

• ‘‘and before July 1, 2007;’’ and 

• ‘‘and for cost reporting periods 

beginning on or after July 1, 2007 and 

before July 1, 2008, the hospital has 

served an inpatient population of whom 

at least 65 percent,’’

We are also removing 

§ 412.23(b)(2)(ii) in its entirety, 

redesignating the existing 

§ 412.23(b)(2)(iii) to § 412.23(b)(2)(ii), 

and revising all references to the 

previously numbered § 412.23(b)(2)(iii) 

accordingly. In response to a comment, 

we are also deleting the phrase ‘‘or 

(b)(2)(ii)’’ from the end of the paragraph 

in section § 412.23(b)(2). 

VIII. Post Acute Care Payment Reform 

In the proposed rule, we discussed 

our ongoing examination of possible 

steps toward achieving a more seamless 

system for the delivery and payment of 

post-acute care (PAC) services in 

various care settings. These include the 

PAC Payment Reform Demonstration 

(PAC–PRD) and its standardized patient 

assessment tool, the Continuity 

Assessment Record and Evaluation 

(CARE) tool. In the related area of valuebased purchasing (VBP) initiatives, we 

described the IPPS preventable hospitalacquired conditions (HAC) payment 

provision, which is designed to ensure 

that the occurrence of selected, 

preventable conditions during 

hospitalization does not have the 

unintended effect of generating higher 

Medicare payments under the IPPS. We 

then discussed the potential application 

of this same underlying principle to 

other care settings in addition to IPPS 

hospitals. For a full and complete 

discussion of this issue as it pertains to 

the IRF setting, please refer to the FY 

2009 IRF PPS proposed rule (73 FR 

22674, 22688 through 22689). 

We received 12 responses to our 

request for comments on the post acute 

care payment reform. 

Comment: We received several 

comments concerning the use of the 

CARE tool. While most of these 

comments acknowledged that the CARE 

tool holds long-term promise in terms of 

potentially facilitating the efficient flow 

of secure electronic patient information, 

they also cautioned that it would be far 

too premature at this point in time to 

draw any definitive conclusions about 

its use, given the very early stage of the 

research currently being conducted in 

this area. 

Response: We agree with the 

commenters’ observations about the 

CARE tool, both in terms of its 

significant future potential and the need 

to await the results of ongoing research 

before reaching any specific conclusions 

about its use. We will continue to 

evaluate the CARE tool closely during 

the remainder of the current 

demonstration, and we plan to keep the 

commenters’ concerns in mind as we 

proceed with our research in this area. 

Comment: A number of commenters 

stressed the need for external research 

in the area of PAC payment reform, as 

well as the importance of obtaining 

input from the stakeholder community. 

Response: We agree with the 

commenters regarding the value of 

obtaining stakeholder input, and believe 

that this is, in fact, crucial to the success 

of our PAC payment reform efforts. We 

also recognize the importance of 

obtaining the benefit of findings from 

research that is currently underway. We 

note that our own activities in this 

regard primarily involve applied 

research through our demonstration 

projects and internal analysis of changes 

in program policy. However, while our 

limited resources in this area preclude 

us from sponsoring any external 

research projects on PAC payment 

reform, we strongly favor such activity 

and encourage interested parties to 

engage in it. 

Comment: We received a number of 

comments regarding the HAC payment 

provision under the IPPS, and the 

possible adoption of a similar approach 

in care settings other than IPPS 

hospitals. The commenters urged us to 

conduct a thorough evaluation of the 

HAC policy’s implementation under the 

IPPS to determine its actual impact and 

efficacy prior to considering whether to 

adopt this type of approach in other care 

settings. Some also questioned the legal 

authority under existing Medicare law 

to expand the HAC payment provision 

beyond the IPPS hospital setting. Others 

raised concerns about the specific 

implications of applying this type of 

policy to the IRF setting. They cited 

‘‘falls’’ as an example of something that 

might be less appropriately 

characterized as ‘‘never events’’ in the 

IRF setting than in the acute care 

hospital setting. They also argued that it 

would be unfair to penalize an IRF 

financially for a condition that actually 

developed during the preceding hospital 

stay but was not detected until after 

transfer to the IRF. In addition, they 

indicated that it might be difficult to 

differentiate a preventable healthcareacquired complication from a normal, 

unavoidable aspect of a terminal illness. 

Response: We appreciate the 

commenters’ thoughtful input about 

application of the principal embodied in 

the IPPS HAC payment provision to the 

IRF setting. While we acknowledge that 

‘‘falls’’ are among the selected HACs in 

the IPPS acute care setting that 

potentially have significant implications 

for the IRF setting, we agree that these 

and other conditions may have different 

implications in the IRF setting. We agree 

with the commenters that it would be 

unfair to penalize an IRF financially for 

a condition that developed in another 

care setting. We note that the IPPS HAC 

payment provision uses Present on 

Admission (POA) indicator data to 

exclude from payment consequences 

conditions that develop outside of the 

IPPS acute care stay, and a similar 

mechanism would be needed to apply 

this type of payment provision to the 

IRF setting. Regarding the commenters’

concerns about the difficulty in 


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differentiating a preventable healthcareacquired complication from a normal, 

unavoidable aspect of a terminal illness, 

we would expect to work closely with 

stakeholders to determine which 

conditions could reasonably be 

prevented through the application of 

evidence-based guidelines. Finally, with 

regard to the comments that questioned 

the existing legal authority for 

expanding the HAC payment provision 

beyond the IPPS hospital setting, we 

note that in this final rule, we are not 

establishing any new Medicare policies 

in this area. However, we will keep the 

commenters’ concerns in mind as our 

implementation of value-based 

purchasing for all Medicare payment 

systems proceeds, and we look forward 

to working with stakeholders in 

continuing to explore possible ways to 

reduce the occurrence of these 

preventable conditions in various care 

settings. 

IX. Miscellaneous Comments 

Comment: One commenter 

recommended that CMS update the IRF 

facility-level adjustments, including the 

rural adjustment, the low-income 

percentage adjustment, and the teaching 

status adjustment, as these adjustments 

were last updated in FY 2006 based on 

analysis of FY 2003 data. This 

commenter also suggested a number of 

methodological changes to the way that 

CMS computes the facility-level 

adjustments, including standardizing 

cost-per-case by outlier payments and 

computing three-year moving averages 

of the adjustments to promote added 

stability and predictability in the 

payment system. 

Response: We note that we did not 

propose any refinements to the IRF 

facility-level adjustment for FY 2009. 

However, we are in the process of 

analyzing the data to determine whether 

future updates to the IRF facility-level 

adjustments are needed. At the same 

time, we are also analyzing the 

commenter’s suggested revisions to the 

methodology for computing these 

adjustments to determine whether these 

revisions would improve the precision 

of our estimates of the appropriate 

facility-level adjustment parameters. We 

will consider proposing to update the 

IRF facility-level adjustments in future 

rules if our analysis indicates that such 

updates are necessary to ensure that IRF 

PPS payments continue to reflect the 

costs of caring for IRF patients 

appropriately. 

Comment: One commenter 

recommended that CMS re-examine the 

weights used to compute the weighted 

motor score for classifying IRF patients. 

The weights that are currently being 

used to compute patients’ motor scores 

were finalized in the FY 2006 IRF PPS 

final rule (70 FR 47880 at 47900) and 

were based on FY 2003 data. The 

commenter expressed concerns that the 

appropriate weights may change over 

time and may need to be updated using 

more recent data. 

Response: We did not propose any 

changes to the weighted motor score in 

the proposed rule. However, we will 

consider the commenter’s suggestions 

for future updates to the weighted motor 

score methodology. 

Comment: Several commenters 

expressed interest in assisting CMS in 

the development of the IRF Report to 

Congress that was mandated in section 

115 of the MMSEA. 

Response: We appreciate the 

commenters’ interest in this important 

project and, as required by statute, we 

will consult with interested parties and 

stakeholders in developing this report. 

Comment: Several commenters noted 

that we reported IRF spending estimates 

of $6.4 billion for FY 2008 in the 

proposed rule (73 FR 22674 at 22686) 

and IRF spending projections of $5.6 

billion for FY 2009 in the press release 

that was issued in conjunction with the 

proposed rule. We believe that these 

commenters mistakenly interpreted 

these spending estimates to mean that a 

12.5 percent decrease in IRF PPS 

payments is estimated to occur between 

FY 2008 and FY 2009. 

Response: The IRF spending estimate 

of $6.4 billion for FY 2008 that was 

reported in the proposed rule (73 FR 

22674 at 22686) did not account for any 

changes in IRF utilization that might 

occur between FYs 2006 and 2008. It 

was based on an analysis of simulated 

IRF payments using IRF claims data 

from FY 2006 (that is, the number and 

types of patients that were being treated 

in IRFs in FY 2006) and the policies that 

were being proposed for FY 2009 with 

IRF utilization held constant. The $6.4 

billion spending estimate should not be 

compared with the $5.6 billion IRF 

spending projection developed by the 

Office of the Actuary for FY 2008, 

which accounts for expected changes in 

IRF utilization between FYs 2006 and 

2008. The Office of the Actuary projects 

that total IRF spending for both FY 2008 

and FY 2009 will be $5.6 billion under 

both the FY 2009 IRF PPS proposed and 

final rules. Thus, for this final rule, we 

estimate only a $40 million decrease in 

IRF PPS spending between FY 2008 and 

FY 2009, which is equal to only 0.7 

percent of total estimated IRF PPS 

payments. We note that this is different 

than the $20 million decrease in IRF 

PPS spending that we had estimated for 

the proposed rule due to the use of 

updated data (that is, FY 2007 IRF 

claims data). The estimated $40 million 

decrease for this final rule is entirely 

due to the adjustment to the outlier 

threshold amount for FY 2009 to set 

estimated IRF outlier payments at 3 

percent of total estimated payments, as 

discussed in detail in section XII of this 

final rule. 

X. Provisions of the Final Rule 

In this final rule, we are adopting the 

provisions as set forth in the FY 2009 

IRF PPS proposed rule (73 FR 22674), 

except as noted elsewhere in the 

preamble. Specifically: 

• We will update the pre-reclassified 

and pre-floor wage indexes based on the 

CBSA changes published in the most 

recent OMB bulletins that apply to the 

hospital wage data used to determine 

the current IRF PPS wage index, as 

discussed in section V.B of this final 

rule. 

• We will update the FY 2009 IRF 

PPS relative weights and average length 

of stay values using the most current 

and complete Medicare claims and cost 

report data, as discussed in section IV 

of this final rule. 

• We will update the FY 2009 IRF 

PPS payment rates by the wage index 

and labor related share in a budget 

neutral manner, as discussed in section 

V.A and B of this final rule. 

• We will update the outlier 

threshold amount for FY 2009, as 

discussed in section VI.A of this final 

rule. 

• We will update the cost-to-charge 

ratio ceiling and the national average 

urban and rural cost-to-charge ratios for 

purposes of determining outlier 

payments under the IRF PPS, as 

discussed in section VI.B of this final 

rule. 

• With respect to § 412.23, we will 

revise the regulation text in paragraph 

(b)(2) and (b)(2)(i) and remove 

paragraph (b)(2)(ii) to reflect section 115 

of the MMSEA, as discussed in section 

VII of this final rule. 

XI. Collection of Information 

Requirements 

This document does not impose 

information collection and 

recordkeeping requirements. 

Consequently, it need not be reviewed 

by the Office of Management and 

Budget under the authority of the 

Paperwork Reduction Act of 1995. 

XII. Regulatory Impact Statement 

We have examined the impact of this 

final rule as required by Executive 

Order 12866 (September 1993, 

Regulatory Planning and Review), the 

Regulatory Flexibility Act (RFA, 


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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)). 

Executive Order 12866, as amended, 

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 one year). 

This final rule does not reach the $100 

million economic threshold and thus is 

not considered a major rule. We 

estimate that the total impact of the 

changes in this final rule would be a 

decrease of approximately $40 million 

or 0.7 percent of total IRF PPS payments 

(this reflects a $40 million decrease due 

to the update to the outlier threshold 

amount to decrease estimated outlier 

payments from approximately 3.7 

percent in FY 2008 to 3 percent in FY 

2009). 

The RFA requires agencies to analyze 

options for regulatory relief of small 

entities. For purposes of the RFA, small 

entities include small businesses, 

nonprofit organizations, and small 

governmental jurisdictions. Most IRFs 

and most other providers and suppliers 

are small entities, either by nonprofit 

status or by having revenues of $6.5 

million to $31.5 million in any one year. 

(For details, see the Small Business 

Administration’s final rule that set forth 

size standards for health care industries, 

at 65 FR 69432, November 17, 2000.) 

Because we lack data on individual 

hospital receipts, we cannot determine 

the number of small proprietary IRFs or 

the proportion of IRFs’ revenue that is 

derived from Medicare payments. 

Therefore, we assume that all IRFs (an 

approximate total of 1,200 IRFs, of 

which approximately 60 percent are 

nonprofit facilities) are considered small 

entities and that Medicare payment 

constitutes the majority of their 

revenues. The Department of Health and 

Human Services generally uses a 

revenue impact of 3 to 5 percent as a 

significance threshold under the RFA. 

Medicare fiscal intermediaries and 

carriers are not considered to be small 

entities. Individuals and States are not 

included in the definition of a small 

entity. The Secretary has determined 

that this final rule (which we estimate 

will result in a decrease in total 

estimated payments to IRFs of 0.7 

percent) would not have a significant 

economic impact on a substantial 

number of small entities and therefore 

an analysis as outlined by the RFA was 

not prepared. 

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 of 

a Metropolitan Statistical Area and has 

fewer than 100 beds. The Secretary has 

determined that this final rule would 

not have a significant impact on the 

operations of a substantial number of 

small rural hospitals and therefore an 

analysis for section 1102(b) of the Act 

was not prepared. 

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 one year of 

$100 million in 1995 dollars, updated 

annually for inflation. That threshold 

level is currently approximately $130 

million. This final rule would not 

mandate any cost requirements on State, 

local, or tribal governments in the 

aggregate, or by the private sector, of 

$130 million. 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed rule (and subsequent final 

rule) that imposes substantial direct 

requirement costs on State and local 

governments, preempts State law, or 

otherwise has Federalism implications. 

As stated above, this final rule would 

not have a substantial effect on State 

and local governments. 

We received one comment on the 

regulatory impact statement included in 

the proposed rule, which is summarized 

below. 

Comment: One commenter expressed 

concern that the regulatory impact 

information provided in the proposed 

rule was not sufficient to calculate the 

projected impact to individual 

providers, and that data on FY 2007 

actual payments, FY 2008 estimated 

payments, and FY 2009 proposed 

payments would be required to fully 

estimate the effects on individual IRFs. 

The commenter requested that CMS 

make information available to allow 

interested parties to recreate CMS’s 

impact table and to make projections on 

a facility-specific basis. 

Response: As discussed above, we did 

not prepare a regulatory impact analysis 

for this final rule (or for the proposed 

rule) because this final rule does not 

reach the $100 million economic 

threshold and thus is not considered a 

major rule. However, we provided an 

IRF rate setting file in conjunction with 

the proposed rule to allow interested 

parties to calculate the payment effects 

of the proposed policies for individual 

IRFs. In addition, we will carefully 

consider all of the commenter’s 

suggestions in updating the final FY 

2009 IRF rate setting file that will be 

posted on the IRF PPS Web site in 

conjunction with this final rule. This 

file will be available for download from 

the IRF PPS Web site soon after 

publication of this final rule at http:// 

www.cms.hhs.gov/ 

InpatientRehabFacPPS/ 

07_DataFiles.asp#TopOfPage. The IRF 

rate setting files posted in conjunction 

with each proposed and final rule 

already contain much of the facilitylevel payment data needed to allow 

interested parties to recreate CMS’s 

analysis and to make projections on a 

facility-specific basis. 

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 412 

Administrative practice and 

procedure, Health facilities, Medicare, 

Puerto Rico, Reporting and 

recordkeeping requirements. 

■ For the reasons set forth in the 

preamble, the Centers for Medicare & 

Medicaid Services amends 42 CFR 

chapter IV as follows: 

PART 412—PROSPECTIVE PAYMENT 

SYSTEMS FOR INPATIENT HOSPITAL 

SERVICES 

■ 1. The authority citation for part 412 

continues to read as follows: 

Authority: Sections 1102 and 1871 of the 

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

1395hh). 

Subpart B—Hospital Services Subject 

to and Excluded From the Prospective 

Payment Systems for Inpatient 

Operating Costs and Inpatient 

Capital—Related Costs 

■ 2. Section 412.23 is amended by—

■ A. Revising introductory text of 

paragraph (b)(2). 

■ B. Revising introductory text of 

paragraph (b)(2)(i). 

■ C. Revising paragraphs (b)(2)(i)(A) and 

(B). 

■ D. Removing paragraph (b)(2)(ii). 


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■ E. Redesignating paragraph (b)(2)(iii) 

as (b)(2)(ii). 

The revision reads as follows: 

§ 412.23 Excluded hospitals: 

Classifications. 

* * * * * 

(b) * * * 

(2) Except in the case of a newly 

participating hospital seeking 

classification under this paragraph as a 

rehabilitation hospital for its first 12- 

month cost reporting period, as 

described in paragraph (b)(8) of this 

section, a hospital must show that 

during its most recent, consecutive, and 

appropriate 12-month time period (as 

defined by CMS or the fiscal 

intermediary), it served an inpatient 

population that meets the criteria under 

paragraph (b)(2)(i) of this section. 

(i) For cost reporting periods 

beginning on or after July 1, 2004 and 

before July 1, 2005, the hospital has 

served an inpatient population of whom 

at least 50 percent, and for cost 

reporting periods beginning on or after 

July 1, 2005, the hospital has served an 

inpatient population of whom at least 

60 percent required intensive 

rehabilitation services for treatment of 

one or more of the conditions specified 

at paragraph (b)(2)(ii) of this section. A 

patient with a comorbidity, as defined at 

§ 412.602, may be included in the 

inpatient population that counts toward 

the required applicable percentage if—

(A) The patient is admitted for 

inpatient rehabilitation for a condition 

that is not one of the conditions 

specified in paragraph (b)(2)(ii) of this 

section; 

(B) The patient has a comorbidity that 

falls in one of the conditions specified 

in paragraph (b)(2)(ii) of this section; 

and 

* * * * * 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance; and Program No. 93.774, 

Medicare—Supplemental Medical Insurance 

Program). 

Dated: July 18, 2008. 

Kerry Weems, 

Acting Administrator, Centers for Medicare 

& Medicaid Services. 

Approved: July 25, 2008. 

Michael O. Leavitt, 

Secretary. 

The following addendum will not 

appear in the Code of Federal 

Regulations. 

Addendum 

This addendum contains the tables referred 

to throughout the preamble of this final rule. 

The tables presented below are as follows: 

Table 1.—Inpatient Rehabilitation Facility 

Wage Index for Urban Areas for Discharges 

Occurring from October 1, 2008 through 

September 30, 2009 

Table 2.—Inpatient Rehabilitation Facility 

Wage Index for Rural Areas for Discharges 

Occurring from October 1, 2008 through 

September 30, 2009 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009 

CBSA code Urban area (constituent counties) Wage index 

10180 ....... Abilene, TX ........................................................................................................................................................................ 0.7957 

Callahan County, TX 

Jones County, TX 

Taylor County, TX 

10380 ....... Aguadilla-Isabela-San Sebastia ́n, PR ............................................................................................................................... 0.3448 

Aguada Municipio, PR 

Aguadilla Municipio, PR 

An ̃asco Municipio, PR 

Isabela Municipio, PR 

Lares Municipio, PR 

Moca Municipio, PR 

Rinco ́n Municipio, PR 

San Sebastia ́n Municipio, PR 

10420 ....... Akron, OH ......................................................................................................................................................................... 0.8794 

Portage County, OH 

Summit County, OH 

10500 ....... Albany, GA ........................................................................................................................................................................ 0.8514 

Baker County, GA 

Dougherty County, GA 

Lee County, GA 

Terrell County, GA 

Worth County, GA 

10580 ....... Albany-Schenectady-Troy, NY .......................................................................................................................................... 0.8588 

Albany County, NY 

Rensselaer County, NY 

Saratoga County, NY 

Schenectady County, NY 

Schoharie County, NY 

10740 ....... Albuquerque, NM .............................................................................................................................................................. 0.9554 

Bernalillo County, NM 

Sandoval County, NM 

Torrance County, NM 

Valencia County, NM 

10780 ....... Alexandria, LA ................................................................................................................................................................... 0.7979 

Grant Parish, LA 

Rapides Parish, LA 

10900 ....... Allentown-Bethlehem-Easton, PA-NJ ............................................................................................................................... 0.9865 

Warren County, NJ 

Carbon County, PA 

Lehigh County, PA 

Northampton County, PA 

11020 ....... Altoona, PA ....................................................................................................................................................................... 0.8618 


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TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Blair County, PA 

11100 ....... Amarillo, TX ....................................................................................................................................................................... 0.9116 

Armstrong County, TX 

Carson County, TX 

Potter County, TX 

Randall County, TX 

11180 ....... Ames, IA ............................................................................................................................................................................ 1.0046 

Story County, IA 

11260 ....... Anchorage, AK .................................................................................................................................................................. 1.1913 

Anchorage Municipality, AK 

Matanuska-Susitna Borough, AK 

11300 ....... Anderson, IN ..................................................................................................................................................................... 0.8827 

Madison County, IN 

11340 ....... Anderson, SC .................................................................................................................................................................... 0.9086 

Anderson County, SC 

11460 ....... Ann Arbor, MI .................................................................................................................................................................... 1.0539 

Washtenaw County, MI 

11500 ....... Anniston-Oxford, AL .......................................................................................................................................................... 0.7926 

Calhoun County, AL 

11540 ....... Appleton, WI ...................................................................................................................................................................... 0.9598 

Calumet County, WI 

Outagamie County, WI 

11700 ....... Asheville, NC ..................................................................................................................................................................... 0.9185 

Buncombe County, NC 

Haywood County, NC 

Henderson County, NC 

Madison County, NC 

12020 ....... Athens-Clarke County, GA ................................................................................................................................................ 1.0517 

Clarke County, GA 

Madison County, GA 

Oconee County, GA 

Oglethorpe County, GA 

12060 ....... Atlanta-Sandy Springs-Marietta, GA ................................................................................................................................. 0.9828 

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 ................................................................................................................................................................. 1.2198 

Atlantic County, NJ 

12220 ....... Auburn-Opelika, AL ........................................................................................................................................................... 0.8090 

Lee County, AL 

12260 ....... Augusta-Richmond County, GA-SC .................................................................................................................................. 0.9645 

Burke County, GA 

Columbia County, GA 

McDuffie County, GA 

Richmond County, GA 

Aiken County, SC 


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46394 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Edgefield County, SC 

12420 ....... Austin-Round Rock, TX .................................................................................................................................................... 0.9544 

Bastrop County, TX 

Caldwell County, TX 

Hays County, TX 

Travis County, TX 

Williamson County, TX 

12540 ....... Bakersfield, CA ................................................................................................................................................................. 1.1051 

Kern County, CA 

12580 ....... Baltimore-Towson, MD ...................................................................................................................................................... 1.0134 

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 ....................................................................................................................................................................... 0.9978 

Penobscot County, ME 

12700 ....... Barnstable Town, MA ........................................................................................................................................................ 1.2603 

Barnstable County, MA 

12940 ....... Baton Rouge, LA ............................................................................................................................................................... 0.8034 

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 ................................................................................................................................................................ 1.0179 

Calhoun County, MI 

13020 ....... Bay City, MI ....................................................................................................................................................................... 0.8897 

Bay County, MI 

13140 ....... Beaumont-Port Arthur, TX ................................................................................................................................................ 0.8531 

Hardin County, TX 

Jefferson County, TX 

Orange County, TX 

13380 ....... Bellingham, WA ................................................................................................................................................................. 1.1474 

Whatcom County, WA 

13460 ....... Bend, OR .......................................................................................................................................................................... 1.0942 

Deschutes County, OR 

13644 ....... Bethesda-Gaithersburg-Frederick, MD ............................................................................................................................. 1.0511 

Frederick County, MD 

Montgomery County, MD 

13740 ....... Billings, MT ........................................................................................................................................................................ 0.8666 

Carbon County, MT 

Yellowstone County, MT 

13780 ....... Binghamton, NY ................................................................................................................................................................ 0.8949 

Broome County, NY 

Tioga County, NY 

13820 ....... Birmingham-Hoover, AL .................................................................................................................................................... 0.8898 

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 .................................................................................................................................................................... 0.7225 

Burleigh County, ND 

Morton County, ND 

13980 ....... Blacksburg-Christiansburg-Radford, VA ........................................................................................................................... 0.8192 

Giles County, VA 

Montgomery County, VA 

Pulaski County, VA 

Radford City, VA 

14020 ....... Bloomington, IN ................................................................................................................................................................. 0.8915 

Greene County, IN 

Monroe County, IN 


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TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Owen County, IN 

14060 ....... Bloomington-Normal, IL .................................................................................................................................................... 0.9325 

McLean County, IL 

14260 ....... Boise City-Nampa, ID ....................................................................................................................................................... 0.9465 

Ada County, ID 

Boise County, ID 

Canyon County, ID 

Gem County, ID 

Owyhee County, ID 

14484 ....... Boston-Quincy, MA ........................................................................................................................................................... 1.1792 

Norfolk County, MA 

Plymouth County, MA 

Suffolk County, MA 

14500 ....... Boulder, CO ...................................................................................................................................................................... 1.0426 

Boulder County, CO 

14540 ....... Bowling Green, KY ............................................................................................................................................................ 0.8159 

Edmonson County, KY 

Warren County, KY 

14740 ....... Bremerton-Silverdale, WA ................................................................................................................................................. 1.0904 

Kitsap County, WA 

14860 ....... Bridgeport-Stamford-Norwalk, CT ..................................................................................................................................... 1.2735 

Fairfield County, CT 

15180 ....... Brownsville-Harlingen, TX ................................................................................................................................................. 0.8914 

Cameron County, TX 

15260 ....... Brunswick, GA ................................................................................................................................................................... 0.9475 

Brantley County, GA 

Glynn County, GA 

McIntosh County, GA 

15380 ....... Buffalo-Niagara Falls, NY ................................................................................................................................................. 0.9568 

Erie County, NY 

Niagara County, NY 

15500 ....... Burlington, NC ................................................................................................................................................................... 0.8747 

Alamance County, NC 

15540 ....... Burlington-South Burlington, VT ....................................................................................................................................... 0.9660 

Chittenden County, VT 

Franklin County, VT 

Grand Isle County, VT 

15764 ....... Cambridge-Newton-Framingham, MA ............................................................................................................................... 1.1215 

Middlesex County, MA 

15804 ....... Camden, NJ ...................................................................................................................................................................... 1.0411 

Burlington County, NJ 

Camden County, NJ 

Gloucester County, NJ 

15940 ....... Canton-Massillon, OH ....................................................................................................................................................... 0.8935 

Carroll County, OH 

Stark County, OH 

15980 ....... Cape Coral-Fort Myers, FL ............................................................................................................................................... 0.9396 

Lee County, FL 

16180 ....... Carson City, NV ................................................................................................................................................................ 1.0003 

Carson City, NV 

16220 ....... Casper, WY ....................................................................................................................................................................... 0.9385 

Natrona County, WY 

16300 ....... Cedar Rapids, IA ............................................................................................................................................................... 0.8852 

Benton County, IA 

Jones County, IA 

Linn County, IA 

16580 ....... Champaign-Urbana, IL ...................................................................................................................................................... 0.9392 

Champaign County, IL 

Ford County, IL 

Piatt County, IL 

16620 ....... Charleston, WV ................................................................................................................................................................. 0.8289 

Boone County, WV 

Clay County, WV 

Kanawha County, WV 

Lincoln County, WV 

Putnam County, WV 

16700 ....... Charleston-North Charleston, SC ..................................................................................................................................... 0.9124 

Berkeley County, SC 

Charleston County, SC 

Dorchester County, SC 

16740 ....... Charlotte-Gastonia-Concord, NC-SC ................................................................................................................................ 0.9520 


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46396 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Anson County, NC 

Cabarrus County, NC 

Gaston County, NC 

Mecklenburg County, NC 

Union County, NC 

York County, SC 

16820 ....... Charlottesville, VA ............................................................................................................................................................. 0.9277 

Albemarle County, VA 

Fluvanna County, VA 

Greene County, VA 

Nelson County, VA 

Charlottesville City, VA 

16860 ....... Chattanooga, TN-GA ........................................................................................................................................................ 0.8994 

Catoosa County, GA 

Dade County, GA 

Walker County, GA 

Hamilton County, TN 

Marion County, TN 

Sequatchie County, TN 

16940 ....... Cheyenne, WY .................................................................................................................................................................. 0.9308 

Laramie County, WY 

16974 ....... Chicago-Naperville-Joliet, IL ............................................................................................................................................. 1.0715 

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 .......................................................................................................................................................................... 1.1290 

Butte County, CA 

17140 ....... Cincinnati-Middletown, OH-KY-IN ..................................................................................................................................... 0.9784 

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 ............................................................................................................................................................. 0.8251 

Christian County, KY 

Trigg County, KY 

Montgomery County, TN 

Stewart County, TN 

17420 ....... Cleveland, TN ................................................................................................................................................................... 0.8052 

Bradley County, TN 

Polk County, TN 

17460 ....... Cleveland-Elyria-Mentor, OH ............................................................................................................................................ 0.9339 

Cuyahoga County, OH 

Geauga County, OH 

Lake County, OH 

Lorain County, OH 

Medina County, OH 

17660 ....... Coeur d’Alene, ID .............................................................................................................................................................. 0.9532 

Kootenai County, ID 

17780 ....... College Station-Bryan, TX ................................................................................................................................................ 0.9358 

Brazos County, TX 

Burleson County, TX 

Robertson County, TX 

17820 ....... Colorado Springs, CO ....................................................................................................................................................... 0.9719 

El Paso County, CO 

Teller County, CO 


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TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

17860 ....... Columbia, MO ................................................................................................................................................................... 0.8658 

Boone County, MO 

Howard County, MO 

17900 ....... Columbia, SC .................................................................................................................................................................... 0.8800 

Calhoun County, SC 

Fairfield County, SC 

Kershaw County, SC 

Lexington County, SC 

Richland County, SC 

Saluda County, SC 

17980 ....... Columbus, GA-AL ............................................................................................................................................................. 0.8729 

Russell County, AL 

Chattahoochee County, GA 

Harris County, GA 

Marion County, GA 

Muscogee County, GA 

18020 ....... Columbus, IN .................................................................................................................................................................... 0.9537 

Bartholomew County, IN 

18140 ....... Columbus, OH ................................................................................................................................................................... 1.0085 

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 ............................................................................................................................................................. 0.8588 

Aransas County, TX 

Nueces County, TX 

San Patricio County, TX 

18700 ....... Corvallis, OR ..................................................................................................................................................................... 1.0959 

Benton County, OR 

19060 ....... Cumberland, MD-WV ........................................................................................................................................................ 0.8294 

Allegany County, MD 

Mineral County, WV 

19124 ....... Dallas-Plano-Irving, TX ..................................................................................................................................................... 0.9915 

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 ......................................................................................................................................................................... 0.8760 

Murray County, GA 

Whitfield County, GA 

19180 ....... Danville, IL ........................................................................................................................................................................ 0.8957 

Vermilion County, IL 

19260 ....... Danville, VA ....................................................................................................................................................................... 0.8240 

Pittsylvania County, VA 

Danville City, VA 

19340 ....... Davenport-Moline-Rock Island, IA-IL ................................................................................................................................ 0.8830 

Henry County, IL 

Mercer County, IL 

Rock Island County, IL 

Scott County, IA 

19380 ....... Dayton, OH ....................................................................................................................................................................... 0.9190 

Greene County, OH 

Miami County, OH 

Montgomery County, OH 

Preble County, OH 

19460 ....... Decatur, AL ....................................................................................................................................................................... 0.7885 

Lawrence County, AL 

Morgan County, AL 

19500 ....... Decatur, IL ......................................................................................................................................................................... 0.8074 

Macon County, IL 

19660 ....... Deltona-Daytona Beach-Ormond Beach, FL .................................................................................................................... 0.9031 

Volusia County, FL 

19740 ....... Denver-Aurora, CO ........................................................................................................................................................... 1.0718 


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46398 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

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 .................................................................................................................................... 0.9226 

Dallas County, IA 

Guthrie County, IA 

Madison County, IA 

Polk County, IA 

Warren County, IA 

19804 ....... Detroit-Livonia-Dearborn, MI ............................................................................................................................................. 0.9999 

Wayne County, MI 

20020 ....... Dothan, AL ........................................................................................................................................................................ 0.7270 

Geneva County, AL 

Henry County, AL 

Houston County, AL 

20100 ....... Dover, DE .......................................................................................................................................................................... 1.0099 

Kent County, DE 

20220 ....... Dubuque, IA ...................................................................................................................................................................... 0.9058 

Dubuque County, IA 

20260 ....... Duluth, MN-WI ................................................................................................................................................................... 0.9975 

Carlton County, MN 

St. Louis County, MN 

Douglas County, WI 

20500 ....... Durham, NC ...................................................................................................................................................................... 0.9816 

Chatham County, NC 

Durham County, NC 

Orange County, NC 

Person County, NC 

20740 ....... Eau Claire, WI ................................................................................................................................................................... 0.9475 

Chippewa County, WI 

Eau Claire County, WI 

20764 ....... Edison, NJ ......................................................................................................................................................................... 1.1181 

Middlesex County, NJ 

Monmouth County, NJ 

Ocean County, NJ 

Somerset County, NJ 

20940 ....... El Centro, CA .................................................................................................................................................................... 0.8914 

Imperial County, CA 

21060 ....... Elizabethtown, KY ............................................................................................................................................................. 0.8711 

Hardin County, KY 

Larue County, KY 

21140 ....... Elkhart-Goshen, IN ............................................................................................................................................................ 0.9611 

Elkhart County, IN 

21300 ....... Elmira, NY ......................................................................................................................................................................... 0.8264 

Chemung County, NY 

21340 ....... El Paso, TX ....................................................................................................................................................................... 0.8989 

El Paso County, TX 

21500 ....... Erie, PA ............................................................................................................................................................................. 0.8495 

Erie County, PA 

21660 ....... Eugene-Springfield, OR .................................................................................................................................................... 1.0932 

Lane County, OR 

21780 ....... Evansville, IN-KY .............................................................................................................................................................. 0.8662 

Gibson County, IN 

Posey County, IN 

Vanderburgh County, IN 

Warrick County, IN 

Henderson County, KY 

Webster County, KY 

21820 ....... Fairbanks, AK .................................................................................................................................................................... 1.1050 

Fairbanks North Star Borough, AK 

21940 ....... Fajardo, PR ....................................................................................................................................................................... 0.4375 

Ceiba Municipio, PR 

Fajardo Municipio, PR 

Luquillo Municipio, PR 


pwalker on PROD1PC71 with RULES2
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46399 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

22020 ....... Fargo, ND-MN ................................................................................................................................................................... 0.8042 

Cass County, ND 

Clay County, MN 

22140 ....... Farmington, NM ................................................................................................................................................................ 0.9587 

San Juan County, NM 

22180 ....... Fayetteville, NC ................................................................................................................................................................. 0.9368 

Cumberland County, NC 

Hoke County, NC 

22220 ....... Fayetteville-Springdale-Rogers, AR-MO ........................................................................................................................... 0.8742 

Benton County, AR 

Madison County, AR 

Washington County, AR 

McDonald County, MO 

22380 ....... Flagstaff, AZ ...................................................................................................................................................................... 1.1687 

Coconino County, AZ 

22420 ....... Flint, MI ............................................................................................................................................................................. 1.1220 

Genesee County, MI 

22500 ....... Florence, SC ..................................................................................................................................................................... 0.8249 

Darlington County, SC 

Florence County, SC 

22520 ....... Florence-Muscle Shoals, AL ............................................................................................................................................. 0.7680 

Colbert County, AL 

Lauderdale County, AL 

22540 ....... Fond du Lac, WI ............................................................................................................................................................... 0.9667 

Fond du Lac County, WI 

22660 ....... Fort Collins-Loveland, CO ................................................................................................................................................. 0.9897 

Larimer County, CO 

22744 ....... Fort Lauderdale-Pompano Beach-Deerfield Beach, FL .................................................................................................... 1.0229 

Broward County, FL 

22900 ....... Fort Smith, AR-OK ............................................................................................................................................................ 0.7933 

Crawford County, AR 

Franklin County, AR 

Sebastian County, AR 

Le Flore County, OK 

Sequoyah County, OK 

23020 ....... Fort Walton Beach-Crestview-Destin, FL .......................................................................................................................... 0.8743 

Okaloosa County, FL 

23060 ....... Fort Wayne, IN .................................................................................................................................................................. 0.9284 

Allen County, IN 

Wells County, IN 

Whitley County, IN 

23104 ....... Fort Worth-Arlington, TX ................................................................................................................................................... 0.9693 

Johnson County, TX 

Parker County, TX 

Tarrant County, TX 

Wise County, TX 

23420 ....... Fresno, CA ........................................................................................................................................................................ 1.0993 

Fresno County, CA 

23460 ....... Gadsden, AL ..................................................................................................................................................................... 0.8159 

Etowah County, AL 

23540 ....... Gainesville, FL .................................................................................................................................................................. 0.9196 

Alachua County, FL 

Gilchrist County, FL 

23580 ....... Gainesville, GA ................................................................................................................................................................. 0.9216 

Hall County, GA 

23844 ....... Gary, IN ............................................................................................................................................................................. 0.9224 

Jasper County, IN 

Lake County, IN 

Newton County, IN 

Porter County, IN 

24020 ....... Glens Falls, NY ................................................................................................................................................................. 0.8256 

Warren County, NY 

Washington County, NY 

24140 ....... Goldsboro, NC .................................................................................................................................................................. 0.9288 

Wayne County, NC 

24220 ....... Grand Forks, ND-MN ........................................................................................................................................................ 0.7881 

Polk County, MN 

Grand Forks County, ND 

24300 ....... Grand Junction, CO .......................................................................................................................................................... 0.9864 

Mesa County, CO 

24340 ....... Grand Rapids-Wyoming, MI .............................................................................................................................................. 0.9315 


pwalker on PROD1PC71 with RULES2
46400 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Barry County, MI 

Ionia County, MI 

Kent County, MI 

Newaygo County, MI 

24500 ....... Great Falls, MT ................................................................................................................................................................. 0.8675 

Cascade County, MT 

24540 ....... Greeley, CO ...................................................................................................................................................................... 0.9658 

Weld County, CO 

24580 ....... Green Bay, WI .................................................................................................................................................................. 0.9727 

Brown County, WI 

Kewaunee County, WI 

Oconto County, WI 

24660 ....... Greensboro-High Point, NC .............................................................................................................................................. 0.9010 

Guilford County, NC 

Randolph County, NC 

Rockingham County, NC 

24780 ....... Greenville, NC ................................................................................................................................................................... 0.9402 

Greene County, NC 

Pitt County, NC 

24860 ....... Greenville-Mauldin-Easley, SC ......................................................................................................................................... 0.9860 

Greenville County, SC 

Laurens County, SC 

Pickens County, SC 

25020 ....... Guayama, PR .................................................................................................................................................................... 0.3064 

Arroyo Municipio, PR 

Guayama Municipio, PR 

Patillas Municipio, PR 

25060 ....... Gulfport-Biloxi, MS ............................................................................................................................................................ 0.8773 

Hancock County, MS 

Harrison County, MS 

Stone County, MS 

25180 ....... Hagerstown-Martinsburg, MD-WV .................................................................................................................................... 0.9013 

Washington County, MD 

Berkeley County, WV 

Morgan County, WV 

25260 ....... Hanford-Corcoran, CA ...................................................................................................................................................... 1.0499 

Kings County, CA 

25420 ....... Harrisburg-Carlisle, PA ..................................................................................................................................................... 0.9280 

Cumberland County, PA 

Dauphin County, PA 

Perry County, PA 

25500 ....... Harrisonburg, VA ............................................................................................................................................................... 0.8867 

Rockingham County, VA 

Harrisonburg City, VA 

25540 ....... Hartford-West Hartford-East Hartford, CT ........................................................................................................................ 1.0959 

Hartford County, CT 

Middlesex County, CT 

Tolland County, CT 

25620 ....... Hattiesburg, MS ................................................................................................................................................................ 0.7366 

Forrest County, MS 

Lamar County, MS 

Perry County, MS 

25860 ....... Hickory-Lenoir-Morganton, NC ......................................................................................................................................... 0.9028 

Alexander County, NC 

Burke County, NC 

Caldwell County, NC 

Catawba County, NC 

25980 ....... Hinesville-Fort Stewart, GA1 ............................................................................................................................................. 0.9187 

Liberty County, GA 

Long County, GA 

26100 ....... Holland-Grand Haven, MI ................................................................................................................................................. 0.9006 

Ottawa County, MI 

26180 ....... Honolulu, HI ...................................................................................................................................................................... 1.1556 

Honolulu County, HI 

26300 ....... Hot Springs, AR ................................................................................................................................................................ 0.9109 

Garland County, AR 

26380 ....... Houma-Bayou Cane-Thibodaux, LA ................................................................................................................................. 0.7892 

Lafourche Parish, LA 

Terrebonne Parish, LA 

26420 ....... Houston-Sugar Land-Baytown, TX ................................................................................................................................... 0.9939 

Austin County, TX 


pwalker on PROD1PC71 with RULES2
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46401 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

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 ...................................................................................................................................... 0.9041 

Boyd County, KY 

Greenup County, KY 

Lawrence County, OH 

Cabell County, WV 

Wayne County, WV 

26620 ....... Huntsville, AL .................................................................................................................................................................... 0.9146 

Limestone County, AL 

Madison County, AL 

26820 ....... Idaho Falls, ID ................................................................................................................................................................... 0.9264 

Bonneville County, ID 

Jefferson County, ID 

26900 ....... Indianapolis-Carmel, IN ..................................................................................................................................................... 0.9844 

Boone County, IN 

Brown County, IN 

Hamilton County, IN 

Hancock County, IN 

Hendricks County, IN 

Johnson County, IN 

Marion County, IN 

Morgan County, IN 

Putnam County, IN 

Shelby County, IN 

26980 ....... Iowa City, IA ...................................................................................................................................................................... 0.9568 

Johnson County, IA 

Washington County, IA 

27060 ....... Ithaca, NY ......................................................................................................................................................................... 0.9630 

Tompkins County, NY 

27100 ....... Jackson, MI ....................................................................................................................................................................... 0.9329 

Jackson County, MI 

27140 ....... Jackson, MS ...................................................................................................................................................................... 0.8011 

Copiah County, MS 

Hinds County, MS 

Madison County, MS 

Rankin County, MS 

Simpson County, MS 

27180 ....... Jackson, TN ...................................................................................................................................................................... 0.8676 

Chester County, TN 

Madison County, TN 

27260 ....... Jacksonville, FL ................................................................................................................................................................. 0.9021 

Baker County, FL 

Clay County, FL 

Duval County, FL 

Nassau County, FL 

St. Johns County, FL 

27340 ....... Jacksonville, NC ................................................................................................................................................................ 0.8079 

Onslow County, NC 

27500 ....... Janesville, WI .................................................................................................................................................................... 0.9702 

Rock County, WI 

27620 ....... Jefferson City, MO ............................................................................................................................................................ 0.8478 

Callaway County, MO 

Cole County, MO 

Moniteau County, MO 

Osage County, MO 

27740 ....... Johnson City, TN .............................................................................................................................................................. 0.7677 

Carter County, TN 

Unicoi County, TN 

Washington County, TN 

27780 ....... Johnstown, PA .................................................................................................................................................................. 0.7543 

Cambria County, PA 

27860 ....... Jonesboro, AR .................................................................................................................................................................. 0.7790 

Craighead County, AR 


pwalker on PROD1PC71 with RULES2
46402 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Poinsett County, AR 

27900 ....... Joplin, MO ......................................................................................................................................................................... 0.8951 

Jasper County, MO 

Newton County, MO 

28020 ....... Kalamazoo-Portage, MI .................................................................................................................................................... 1.0433 

Kalamazoo County, MI 

Van Buren County, MI 

28100 ....... Kankakee-Bradley, IL ........................................................................................................................................................ 1.0238 

Kankakee County, IL 

28140 ....... Kansas City, MO-KS ......................................................................................................................................................... 0.9504 

Franklin County, KS 

Johnson County, KS 

Leavenworth County, KS 

Linn County, KS 

Miami County, KS 

Wyandotte County, KS 

Bates County, MO 

Caldwell County, MO 

Cass County, MO 

Clay County, MO 

Clinton County, MO 

Jackson County, MO 

Lafayette County, MO 

Platte County, MO 

Ray County, MO 

28420 ....... Kennewick-Richland-Pasco, WA ....................................................................................................................................... 1.0075 

Benton County, WA 

Franklin County, WA 

28660 ....... Killeen-Temple-Fort Hood, TX .......................................................................................................................................... 0.8249 

Bell County, TX 

Coryell County, TX 

Lampasas County, TX 

28700 ....... Kingsport-Bristol-Bristol, TN-VA ........................................................................................................................................ 0.7658 

Hawkins County, TN 

Sullivan County, TN 

Bristol City, VA 

Scott County, VA 

Washington County, VA 

28740 ....... Kingston, NY ..................................................................................................................................................................... 0.9556 

Ulster County, NY 

28940 ....... Knoxville, TN ..................................................................................................................................................................... 0.8036 

Anderson County, TN 

Blount County, TN 

Knox County, TN 

Loudon County, TN 

Union County, TN 

29020 ....... Kokomo, IN ....................................................................................................................................................................... 0.9591 

Howard County, IN 

Tipton County, IN 

29100 ....... La Crosse, WI-MN ............................................................................................................................................................ 0.9685 

Houston County, MN 

La Crosse County, WI 

29140 ....... Lafayette, IN ...................................................................................................................................................................... 0.8869 

Benton County, IN 

Carroll County, IN 

Tippecanoe County, IN 

29180 ....... Lafayette, LA ..................................................................................................................................................................... 0.8247 

Lafayette Parish, LA 

St. Martin Parish, LA 

29340 ....... Lake Charles, LA .............................................................................................................................................................. 0.7777 

Calcasieu Parish, LA 

Cameron Parish, LA 

29404 ....... Lake County-Kenosha County, IL-WI ............................................................................................................................... 1.0603 

Lake County, IL 

Kenosha County, WI 

29420 ....... Lake Havasu City-Kingman, AZ ........................................................................................................................................ 0.9333 

Mohave County, AZ 

29460 ....... Lakeland, FL ..................................................................................................................................................................... 0.8661 

Polk County, FL 

29540 ....... Lancaster, PA .................................................................................................................................................................... 0.9252 

Lancaster County, PA 


pwalker on PROD1PC71 with RULES2
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46403 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

29620 ....... Lansing-East Lansing, MI ................................................................................................................................................. 1.0119 

Clinton County, MI 

Eaton County, MI 

Ingham County, MI 

29700 ....... Laredo, TX ........................................................................................................................................................................ 0.8093 

Webb County, TX 

29740 ....... Las Cruces, NM ................................................................................................................................................................ 0.8676 

Dona Ana County, NM 

29820 ....... Las Vegas-Paradise, NV ................................................................................................................................................... 1.1799 

Clark County, NV 

29940 ....... Lawrence, KS .................................................................................................................................................................... 0.8227 

Douglas County, KS 

30020 ....... Lawton, OK ....................................................................................................................................................................... 0.8025 

Comanche County, OK 

30140 ....... Lebanon, PA ..................................................................................................................................................................... 0.8192 

Lebanon County, PA 

30300 ....... Lewiston, ID-WA ............................................................................................................................................................... 0.9454 

Nez Perce County, ID 

Asotin County, WA 

30340 ....... Lewiston-Auburn, ME ........................................................................................................................................................ 0.9193 

Androscoggin County, ME 

30460 ....... Lexington-Fayette, KY ....................................................................................................................................................... 0.9191 

Bourbon County, KY 

Clark County, KY 

Fayette County, KY 

Jessamine County, KY 

Scott County, KY 

Woodford County, KY 

30620 ....... Lima, OH ........................................................................................................................................................................... 0.9424 

Allen County, OH 

30700 ....... Lincoln, NE ........................................................................................................................................................................ 1.0051 

Lancaster County, NE 

Seward County, NE 

30780 ....... Little Rock-North Little Rock-Conway, AR ........................................................................................................................ 0.8863 

Faulkner County, AR 

Grant County, AR 

Lonoke County, AR 

Perry County, AR 

Pulaski County, AR 

Saline County, AR 

30860 ....... Logan, UT-ID ..................................................................................................................................................................... 0.9183 

Franklin County, ID 

Cache County, UT 

30980 ....... Longview, TX .................................................................................................................................................................... 0.8717 

Gregg County, TX 

Rusk County, TX 

Upshur County, TX 

31020 ....... Longview, WA ................................................................................................................................................................... 1.0827 

Cowlitz County, WA 

31084 ....... Los Angeles-Long Beach-Santa Ana, CA ........................................................................................................................ 1.1771 

Los Angeles County, CA 

31140 ....... Louisville-Jefferson County, KY-IN ................................................................................................................................... 0.9065 

Clark County, IN 

Floyd County, IN 

Harrison County, IN 

Washington County, IN 

Bullitt County, KY 

Henry County, KY 

Meade County, KY 

Nelson County, KY 

Oldham County, KY 

Shelby County, KY 

Spencer County, KY 

Trimble County, KY 

31180 ....... Lubbock, TX ...................................................................................................................................................................... 0.8680 

Crosby County, TX 

Lubbock County, TX 

31340 ....... Lynchburg, VA ................................................................................................................................................................... 0.8732 

Amherst County, VA 

Appomattox County, VA 

Bedford County, VA 


pwalker on PROD1PC71 with RULES2
46404 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Campbell County, VA 

Bedford City, VA 

Lynchburg City, VA 

31420 ....... Macon, GA ........................................................................................................................................................................ 0.9541 

Bibb County, GA 

Crawford County, GA 

Jones County, GA 

Monroe County, GA 

Twiggs County, GA 

31460 ....... Madera, CA ....................................................................................................................................................................... 0.8069 

Madera County, CA 

31540 ....... Madison, WI ...................................................................................................................................................................... 1.0935 

Columbia County, WI 

Dane County, WI 

Iowa County, WI 

31700 ....... Manchester-Nashua, NH ................................................................................................................................................... 1.0273 

Hillsborough County, NH 

31900 ....... Mansfield, OH 1 ................................................................................................................................................................. 0.9271 

Richland County, OH 

32420 ....... Mayagu ̈ez, PR ................................................................................................................................................................... 0.3711 

Hormigueros Municipio, PR 

Mayagu ̈ez Municipio, PR 

32580 ....... McAllen-Edinburg-Mission, TX .......................................................................................................................................... 0.9123 

Hidalgo County, TX 

32780 ....... Medford, OR ...................................................................................................................................................................... 1.0318 

Jackson County, OR 

32820 ....... Memphis, TN-MS-AR ........................................................................................................................................................ 0.9250 

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 ....................................................................................................................................................................... 1.2120 

Merced County, CA 

33124 ....... Miami-Miami Beach-Kendall, FL ....................................................................................................................................... 1.0002 

Miami-Dade County, FL 

33140 ....... Michigan City-La Porte, IN ................................................................................................................................................ 0.8914 

LaPorte County, IN 

33260 ....... Midland, TX ....................................................................................................................................................................... 1.0017 

Midland County, TX 

33340 ....... Milwaukee-Waukesha-West Allis, WI ................................................................................................................................ 1.0214 

Milwaukee County, WI 

Ozaukee County, WI 

Washington County, WI 

Waukesha County, WI 

33460 ....... Minneapolis-St. Paul—Bloomington, MN-WI .................................................................................................................... 1.1093 

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 ..................................................................................................................................................................... 0.8953 

Missoula County, MT 

33660 ....... Mobile, AL ......................................................................................................................................................................... 0.8033 

Mobile County, AL 

33700 ....... Modesto, CA ..................................................................................................................................................................... 1.1962 

Stanislaus County, CA 

33740 ....... Monroe, LA ........................................................................................................................................................................ 0.7832 

Ouachita Parish, LA 

Union Parish, LA 


pwalker on PROD1PC71 with RULES2
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46405 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

33780 ....... Monroe, MI ........................................................................................................................................................................ 0.9414 

Monroe County, MI 

33860 ....... Montgomery, AL ................................................................................................................................................................ 0.8088 

Autauga County, AL 

Elmore County, AL 

Lowndes County, AL 

Montgomery County, AL 

34060 ....... Morgantown, WV ............................................................................................................................................................... 0.8321 

Monongalia County, WV 

Preston County, WV 

34100 ....... Morristown, TN .................................................................................................................................................................. 0.7388 

Grainger County, TN 

Hamblen County, TN 

Jefferson County, TN 

34580 ....... Mount Vernon-Anacortes, WA .......................................................................................................................................... 1.0529 

Skagit County, WA 

34620 ....... Muncie, IN ......................................................................................................................................................................... 0.8214 

Delaware County, IN 

34740 ....... Muskegon-Norton Shores, MI ........................................................................................................................................... 0.9836 

Muskegon County, MI 

34820 ....... Myrtle Beach-Conway-North Myrtle Beach, SC ................................................................................................................ 0.8634 

Horry County, SC 

34900 ....... Napa, CA ........................................................................................................................................................................... 1.4476 

Napa County, CA 

34940 ....... Naples-Marco Island, FL ................................................................................................................................................... 0.9487 

Collier County, FL 

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

Cannon County, TN 

Cheatham County, TN 

Davidson County, TN 

Dickson County, TN 

Hickman County, TN 

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 ........................................................................................................................................................... 1.2640 

Nassau County, NY 

Suffolk County, NY 

35084 ....... Newark-Union, NJ-PA ....................................................................................................................................................... 1.1862 

Essex County, NJ 

Hunterdon County, NJ 

Morris County, NJ 

Sussex County, NJ 

Union County, NJ 

Pike County, PA 

35300 ....... New Haven-Milford, CT ..................................................................................................................................................... 1.1871 

New Haven County, CT 

35380 ....... New Orleans-Metairie-Kenner, LA .................................................................................................................................... 0.8897 

Jefferson Parish, LA 

Orleans Parish, LA 

Plaquemines Parish, LA 

St. Bernard Parish, LA 

St. Charles Parish, LA 

St. John the Baptist Parish, LA 

St. Tammany Parish, LA 

35644 ....... New York-White Plains-Wayne, NY-NJ ............................................................................................................................ 1.3115 

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 


pwalker on PROD1PC71 with RULES2
46406 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Westchester County, NY 

35660 ....... Niles-Benton Harbor, MI ................................................................................................................................................... 0.9141 

Berrien County, MI 

35980 ....... Norwich-New London, CT ................................................................................................................................................. 1.1432 

New London County, CT 

36084 ....... Oakland-Fremont-Hayward, CA ........................................................................................................................................ 1.5685 

Alameda County, CA 

Contra Costa County, CA 

36100 ....... Ocala, FL ........................................................................................................................................................................... 0.8627 

Marion County, FL 

36140 ....... Ocean City, NJ .................................................................................................................................................................. 1.0988 

Cape May County, NJ 

36220 ....... Odessa, TX ....................................................................................................................................................................... 1.0042 

Ector County, TX 

36260 ....... Ogden-Clearfield, UT ........................................................................................................................................................ 0.9000 

Davis County, UT 

Morgan County, UT 

Weber County, UT 

36420 ....... Oklahoma City, OK ........................................................................................................................................................... 0.8815 

Canadian County, OK 

Cleveland County, OK 

Grady County, OK 

Lincoln County, OK 

Logan County, OK 

McClain County, OK 

Oklahoma County, OK 

36500 ....... Olympia, WA ..................................................................................................................................................................... 1.1512 

Thurston County, WA 

36540 ....... Omaha-Council Bluffs, NE-IA ........................................................................................................................................... 0.9561 

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-Kissimmee, FL .................................................................................................................................................... 0.9226 

Lake County, FL 

Orange County, FL 

Osceola County, FL 

Seminole County, FL 

36780 ....... Oshkosh-Neenah, WI ........................................................................................................................................................ 0.9551 

Winnebago County, WI 

36980 ....... Owensboro, KY ................................................................................................................................................................. 0.8652 

Daviess County, KY 

Hancock County, KY 

McLean County, KY 

37100 ....... Oxnard-Thousand Oaks-Ventura, CA ............................................................................................................................... 1.1852 

Ventura County, CA 

37340 ....... Palm Bay-Melbourne-Titusville, FL ................................................................................................................................... 0.9325 

Brevard County, FL 

37380 ....... Palm Coast, FL ................................................................................................................................................................. 0.8945 

Flagler County, FL 

37460 ....... Panama City-Lynn Haven, FL ........................................................................................................................................... 0.8313 

Bay County, FL 

37620 ....... Parkersburg-Marietta-Vienna, WV-OH .............................................................................................................................. 0.8105 

Washington County, OH 

Pleasants County, WV 

Wirt County, WV 

Wood County, WV 

37700 ....... Pascagoula, MS ................................................................................................................................................................ 0.8647 

George County, MS 

Jackson County, MS 

37764 ....... Peabody, MA ..................................................................................................................................................................... 1.0650 

Essex County, MA 

37860 ....... Pensacola-Ferry Pass-Brent, FL ....................................................................................................................................... 0.8281 

Escambia County, FL 

Santa Rosa County, FL 

37900 ....... Peoria, IL ........................................................................................................................................................................... 0.9299 

Marshall County, IL 


pwalker on PROD1PC71 with RULES2
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46407 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Peoria County, IL 

Stark County, IL 

Tazewell County, IL 

Woodford County, IL 

37964 ....... Philadelphia, PA ................................................................................................................................................................ 1.0925 

Bucks County, PA 

Chester County, PA 

Delaware County, PA 

Montgomery County, PA 

Philadelphia County, PA 

38060 ....... Phoenix-Mesa-Scottsdale, AZ ........................................................................................................................................... 1.0264 

Maricopa County, AZ 

Pinal County, AZ 

38220 ....... Pine Bluff, AR .................................................................................................................................................................... 0.7839 

Cleveland County, AR 

Jefferson County, AR 

Lincoln County, AR 

38300 ....... Pittsburgh, PA ................................................................................................................................................................... 0.8525 

Allegheny County, PA 

Armstrong County, PA 

Beaver County, PA 

Butler County, PA 

Fayette County, PA 

Washington County, PA 

Westmoreland County, PA 

38340 ....... Pittsfield, MA ..................................................................................................................................................................... 1.0091 

Berkshire County, MA 

38540 ....... Pocatello, ID ...................................................................................................................................................................... 0.9465 

Bannock County, ID 

Power County, ID 

38660 ....... Ponce, PR ......................................................................................................................................................................... 0.4450 

Juana Dı ́az Municipio, PR 

Ponce Municipio, PR 

Villalba Municipio, PR 

38860 ....... Portland-South Portland-Biddeford, ME ............................................................................................................................ 1.0042 

Cumberland County, ME 

Sagadahoc County, ME 

York County, ME 

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

Clackamas County, OR 

Columbia County, OR 

Multnomah County, OR 

Washington County, OR 

Yamhill County, OR 

Clark County, WA 

Skamania County, WA 

38940 ....... Port St. Lucie, FL .............................................................................................................................................................. 1.0016 

Martin County, FL 

St. Lucie County, FL 

39100 ....... Poughkeepsie-Newburgh-Middletown, NY ........................................................................................................................ 1.0982 

Dutchess County, NY 

Orange County, NY 

39140 ....... Prescott, AZ ...................................................................................................................................................................... 1.0020 

Yavapai County, AZ 

39300 ....... Providence-New Bedford-Fall River, RI-MA ..................................................................................................................... 1.0574 

Bristol County, MA 

Bristol County, RI 

Kent County, RI 

Newport County, RI 

Providence County, RI 

Washington County, RI 

39340 ....... Provo-Orem, UT ................................................................................................................................................................ 0.9557 

Juab County, UT 

Utah County, UT 

39380 ....... Pueblo, CO ........................................................................................................................................................................ 0.8851 

Pueblo County, CO 

39460 ....... Punta Gorda, FL ............................................................................................................................................................... 0.9254 

Charlotte County, FL 

39540 ....... Racine, WI ......................................................................................................................................................................... 0.9498 

Racine County, WI 

39580 ....... Raleigh-Cary, NC .............................................................................................................................................................. 0.9839 


pwalker on PROD1PC71 with RULES2
46408 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Franklin County, NC 

Johnston County, NC 

Wake County, NC 

39660 ....... Rapid City, SD .................................................................................................................................................................. 0.8811 

Meade County, SD 

Pennington County, SD 

39740 ....... Reading, PA ...................................................................................................................................................................... 0.9356 

Berks County, PA 

39820 ....... Redding, CA ...................................................................................................................................................................... 1.3541 

Shasta County, CA 

39900 ....... Reno-Sparks, NV .............................................................................................................................................................. 1.0715 

Storey County, NV 

Washoe County, NV 

40060 ....... Richmond, VA ................................................................................................................................................................... 0.9425 

Amelia County, VA 

Caroline County, VA 

Charles City County, VA 

Chesterfield County, VA 

Cumberland County, VA 

Dinwiddie County, VA 

Goochland County, VA 

Hanover County, VA 

Henrico County, VA 

King and Queen County, VA 

King William County, VA 

Louisa County, VA 

New Kent County, VA 

Powhatan County, VA 

Prince George County, VA 

Sussex County, VA 

Colonial Heights City, VA 

Hopewell City, VA 

Petersburg City, VA 

Richmond City, VA 

40140 ....... Riverside-San Bernardino-Ontario, CA ............................................................................................................................. 1.1100 

Riverside County, CA 

San Bernardino County, CA 

40220 ....... Roanoke, VA ..................................................................................................................................................................... 0.8691 

Botetourt County, VA 

Craig County, VA 

Franklin County, VA 

Roanoke County, VA 

Roanoke City, VA 

Salem City, VA 

40340 ....... Rochester, MN .................................................................................................................................................................. 1.0755 

Dodge County, MN 

Olmsted County, MN 

Wabasha County, MN 

40380 ....... Rochester, NY ................................................................................................................................................................... 0.8858 

Livingston County, NY 

Monroe County, NY 

Ontario County, NY 

Orleans County, NY 

Wayne County, NY 

40420 ....... Rockford, IL ....................................................................................................................................................................... 0.9814 

Boone County, IL 

Winnebago County, IL 

40484 ....... Rockingham County, NH .................................................................................................................................................. 1.0111 

Rockingham County, NH 

Strafford County, NH 

40580 ....... Rocky Mount, NC .............................................................................................................................................................. 0.9001 

Edgecombe County, NC 

Nash County, NC 

40660 ....... Rome, GA ......................................................................................................................................................................... 0.9042 

Floyd County, GA 

40900 ....... Sacramento—Arden-Arcade—Roseville, CA .................................................................................................................... 1.3505 

El Dorado County, CA 

Placer County, CA 

Sacramento County, CA 

Yolo County, CA 

40980 ....... Saginaw-Saginaw Township North, MI ............................................................................................................................. 0.8812 


pwalker on PROD1PC71 with RULES2
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46409 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Saginaw County, MI 

41060 ....... St. Cloud, MN .................................................................................................................................................................... 1.0549 

Benton County, MN 

Stearns County, MN 

41100 ....... St. George, UT .................................................................................................................................................................. 0.9358 

Washington County, UT 

41140 ....... St. Joseph, MO-KS ........................................................................................................................................................... 0.8762 

Doniphan County, KS 

Andrew County, MO 

Buchanan County, MO 

DeKalb County, MO 

41180 ....... St. Louis, MO-IL ................................................................................................................................................................ 0.9024 

Bond County, IL 

Calhoun County, IL 

Clinton County, IL 

Jersey County, IL 

Macoupin County, IL 

Madison County, IL 

Monroe County, IL 

St. Clair County, IL 

Crawford County, MO 

Franklin County, MO 

Jefferson County, MO 

Lincoln County, MO 

St. Charles County, MO 

St. Louis County, MO 

Warren County, MO 

Washington County, MO 

St. Louis City, MO 

41420 ....... Salem, OR ......................................................................................................................................................................... 1.0572 

Marion County, OR 

Polk County, OR 

41500 ....... Salinas, CA ....................................................................................................................................................................... 1.4775 

Monterey County, CA 

41540 ....... Salisbury, MD .................................................................................................................................................................... 0.8994 

Somerset County, MD 

Wicomico County, MD 

41620 ....... Salt Lake City, UT ............................................................................................................................................................. 0.9399 

Salt Lake County, UT 

Summit County, UT 

Tooele County, UT 

41660 ....... San Angelo, TX ................................................................................................................................................................. 0.8579 

Irion County, TX 

Tom Green County, TX 

41700 ....... San Antonio, TX ................................................................................................................................................................ 0.8834 

Atascosa County, TX 

Bandera County, TX 

Bexar County, TX 

Comal County, TX 

Guadalupe County, TX 

Kendall County, TX 

Medina County, TX 

Wilson County, TX 

41740 ....... San Diego-Carlsbad-San Marcos, CA .............................................................................................................................. 1.1492 

San Diego County, CA 

41780 ....... Sandusky, OH ................................................................................................................................................................... 0.8822 

Erie County, OH 

41884 ....... San Francisco-San Mateo-Redwood City, CA .................................................................................................................. 1.5195 

Marin County, CA 

San Francisco County, CA 

San Mateo County, CA 

41900 ....... San Germa ́n-Cabo Rojo, PR ............................................................................................................................................ 0.4729 

Cabo Rojo Municipio, PR 

Lajas Municipio, PR 

Sabana Grande Municipio, PR 

San Germa ́n Municipio, PR 

41940 ....... San Jose-Sunnyvale-Santa Clara, CA .............................................................................................................................. 1.5735 

San Benito County, CA 

Santa Clara County, CA 

41980 ....... San Juan-Caguas-Guaynabo, PR .................................................................................................................................... 0.4528 

Aguas Buenas Municipio, PR 


pwalker on PROD1PC71 with RULES2
46410 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Aibonito Municipio, PR 

Arecibo Municipio, PR 

Barceloneta Municipio, PR 

Barranquitas Municipio, PR 

Bayamo ́n Municipio, PR 

Caguas Municipio, PR 

Camuy Municipio, PR 

Cano ́vanas Municipio, PR 

Carolina Municipio, PR 

Catan ̃o Municipio, PR 

Cayey Municipio, PR 

Ciales Municipio, PR 

Cidra Municipio, PR 

Comer ́ıo Municipio, PR 

Corozal Municipio, PR 

Dorado Municipio, PR 

Florida Municipio, PR 

Guaynabo Municipio, PR 

Gurabo Municipio, PR 

Hatillo Municipio, PR 

Humacao Municipio, PR 

Juncos Municipio, PR 

Las Piedras Municipio, PR 

Lo ́ıza Municipio, PR 

Manat ́ı Municipio, PR 

Maunabo Municipio, PR 

Morovis Municipio, PR 

Naguabo Municipio, PR 

Naranjito Municipio, PR 

Orocovis Municipio, PR 

Quebradillas Municipio, PR 

R ́ıo Grande Municipio, PR 

San Juan Municipio, PR 

San Lorenzo Municipio, PR 

Toa Alta Municipio, PR 

Toa Baja Municipio, PR 

Trujillo Alto Municipio, PR 

Vega Alta Municipio, PR 

Vega Baja Municipio, PR 

Yabucoa Municipio, PR 

42020 ....... San Luis Obispo-Paso Robles, CA ................................................................................................................................... 1.2488 

San Luis Obispo County, CA 

42044 ....... Santa Ana-Anaheim-Irvine, CA ......................................................................................................................................... 1.1766 

Orange County, CA 

42060 ....... Santa Barbara-Santa Maria-Goleta, CA ........................................................................................................................... 1.1714 

Santa Barbara County, CA 

42100 ....... Santa Cruz-Watsonville, CA ............................................................................................................................................. 1.6122 

Santa Cruz County, CA 

42140 ....... Santa Fe, NM .................................................................................................................................................................... 1.0734 

Santa Fe County, NM 

42220 ....... Santa Rosa-Petaluma, CA ................................................................................................................................................ 1.4696 

Sonoma County, CA 

42260 ....... Sarasota-Bradenton-Venice, FL ........................................................................................................................................ 0.9933 

Manatee County, FL 

Sarasota County, FL 

42340 ....... Savannah, GA ................................................................................................................................................................... 0.9131 

Bryan County, GA 

Chatham County, GA 

Effingham County, GA 

42540 ....... Scranton—Wilkes-Barre, PA ............................................................................................................................................. 0.8457 

Lackawanna County, PA 

Luzerne County, PA 

Wyoming County, PA 

42644 ....... Seattle-Bellevue-Everett, WA ............................................................................................................................................ 1.1572 

King County, WA 

Snohomish County, WA 

42680 ....... Sebastian-Vero Beach, FL ................................................................................................................................................ 0.9412 

Indian River County, FL 

43100 ....... Sheboygan, WI .................................................................................................................................................................. 0.8975 

Sheboygan County, WI 

43300 ....... Sherman-Denison, TX ....................................................................................................................................................... 0.8320 


pwalker on PROD1PC71 with RULES2
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46411 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Grayson County, TX 

43340 ....... Shreveport-Bossier City, LA .............................................................................................................................................. 0.8476 

Bossier Parish, LA 

Caddo Parish, LA 

De Soto Parish, LA 

43580 ....... Sioux City, IA-NE-SD ........................................................................................................................................................ 0.9251 

Woodbury County, IA 

Dakota County, NE 

Dixon County, NE 

Union County, SD 

43620 ....... Sioux Falls, SD ................................................................................................................................................................. 0.9563 

Lincoln County, SD 

McCook County, SD 

Minnehaha County, SD 

Turner County, SD 

43780 ....... South Bend-Mishawaka, IN-MI ......................................................................................................................................... 0.9617 

St. Joseph County, IN 

Cass County, MI 

43900 ....... Spartanburg, SC ............................................................................................................................................................... 0.9422 

Spartanburg County, SC 

44060 ....... Spokane, WA .................................................................................................................................................................... 1.0455 

Spokane County, WA 

44100 ....... Springfield, IL .................................................................................................................................................................... 0.8944 

Menard County, IL 

Sangamon County, IL 

44140 ....... Springfield, MA .................................................................................................................................................................. 1.0366 

Franklin County, MA 

Hampden County, MA 

Hampshire County, MA 

44180 ....... Springfield, MO ................................................................................................................................................................. 0.8695 

Christian County, MO 

Dallas County, MO 

Greene County, MO 

Polk County, MO 

Webster County, MO 

44220 ....... Springfield, OH .................................................................................................................................................................. 0.8694 

Clark County, OH 

44300 ....... State College, PA .............................................................................................................................................................. 0.8768 

Centre County, PA 

44700 ....... Stockton, CA ..................................................................................................................................................................... 1.1855 

San Joaquin County, CA 

44940 ....... Sumter, SC ........................................................................................................................................................................ 0.8599 

Sumter County, SC 

45060 ....... Syracuse, NY .................................................................................................................................................................... 0.9910 

Madison County, NY 

Onondaga County, NY 

Oswego County, NY 

45104 ....... Tacoma, WA ..................................................................................................................................................................... 1.1055 

Pierce County, WA 

45220 ....... Tallahassee, FL ................................................................................................................................................................. 0.9025 

Gadsden County, FL 

Jefferson County, FL 

Leon County, FL 

Wakulla County, FL 

45300 ....... Tampa-St. Petersburg-Clearwater, FL .............................................................................................................................. 0.9020 

Hernando County, FL 

Hillsborough County, FL 

Pasco County, FL 

Pinellas County, FL 

45460 ....... Terre Haute, IN ................................................................................................................................................................. 0.8805 

Clay County, IN 

Sullivan County, IN 

Vermillion County, IN 

Vigo County, IN 

45500 ....... Texarkana, TX-Texarkana, AR ......................................................................................................................................... 0.7770 

Miller County, AR 

Bowie County, TX 

45780 ....... Toledo, OH ........................................................................................................................................................................ 0.9431 

Fulton County, OH 

Lucas County, OH 

Ottawa County, OH 


pwalker on PROD1PC71 with RULES2
46412 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

Wood County, OH 

45820 ....... Topeka, KS ....................................................................................................................................................................... 0.8538 

Jackson County, KS 

Jefferson County, KS 

Osage County, KS 

Shawnee County, KS 

Wabaunsee County, KS 

45940 ....... Trenton-Ewing, NJ ............................................................................................................................................................ 1.0699 

Mercer County, NJ 

46060 ....... Tucson, AZ ........................................................................................................................................................................ 0.9245 

Pima County, AZ 

46140 ....... Tulsa, OK .......................................................................................................................................................................... 0.8340 

Creek County, OK 

Okmulgee County, OK 

Osage County, OK 

Pawnee County, OK 

Rogers County, OK 

Tulsa County, OK 

Wagoner County, OK 

46220 ....... Tuscaloosa, AL ................................................................................................................................................................. 0.8303 

Greene County, AL 

Hale County, AL 

Tuscaloosa County, AL 

46340 ....... Tyler, TX ............................................................................................................................................................................ 0.9114 

Smith County, TX 

46540 ....... Utica-Rome, NY ................................................................................................................................................................ 0.8486 

Herkimer County, NY 

Oneida County, NY 

46660 ....... Valdosta, GA ..................................................................................................................................................................... 0.8098 

Brooks County, GA 

Echols County, GA 

Lanier County, GA 

Lowndes County, GA 

46700 ....... Vallejo-Fairfield, CA .......................................................................................................................................................... 1.4666 

Solano County, CA 

47020 ....... Victoria, TX ........................................................................................................................................................................ 0.8302 

Calhoun County, TX 

Goliad County, TX 

Victoria County, TX 

47220 ....... Vineland-Millville-Bridgeton, NJ ........................................................................................................................................ 1.0133 

Cumberland County, NJ 

47260 ....... Virginia Beach-Norfolk-Newport News, VA-NC ................................................................................................................ 0.8818 

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 ....................................................................................................................................................... 1.0091 

Tulare County, CA 

47380 ....... Waco, TX .......................................................................................................................................................................... 0.8518 

McLennan County, TX 

47580 ....... Warner Robins, GA ........................................................................................................................................................... 0.9128 

Houston County, GA 

47644 ....... Warren-Troy-Farmington Hills, MI ..................................................................................................................................... 1.0001 

Lapeer County, MI 

Livingston County, MI 

Macomb County, MI 

Oakland County, MI 

St. Clair County, MI 

47894 ....... Washington-Arlington-Alexandria, DC-VA-MD-WV ........................................................................................................... 1.0855 


pwalker on PROD1PC71 with RULES2
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46413 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

District of Columbia, DC 

Calvert County, MD 

Charles County, MD 

Prince George’s County, MD 

Arlington County, VA 

Clarke County, VA 

Fairfax County, VA 

Fauquier County, VA 

Loudoun County, VA 

Prince William County, VA 

Spotsylvania County, VA 

Stafford County, VA 

Warren County, VA 

Alexandria City, VA 

Fairfax City, VA 

Falls Church City, VA 

Fredericksburg City, VA 

Manassas City, VA 

Manassas Park City, VA 

Jefferson County, WV 

47940 ....... Waterloo-Cedar Falls, IA ................................................................................................................................................... 0.8519 

Black Hawk County, IA 

Bremer County, IA 

Grundy County, IA 

48140 ....... Wausau, WI ....................................................................................................................................................................... 0.9679 

Marathon County, WI 

48260 ....... Weirton-Steubenville, WV-OH ........................................................................................................................................... 0.7924 

Jefferson County, OH 

Brooke County, WV 

Hancock County, WV 

48300 ....... Wenatchee, WA ................................................................................................................................................................ 1.1469 

Chelan County, WA 

Douglas County, WA 

48424 ....... West Palm Beach-Boca Raton-Boynton Beach, FL ......................................................................................................... 0.9728 

Palm Beach County, FL 

48540 ....... Wheeling, WV-OH ............................................................................................................................................................. 0.6961 

Belmont County, OH 

Marshall County, WV 

Ohio County, WV 

48620 ....... Wichita, KS ........................................................................................................................................................................ 0.9062 

Butler County, KS 

Harvey County, KS 

Sedgwick County, KS 

Sumner County, KS 

48660 ....... Wichita Falls, TX ............................................................................................................................................................... 0.7920 

Archer County, TX 

Clay County, TX 

Wichita County, TX 

48700 ....... Williamsport, PA ................................................................................................................................................................ 0.8043 

Lycoming County, PA 

48864 ....... Wilmington, DE-MD-NJ ..................................................................................................................................................... 1.0824 

New Castle County, DE 

Cecil County, MD 

Salem County, NJ 

48900 ....... Wilmington, NC ................................................................................................................................................................. 0.9410 

Brunswick County, NC 

New Hanover County, NC 

Pender County, NC 

49020 ....... Winchester, VA-WV .......................................................................................................................................................... 0.9913 

Frederick County, VA 

Winchester City, VA 

Hampshire County, WV 

49180 ....... Winston-Salem, NC ........................................................................................................................................................... 0.9118 

Davie County, NC 

Forsyth County, NC 

Stokes County, NC 

Yadkin County, NC 

49340 ....... Worcester, MA .................................................................................................................................................................. 1.1287 

Worcester County, MA 

49420 ....... Yakima, WA ...................................................................................................................................................................... 1.0267 

Yakima County, WA 


pwalker on PROD1PC71 with RULES2
46414 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

TABLE 1—INPATIENT REHABILITATION FACILITY WAGE INDEX FOR URBAN AREAS FOR DISCHARGES OCCURRING FROM

OCTOBER 1, 2008 THROUGH SEPTEMBER 30, 2009—Continued 

CBSA code Urban area (constituent counties) Wage index 

49500 ....... Yauco, PR ......................................................................................................................................................................... 0.3284 

Gua ́nica Municipio, PR 

Guayanilla Municipio, PR 

Pen ̃uelas Municipio, PR 

Yauco Municipio, PR 

49620 ....... York-Hanover, PA ............................................................................................................................................................. 0.9359 

York County, PA 

49660 ....... Youngstown-Warren-Boardman, OH-PA .......................................................................................................................... 0.9002 

Mahoning County, OH 

Trumbull County, OH 

Mercer County, PA 

49700 ....... Yuba City, CA ................................................................................................................................................................... 1.0756 

Sutter County, CA 

Yuba County, CA 

49740 ....... Yuma, AZ .......................................................................................................................................................................... 0.9488 

Yuma County, AZ 

1At this time, there are no hospitals located in this urban area on which to base a wage index. 

TABLE 2—INPATIENT REHABILITATION

FACILITY WAGE INDEX FOR RURAL

AREAS FOR DISCHARGES OCCURRING FROM OCTOBER 1, 2008 

THROUGH SEPTEMBER 30, 2009 

CBSA code Nonurban area Wage index 

1 ................ Alabama ............ 0.7533 

2 ................ Alaska ................ 1.2109 

3 ................ Arizona .............. 0.8479 

4 ................ Arkansas ............ 0.7371 

5 ................ California ........... 1.2023 

6 ................ Colorado ............ 0.9704 

7 ................ Connecticut ........ 1.1119 

8 ................ Delaware ........... 0.9727 

10 .............. Florida ................ 0.8465 

11 .............. Georgia .............. 0.7659 

12 .............. Hawaii ................ 1.0612 

13 .............. Idaho .................. 0.7920 

14 .............. Illinois ................. 0.8335 

15 .............. Indiana ............... 0.8576 

16 .............. Iowa ................... 0.8566 

17 .............. Kansas ............... 0.7981 

18 .............. Kentucky ............ 0.7793 

19 .............. Louisiana ........... 0.7373 

20 .............. Maine ................. 0.8476 

21 .............. Maryland ............ 0.9034 

22 .............. Massachusetts 1 1.1589 

23 .............. Michigan ............ 0.8953 

24 .............. Minnesota .......... 0.9079 

TABLE 2—INPATIENT REHABILITATION

FACILITY WAGE INDEX FOR RURAL

AREAS FOR DISCHARGES OCCURRING FROM OCTOBER 1, 2008 

THROUGH SEPTEMBER 30, 2009—

Continued 

CBSA code Nonurban area Wage index 

25 .............. Mississippi ......... 0.7700 

26 .............. Missouri ............. 0.7930 

27 .............. Montana ............. 0.8379 

28 .............. Nebraska ........... 0.8849 

29 .............. Nevada .............. 0.9272 

30 .............. New Hampshire 0.0470 

31 .............. New Jersey 1 ..... —

32 .............. New Mexico ....... 0.8940 

33 .............. New York ........... 0.8268 

34 .............. North Carolina ... 0.8603 

35 .............. North Dakota ..... 0.7182 

36 .............. Ohio ................... 0.8714 

37 .............. Oklahoma .......... 0.7492 

38 .............. Oregon ............... 0.9906 

39 .............. Pennsylvania ..... 0.8385 

40 .............. Puerto Rico 1 ..... 0.4047 

41 .............. Rhode Island 1 ... —

42 .............. South Carolina ... 0.8656 

43 .............. South Dakota ..... 0.8549 

44 .............. Tennessee ......... 0.7723 

45 .............. Texas ................. 0.7968 

TABLE 2—INPATIENT REHABILITATION

FACILITY WAGE INDEX FOR RURAL

AREAS FOR DISCHARGES OCCURRING FROM OCTOBER 1, 2008 

THROUGH SEPTEMBER 30, 2009—

Continued 

CBSA code Nonurban area Wage index 

46 .............. Utah ................... 0.8116 

47 .............. Vermont ............. 0.9919 

48 .............. Virgin Islands ..... 0.6830 

49 .............. Virginia ............... 0.7896 

50 .............. Washington ........ 1.0259 

51 .............. West Virginia ..... 0.7454 

52 .............. Wisconsin .......... 0.9667 

53 .............. Wyoming ............ 0.9287 

65 .............. Guam ................. 0.9611 

1All counties within the State are classified 

as urban, with the exception of Massachusetts 

and Puerto Rico. Massachusetts and Puerto 

Rico have areas designated as rural; however, 

no short-term, acute care hospitals are located 

in the area(s) for FY 2009. The rural Massachusetts wage index is calculated as the average of all contiguous CBSAs. The Puerto Rico 

wage index is the same as FY 2008. 

[FR Doc. E8–17797 Filed 7–31–08; 4:15 pm] 

BILLING CODE 4120–01–P 


pwalker on PROD1PC71 with RULES2