46464 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 418 

[CMS–1548–F] 

RIN 0938–AP14 

Medicare Program; Hospice Wage 

Index for Fiscal Year 2009 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Final rule. 

SUMMARY: This final rule sets forth the 

hospice wage index for fiscal year 2009. 

In addition, this final rule finalizes the 

policy to phase out the Medicare 

hospice budget neutrality adjustment 

factor, and clarifies two wage index 

issues pertaining to the definition of 

rural and urban areas and multi-campus 

hospital facilities. 

DATES: Effective Dates: These 

regulations are effective on October 1, 

2008. 

FOR FURTHER INFORMATION CONTACT: 

Katie Lucas (410) 786–7723 or Randy 

Throndset (410) 786–0131. 

SUPPLEMENTARY INFORMATION: 

I. Background 

A. General 

1. Hospice Care 

Hospice care is an approach to 

treatment that recognizes that the 

impending death of an individual 

warrants a change in the focus from 

curative care to palliative care for relief 

of pain and for symptom management. 

The goal of hospice care is to help 

terminally ill individuals continue life 

with minimal disruption to normal 

activities while remaining primarily in 

the home environment. A hospice uses 

an interdisciplinary approach to deliver 

medical, nursing, social, psychological, 

emotional, and spiritual services 

through use of a broad spectrum of 

professional and other caregivers, with 

the goal of making the individual as 

physically and emotionally comfortable 

as possible. Counseling services and 

inpatient respite services are available 

to the family of the hospice patient. 

Hospice programs consider both the 

patient and the family as a unit of care. 

Section 1861(dd) of the Social 

Security Act (the Act) provides for 

coverage of hospice care for terminally 

ill Medicare beneficiaries who elect to 

receive care from a participating 

hospice. Section 1814(i) of the Act 

provides payment for Medicare 

participating hospices. 

2. Medicare Payment for Hospice Care 

Our regulations at 42 CFR part 418 

establish eligibility requirements, 

payment standards and procedures, 

define covered services, and delineate 

the conditions a hospice must meet to 

be approved for participation in the 

Medicare program. Part 418 subpart G 

provides for payment in one of four 

prospectively-determined rate categories 

(routine home care, continuous home 

care, inpatient respite care, and general 

inpatient care) to hospices based on 

each day a qualified Medicare 

beneficiary is under a hospice election. 

B. Hospice Wage Index 

Our regulations at § 418.306(c) require 

each hospice’s labor market to be 

established using the most current 

hospital wage data available, including 

any changes by the Office of 

Management and Budget (OMB) to the 

Metropolitan Statistical Areas (MSAs) 

definitions, which have been 

superseded by the Core Based Statistical 

Areas (CBSAs). 

The hospice wage index is used to 

adjust payment rates for hospice 

agencies under the Medicare program to 

reflect local differences in area wage 

levels. The original hospice wage index 

was based on the 1981 Bureau of Labor 

Statistics hospital data and had not been 

updated since 1983. In 1994, because of 

disparity in wages from one 

geographical location to another, the 

Hospice Wage Index Negotiated 

Rulemaking Committee was formulated 

to negotiate a wage index methodology 

to be used for updating the hospice 

wage index. This Committee, 

functioning under a process established 

by the Negotiated Rulemaking Act of 

1990, signed an agreement for the 

methodology to be used for updating the 

hospice wage index on April 13, 1995. 

On August 8, 1997, we published in 

the Federal Register a final rule (62 FR 

42860) implementing a new 

methodology for calculating the hospice 

wage index based on the 

recommendations of the negotiated 

rulemaking committee. The committee 

statement was included in the appendix 

of that final rule (62 FR 42883). 

The hospice wage index is updated 

annually. Our most recent annual 

update final rule (72 FR 50214) 

published in the Federal Register on 

August 31, 2007, set forth updates to the 

hospice wage index for fiscal year (FY) 

2008. 

1. Raw Wage Index Values (Raw PreFloor, Pre-Reclassified Hospital Wage 

Index) 

As described in the August 8, 1997 

hospice wage index final rule (62 FR 

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

as the raw wage index for the hospice 

benefit. These raw wage index values 

are then subject to either a budget 

neutrality adjustment or application of 

the hospice floor to compute the 

hospice wage index used to determine 

payments to hospices. 

Raw pre-floor, pre-reclassified 

hospital wage index values of 0.8 or 

greater are adjusted by the Budget 

Neutrality Adjustment Factor (BNAF). 

Raw pre-floor, pre-reclassified hospital 

wage index values below 0.8 are 

adjusted by the greater of: (1) The 

hospice BNAF; or (2) the hospice floor 

(which is a 15 percent increase) subject 

to a maximum wage index value of 0.8. 

The BNAF has been computed and 

applied annually to the labor portion of 

the hospice payment. Currently, the 

labor portion of the payment rates is as 

follows: for routine home care, 68.71 

percent; for continuous home care, 

68.71 percent; for general inpatient care, 

64.01 percent; and for respite care, 54.13 

percent. The non-labor portion is equal 

to 100 percent minus the labor portion 

for each level of care. 

2. Changes to Core-Based Statistical 

Area (CBSA) Designations 

The annual update to the hospice 

wage index is published in the Federal 

Register and is based on the most 

current available hospital wage data, as 

well as any changes by the OMB to the 

definitions of MSAs, which now 

include CBSA designations. 

3. Definition of Rural and Urban Areas 

Each hospice’s labor market is 

determined based on definitions of 

MSAs issued by OMB. In general, an 

urban area is defined as an MSA or New 

England County Metropolitan Area 

(NECMA) as defined by OMB. Under 42 

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

defined as any area outside of the urban 

area. The urban and rural area 

geographic classifications are defined in 

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

have been used for the Medicare 

hospice benefit since implementation. 

4. Areas Without Hospital Wage Data 

When adopting OMB’s new labor 

market designations in FY 2006, we 

identified some geographic areas where 

there were no hospitals, and no hospital 

wage index data on which to base the 

calculation of the hospice wage index. 

Beginning in FY 2006, we adopted a 


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policy to use the FY 2005 raw pre-floor, 

pre-reclassified hospital wage index 

value for rural areas when no hospital 

wage data were available. Under the 

CBSA labor market areas, there are no 

hospitals in rural locations in 

Massachusetts and Puerto Rico. We also 

adopted the policy that for urban labor 

markets without a hospital from which 

hospital wage index data could be 

derived, all of the CBSAs within the 

State would be used to calculate a 

statewide urban average raw pre-floor, 

pre-reclassified hospital wage index 

value to use as a reasonable proxy for 

these areas. The only affected CBSA is 

25980, Hinesville-Fort Stewart, Georgia. 

In the FY 2008 final rule (72 FR 

50214, 50217), in cases where there was 

a rural area without rural hospital wage 

data, we used the average raw pre-floor, 

pre-reclassified hospital wage index 

data from all contiguous CBSAs to 

represent a reasonable proxy for the 

rural area. This approach does not use 

rural data; however, the approach uses 

raw pre-floor, pre-reclassified hospital 

wage data, and is easy to evaluate, easy 

to update from year-to-year, and uses 

the most local data available. In the FY 

2008 rule (72 FR at 50217), we noted 

that in determining an imputed rural 

raw pre-floor, pre-reclassified hospital 

wage index, we interpret the term 

‘‘contiguous’’ to mean sharing a border. 

For example, in the case of 

Massachusetts, the entire rural area 

consists of Dukes and Nantucket 

counties. We determined that the 

borders of Dukes and Nantucket 

counties are contiguous with Barnstable 

and Bristol counties. Under the adopted 

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

for the counties of Barnstable (CBSA 

12700, Barnstable Town, MA) and 

Bristol (CBSA 39300, Providence-New 

Bedford-Fall River, RI-MA) were 

averaged, resulting in an imputed raw 

pre-floor, pre-reclassified rural hospital 

wage index for FY 2008. 

We also noted that we do not believe 

that this policy would be appropriate for 

Puerto Rico, as there are sufficient 

economic differences between hospitals 

in the United States and those in Puerto 

Rico, including the payment of hospitals 

in Puerto Rico using blended Federal/ 

Commonwealth-specific rates. 

Therefore, we believe that a separate 

and distinct policy for Puerto Rico is 

necessary. Any alternative methodology 

for imputing a raw pre-floor, prereclassified hospital wage index for 

rural Puerto Rico would need to take 

into account the economic differences 

between hospitals in the United States 

and those in Puerto Rico. While we have 

not yet identified an alternative 

methodology for imputing a raw prefloor, pre-reclassified hospital wage 

index for rural Puerto Rico, we will 

continue to evaluate the feasibility of 

using existing hospital wage data and, 

possibly, wage data from other sources. 

For FY 2008, we used the most recent 

raw pre-floor, pre-reclassified hospital 

wage index available for Puerto Rico, 

which is 0.4047. 

5. CBSA Nomenclature Changes 

The OMB regularly publishes a 

bulletin that updates the titles of certain 

CBSAs. In the FY 2008 final rule (72 FR 

50218), we noted that the FY 2008 rule 

and all subsequent hospice wage index 

rules and notices would incorporate 

CBSA changes from the most recent 

OMB bulletins. The OMB bulletins may 

be accessed at http:// 

www.whitehouse.gov/omb/bulletins/ 

index.html. 

6. Hospice Payment Rates 

Payment rates have been updated 

according to section 1814(i)(1)(C)(ii)(VII) 

of the Act, which states that the update 

to the payment rates for FYs since 2002 

will be the market basket percentage for 

the fiscal year. According to section 

1814(i)(1)(C) of the Act, hospices are to 

use the inpatient hospital market basket 

as a proxy for a hospice market basket. 

Historically, the rate update has been 

published through a separate 

administrative instruction issued 

annually in the summer to provide 

adequate time to implement system 

change requirements. Providers 

determine their payments by applying 

the hospice wage index in this final rule 

to the labor portion of the published 

hospice rates. 

Requirements for Issuance of 

Regulations 

Section 902 of the Medicare 

Prescription Drug, Improvement, and 

Modernization Act of 2003 (MMA) 

amended section 1871(a) of the Act and 

requires the Secretary, in consultation 

with the Director of the OMB, to 

establish and publish timelines for the 

publication of Medicare final 

regulations based on the previous 

publication of a Medicare proposed or 

interim final regulation. Section 902 of 

the MMA also states that the timelines 

for these regulations may vary but shall 

not exceed 3 years after publication of 

the preceding proposed or interim final 

regulation except under exceptional 

circumstances. 

This final rule finalizes provisions 

proposed in the May 1, 2008 proposed 

rule. In addition, this final rule has been 

published within the 3-year time limit 

imposed by section 902 of the MMA. 

Therefore, we believe that the final rule 

is in accordance with the Congress’

intent to ensure timely publication of 

final regulations. 

II. Provisions of the Proposed Rule and 

Analysis of and Responses to Public 

Comments 

On May 1, 2008, we published a 

proposed rule in the Federal Register 

(73 FR 24000) that set forth the 

proposed hospice wage index for FY 

2009. We received 540 timely items of 

correspondence. The following is a 

summary of each of the proposals 

followed by our responses to these 

public comments. 

A. Clarification of New England Deemed 

Counties 

In the May 1, 2008 proposed rule, we 

proposed to amend § 418.306(c) to 

cross-reference to the definitions of 

urban and rural in the Inpatient 

Prospective Payment System (IPPS) 

regulations in 42 CFR Part 412 subpart 

D. In that proposed rule, we addressed 

the IPPS change in the designation of 

‘‘New England deemed counties,’’

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

These counties were deemed to be part 

of urban areas under section 601(g) of 

the Social Security Amendments of 

1983. However, under the OMB 

geographic definitions, these counties 

were considered rural. In the FY 2008 

IPPS final rule, CMS adopted a change 

that resulted in these counties no longer 

being ‘‘deemed’’ urban. The counties 

include Litchfield County, Connecticut; 

York County, Maine; Sagadahoc County, 

Maine; Merrimack County, New 

Hampshire; and Newport County, 

Rhode Island. Of these five ‘‘New 

England deemed counties,’’ three (York 

County, Sagadahoc County, and 

Newport County) are included in 

metropolitan statistical areas defined by 

OMB and are therefore urban under the 

current IPPS labor market area 

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

remaining two counties, Litchfield 

County and Merrimack County, are 

geographically located in areas that are 

rural under the current IPPS labor 

market area definitions. 

In the August 22, 2007 FY 2008 IPPS 

final rule with comment period (72 FR 

47130), § 412.64(b)(1)(ii)(B) was revised 

such that the two ‘‘New England 

deemed counties’’ that are still 

considered rural under the OMB 

definitions (Litchfield County, CT and 

Merrimack County, NH) are no longer 

considered urban effective for 

discharges occurring on or after October 

1, 2007. Therefore, these two counties 

are considered rural in accordance with 

§ 412.64(b)(1)(ii)(C). However, for 


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purposes of payment under the IPPS, 

acute care hospitals located within 

those areas are treated as being 

reclassified to their deemed urban area 

effective for discharges occurring on or 

after October 1, 2007 (see 72 FR 47337 

through 47338). We also noted that this 

policy change was limited to the ‘‘New 

England deemed counties’’ IPPS 

hospitals only, and that any change to 

non-IPPS provider wage indexes would 

be addressed in the respective payment 

system rules. The hospice program does 

not provide for such geographic 

reclassification as the IPPS does. 

The recommendations to adjust 

payments to reflect local differences in 

wages are codified in § 418.306(c) of our 

regulations; however there is no explicit 

reference to § 412.64 in § 418.306(c). 

Although § 412.64 is not explicitly 

referred to, the hospice program has 

used the definition of urban in 

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

definition of rural as any area outside of 

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

proposed to explicitly refer to those 

provisions in § 412.64 to make it 

absolutely clear how we define urban 

and rural for purposes of the hospice 

wage index. We received no comments 

on this proposal and will implement it 

as proposed. 

Litchfield county, CT and Merrimack 

county, NH are considered rural areas 

for hospital IPPS purposes in 

accordance with § 412.64. Effective 

October 1, 2008, Litchfield county, CT 

will no longer be considered part of 

urban CBSA 25540 (Hartford-West 

Hartford-East Hartford, CT), and 

Merrimack county, NH will no longer be 

considered part of urban CBSA 31700 

(Manchester-Nashua, NH). Rather, these 

counties will be considered to be rural 

areas within their respective States 

under the hospice payment system. 

When the raw pre-floor, pre-reclassified 

hospital wage index was adopted for use 

in deriving the hospice wage, it was 

decided not to take into account IPPS 

geographic reclassifications. This 

proposed policy to follow OMB 

designations of rural or urban, rather 

than considering some counties to be 

‘‘deemed’’ urban, is consistent with our 

policy of not taking into account IPPS 

geographic reclassifications in 

determining payments under the 

hospice wage index. 

We received no comments on this 

proposal, and will implement it as 

proposed without change. 

B. Wage Data for Multi-Campus 

Hospitals 

Historically, under the Medicare 

hospice benefit, we have established 

hospice wage index values calculated 

from the raw pre-floor, pre-reclassified 

hospital wage data (also called the IPPS 

wage index) without taking into account 

geographic reclassification under 

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

Act. The wage adjustment established 

under the Medicare hospice benefit is 

based on the location where services are 

furnished without any reclassification. 

For FY 2009, the data collected from 

cost reports submitted by hospitals for 

cost reporting periods beginning during 

FY 2004 were used to compute the 2008 

raw pre-floor, pre-reclassified hospital 

wage index data without taking into 

account geographic reclassification 

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

the Act. This 2008 raw pre-floor, prereclassified hospital wage index was 

used to derive the applicable wage 

index values for the hospice wage index 

because these data (FY 2004) are the 

most recent complete data (for 

information on the data used to 

compute the FY 2008 IPPS wage index, 

refer to the FY 2008 IPPS final rule with 

comment period (72 FR 47308 through 

47309, 47315)). 

Beginning in FY 2008, the IPPS 

apportioned the wage data for multicampus hospitals located in different 

labor market areas (CBSAs) to each 

CBSA where the campuses are located 

(see the FY 2008 IPPS final rule with 

comment period (72 FR 47317 through 

47320)). We are continuing to use the 

raw pre-floor, pre-reclassified hospital 

wage data as a basis to determine the 

hospice wage index values for FY 2009 

because hospitals and hospices both 

compete in the same labor markets, and 

therefore, experience similar wagerelated costs. We note that the use of 

raw pre-floor, pre-reclassified hospital 

(IPPS) wage data, used to derive the FY 

2009 hospice wage index values, reflects 

the application of our policy to use that 

data to establish the hospice wage 

index. The FY 2009 hospice wage index 

values presented in this final rule were 

computed consistent with our raw prefloor, pre-reclassified hospital (IPPS) 

wage index policy (that is, our historical 

policy of not taking into account IPPS 

geographic reclassifications in 

determining payments for hospice). For 

the FY 2009 Medicare hospice benefit, 

the wage index was computed from 

IPPS wage data (submitted by hospitals 

for cost reporting periods beginning in 

FY 2004 (just like the FY 2008 IPPS 

wage index)), which allocated salaries 

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

are located in different labor areas, one 

in Massachusetts and another in Illinois. 

Thus, the FY 2009 hospice wage index 

values for the following CBSAs are 

affected by this policy: Boston-Quincy, 

MA (CBSA 14484), Providence-New 

Bedford-Falls River, RI-MA (CBSA 

39300), Chicago-Naperville-Joliet, IL 

(CBSA 16974), and Lake CountyKenosha County, IL-WI (CBSA 29404). 

We received no comments on this 

proposal, and will implement it as 

proposed without change. 

C. FY 2009 Hospice Wage Index With 

Phase Out of the Budget Neutrality 

Adjustment Factor (BNAF) 

1. Background 

The hospice final rule published in 

the Federal Register on December 16, 

1983 (48 FR 56008) provided for 

adjustment to hospice payment rates to 

reflect differences in area wage levels. 

We apply the appropriate hospice wage 

index value to the labor portion of the 

hospice payment rates based on the 

geographic area where hospice care was 

furnished. As noted earlier, each 

hospice’s labor market area is based on 

definitions of Metropolitan Statistical 

Areas (MSAs) issued by the OMB. For 

FY 2009, we proposed to use a raw prefloor, pre-reclassified hospital wage 

index based solely on the CBSA 

designations. 

As noted above, our hospice payment 

rules utilize the wage adjustment factors 

used by the Secretary for purposes of 

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

hospital wage adjustments. Again, we 

proposed to use the raw pre-floor and 

pre-reclassified hospital wage index 

data to adjust the labor portion of the 

hospice payment rates based on the 

geographic area where the beneficiary 

receives hospice care. We believe the 

use of the raw pre-floor, pre-reclassified 

hospital wage index data results in the 

appropriate adjustment to the labor 

portion of the costs. For the FY 2009 

update to hospice payment rates, we 

proposed using the most recent raw prefloor, pre-reclassified hospital wage 

index available at the time of 

publication. 

Comment: A few commenters were 

unhappy with CMS’ use of the raw prefloor, pre-reclassified hospital wage 

index as the input for the hospice wage 

index, and suggested it is flawed. Some 

commenters noted that the hospitalbased wage index has undergone 

multiple changes over the past 10 years 

and that providers were not invited to 

provide comment for CMS to consider 

when formalizing these changes. One 

commenter added that the existence of 

exceptions to the hospital wage index 

system in the form of reclassifications 

demonstrates the unfairness and 

inadequacy of the hospital-based wage 

index system. 


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Several commenters mentioned that a 

2007 MedPAC report on the hospital 

wage index suggested that CMS repeal 

the existing hospital wage index, and 

develop a new one. The commenter 

stated that MedPAC recommended that 

CMS evaluate the use of the revised 

wage index in other Medicare payment 

systems, which includes hospice. A 

commenter asked CMS to devise a 

hospice-specific reimbursement system, 

rather than using the hospital-based 

wage index. Several of these 

commenters offered to work with CMS 

in reforming the wage index, and 

recommended use of the collaborative 

negotiated rulemaking process. They 

suggested that CMS use the established 

wage index methodology, including the 

BNAF, until a viable alternative is 

found. 

In addition, a commenter wrote that 

hospices compete in the same labor 

market as hospitals for staff but 

hospitals do not use the same wage 

index, and that the wage index does not 

reflect the reality of wages in a 

healthcare community. 

Response: The raw pre-floor, prereclassified hospital wage index was 

adopted in 1998 as the wage index from 

which the hospice wage index is 

derived. The Negotiated Rulemaking 

Committee considered several wage 

index options: (1) Continuing with 

Bureau of Labor Statistics data; (2) using 

updated hospital wage data; (3) using 

hospice-specific data; and (4) using data 

from the physician payment system. 

The Committee determined that the raw 

pre-floor, pre-reclassified hospital wage 

index was the best option for hospice. 

The raw pre-floor, pre-reclassified 

hospital wage index is updated 

annually, and reflects the wages of 

highly skilled hospital workers. 

We agree that the hospital-based wage 

index has undergone some changes in 

the past 10 years. Those changes were 

put forward through rulemaking, which 

provided the public an opportunity to 

provide comments. Therefore, we 

disagree that hospice providers have not 

had an opportunity to comment on 

hospital wage index changes. 

The reclassification provision 

provided at section 1886(d)(10) of the 

Act is specific to hospitals. We believe 

the use of the most recent available raw 

pre-floor and pre-reclassified hospital 

wage index results in the most 

appropriate adjustment to the labor 

portion of hospice costs as required in 

42 CFR 418.306(c). Additionally, use of 

the unadjusted hospital wage data 

avoids further reductions in certain 

rural statewide wage index values that 

result from reclassification. We also 

note that the wage index adjustment is 

based on the geographic area where the 

beneficiary is located, and not where the 

hospice is located. 

We continue to believe that the 

unadjusted hospital wage index, which 

is updated yearly and is used by many 

other CMS payments systems including 

home health, appropriately accounts for 

geographic variances in labor costs for 

hospices. Home health agencies and 

hospices are Medicare’s only homebased benefits, and home health 

agencies and hospices share labor pools. 

In the future, when looking into 

reforming the hospice payment system, 

we will consider wage index 

alternatives, to include those 

recommended by MedPAC. 

We are implementing as final the 

proposal to continue to use the raw prefloor, pre-reclassified hospital wage 

index. 

2. Areas Without Hospital Wage Data 

In adopting the CBSA designations, 

we identified some geographic areas 

where there are no hospitals, and thus 

no hospital wage data on which to base 

the calculation of the hospice wage 

index. These areas were described in 

section I.B.4 of the proposed rule (73 FR 

24004). Beginning in FY 2006, we 

adopted a policy that, for urban labor 

markets without an urban hospital from 

which a raw pre-floor, pre-reclassified 

hospital wage index can be derived, all 

of the urban CBSA raw pre-floor, prereclassified hospital wage index values 

within the State would be used to 

calculate a statewide urban average raw 

pre-floor, pre-reclassified hospital wage 

index to use as a reasonable proxy for 

these areas. Currently, the only CBSA 

that would be affected by this policy is 

CBSA 25980, Hinesville-Fort Stewart, 

Georgia. We proposed to continue this 

policy for FY 2009. 

Currently, the only rural areas where 

there are no hospitals from which to 

calculate a raw pre-floor, prereclassified hospital wage index are in 

Massachusetts and Puerto Rico. In 

August 2007 (72 FR 50217) we adopted 

the following methodology for imputing 

rural raw pre-floor, pre-reclassified 

hospital wage index values for areas 

where no hospital wage data are 

available as an acceptable proxy. We 

imputed an average raw pre-floor, prereclassified hospital wage index value 

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

from contiguous CBSAs as a reasonable 

proxy for rural areas with no hospital 

wage data from which to calculate a raw 

pre-floor, pre-reclassified hospital wage 

index. In determining an imputed rural 

raw pre-floor, pre-reclassified hospital 

wage index, we define ‘‘contiguous’’ as 

sharing a border. In the proposed rule, 

we proposed to apply this methodology 

for imputing a rural raw pre-floor, prereclassified hospital wage index for 

those rural areas without rural hospital 

wage data in FY 2009. For 

Massachusetts, rural Massachusetts 

currently consists of Dukes and 

Nantucket Counties. We determined 

that the borders of Dukes and Nantucket 

counties are ‘‘contiguous’’ with 

Barnstable and Bristol counties. We did 

not receive any comments on this 

proposal, and are implementing it as 

proposed. 

As we noted in our proposed rule, we 

do not believe that this methodology for 

imputing a rural raw pre-floor, prereclassified hospital wage index value is 

appropriate for Puerto Rico. We noted 

that there are sufficient economic 

differences between the hospitals in the 

United States and those in Puerto Rico, 

including the fact that hospitals in 

Puerto Rico are paid on blended 

Federal/Commonwealth-specific rates, 

to make a separate distinct policy for 

Puerto Rico necessary. 

We did not receive any comments on 

this proposal, and are implementing it 

as proposed without change. Therefore, 

in this final rule, for FY 2009, we are 

continuing to use the most recent raw 

pre-floor, pre-reclassified hospital wage 

index value available for Puerto Rico, 

which is 0.4047. This raw pre-floor, prereclassified hospital wage index value is 

then adjusted upward by the hospice 

floor in the computing of the final FY 

2009 hospice wage index. 

3. Phase Out of the Budget Neutrality 

Adjustment Factor (BNAF) 

As previously stated, the current 

hospice wage index methodology was 

developed through a negotiated 

rulemaking process and implemented in 

1997. The rulemaking committee sought 

to address the inaccuracies in the 

original Bureau of Labor Statistics 

(BLS)-based hospice wage index, 

account better for disparities from one 

geographic location to another, and 

develop a wage index that would be as 

accurate, reliable and equitable as 

possible. The resulting hospice wage 

index reflects a special adjustment (a 

BNAF) to ensure payments in the 

aggregate are budget neutral to 

payments using the original 1983 

hospice wage index. The adjustment, 

which is still in place today, results in 

providers currently receiving about 4 

percent more in payments than they 

would have received if the adjustment 

factor were not applied. We believe the 

rationale for maintaining this 

adjustment is outdated, as explained in 

detail below, particularly given the 


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amount of time that has elapsed since it 

was first put into place and the 

continuing growth that is occurring in 

the hospice benefit. In the proposed 

rule, we proposed to phase out this 

adjustment over 3 years, reducing it by 

25 percent in FY 2009, by an additional 

50 percent for a total of 75 percent in 

FY 2010, and eliminating it completely 

in FY 2011. Additionally, from a parity 

perspective, because hospices and home 

health agencies have a similar labor 

mix, we believe that adjusting for 

geographic variances in both of these 

Medicare home-based benefits with the 

raw pre-floor and pre-reclassified 

hospital wage index is appropriate. 

The original hospice wage index that 

was used when the benefit was first 

implemented was based on the 1981 

BLS hospital data and had not been 

updated from 1983 until the current raw 

pre-floor and pre-reclassified hospital 

wage index was adopted. During earlier 

attempts to update the original hospice 

wage index, the hospice industry raised 

concerns over the adverse financial 

impact of a new wage index on 

individual hospices and a possible 

overall reduction in Medicare payments. 

Thus, the result was that in the absence 

of agreement on a new wage index, we 

continued to use the original wage 

index that was clearly obsolete for 

geographically adjusting Medicare 

hospice payments (see ‘‘Medicare 

Program; Notice Containing the 

Statement Drafted by the Committee 

Established to Negotiate the Wage Index 

to Be Used to Adjust Hospice Payment 

Rates Under Medicare’’, November 29, 

1995, 60 FR 61264). 

Changing to a new, more accurate 

wage index would result in some areas 

gaining as their wage index value would 

increase, but other areas would see 

declines in payments as their wage 

index value dropped. In 1994, we noted 

that a majority of hospices would have 

their wage index reduced with the new 

wage index that is based on using the 

raw pre-floor, pre-reclassified hospital 

wage index. These reductions would 

have occurred for two key reasons: (1) 

Hospices were located in areas where 

the original hospice wage index was 

artificially high due to flaws in the 1981 

BLS data; and (2) hospices were located 

in areas where wages had gone down 

relative to other geographic areas (see 

‘‘Hospice Services Under Medicare 

Program: Intent to Form Negotiated 

Rulemaking Committee’’, October 14, 

1994, 59 FR 52130). 

Because of the negative impact to 

certain areas that was expected with the 

change to a new wage index, a 

committee (the Committee) was 

formulated in 1994, under the process 

established by the Negotiated 

Rulemaking Act of 1990 (Pub. L. 101–

648). The Committee was established to 

negotiate the hospice wage index 

methodology rather than to go through 

the usual rulemaking process. On 

September 4, 1996, we published a 

proposed rule (61 FR 46579) in which 

we proposed a methodology to update 

the hospice wage index used to adjust 

Medicare hospice payment rates. This 

proposed methodology contained the 

negotiated rule making committee’s 

recommendations. 

In formulating the provisions of that 

proposed rule, the Committee 

considered criteria in evaluating the 

available data sources. These criteria 

included the need for fundamental 

equity of the wage index, data that 

reflected actual work performed by 

hospice personnel, compatibility with 

wage indexes used by CMS for other 

Medicare providers, and availability of 

the data for timely implementation. 

The Committee agreed that the 

hospice wage index be derived from the 

1993 hospital cost report data and that 

these data, prior to reclassification, 

would form the basis for the FY 1998 

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

index would not be adjusted to take into 

account the geographic reclassification 

of hospitals in accordance with sections 

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

The methodology is codified in 

§ 418.306(c). The hospice wage index 

for subsequent years would be based on 

raw pre-floor, pre-reclassified hospital 

wage index data. 

The Committee was also concerned 

that while some hospices would see 

increases in their payments, use of the 

raw pre-floor, pre-reclassified hospital 

wage index as the wage index for 

hospices would result in a net reduction 

in aggregate Medicare payments for 

hospices. As noted above, a majority of 

hospices would have had their wage 

index lowered by using the new wage 

index because the prior hospice wage 

indices were based on outdated data 

which were artificially high due to flaws 

in the 1981 BLS data, and because some 

hospices were located in areas where 

wages had gone down relative to other 

geographic areas. The reduction in 

overall Medicare payments if a new 

wage index were adopted was noted in 

the November 29, 1995 final rule (60 FR 

61264). Therefore, the Committee also 

decided that for each year in updating 

the hospice wage index, aggregate 

Medicare payments to hospices would 

remain budget neutral to payments as if 

the 1983 wage index had been used. 

As decided upon by the Committee, 

budget neutrality means that, in a given 

year, estimated aggregate payments for 

Medicare hospice services using the 

updated hospice values will equal 

estimated payments that would have 

been made for these services if the 1983 

hospice wage index values had 

remained in effect, after adjusting the 

payment rates for inflation. Therefore, 

although payments to individual 

hospice programs may change each 

year, the total payments each year to 

hospices would not be affected by using 

the updated hospice wage index 

because total payments would be budget 

neutral as if the 1983 wage index had 

been used. To implement this policy, a 

BNAF would be computed and applied 

annually. 

The BNAF is calculated by computing 

estimated payments using the most 

recent completed year of hospice claims 

data. The units (days or hours) from 

those claims are multiplied by the 

updated hospice payment rates to 

calculate estimated payments. The 

updated hospice wage index values are 

then applied to the labor portion of the 

payments. For this final rule, that means 

estimating payments for FY 2009 using 

FY 2007 hospice claims data as of 

March 2008, and applying the estimated 

updated FY 2009 hospice payment rates 

(updating the FY 2008 rates by the FY 

2009 market basket update). The final 

FY 2009 hospice wage index values are 

then applied to the labor portion only. 

The procedure is repeated using the 

same claims data and payment rates, but 

using the 1983 BLS-based wage index 

instead of the updated raw pre-floor, 

pre-reclassified hospital wage index. 

The total payments are then compared, 

and the adjustment required to make 

total payments equal is computed; that 

adjustment factor is the BNAF. 

All raw pre-floor, pre-reclassified 

hospital wage index values of 0.8 or 

greater would be adjusted by the BNAF, 

which would be calculated and applied 

annually. Also, all raw pre-floor, prereclassified hospital wage index values 

below 0.8 would receive the greater of 

the following: (1) A 15-percent increase 

subject to a maximum hospice wage 

index value of 0.8; or (2) an adjustment 

by the BNAF. 

While the Committee sought to adopt 

a wage index methodology that would 

be as accurate, reliable, and equitable as 

possible, the Committee also decided to 

incorporate a BNAF into the calculation 

of the hospice wage index that would 

otherwise apply in order to mitigate 

adverse financial impacts some hospices 

would experience through a decrease in 

their wage index value by transitioning 

to a raw pre-floor, pre-reclassified 

hospital wage index. 


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In the August 8, 1997, final rule (62 

FR 42860), we indicated that the annual 

updates of the hospice wage index 

values would be made in accordance 

with the methodology agreed to by the 

Committee. We also noted that in the 

event that we decide to change this 

methodology by which the hospice 

wage index is computed, we would 

propose to do so in the Federal Register. 

In the May 2008 proposed rule, we 

proposed to change this methodology. 

In FY 1998, the BNAF was 1.020768 

and in FY 2008, the BNAF was 

1.066671. Any raw pre-floor, prereclassified hospital wage index value 

greater than 0.8 was increased by over 

2 percent in FY 1998 and increased by 

almost 7 percent in FY 2008. In FY 

2008, this adjustment resulted in 

hospice providers receiving about 4 

percent more in payments than they 

would have received if the BNAF had 

not been applied. 

The Committee also recommended 

that the transition to the new hospice 

wage index occur over 3-years, from FY 

1998 to FY 2001. The intent of both the 

3-year transition and the budget 

neutrality adjustment was to mitigate 

the negative financial impact to many 

hospices resulting from the wage index 

change. Additionally, the committee 

sought to ensure that access to hospice 

care was not jeopardized as a result of 

the wage index change. 

We believe that the rationale for 

maintaining the BNAF is outdated for 

several reasons. 

First, the original purpose of the 

BNAF was to prevent reductions in 

payments to the majority of hospices 

whose wage index was based on the 

original hospice wage index which was 

artificially high due to flaws in the 1981 

BLS data. Additionally, the BNAF was 

adopted to ensure that aggregate 

payments made to the hospice industry 

would not be decreased or increased as 

a result of the wage index change. While 

incorporating a BNAF into hospice wage 

indices could be rationalized in 1997 as 

a way to smooth the transition from an 

old wage index to a new one, since 

hospices have had plenty of time to 

adjust to the then new wage index, it is 

difficult to justify maintaining in 

perpetuity a BNAF which was in part 

compensating for artificially high data 

to begin with. 

Second, the new wage index adopted 

in 1997 resulted in increases in wage 

index values for hospices in certain 

areas. The BNAF applies to hospices in 

all areas. Thus, hospices in areas that 

would have had increases without the 

BNAF received an artificial boost in the 

wage index for the past 11 years. We 

believe that continuation of this excess 

payment can no longer be justified. 

Third, an adjustment factor that is 

based on 24-year-old wage index values 

is not in keeping with our goal of using 

a hospice wage index that is as accurate, 

reliable, and equitable as possible in 

accounting for geographic variation in 

wages. We believe that those goals can 

be better achieved by using the raw prefloor, pre-reclassified hospital wage 

index, without the outdated BNAF, 

consistent with other providers. For 

instance, Medicare payments to home 

health agencies, that utilize a similar 

labor mix, are adjusted by the raw prefloor, pre-reclassified hospital wage 

index without any budget neutrality 

adjustment. We believe that using the 

raw pre-floor, pre-reclassified hospital 

wage index provides a good measure of 

area wage differences for both these 

home-based reimbursement systems. 

Fourth, in the 13 years since concerns 

about the impact of switching from an 

old to a new wage index were voiced, 

the hospice industry and hospice 

payments have grown substantially. 

Hospice expenditures in 2006 were $9.2 

billion, compared to about $2.2 billion 

in 1998. Aggregate hospice expenditures 

are increasing at a rate of about $1 

billion per year. MedPAC reports that 

expenditures are expected to grow at a 

rate of 9 percent per year through 2015, 

outpacing the growth rate of projected 

expenditures for hospitals, skilled 

nursing facilities, and physician and 

home health services. We believe that 

this growth in Medicare spending for 

hospice indicates that the original 

rationale of the BNAF, to cushion the 

impact of using the new wage index, is 

no longer justified. These spending 

growth figures also indicate that any 

negative financial impact to the hospice 

industry as a result of eliminating the 

BNAF is no longer present, and thus the 

need for a transitional adjustment has 

passed. 

Fifth, 13 years ago the industry also 

voiced concerns about the negative 

financial impact on individual hospices 

that could occur by adopting a new 

wage index. In August 1994 there were 

1,602 hospices; currently there are 3,111 

hospices. Clearly any negative financial 

impact from adopting a new wage index 

in 1997 is no longer present, or we 

would not have seen this growth in the 

industry. The number of Medicarecertified hospices has continued to 

increase, with a 26 percent increase in 

the number of hospice providers from 

2001 to 2005. This ongoing growth in 

the industry also suggests that phasing 

out the BNAF would not have a negative 

impact on access to care. Therefore, for 

these reasons, we believe that 

continuing to apply a BNAF for the 

purpose of mitigating any adverse 

financial impact on hospices or negative 

impact on access to care is no longer 

necessary. 

Finally, we proposed to phase out the 

BNAF over a 3-year period, reducing the 

BNAF by 25 percent in FY 2009, by 75 

percent in FY 2010, and eliminating it 

in FY 2011. We believe that the 

proposed 3-year phase-out period will 

reduce any adverse financial impact that 

the industry might experience if we 

eliminated the BNAF in a single year. 

We also proposed to maintain the 

hospice floor, which offers protection to 

hospices with raw pre-floor, prereclassified hospital wage index values 

less than 0.8, noting that the steps in the 

calculation which involve the BNAF 

will become unnecessary. We are 

implementing the BNAF phase-out as 

proposed, and maintaining the hospice 

floor as proposed. 

We received several comments on the 

phase-out of the BNAF. Specific 

comments and our responses to these 

comments are as follows: 

Comment: Several commenters 

disputed CMS’ description of the 

purpose of the BNAF in the proposed 

rule. The commenters stated CMS 

asserted that the purpose was to smooth 

the transition from an outdated BLSbased wage index to the hospital-based 

wage index in 1998, the language in 

several payment rules suggested that the 

BNAF was not a time-limited 

adjustment and was to be applied 

annually, during and after the transition 

to the hospital-based wage index. One 

comment supported keeping the BNAF, 

stating that a payment reduction for FY 

2009 to FY 2011 is no less disruptive 

than any payment reduction which 

occurred through the wage index 

transition in 1997. Another commenter 

stated that the hospice negotiated wage 

index rule that was finalized by CMS in 

1997 recognized the need to include a 

budget neutrality adjustment to offset 

the flaws in the hospital wage index, 

and therefore protect the viability of 

hospices. The commenter also stated 

that reason remains as valid today as 

eleven years ago. Another commenter 

said CMS’ rationale for phasing out the 

BNAF suggested that eliminating the 

BNAF would restore fairness to the 

hospice wage index, when in reality no 

wage index methodology is perfect. 

Other commenters stated that CMS has 

previously recognized that BNAF 

protects hospices from inadequacies in 

the hospital wage index, and 

inadequacies in the hospice payment 

rates. Another commenter stated that 

the BNAF was put into place because of 

the dramatic changes triggered by 


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implementation of the new wage index, 

so that access to care was protected. 

In addition, a commenter asserted that 

the fundamental reason for the BNAF 

was that no component of the current 

reimbursement system accurately 

replicates hospice costs. A commenter 

also indicated that CMS stated that 

hospice payments and providers had 

increased over the past 10 years, and 

that the hospice wage index 

methodology is dated. The commenter 

further stated that by those standards, 

the wage index model used by every 

Medicare provider type would need 

revision. Furthermore, a commenter 

asked why, other than time passing, is 

the BNAF outdated. Commenters 

indicated that the rationale for applying 

the BNAF originally is still valid. 

Response: We continue to believe that 

the hospice wage index negotiating 

committee intended the BNAF to 

mitigate the negative financial impact of 

the 1998 hospice wage index change. 

We continue to believe that because of 

the growth in the industry and the 

amount of time that has passed since the 

transition, the rationale for maintaining 

the BNAF is no longer justified. In 

addition, from a parity perspective, we 

believe that an raw pre-floor, prereclassified hospital wage index is 

appropriate for use in adjusting rates for 

geographic variances in both of our 

home-based benefits, hospice and home 

health. Nothing in our data analysis has 

shown us that hospice labor costs differ 

substantially from home health labor 

costs. Therefore, we believe we can no 

longer justify the 6 percent increase in 

the hospice wage index, which results 

from the BNAF. We agree with the 

commenter that BNAF was put into 

place so that beneficiary access to 

hospice care would be protected. We 

believe the Committee was primarily 

concerned about those areas of the 

country that would see their payments 

reduced as a result of the wage index 

change. The Committee was concerned 

that the payment reductions might affect 

the viability of hospices in these areas, 

thus ultimately risking access to care. 

The Committee intended that aggregate 

payments to hospices not be reduced as 

a result of the wage index change. We 

do not believe that the Committee 

foresaw the amount of growth in the 

number of new hospices that would 

occur over the following decade. While 

we agree with the commenter that our 

regulations describe that the BNAF be 

applied during and after the transition 

to the new wage index, we continue to 

believe that those decisions were made 

as part of the negotiations to address 

transitional issues, and do not negate 

our ability to make future policy 

changes. We believe that our 

regulations, the negotiating committee 

statement, and the negotiating 

committee workgroup notes support 

these beliefs. We also believe that given 

the current industry climate, it is 

appropriate that a policy change now 

occur. 

The decision to transition from the 

BLS-based wage index to the hospitalbased wage index was a long process. In 

the October 14, 1994, proposed rule (59 

FR 52130), we noted that both CMS 

(formally HCFA) and industry 

projections indicated that most hospices 

would have their wage indices lowered 

if a new wage index were based on 

unadjusted hospital data. The preamble 

of the final rule stated that, ‘‘During the 

discussions preliminary to developing a 

new wage index, the industry voiced 

concerns over the adverse financial 

impact of a new wage index on 

individual hospices and a possible 

reduction in overall Medicare hospice 

care payments’’ (59 FR 52130). There 

were also concerns that access to 

hospice care could be affected. We 

noted that as a result of the impact of 

the lower payments to hospices in the 

aggregate, the new wage index would 

have to be at least budget neutral (59 FR 

52131). The Committee Statement of 

April 13, 1995, which was published in 

a notice on November 29, 1995 (60 FR 

61265), said that we would apply a 

factor to achieve budget neutrality, and 

noted that budget neutrality meant that 

aggregate Medicare hospice payments 

using the new hospital-based wage 

index would have to equal estimated 

payments that would have been made 

under the original hospice wage index. 

We do not believe that the Committee 

foresaw the tremendous growth in the 

industry. As a result of this growth, the 

surge of new entrants into the industry 

over the past 10 years has benefited 

from this adjustment. We continue to 

believe that the committee adopted the 

BNAF to help existing hospices 

transition to the 1998 wage index 

change, and did not expect that the 

BNAF would result in these payment 

increases to new providers in 

perpetuity. Impact analysis performed 

by participants in the negotiating 

process showed pockets of the country 

where the migration to the new hospital 

wage index would result in wage index 

values decreasing nearly 30 percent. 

The committee was clearly concerned 

about hospice viability in those areas of 

the country, with a corresponding 

concern about access to care. We 

continue to believe that the unique 

BNAF methodology, coupled with the 3- 

year transition period, served to address 

those transitional concerns. It also 

continues to be our belief that because 

of the growth in the number of hospices, 

and the growth in the beneficiaries 

served that has occurred during the last 

decade, the committee’s goal to ensure 

that access to hospice care not be 

reduced as a result of the wage index 

change has been achieved. Therefore, 

we believe that this unique 

methodology for achieving budget 

neutrality has served its purpose and is 

no longer necessary to be continued. 

We disagree with the commenters 

who wrote that the BNAF was intended 

to offset flaws in the hospital wage 

index or address inadequacy of the 

hospice payment rates. None of our 

hospice regulations or notices from 1994 

to 1998 which deal with the transition 

to a new wage index indicated that the 

BNAF was put into place because of 

flaws in the hospital-based wage index, 

rate inadequacies, or because of any 

inaccurate replication of hospice costs 

under the current reimbursement 

system. We continue to believe, as the 

Committee did, that the raw pre-floor, 

pre-reclassified hospital wage index is 

currently the best choice for use in 

deriving the hospice wage index. 

We agree with the commenter that the 

language in the August 8, 1997 final rule 

indicated that the BNAF would be 

applied during and after the transition 

period (62 FR 42862), however this 

language did not imply that the BNAF 

could not be changed or eliminated. 

That same final rule also included a 

provision for us to change the wage 

index methodology, through notice and 

comment rulemaking (62 FR 42863). 

In our rationale for the BNAF phaseout, we noted the increase in payments 

and in the number of providers to show 

that the hospice industry was growing. 

Growth such as this, rather than 

industry contraction, typically occurs in 

a favorable business climate. The 

presence of a favorable business climate 

suggests that concerns about the 

financial impact of changing to a new 

wage index had passed. Finally, we did 

not state that all hospice wage index 

methodology was outdated, but only 

that the BNAF was outdated, and we 

continue to believe that is the case. 

Given that the impact of the BNAF 

phase-out is relatively small (1.1 percent 

payment reduction for FY 2009), and is 

being offset by a 3.6 percent market 

basket update, we do not feel that the 

phase-out will be disruptive to the 

hospice industry. However, we will 

monitor the impact as the phase-out 

occurs. 

Comment: A commenter wrote that 

CMS justified phasing out the BNAF in 

part because the combination of 

increases in the wage index in certain 


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areas with the BNAF led to an artificial 

boost in the wage index for the past 11 

years, which CMS concluded was an 

excess payment. The commenter also 

stated that CMS said that if there had 

been no wage index change in 1997, the 

total payments to hospices would be 

greater than the payments that will be 

made if the proposal is implemented. 

The commenter concludes that there is 

no excess spending triggered by the 

BNAF, but instead there is an 

unauthorized reduction under the CMS 

proposal. 

Another commenter felt that CMS is 

singling out the BNAF because some 

hospices benefited more from it than 

others. The commenter also suggested 

that CMS change the methodology for 

the limited number of hospices that 

benefited unduly from the ‘‘artificial 

boost’’ given by the BNAF. 

In addition, a commenter stated that 

CMS had indicated one reason for the 

BNAF phase-out was because the 

growth in hospice expenditures 

indicates that any negative financial 

impact from the transition to the 

hospital-based wage index in 1998 was 

no longer present. The commenter 

indicated that CMS assumed this growth 

in spending was excess spending, and 

that CMS had put forward no evidence 

that there was excess spending in 

hospice versus appropriate increases in 

spending. 

Response: We continue to believe that 

applying the BNAF to the raw hospitalbased wage index does not, as 

accurately as possible, account for 

geographic variances in hospice labor 

costs. When the hospice industry 

changed from the BLS-based wage index 

to the raw pre-floor, pre-reclassified 

hospital wage index, it began using 

more accurate, more current data which 

are updated annually. When that 

transition occurred, there were hospices 

whose wage index value increased, but 

many hospices saw their wage index 

value decrease. This is because the BLSbased wage index values, which were 

applied to hospice payments, were 

artificially high in some areas of the 

country. The Committee itself 

acknowledged that the BLS data were 

‘‘inaccurate and outdated’’ in its 

Committee Statement (62 FR 42883). 

The hospital-based wage index was 

considered more accurate, even though 

its wage index values were lower for 

many hospices. Therefore before the 

transition to the hospital-based wage 

index, many hospices were receiving 

payments that were inflated due to the 

artificially high BLS-based wage index. 

In addition, the BNAF was put into 

place to mitigate the adverse financial 

impact to hospice providers of changing 

wage indices, since the change would 

lead to a reduction in payments, which 

could threaten access to care. However, 

as we previously described in the 

comment above, the BNAF has been 

applied not only to those hospices that 

were in existence at the time of the wage 

index change, but also to those new 

hospices that were established after 

1998. We continue to believe that these 

new entrants have received an artificial 

boost to their payments as a result of the 

BNAF, which was not the intent of the 

negotiating committee. 

The commenter is correct that if the 

hospice industry had not adopted the 

hospital-based wage index, but had 

remained with the BLS-based data, each 

year’s total Medicare hospice payments 

would be higher than they will be when 

the BNAF is phased out. However, as 

noted above, because of the inaccuracy 

and outdatedness of the BLS-based wage 

data, those payments would also be 

inaccurate, and CMS must do its best to 

ensure the accuracy of Medicare 

payments. 

The commenter correctly noted that 

we feel that the growth in hospice 

expenditures indicates that the need to 

mitigate any adverse financial impact 

from the change to a hospital-based 

wage index has passed. However we did 

not assume that this growth was due to 

excess spending associated with the 

BNAF. We recognize that many factors 

contribute to expected and appropriate 

growth in spending, including increased 

numbers of Medicare beneficiaries 

eligible for hospice care; increased 

awareness of the benefit by 

beneficiaries, their families, and 

physicians; some longer lengths of stay; 

etc. 

We believe that the growth in 

Medicare hospice expenditures 

indicates the overall good financial 

health of the hospice industry and that 

this further demonstrates that the BNAF 

has outlived its usefulness and is no 

longer appropriate. As stated 

previously, we believe that given the 

current industry climate, it is 

appropriate that a policy change to 

phase out the BNAF be implemented. 

Comment: A commenter wrote that 

CMS had justified the BNAF phase-out 

by noting that there had been an 86 

percent increase in growth in the 

number of hospices. The commenter 

maintained that growth in the number 

of hospice providers does not 

demonstrate that hospices can absorb 

the payment reduction triggered by the 

BNAF phase-out. The commenter also 

stated that CMS does not know the 

financial status of those hospices or the 

level of demand for their services. 

Several commenters stated that CMS 

has concluded that the growth in the 

hospice benefit was due to the BNAF, 

thereby justifying its elimination. The 

commenters noted a number of factors 

that have contributed to the hospice 

industry’s growth, including an 

increased number of beneficiaries using 

the benefit, longer lengths of stay, 

increased acceptance of hospices for 

end-of-life care by the physician and 

patient/family communities, changes in 

the mix of patients using hospice, and 

educational efforts by providers and by 

CMS to beneficiaries and health care 

providers. 

Several commenters felt that the 

proposed BNAF reduction is a reaction 

to increasing hospice reimbursements 

overall. Another commenter stated that 

hospice is a small portion of all 

Medicare spending. 

Response: We appreciate these 

comments. As we indicated in our 

responses, the FY 2009 financial impact 

of the BNAF phase-out is no more than 

a 1.1 percent reduction in payments. 

Therefore, with a 3.6 percent market 

basket update factor for FY 2009, we do 

not believe that there will be a 

significant adverse effect on the new 

providers, or on long-standing 

providers. We agree that demand for 

hospice services is growing as the U.S. 

population ages, and as the baby boomer 

generation begins to be eligible for 

Medicare. 

We disagree with the commenter’s 

suggestion that CMS does not know the 

financial status of hospices. In fact, the 

Medicare Payment Advisory 

Commission (MedPAC) has performed 

extensive analysis on various aspects of 

hospice financial performance and 

utilization trends over the last few 

years, including an assessment of 

growth trends in the hospice industry. 

We believe that both the growth in 

hospice expenditures and the growth in 

the number of hospices are indicators of 

financial stability in the industry, 

especially given the growth surge in the 

number of for-profit providers. MedPAC 

noted that hospice care has changed 

considerably since the benefit’s 

implementation. In 1983 most providers 

were nonprofits affiliated with religious 

or community organizations, but now 

for-profit hospices constitute the 

majority of providers and the vast 

majority of new entrants into the 

program since 2000 (MedPAC, p. 206). 

In 1998, for-profit providers comprised 

26.9 percent of the industry (63 FR 

53456), while in 2007, for-profits 

comprised 51 percent (MedPAC, p. 216). 

The growth in not-for-profit hospices 

since 1998 has remained relatively flat. 


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MedPAC has also provided some 

information about the financial health of 

hospices, particular those who are new 

entrants into the market. MedPAC noted 

that hospices that began participating in 

the market in 2000 or after had 

consistently and substantially higher 

margins than those participating in 

Medicare before 2000. In addition, these 

higher margins are consistent with the 

growth in the number of for-profit 

providers (MedPAC, p. 223–224). 

Therefore, we do not believe that the 

newer entrants will be more affected by 

the BNAF reduction than older 

hospices. 

We disagree with the comment that 

we asserted that the growth in the 

hospice industry was due to the BNAF 

or that the BNAF reduction is a reaction 

to the growth in hospice 

reimbursements. However, the 

commenters correctly noted several 

factors that have contributed to industry 

growth. We indicated that the BNAF 

phase-out was not a reaction to that 

growth—in the proposed rule, rather we 

stated that the BNAF was put in place 

to mitigate any adverse financial impact 

that individual hospices might 

experience as a result of transitioning to 

the new hospital-based wage index in 

1998. We note that industries do not 

typically expand and grow during times 

of financial adversity; often there is 

industry contraction instead. We stated 

that the growth in the industry is an 

indication that any adverse financial 

effects of transitioning to a new wage 

index had ended. 

We agree that relative to all Medicare 

spending, hospice spending is a small 

portion accounting for an expected 2.3 

percent of spending overall in FY 2009. 

However, we estimate that hospice 

spending will more than double in the 

next 10 years. The growth in hospice 

spending has outpaced the rate of 

growth for other Medicare provider 

types. Furthermore, CMS has a 

responsibility to safeguard trust fund 

dollars by paying accurately and 

appropriately for all Medicare services. 

Finally, we disagree with the 

commenter that the proposed reduction 

in the BNAF is simply a reaction to 

increasing hospice reimbursements. 

Rather, as we have stated in the 

previous responses, we believe that the 

purpose of the BNAF was to mitigate the 

negative financial impact of a 1998 wage 

index change. We believe this 

mitigation for the transition to a ‘‘new’’

wage index is no longer necessary. We 

also believe that phasing out the BNAF 

places both Medicare home-based 

benefits on a more equal footing in 

terms of recruiting staff. 

Comment: A commenter stated that 

cutting hospice payments disregards the 

significant, collaborative progress made 

in the Medicare hospice program over 

the last decade. A few commenters 

stated that CMS circumvented Congress 

by going through rulemaking to propose 

and possibly finalize a BNAF phase-out. 

Several commenters suggested CMS 

should use negotiated rulemaking to 

refine payment policy such as the 

BNAF. Another commenter stated that 

the wage index calculation is not and 

never has been intended to be used as 

a method to form payment policy. This 

commenter stated that role historically 

has been reserved for Congress. Another 

commenter stated that the BNAF phaseout was an administrative proposal put 

forward in the President’s budget, and 

therefore should be enacted by Congress 

rather than effectuated through CMS 

rulemaking. Another commenter stated 

that the Secretary of the Department of 

Health and Human Services is required 

to propose reforms to the wage index 

calculations. One commenter stated that 

the proposed rulemaking process 

administratively circumvented the 

legislative intent to maintain and ensure 

adequate hospice funding levels. 

Response: We appreciate these 

comments, but respectfully disagree 

with the commenters. The BNAF was 

put into place through use of a 

Negotiated Rulemaking Committee. We 

recognized that the wage index 

methodology, including the BNAF, 

could be changed when we included the 

following statement in Section IV (B) of 

the August 8, 1997 Final Rule entitled 

‘‘Medicare Program; Hospice Wage 

Index’’ (62 FR 42863): 

The annual updates will update the 

hospice wage index values according to the 

methodology agreed to by the rulemaking 

committee and implemented by this final 

rule. In the event that we decide to change 

the methodology by which the wage index is 

computed, this will be reflected in a 

proposed rule published in the Federal 

Register. 

The ‘‘we’’ in this paragraph refers to 

CMS (formally HCFA), which published 

the final rule in 1997. It is clear from 

this statement that the wage index 

methodology, including the BNAF, is 

subject to changes by CMS, and that any 

such changes do not have to go through 

negotiated rulemaking, but rather 

through our rulemaking process of 

publishing proposed and final rules in 

the Federal Register. There is no 

statutory requirement that requires wage 

adjustment methodology changes to go 

through Congress. While legislative 

proposals in the President’s Budget 

require Congressional action, 

administrative proposals in the budget 

simply indicate intended administrative 

action, and do not require any 

Congressional action. 

We believe that the intent of the 

BNAF was to protect hospice payments 

during the transition to the hospitalbased wage index. The growth in the 

industry and in payments suggests that 

the industry has adequate funding 

levels, and is one reason for our 

proposal to phase out the adjustment. 

We value the collaborative process, 

but do not feel that it is limited to 

Negotiated Rulemaking. The notice and 

comment rulemaking process, which we 

are following, allows for industry input 

and comment and is the general process 

by which changes to Medicare payment 

policy most often occur. We look 

forward to continuing to work with the 

industry in the future. 

Comment: Many commenters stated 

that achieving budget neutrality was 

always a goal of the negotiated 

rulemaking process. A commenter 

disputed CMS’ assertion that the BNAF 

was intended to prevent reductions in 

payments to the majority of hospices 

whose wage index was based on the 

original hospice wage index, which was 

artificially high due to flaws in the BLS 

data, and stated that the BNAF was 

never a point of contention during the 

Negotiated Rulemaking Process. The 

commenter stated that before the 

Negotiated Rulemaking Committee 

began its negotiations, CMS (formally 

HCFA) indicated that the wage index 

could not be used as a tool to increase 

payments to hospices, nor would it be 

used as a tool to lower aggregate 

payments to hospices. The commenter 

quoted our regulation (59 FR 52131), 

which stated that ‘‘We [HCFA] consider 

it a given of negotiation that any revised 

wage index would have to be at least 

budget neutral; that is, total aggregate 

payments for the same services could 

not be more using the revised wage 

index than if such payments were made 

using the current index.’’

Response: We stand by our assertion 

that the BNAF was intended to prevent 

reductions in payment, and point to the 

quote from the 1994 proposed rule (59 

FR 52131), which the commenter 

included that the BNAF was designed to 

protect aggregate payments. We did not 

state or imply that the adoption of the 

BNAF was a point of contention during 

Negotiated Rulemaking. Rather, we said 

that the BNAF was now outdated, and 

is no longer needed for the reasons 

given in the proposed rule (73 FR 

24006). 

It is clear that we have the authority 

to make changes to the hospice wage 

index methodology, as noted in the 

August 8, 1997 final rule (62 FR 42862): 


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‘‘In the event we decide to change the 

methodology by which the wage index 

is computed, this will be reflected in a 

proposed rule published in the Federal 

Register. 

a. Effects of Phasing Out the BNAF 

Using the Published FY 2008 Hospice 

Wage Index 

In the proposed rule, we used the 

August 31, 2007 FY 2008 hospice wage 

index (72 FR 50214) to illustrate the 

effects of phasing out the BNAF over 3 

years. This analysis and discussion is 

for illustrative purposes only and does 

not affect any of the hospice wage index 

values for FY 2008. 

The BNAF that was calculated and 

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

was 6.6671 percent. We will reduce the 

BNAF by 25 percent for FY 2009, by 75 

percent for FY 2010, and eliminate it 

altogether for FY 2011 and beyond. A 25 

percent reduction in the BNAF can be 

accomplished by blending 75 percent of 

the FY 2008 hospice wage index that 

applied the full 6.6671 percent BNAF 

with 25 percent of the FY 2008 hospice 

wage index that used no BNAF. This is 

mathematically equivalent to taking 75 

percent of the full BNAF value, or 

multiplying 0.066671 by 0.75, which 

equals 0.050003, or 5.0003 percent. The 

BNAF of 5.0003 percent reflects a 25 

percent reduction in the full BNAF. The 

25 percent reduction in the BNAF of 

5.0003 percent would be applied to the 

raw pre-floor, pre-reclassified hospital 

wage index values of 0.8 or greater used 

in the published FY 2008 hospice wage 

index. 

The hospice floor calculation will still 

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

less than 0.8. Currently, the floor 

calculation has 4 steps—(1) Raw prefloor, pre-reclassified hospital wage 

index values that are less than 0.8 are 

first multiplied by 1.15; (2) the 

minimum of 0.8 or the raw pre-floor, 

pre-reclassified hospital wage index 

value times 1.15 is chosen as the 

preliminary hospice wage index value; 

(3) the raw pre-floor, pre-reclassified 

hospital wage index value is multiplied 

by BNAF; and (4) the greater result of 

either step 2 or step 3 is chosen as the 

final hospice wage index value. We left 

the hospice floor calculation 

unchanged, noting that steps 3 and 4 

will become unnecessary once the 

BNAF is eliminated. 

For the simulations of the BNAF 

phase-out for FY 2010 and FY 2011, we 

used the same raw pre-floor, prereclassified hospital wage index values 

and claims data as the example above, 

and simply changed the value of the 

BNAF to reflect either a 75 percent 

reduction for FY 2010 or a 100 percent 

reduction for FY 2011. In both cases we 

started with the full BNAF of 6.6671 

percent. We changed the calculation to 

take 25 percent of the full BNAF to 

reflect a 75 percent reduction for FY 

2010, or eliminated the BNAF altogether 

to reflect a 100 percent reduction for FY 

2011. For FY 2010, the reduced BNAF 

or the hospice floor was then applied to 

the 2007 raw pre-floor, pre-reclassified 

hospital wage index as described 

previously. For FY 2011 and subsequent 

years, the raw pre-floor, pre-reclassified 

hospital wage index values would be 

unadjusted unless they are less than 0.8, 

in which case the hospice floor 

calculation would be applied. Again, we 

note that the steps in the calculation 

that involve the BNAF will become 

unnecessary once the BNAF is phased 

out. 

For our simulations, the calculations 

of the BNAF are as follows: 

• A 75 percent reduction to the BNAF 

in FY 2010 would be 0.066671 × 0.25 = 

0.016668 or 1.6668 percent. 

• A 100 percent reduction or 

elimination of the BNAF in FY 2011 

would be 0.066671 × 0.0 = 0.0 or 0 

percent. 

We examined the effects of phasingout the BNAF versus using the full 

BNAF of 6.6671 percent on the FY 2008 

hospice wage index. The FY 2009 BNAF 

reduction of 25 percent resulted in 

approximately a 1.55 to 1.57 percent 

reduction in the hospice wage index 

values. The FY 2010 BNAF reduction of 

75 percent would result in an estimated 

additional 3.12 to 3.13 percent 

reduction from the FY 2009 hospice 

wage index values. The elimination of 

the BNAF in FY 2011 would result in 

an estimated final reduction of the FY 

2011 hospice wage index values of 

approximately 1.55 to 1.57 percent 

compared to FY 2010 hospice wage 

index values. 

Those CBSAs whose raw pre-floor, 

pre-reclassified hospital wage index 

values had the hospice floor calculation 

applied before any change to the BNAF 

would not be affected by the phase-out 

of the BNAF. These CBSAs, which 

typically include rural areas, are 

protected by the hospice floor 

calculation. Additionally, those CBSAs, 

which were eligible for the hospice floor 

calculation, but whose hospice wage 

index values were previously 0.8 or 

greater after the calculation was applied, 

but which would have values less than 

0.8 after the calculation using a reduced 

BNAF was applied, would see a smaller 

reduction in their hospice wage index 

values. We have estimated the number 

of CBSAs that would have their raw prefloor, pre-reclassified hospital wage 

index value eligible for the floor 

calculation after applying the 25, 75, 

and 100 percent reductions in the 

BNAF. Three CBSAs would be affected 

by the 25 percent reduction, 12 would 

be affected by the 75 percent reduction, 

and 22 would be affected by the 100 

percent reduction. Because of the 

protection given by the hospice floor 

calculation, these CBSAs would see 

smaller percentage decreases in their 

hospice wage index values than those 

CBSAs that are not eligible for the floor 

calculation. This will benefit those 

hospices with lower hospice wage index 

values, which are typically in rural 

areas. 

Finally, the hospice wage index 

values only apply to the labor portion of 

the payment rates; the labor portion was 

described in section I.B.1 of the 

proposed rule (73 FR 24002). Therefore, 

the estimated reduction in payments 

due to the phase-out of the BNAF would 

be less than the percentage reductions to 

the hospice wage index values that 

would result from reducing or 

eliminating the BNAF. In addition, the 

effects of the phase-out of the BNAF 

will also be mitigated by a hospital 

market basket update in payments, 

which in FY 2008 was a 3.3 percent 

increase in payment rates. The hospital 

market basket update for FY 2009 will 

be 3.6 percent. This update and the FY 

2009 payment rates will be officially 

communicated through an 

administrative instruction and not 

through rulemaking. The estimated 

effects on payment described in column 

5 of Table 2 in section V of this final 

rule include the projected effect of a FY 

2009 3.6 percent hospital market basket 

update. 

b. Effects of Phasing Out the BNAF 

Using the Updated Raw Pre-Floor, PreReclassified Hospital Wage Index Data 

(FY 2009 Proposal) 

In this final rule, for FY 2009, we are 

updating the hospice wage index using 

the 2008 raw pre-floor, pre-reclassified 

hospital wage index and the most 

complete claims data available (FY 2007 

claims as of March 2008). Using these 

data, we computed a full BNAF of 

6.6255 percent. For the first year of the 

BNAF phase-out (FY 2009), the BNAF 

will be reduced by 25 percent, or 

0.066255 × 0.75 = 0.049691, to 4.9691 

percent. This will decrease hospice 

wage index values by approximately 

1.55 to 1.56 percent from wage index 

values with the full BNAF applied. As 

noted in the previous discussion on the 

effects of the BNAF reduction in the 

published FY 2008 hospice wage index, 

those CBSAs which already have raw 


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pre-floor, pre-reclassified hospital wage 

index values that have the hospice floor 

applied before implementing a BNAF 

reduction will be completely unaffected 

by this BNAF reduction (for example, 

rural West Virginia, and CBSA 13900, 

Bismarck, ND). Those CBSAs which are 

eligible for the hospice floor, and which 

previously had hospice wage index 

values above 0.8 after applying the full 

BNAF (as part of the floor calculation), 

but which now are below 0.8 with the 

25 percent reduction in the BNAF, will 

be less affected by the BNAF reduction 

than those CBSAs which are 0.8 or 

above after applying the BNAF. They 

are protected by the hospice floor 

calculation (for example, rural Alabama 

would realize a decrease in its wage 

index value of only 0.40 percent, and 

CBSA 27780, Johnstown, PA, would 

realize a decrease in its wage index 

value of only 0.53 percent). 

Additionally, the final hospice wage 

index is only applied to the labor 

portion of the payment rates, so the 

actual effect on estimated payment will 

be less than the anticipated percent 

reduction in the hospice wage index 

value. Furthermore, that effect will be 

mitigated by a market basket update. 

The final market basket update for FY 

2009 will be 3.6 percent rather than the 

3.0 percent estimated in the proposed 

rule. 

Column 3 of Table 2 (section V of this 

final rule) shows the impact of using the 

most recent wage index data (the 2008 

raw pre-floor, pre-reclassified hospital 

wage index not including any 

reclassification under section 

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

the 2007 raw pre-floor, pre-reclassified 

hospital wage index data which was 

used to derive the FY 2008 hospice 

wage index. Column 4 of Table 2 in 

Section V of this final rule shows the 

impact of incorporating the 25 percent 

reduction in the BNAF in the FY 2009 

hospice wage index along with using 

the most recent wage index data (2008 

raw pre-floor, pre-reclassified hospital 

wage index). Finally, column 5 of Table 

2 shows the combined effects of using 

the updated raw pre-floor, prereclassified hospital wage index, the 25 

percent reduced BNAF, and a FY 2009 

market basket update of 3.6 percent. The 

FY 2009 rural and urban hospice wage 

indexes can be found in Addenda A and 

B of this final rule. The raw pre-floor, 

pre-reclassified hospital wage index 

values were adjusted by the 25 percent 

reduced BNAF or by the hospice floor. 

Comment: Many commenters stated 

that the impact of the phased 

elimination of the budget neutrality 

provision is much greater than the 1.1 

percent reduction in payment that was 

described in the proposed rule. These 

commenters stated that some providers 

will experience reductions ranging from 

5 percent to in excess of 14 percent over 

the 3 years as a result of the BNAF 

phase-out, and stated that the cuts 

would create hardship for hospices. 

Several commenters gave specific 

examples of CBSAs where wage index 

values decreased more than 1.1 percent, 

or of wage index values in contiguous 

CBSAs which decreased, but by 

differing amounts. The commenters 

stated that they cannot match pay scales 

with such a disparity in wage index 

values, and that there are no differences 

in medical costs between adjoining 

CBSAs. 

Response: We appreciate the 

comments about the financial impact of 

the proposed rule, but are very 

concerned that incorrect percentage 

impacts on payments from the BNAF 

reduction are being cited in many of the 

comments. Some commenters may have 

confused the effect of the BNAF 

reduction with the effect of fluctuations 

in the wage index values from the raw 

pre-floor, pre-reclassified hospital wage 

index. This hospital wage index is used 

to derive the hospice wage index. We 

emphasize that the BNAF reduction will 

result in a payment reduction to 

hospices of no more than 1.1 percent in 

FY 2009. The large payment cuts which 

hospices repeatedly cited are not due to 

the BNAF reduction. The impact table 

in the proposed rule shows the effects 

of using the updated wage index values, 

the combined effects of using updated 

wage index values and the 25 percent 

reduction in the BNAF, and the 

combined effects of the updated wage 

index values, the 25 percent BNAF 

reduction, and the market basket 

update. Given the apparent confusion, 

we will clarify our methodology for 

calculating the FY 2009 hospice wage 

index to include the BNAF reduction, 

and we will expand our explanation of 

the associated impacts. 

In the proposed rule, using the most 

current data available, we first 

calculated the unreduced BNAF for FY 

2009, which was 6.5357 percent. We 

reduced that number by 25 percent, to 

arrive at 4.9018 percent. The raw wage 

index values from the raw pre-floor, prereclassified hospital wage index were 

increased by 4.9018 percent instead of 

by 6.5357 percent for every CBSA or 

rural area with a wage index value of 0.8 

or greater (if the raw wage index value 

was less than 0.8, the hospice floor 

applied). The difference in the wage 

index value was 6.5357 percent ¥ 

4.9018 percent = 1.6339 percent. 

However, the wage index value only 

applies to the labor portion of payments, 

so the effect on payments is less. The 

labor percentages do not vary by 

hospice or by CBSA; they are the same 

for every provider. Therefore the impact 

of the BNAF reduction on payments 

does not and cannot vary from one 

location to another. 

In the proposed rule, our impacts 

showed the effect of the 25 percent 

BNAF reduction (not including the 

effect of using the updated wage index) 

on total payments to be a 1.0 percent 

reduction (1.1 percent in this final rule), 

compared to what hospices would have 

received if the full BNAF had been 

used. We noted in the proposed rule 

that this reduction would be offset by a 

market basket update that was estimated 

at 3.0 percent. Because the BNAF 

reduction is applied across the board to 

the raw pre-floor, pre-reclassified 

hospital wage index values as a 

percentage reduction, all hospices 

(except those subject to the floor) are 

affected the same in that this final rule’s 

estimated reduction in payments to all 

hospices is approximately 1.1 percent. 

Over the course of the 3-year phase-out, 

the elimination of the BNAF will reduce 

payments by about 4 percent: We 

estimated a 1.1 percent reduction in FY 

2009, an additional 2 percent reduction 

in FY 2010, and an additional 1 percent 

reduction in FY 2011. However those 

reductions do not include 3 years of 

market basket updates for FY 2009, FY 

2010, and FY 2011. Therefore, assuming 

market basket updates’ inclusion in FY 

2010 and FY 2011, hospices will still 

have a net gain in payments over the 3 

years. While we do not know what the 

market basket updates will be for FY 

2010 and FY 2011, hospices received 

market basket updates ranging from 3.3 

percent to 3.7 percent from FY 2005 to 

FY 2008. The market basket update for 

FY 2009 is 3.6 percent. Because we do 

not know how the commenters 

calculated the percentage reductions 

they cited, it is unclear whether they 

accounted for market basket updates in 

their analyses. Therefore, not knowing 

the details of the analysis, we are unable 

to comment further on, or substantiate, 

the commenters’ analysis. 

As with the estimated reduction for 

FY 2009, the reductions in FY 2010 and 

FY 2011 payments will apply uniformly 

to all hospices with wage index values 

≥0.8. Therefore, for hospices with raw 

pre-floor, pre-reclassified hospital wage 

index values ≥0.8, the reductions over 

the 3 years will not be larger for one 

hospice versus another. As noted in the 

proposed rule, those with raw pre-floor, 

pre-reclassified wage index values <0.8 

will be less affected or unaffected by the 

BNAF phase-out. 


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In this final rule, we calculated the 

BNAF using updated claims data (2007 

claims as of March 2008). The full 

BNAF was slightly higher at 6.6255 

percent; the 25 percent reduced BNAF 

was 4.9691 percent, which is slightly 

higher than the BNAF in the proposed 

rule. Therefore, the raw pre-floor, prereclassified hospital wage index values 

used to derive the hospice wage index 

were increased by 4.9691. Because of 

the increase in the BNAF itself from the 

proposed rule to the final rule, the 

hospice wage index values in this final 

rule are slightly higher than those that 

were in the proposed rule. 

Additionally, the final market basket 

update for FY 2009 is 3.6 percent rather 

than the 3.0 percent estimated in the 

proposed rule. That means the total 

impact of using an updated wage index, 

of reducing the BNAF by 25 percent, 

and of the market basket update is 

estimated to be a 2.5 percent increase in 

payments to hospices in FY 2009. 

The impact of the BNAF reduction 

does not vary from hospice to hospice 

(except for those subject to the floor) as 

the same adjustment was applied across 

the board to the raw pre-floor, prereclassified hospital wage index values. 

Likewise, the impact of the market 

basket update does not vary from 

hospice to hospice, as the 3.6 percent 

increase is applied to the same base 

rates across the board. Therefore our 

impacts do not and cannot mask the 

effects of the BNAF reduction by 

presenting aggregate data. 

The only place for variation in 

payment at the individual hospice level 

is within the raw pre-floor, prereclassified hospital wage index values 

themselves. These raw wage index 

values are the input values which are 

adjusted by either the BNAF or the 

hospice floor calculation to derive the 

hospice wage index. To show the 

changes from FY 2008 to FY 2009 in the 

raw pre-floor, pre-reclassified hospital 

wage index, from which the hospice 

wage index is derived, see Addendum C 

in this final rule. 

Addendum C shows that large 

fluctuations in some wage index values 

exist from year to year, some positive 

and some negative. These fluctuations 

are the source of negative and positive 

effects on payment to hospices beyond 

the 1.1 percent reduction due to the 

BNAF and the 3.6 percent increase due 

to the market basket update. Between 

FY 2008 and FY 2009, there were 21 

CBSAs or rural areas with raw pre-floor, 

pre-reclassified hospital wage index 

values which decreased 5 percent or 

more, and 16 CBSAs or rural areas with 

raw pre-floor, pre-reclassified hospital 

wage index values which increased 5 

percent or more. We have also included 

Addendum D, comparing FY 2008 raw 

pre-floor, pre-reclassified hospital wage 

index values with those from FY 2007 

to demonstrate that fluctuations in raw 

wage index values occur every year. 

Addendum D shows that there were 

actually more fluctuations between FY 

2007 and FY 2008 than between FY 

2008 and FY2009; Addendum D also 

shows that between FY 2007 and FY 

2008, 23 CBSAs or rural areas had raw 

pre-floor, pre-reclassified hospital wage 

index values that decreased by 5 percent 

or more, and 17 CBSAs or rural areas 

that increased by 5 percent or more. We 

remind commenters that these raw prefloor, pre-reclassified hospital wage 

index values are adjusted upward by the 

hospice floor if the value is below 0.8. 

These fluctuations do not translate into 

an equivalent increase or decrease in 

payments, as the wage index value only 

applies to the labor portion of payments. 

Additionally, in considering the total 

impact on payments, commenters 

would need to account for the market 

basket increase that applies to hospice 

payment rates. 

The raw pre-floor, pre-reclassified 

hospital wage index originates from data 

provided on each hospital’s cost reports. 

Hospitals must report their wages paid; 

Medicare takes those data for the 

hospitals in each CBSA and computes a 

CBSA average hourly rate. It also takes 

the data for all hospitals and computes 

a national average hourly rate, which 

becomes the standard. The raw prefloor, pre-reclassified wage index values 

for each CBSA are computed by 

dividing the CBSA’s average hourly rate 

by the national average hourly rate. 

Therefore, if a wage index value is 

increasing or decreasing, it is because 

hospital wages within that CBSA are 

increasing or decreasing relative to the 

national average. 

CMS performs an intensive review of 

the hospital wage data, mostly through 

use of edits to identify aberrant data. 

The Fiscal Intermediary/MAC then 

revises or verifies the data elements that 

resulted in specific edit failures. 

Table 1 below shows calculation of 

the hospice wage index for both FY 

2008 and FY 2009, beginning with the 

raw pre-floor, pre-reclassified wage 

index value (the input), and applying 

the BNAF or hospice floor for 3 CBSAs. 

For the first CBSA (31020), the raw prefloor/pre-reclassified hospital wage 

index for FY 2009 is greater than it was 

in FY 2008. Conversely, the raw prefloor/pre-reclassified hospital wage 

index values for CBSAs 41780 and 

48540 are less in FY 2009 than in FY 

2008. Table 1 shows the computation of 

the hospice wage index values for these 

CBSAs for FY 2008 and for FY 2009 

(using proposed rule BNAF values). The 

table also demonstrates that the hospice 

floor protects values <0.8 from the 

effects of the BNAF reduction. In this 

case (CBSA 48540), the FY 2009 

proposed wage index value is 

unchanged from the final wage index 

value for FY 2008. Therefore, as we 

noted in the proposed rule, the BNAF 

reduction had no effect in this 

circumstance. 

The cities and counties which make 

up CBSAs are not determined by CMS, 

but instead are set by the OMB. 

Information about CBSA designations is 

available at the following Web site: 

http://www.whitehouse.gov/omb/ 

bulletins/fy2008/b08-01.pdf. We 

continue to believe that OMB’s CBSA 

designations reflect the most recent 

available geographic classifications and 

are a reasonable and appropriate way to 

define geographic areas for the purposes 

of determining wage index values. 

Currently there are limited data 

available for analysis of the impact of 

the phase-out of the BNAF on quality. 

The new claims data (with visit 

reporting beginning July 1st, 2008) and 

the new Conditions of Participation will 

provide data related to quality of care. 

We will monitor these data for any 

unanticipated effects of the BNAF 

phase-out. 


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TABLE 1—EXAMPLES OF HOW THE PROPOSED FY 2009 WAGE INDEX VALUES WERE DERIVED

CBSA 

FY08 input— 

raw pre-floor 

pre-reclassified hospital 

wage index for 

FY08 

FY 08 BNAF— 

Full BNAF = 0.066671 

increases input value for all 

providers w/WI 

values ≥ 0.8; or apply hospice floor 

Output— 

FY 2008 final 

hospice wage 

index value 

FY09 input— 

raw pre-floor 

pre-reclassified hospital 

wage index for 

FY09 

FY 09 proposed BNAF— 

25% reduced BNAF = 

0.049018 

increases input value for all 

providers w/WI 

values ≥ 0.8; or apply hospice floor 

Output— 

FY 2009 

NPRM hospice 

wage index 

value 

31020 ........... 1.0011 × 1.066671 1.0678 1.0827 × 1.049018 1.1358 

41780 ........... 0.9302 × 1.066671 0.9922 0.8822 × 1.049018 0.9254 

FY08 input < 0.8; hospice 

floor applies 

........................ ........................ FY09 input < 0.8; hospice 

floor applies 

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

0.7010 × 1.15 = 0.8062; 

(Subject to 0.8000 max) 

........................ ........................ 0.6961 × 1.15 = 0.8005; 

(Subject to 0.8000 max) 

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

0.7010 × 1.066671 = 0.7477 ........................ ........................ 0.6961 × 1.049018 = 0.7302 ........................

48540 ........... 0.7010 Take greater of 15% increase (subject to 0.8 

maximum) or BNAF increase 

0.8000 0.6961 Take greater of 15% increase (subject to 0.8 

maximum) or BNAF increase 

0.8000 

Comment: A number of commenters 

referred to the BNAF phase-out as a 

‘‘rate reduction’’ or stated that CMS was 

cutting rates. In addition, a commenter 

asked CMS to publish the rate updates 

as part of the rule in the Federal 

Register, rather than in an 

administrative notice such as a Change 

Request. 

Response: The BNAF is an adjustment 

which increases the raw pre-floor, prereclassified hospital wage index values 

that are 0.8 or greater, with the result 

being the hospice wage index. Raw prefloor, pre-reclassified hospital wage 

index values <0.8 have the hospice floor 

calculation applied instead. 

The hospice payment rates are per 

diems for routine home care, continuous 

home care, respite care, and general 

inpatient care. They were put into place 

by Congress, and are updated annually 

by the market basket update. We have 

not proposed any cut to the payment 

rates. In the proposed rule, we estimated 

that the per diems would increase due 

to a 3.0 percent market basket update; 

for the final FY 2009 rule the market 

basket update to be applied to the per 

diems increased to 3.6 percent. 

Therefore, we are not cutting hospice 

payment rates. Conversely, hospice 

payment rates for FY 2009 will be 

increased by the hospital market basket 

update of 3.6 percent, and will be 

communicated through a separate 

administrative instruction/issuance this 

summer. 

We appreciate the comment about 

where payment rate updates are 

published. Historically, the payment 

rate updates have been issued through 

a separate administrative instruction or 

administrative issuance in the summer 

of each year to provide adequate time to 

implement the necessary system 

changes. In previous years, the hospice 

wage regulation was often published 

after August 1st, which does not allow 

sufficient time for system changes to be 

made to accommodate the October 1st 

implementation of payment updates. 

We will look into including the updated 

payment rates in the Federal Register in 

the future. 

Comment: CMS received a number of 

comments suggesting that a BNAF 

phase-out would limit access to hospice 

care. Multiple commenters noted that 

costs were rising, including gasoline, 

wages, pharmacy costs, medical 

supplies, insurance, utilities, and food, 

and that hospices cannot absorb these 

costs in addition to the BNAF reduction 

without adversely affecting Medicare 

beneficiary hospice care. One 

commenter mentioned the high cost of 

converting to electronic health records. 

Many commenters stated that the BNAF 

reduction exacerbates the financial 

strain that CMS has already imposed on 

hospices this year, noting new hospice 

costs resulting from CMS’s requirements 

to implement new Hospice Conditions 

of Participation (CoPs), and CMS’s new 

visit data collection requirements (CR 

5567). A few commenters stated that 

agencies are having difficulty soliciting 

donations in this economic downturn. 

Some rural providers commented that 

their staff may drive 100 miles each way 

to visit patients, and that they cannot 

afford the rising cost of gasoline. Rural 

and urban commenters stated that they 

could not survive a reduction in 

payments in the face of rising costs. 

These commenters stated that as a result 

of the BNAF reduction, they would have 

to limit the geographic areas they 

service, thus limiting hospice access to 

beneficiaries, especially in rural areas. 

In addition, few commenters stated 

that there was anecdotal evidence that 

an increasing number of hospices had 

ceased operations or were in danger of 

closing, due to rising gas prices and to 

cap overpayments. Other commenters 

stated that they may have to delay 

expansion. Some commenters stated 

that they would have to discontinue 

programs, including bereavement 

programs, outreach programs, programs 

to specific underserved groups (for 

example, to inner city beneficiaries), 

complementary treatments (that is, 

acupuncture and art therapy) or comfort 

items such as overlay airflow 

mattresses, and charity care. Several 

commenters mentioned that hospices 

would be forced to limit access by 

restricting admissions, limiting the 

number of admissions for costly, 

medically complex patients such as 

cancer patients needing expensive 

palliative treatments. There was concern 

among many commenters that the BNAF 

phase-out would lead to cost-cutting 

within hospices, including staff 

reductions that would jeopardize 

quality patient care. Commenters stated 

that quality care takes time, but if 

staffing is reduced, the nurse-to-patient 

ratio will be unfavorable, and hospice 

workers will spend less time with 

patients. One commenter stated that 

hospices may cut the number of visits 

they make, and use phone contact 

instead. Another stated that the 

reduction disproportionately punishes 

best practices which hold true to the 

hospice concept. A commenter felt that 

the BNAF reduction punishes high 

quality, high quantity providers. 

Response: We appreciate the 

commenters’ concerns about rising costs 

and about access to hospice care. We 

agree that costs are rising and that it is 

vital to preserve access to hospice care 

for Medicare beneficiaries. As noted in 

our response to a previous comment, it 

appears that the changes in payments to 

individual hospices have been 


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misunderstood as being due to the 

BNAF reduction. For FY 2009, the 

BNAF reduction cannot affect any 

hospice by more than 1.1 percent. As 

stated in an earlier response, it is worth 

noting that while it is true that, in a 

given year, some areas will see what 

could be considered a significant 

decrease in their raw pre-floor, prereclassified hospital wage index value, 

other areas will see significant increases 

in their raw pre-floor, pre-reclassified 

hospital wage index value. These 

fluctuations in the raw pre-floor, prereclassified hospital wage index occur 

every year (Addenda C and D of this 

final rule show fluctuations from FY 

2007 to FY 2008 and from FY 2008 to 

FY 2009). These fluctuations are not 

related to the BNAF reduction, and we 

believe the 1.1 percent impact of the 

BNAF, which is offset by the 3.6 percent 

FY 2009 market basket update, will not 

force hospices to close their doors or 

otherwise affect access to the quality, 

compassionate care which beneficiaries 

expect and deserve. 

We agree that rising gas prices are a 

concern for hospices, and note that the 

hospital market basket update which is 

used by hospices includes an energy 

component that is sensitive to 

petroleum costs. It is reasonable to 

expect that future market basket updates 

will continue to account for any 

continuation of rising fuel costs. The FY 

2009 market basket update increased 

from 3.0 percent in the proposed rule to 

3.6 percent in this final rule, partly due 

to rising energy costs. We refer the 

reader to the comment about the market 

basket update later in this section for 

more details on the market basket 

update. 

In addition, we believe that the 

requirements associated with the CoPs 

and CR5567 are part of the cost of doing 

business, and that the industry has had 

ample time to plan and budget for these 

changes. We do not believe that these 

requirements will have adverse affects 

on admissions or services, but instead 

expect that the emphasis on quality and 

the increased awareness of visits 

provided could enhance services. 

We believe that in a time of 

inflationary pressure, all businesses, 

including hospices, will seek to operate 

more efficiently. We do not believe that 

the BNAF reduction will lead to the 

type of cost-cutting that would 

jeopardize quality care. However, we 

plan to monitor the effect of the BNAF 

reduction to assess whether 

unanticipated effects occur. 

Comment: Several commenters 

mentioned the Medicare Payment 

Advisory Commission’s (MedPAC’s) 

June 2008 report which includes a 

discussion of hospice margins. 

Commenters stated that MedPAC 

reports hospice margins for the period 

2001 through 2005 averaged 3.4 percent, 

and margins for some categories of 

providers were even lower. For 

example, commenters stated that 

MedPAC reported margins for not-forprofit hospices that were ¥2.8 percent 

during this period. Commenters stated 

that hospices cannot withstand the 

payment reductions resulting from the 

BNAF phase-out, stating that complete 

elimination of the BNAF would result in 

negative margins for all hospice 

provider types. Commenters were 

especially concerned about the effect 

any BNAF reduction would have on 

not-for-profit hospices, stating that the 

reduction will further reduce margins 

which are already in the negative range. 

Commenters were concerned that the 

BNAF reduction will reduce 

profitability and increases losses such 

that hospices will close. 

Response: In June 2008, MedPAC 

published a report entitled ‘‘Evaluating 

Medicare’s Hospice Benefit’’ (MedPAC, 

pp. 203–237). This is the first time 

margins have been analyzed for 

hospices. MedPAC estimated Medicare 

hospice margins using Medicare claims 

and cost report data for the period from 

2001 to 2005. Their report stated, 

‘‘These margins may not provide a full 

picture of hospices’ financial status. 

Nonprofit hospices derive revenues 

from philanthropic donations, which 

are an integral part of their operations 

and mission; these revenues are not 

consistently reported on Medicare cost 

reports. These revenues may help offset 

the generally negative margins we 

observe for nonprofit hospice providers. 

Additionally * * * hospitals may find 

it desirable to operate hospices, even in 

light of negative hospice margins. 

Harrison and colleagues (2005) found 

that hospitals that operated hospice 

programs had higher return on assets 

and higher hospital occupancy rates, as 

well as shorter lengths of stay, than 

hospitals without hospices’’ (MedPAC, 

p. 224). 

As noted above, the margins that 

MedPAC showed in its report may not 

tell the full story of hospice 

profitability. MedPAC noted that 

financial analysts have estimated 

margins of 6 to 15 percent for 2006 for 

the 3 largest publicly traded hospice 

chains. Further, MedPAC noted that 

Security and Exchange Commission 

(SEC) filings on publicly traded 

hospices estimated margins based on all 

revenues and costs (not just Medicare, 

which accounts for more than 90 

percent hospice revenues). Two major 

for-profit chains had 7 percent and 7.8 

percent margins in CY 2006. A third 

chain showed a loss of 3 percent for FY 

2007, but attributed it partly to 

corporate restructuring costs and their 

cap liability (they have since reduced 

their cap exposure). MedPAC noted that 

the chain with the 7.8 percent margin 

was seeking to acquire the chain with 

the loss. In addition, analysts project 

that the prospective buyer’s margins 

will be 11 to 12 percent over the next 

several years. 

We will continue to work with 

MedPAC to assess the appropriateness 

of future enhancements to the Hospice 

payment system. We will work closely 

with them as they review and refine 

their margin analysis and assess the 

impact of the BNAF reduction on 

margins. Phasing out the BNAF rather 

than eliminating it all at once enables us 

to iteratively assess the impact of the 

reduction. 

Comment: Many commenters wrote 

about the financial hardship to hospices 

as a result of rising fuel costs. Two 

commenters said they do not reimburse 

volunteers for mileage, and that they 

were losing volunteers because of high 

gasoline prices, with rural areas being 

particularly hard hit. Several providers, 

particularly rural ones, noted that their 

staff may drive 100 miles each way to 

see a patient or that their service area 

may cover over 1,000 square miles. A 

commenter also asked that we develop 

a hospice-specific reimbursement 

system that would entail developing a 

hospice-specific market basket. A 

commenter noted that the per diems are 

updated by an index which is not 

hospice specific, and that the 

assumptions in the per diem 

components had changed. Pharmacy 

costs, travel costs, and salaries have 

risen at rates that are not provided for 

in the subsequent market basket 

updates. Several noted that using the 

hospital market basket was 

disadvantageous to hospices because of 

differences in the way hospices and 

hospitals operate; some mentioned that 

hospice providers have been adversely 

impacted by the tremendous rise in 

gasoline prices far more than hospitals, 

because hospice services are provided 

where the patient resides rather than in 

a single facility. A commenter added 

that the market basket updates are not 

driven by an objective analysis of 

hospice costs. 

Response: Section 1814(i)(1)(C)(ii)(I) 

of the Act requires that the hospice PPS 

market basket update factor be based on 

the IPPS hospital market basket (as 

defined in Section 1886(b)(3)(B)(iii) of 

the Act). The IPPS market basket reflects 

the operating cost structures of IPPS 

hospitals and the inflationary pressures 


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facing these providers. The market 

basket update factor includes any 

associated price changes with labor, 

energy, insurance, food, pharmacy, and 

other IPPS hospital operating costs. 

Hospitals and hospice facilities both 

hire staff from the same healthcare 

worker labor pool; however, hospitals 

tend to have a higher skill occupation 

mix compared to hospice facilities. The 

IPPS market basket update factor 

reflects the inflationary pressures on 

these highly skilled healthcare 

occupations. 

The hospice per diems are updated 

using the hospital market basket, which 

we agree is not hospice-specific. While 

the hospital market basket does not have 

a specific transportation factor, it does 

include energy costs. It also includes 

pharmacy costs and wage costs. To see 

the components in the hospital market 

basket, we refer the reader to: http:// 

www.cms.hhs.gov/ 

MedicareProgramRatesStats/ 

downloads/mktbskt-pps-hospital2002.pdf. To better understand the 

market baskets and how they are 

constructed, we also refer the reader to: 

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

MedicareProgramRatesStats/ 

downloads/info.pdf. 

Regarding the development of a 

hospice-specific market basket, CMS 

will investigate the cost structures 

specific to hospice facilities and how 

they compare to IPPS hospitals. 

However, we believe that Congress 

intended us to use the hospital market 

basket to adjust for hospice inflationary 

pressures, and therefore, the authority to 

create and use a hospice-specific market 

basket is determined by Congress. 

Comment: Several commenters stated 

that there were likely to be major 

revisions to the hospital wage index in 

the future and that CMS should not 

remove the BNAF when the wage index 

is fluctuating. A few commenters 

indicated that CMS has not studied the 

impact on the hospice payment system 

of hospital wage index changes which 

occurred over the past 10 years. These 

commenters also stated that CMS 

justified the application of hospitalspecific changes to the hospice payment 

system by application of the BNAF, 

which serves as a ‘‘cushion’’ for 

hospice. They also indicated that 

hospice providers were never given an 

opportunity to study the impact of these 

changes. Finally, these commenters 

stated that eliminating the BNAF now 

would subject hospices to multiple, 

significant changes over a short period 

of time. One commenter stated that CMS 

proposal to phase-out the BNAF is not 

reform. Another commenter indicated 

that wage index is as important to the 

stability of hospice care as are base 

payment rates, the annual inflation rate 

update, and the aggregate annual 

hospice cap, and suggested that stability 

would be lost if the BNAF were phasedout. 

Furthermore, a commenter indicated 

that the current hospital-based wage 

index was not accurate, reliable, or 

equitable. The commenter stated that 

some hospices are part of health systems 

that have wage indices lower than a 

hospital in the same system and the 

same geographic area. Therefore, the 

commenter asserts, CMS cannot reason 

that the BNAF phase-out is needed for 

accuracy, reliability, and equity. 

Response: In the May 1, 2008 

proposed rule, we proposed phasing out 

the BNAF over 3 years because this 

adjustment has served its purpose, 

which was to mitigate the adverse 

financial impact of transitioning to a 

new wage index in 1998. The need for 

the BNAF has passed for a variety of 

reasons, as stated in section II.C.3 of this 

final rule. We did not propose to reform 

the raw pre-floor, pre-reclassified 

hospital wage index or the hospice 

payment system, but only to phase out 

the BNAF. We did not propose to phase 

out the hospice floor calculation, which 

continues to apply when raw pre-floor, 

pre-reclassified hospital wage index 

values are < 0.8, though we noted that 

the steps involving the BNAF would 

become unnecessary once the phase-out 

is complete. 

The raw pre-floor, pre-reclassified 

hospital wage index is the same wage 

index used by the other home-based 

Medicare benefit, home health, which 

draws from the same labor pool as 

hospices. Home health agencies 

experience the same wage index 

fluctuations, but do not receive an 

adjustment such as the BNAF; therefore, 

we do not believe that phasing out the 

hospice BNAF in the presence of normal 

wage index fluctuation will be 

detrimental to the industry or threaten 

stability. 

Our purpose in phasing out the BNAF 

is not to reform the wage index, but 

rather to phase out an adjustment which 

served its purpose. The BNAF helped 

hospices adjust to the negative financial 

impact of changing from the Bureau of 

Labor Statistics-based wage index to the 

raw pre-floor, pre-reclassified hospital 

wage index. There is no longer a need 

for this adjustment given that the 

transition occurred over 10 years ago 

and the growth that has occurred in the 

industry. 

In our proposed rule, we stated that 

one reason for phasing out the BNAF is 

that it is not as accurate, reliable, and 

equitable as possible in accounting for 

geographic variation. The BNAF ties 

payments back to an outdated 1981 

BLS-based wage index that the 

Negotiated Rulemaking Committee 

called ‘‘inaccurate’’ in its Committee 

Statement (62 FR 42883). We are unable 

to respond to the comment about one 

health system’s wage index being 

different from that of a hospital in the 

same area as it is outside the scope of 

this rule. 

Comment: One commenter suggested 

that CMS conduct a study to determine 

the appropriate per diems for rural 

hospices, asserting that rural costs are 

not adequately addressed in the current 

payment system. This commenter 

suggested CMS include an additional 

time and distance factor for rural 

hospices to align the per diem with 

rural costs. 

Response: Medicare pays one of four 

daily rates to hospice providers, based 

on the intensity level of care the patient 

requires. These per diem payment rates 

are the same, regardless of whether the 

services are provided in an urban area 

or a rural area. The hospice wage index, 

which includes a floor calculation 

which benefits many rural providers, is 

the vehicle we use to adjust for 

geographic variances in labor costs. In a 

time of high gasoline costs, we are 

sensitive to concerns from rural 

hospices that the additional time and 

distance required to visit a rural patient 

adds significantly to their costs, and 

their assertion that payments are not 

adequate. However, we believe that an 

additional payment for rural providers, 

which is sometimes called a rural addon payment, would have to be 

legislated. 

Comment: Several commenters 

indicated that hospices sometimes care 

for high cost patients such as those who 

require more expensive palliative 

radiation or chemotherapy, and that 

hospice reimbursements are not 

sufficient to provide quality care to 

these complex patients. Another 

commenter stated that the original 

hospice per diems were arbitrarily set 

by CMS (formally HCFA) and had to be 

raised by Congress. A commenter stated 

that increased case mix and new 

treatment options have also affected 

hospice costs. A commenter 

recommended that CMS study the real 

costs of hospice care and devise a 21st 

century, hospice-specific 

reimbursement system. One commenter 

recommended that CMS raise the wagerelated per diem. 

Several commenters asked CMS not to 

decrease payments because they are 

already providing services above the 

level of reimbursement that is presently 

provided in the daily rate. Another 


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commenter stated that Medicare does 

not pay for staff consultations, preadmission consults, travel time to 

patients’ homes, or the cost of fuel. A 

few commenters stated that hospices 

now provide an ever-expanding array of 

costly palliative treatments. 

Response: While these comments 

addressed issues that are beyond the 

scope of this final rule because they 

concern issues about which we did not 

make any proposals, we will address 

them briefly since they pertain to 

overall hospice reimbursement. In its 

June 2008 report, MedPAC wrote that 

hospice payments are generally 

adequate in the aggregate, but noted that 

individual hospices’ performance varies 

(MedPAC, p. 205). 

The hospice per diems were designed 

to cover hospice costs and were 

developed based on cost information 

gathered from a demonstration project 

that began in October, 1980 and which 

included 26 hospices. The per diems 

include costs of the services hospices 

provide, plus overhead costs such as 

maintenance, depreciation, general 

accounting, capital, and other 

administrative costs in the calculation 

of the individual service components 

(that is, nursing services and aide 

services). A cost component is included 

for hospital outpatient charges for 

palliative radiation and chemotherapy, 

based on a sample of Medicare patients 

who died from cancer in 1980, and 

adjusted for inflation. In the future, we 

plan to perform analyses on hospice 

resource utilization, in the hopes of 

refining our hospice payment system. 

We will consider the high cost of certain 

palliative treatments in future payment 

refinements analyses. 

As some commenters stated there 

have been changes in hospice case mix, 

with proportionally fewer cancer 

patients and more patients with other 

diagnoses such as dementia and 

congestive heart failure. At this time, we 

do not have the data on services 

provided to patients with specific 

diagnoses, and therefore cannot easily 

determine the adequacy of Medicare 

payments relative to the cost of care. 

However, hospices were required to 

begin reporting visits for nurses, 

physicians, social workers, and aides as 

of July 1, 2008 (This is just a beginning 

in data collection efforts that should 

provide the information needed to 

refine payments in the future). We note 

that because hospice rates are currently 

described in statute, any hospice 

payment refinements which affect those 

rates would need to be enacted by 

Congress. 

Comment: Many commenters praised 

the benefits of hospice, which provides 

care to the most vulnerable Medicare 

beneficiaries for example, the dying and 

does so in a cost-effective fashion that 

saves Medicare money. They suggested 

that if hospice utilization declines, 

beneficiaries would be forced to use 

more costly medical care, driving up 

Medicare costs in the long run. Others 

commented on the quality, 

compassionate care and comfort that 

hospice provides to patients and their 

families. Another commenter stated that 

hospice provides tremendous aid at end 

of life, serving the dying equally, 

regardless of color and economic status. 

These commenters and others asked that 

CMS not reduce payments. Several 

commenters also questioned the timing 

of CMS’ proposal to eliminate the 

BNAF. They felt CMS should not be 

cutting hospice benefits at a time when 

the demand for services is growing. One 

commenter stated that the industry 

growth is a testament to the service gap 

that hospice fills, the growing awareness 

of hospice, and preference for a hospice 

death. A few mentioned that CMS has 

encouraged hospice usage. One 

commenter indicated that studies show 

that patients live longer on hospice, but 

there is still a need for earlier referrals 

to the benefit. The commenters stated 

that the population is aging and the 

baby boomer generation is getting older. 

Response: We agree that the Medicare 

hospice benefit has been of tremendous 

benefit to those at end-of-life and to 

their families, and applaud those who 

serve the dying as hospice staff and 

volunteers. We also agree that the 

hospice benefit often saves Medicare 

money, and appreciate the studies 

which have highlighted the areas where 

it provides costs savings to the Medicare 

program. However, hospice care does 

not save money in every instance. 

MedPAC has noted that ‘‘hospice’s net 

reduction in Medicare spending 

decreases the longer the patient is 

enrolled and beneficiaries with very 

long hospice stays may incur higher 

Medicare spending than those who do 

not elect hospice.’’ (MedPAC, p. 209). 

We do not believe that hospice 

utilization will decline due to the BNAF 

phase-out, and therefore, do not believe 

that Medicare costs will be shifted from 

hospice to more expensive forms of 

care. As noted in our response to a 

previous comment, the FY 2009 impact 

of the BNAF phase-out is, at most, 1.1 

percent for every provider, and is being 

offset by a 3.6 percent FY 2009 market 

basket update, resulting in a 2.5 percent 

increase in payments to hospice 

providers in FY 2009. 

We agree that the hospice industry is 

growing and that the demand for 

hospice services is likely to grow in the 

future, particularly with an aging 

population. We also agree that CMS has 

encouraged hospice usage. We have not 

cut Medicare hospice benefits in any 

way—terminally ill Medicare patients 

are still eligible to receive the same 

quality, compassionate end-of-life care 

that has been the hallmark of hospice. 

We expect the hospice benefit to 

continue to grow: CMS’ Office of the 

Actuary projects that Medicare hospice 

spending will more than double in the 

next 10 years. However, we will monitor 

the impact of the BNAF phase-out for 

any unintended impact. 

Comment: Several commenters 

recommended that CMS delay any 

BNAF reduction or phase-out. They 

suggested waiting for better and more 

reliable data, for time to evaluate the 

impact of the requirements from the 

new Conditions of Participation and 

from CR 5567. A commenter stated that 

CMS lacks the data to conduct a 

reasoned analysis, citing MedPAC’s 

June 2008 report which stated that CMS 

needs substantially more data. One 

commenter recommended that CMS 

consider a 1-year freeze on any 

reductions and wait for more available 

data. Another commenter recommended 

that CMS delay until we had gathered 

data on the potential impact on hospice 

operations and quality of care of 

eliminating the BNAF. A commenter 

stated that there was not enough time to 

prepare for a change due to a BNAF 

phase-out. Other commenters asked 

CMS to wait until MedPAC completes 

its hospice analysis and CMS updates 

its hospice payment system, before 

eliminating the BNAF. Several other 

commenters recommended phasing out 

the BNAF more gradually. Some 

recommended a gradual phase-out that 

would help minimize the economic 

impact of such a change, particularly at 

a time of rising gas prices. One 

commenter recommended a 5-year 

phase-out, and another recommended a 

7-year phase-out, with a 25 percent 

reduction in FY 2009, a 15 percent 

reduction in FY 2010, and a 10 percent 

reduction through FY 2016. Another 

commenter recommended that 

implementing the BNAF reduction on a 

more gradual schedule would allow 

hospices time to evaluate the impact of 

the reduction of the new CoPs, hospital 

versus hospice costs, and of the June 

2008 MedPAC report. Even with the 

proposed schedule for reducing, and 

ultimately eliminating the BNAF, 

commenters suggested that by CMS not 

providing impacts for the 2nd and 3rd 

year of reducing the BNAF, the industry 

was not afforded information as to the 

impact on hospices beyond the 


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proposed first year’s reduction of the 

BNAF. 

Response: We appreciate the 

commenters’ input. However, we 

continue to believe that our phase-out 

approach as described in the proposed 

rule is appropriate. One reason we 

decided to implement a phased-out 

approach to reducing the BNAF was to 

ensure we would have the ability to 

assess the impact of the BNAF reduction 

iteratively. We plan to monitor the 

impact of the BNAF reduction for 

unintended effects. The financial impact 

of the phase-out is very clear; in FY 

2009 it is estimated to affect hospices by 

no more than negative 1.1 percent. We 

continue to believe that because the FY 

2009 market basket update is 3.6 

percent, and hospices will receive 2.5 

percent more in payments in FY 2009 

than they received in FY 2008, the FY 

2009 reduction should not have an 

adverse impact on hospice operations or 

quality. 

The hospice CoPs were developed 

with input from the industry. The CoPs 

have been in development for 9 years 

and have widespread support from the 

industry. Hospices have been expecting 

these since the Conditions of 

Participation proposed rule was 

published in May of 2005, providing 

time to plan and budget for these 

changes accordingly. Hospices were 

required to report certain visit data as of 

July 1, 2008. This requirement was 

implemented through CR 5567 after 

MedPAC, the General Accounting 

Office, and the Office of the Inspector 

General recommended that CMS gather 

data on Medicare hospice service 

utilization. While the most recent 

revision of CR 5567 occurred on April 

29, 2008, the initial issuance of the CR 

occurred on July 20, 2007, providing 

ample time for hospices to plan and 

budget for these requirements. CR 5567 

requires reporting of visit data that 

many hospice software programs 

already track. We do not feel it will 

cause undue burden, especially since 

we recently revised the CR 5567 

requirements to suspend a subset of the 

reporting requirements to address an 

industry concern. Additionally, we 

believe the industry has ample time to 

prepare for the BNAF phase-out. The FY 

2009 President’s budget was published 

in February, 2008 and contained a 

provision to phase out the BNAF. In the 

interest of transparency, we made 

public our intent to propose the BNAF 

reduction via FY 2009 rulemaking 

shortly after publication of the budget, 

over 2 months in advance of our 

proposed rule publication. 

We agree that MedPAC recommended 

that CMS collect additional data to 

better understand what services we are 

paying for, and for use in future 

payment refinements. We did not 

propose to reform the payment system, 

but simply to remove an outdated 

adjustment. 

We acknowledge that the impacts 

reflected in this rule are for FY 2009 

only. The purpose of this final rule, so 

far as impacts, is to show the estimated 

impacts on hospice providers for FY 

2009. We have, in the proposed rule (72 

FR 24005, 24006) and in a response to 

a previous comment, communicated 

that over the course of the three-year 

phase-out, the elimination of the BNAF 

will reduce payments by about 4 

percent: We estimated a 1.1 percent 

reduction in FY 2009, an additional 2 

percent reduction for a cumulative 

reduction of 3.1 percent in FY 2010, and 

an additional 1 percent reduction for a 

cumulative reduction of 4.1 percent in 

FY 2011. However those reductions do 

not include 3 years of market basket 

updates for FY 2009, FY 2010, and FY 

2011. Therefore, assuming market 

basket updates’ inclusion in FY 2010 

and FY 2011, hospices will still have a 

net gain in payments over the 3 years. 

While we do not know what the market 

basket updates will be for FY 2010 and 

FY 2011, hospices received market 

basket updates ranging from 3.3 percent 

to 3.7 percent from FY 2005 to FY 2008. 

The market basket update for FY 2009 

is 3.6 percent. We will provide similar 

impacts for FY 2010 and FY 2011 in 

future rulemaking. 

For all of these reasons, we do not feel 

that there is a reason to delay the phaseout of an outdated adjustment. While 

we believe that a 3-year phase-out is fair 

and appropriate, we will monitor the 

effects of the phase-out as it occurs. 

Comment: A commenter wrote that 

hospitals and home health agencies 

receive the BNAF. The commenter said 

that since hospices compete with home 

health agencies and hospitals for staff, 

phasing out the BNAF for hospice 

creates an uneven playing field for 

recruiting and retaining staff. A few 

commenters stated that CMS should not 

justify removing the BNAF so that the 

hospice and home health wage indices 

were consistent. One commenter stated 

that the new CoPs recognized the 

differences between hospice and home 

care patients, noting that hospice 

patients are more fragile. Additionally, 

other aspects of the hospice and home 

health payment systems differ. These 

commenters indicated that the rules 

regarding hospice payment should 

remain unique, and do not need to 

mirror those for home health. 

Response: We agree that there should 

be a level playing field for recruiting 

and retaining staff for home-based 

benefits such as hospice and home 

health. As we described in our proposed 

rule, because hospices and home health 

agencies share labor pools, we believe 

that there should be consistency in the 

wage index used by both these homebased benefits. Nothing in our data 

analysis has shown us that hospice 

labor costs differ substantially from 

home health labor costs, making it 

difficult to justify a 6 percent increase 

in the hospice wage index. We continue 

to believe that the raw pre-floor, prereclassified hospital wage index 

provides a good measure to account for 

geographic variances in labor costs for 

both these home-based benefits. 

Phasing-out the BNAF enables us to 

achieve this consistency. 

The other commenters noted the 

differences between services provided 

in hospice care and home health care, 

citing the hospice CoPs. We agree that 

hospice patients can be more fragile and 

that hospice care is unique, and it is 

appropriate for hospice and home 

health to have different payment 

systems. However, the purpose of a 

wage index is to account for geographic 

variances in labor costs. We believe that 

the use of a consistent wage index in 

both these home-based benefits enables 

hospices and home health agencies to 

compete for staff on a level playing 

field. 

Comment: One commenter stated that 

hospice reimbursement does not 

consider the higher cost of hospice care 

in the home versus in a nursing home. 

Hospice patients in the home require 

more staff visits, increased on-call 

expense, and increased mileage 

expense. The commenter stated that 

hospice patients in nursing homes do 

not need the same intensity of care as 

hospice patients who are residing in 

their own homes. 

Response: While these comments 

address issues that are beyond the scope 

of this final rule, we will address them 

briefly since they generally relate to 

hospice reimbursement. The hospice 

benefit was designed as a home-based 

benefit, and the per diems were set up 

assuming that most care was routine 

care given in the home. Rather than 

considering the per diem inadequate 

because home care is more costly, we 

view the per diem as adequate for home 

care but possibly more than adequate for 

hospice patients residing in a nursing 

home. The routine home care per diem 

was built assuming costs for aides, and 

hospices do not have to provide the 

personal care that aides normally give to 

their patients who reside in nursing 

homes, because the nursing home staff 

is required to provide that care. 


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Likewise, if the hospice has multiple 

patients in the same nursing home, then 

hospice patients in nursing homes are 

less costly in terms of mileage and 

driving time. Hospice patients in 

nursing homes may require an equal 

intensity of service as patients in the 

home, and hospices should be prepared 

to provide all necessary services for 

their patients who reside in nursing 

homes. 

Comment: A few commenters felt that 

CMS had not provided the sufficient 

data analysis to justify the elimination 

of the BNAF. They felt CMS’s decision 

to eliminate it was arbitrary and 

capricious, and recommended that CMS 

withdraw the proposal. A few 

commenters stated that CMS did not 

follow the Administrative Procedures 

Act in proposing the BNAF phase-out. 

Another commenter stated that CMS 

advanced the proposal to phase out the 

BNAF because it offers the potential for 

reducing hospice payments quickly, to 

meet short term budget goals, without 

the need to collect and analyze data. 

Response: We believe we complied 

fully with the Administrative 

Procedures Act in proposing to phase 

out the BNAF, by fully describing our 

proposals and rationale for our 

proposals, by providing the full impact 

of the proposal, and by providing 

opportunity for public comment. The 

effect of the BNAF is clearly illustrated 

in the impact analysis presented in the 

proposed rule, and in the updated 

impacts presented in this final rule. For 

FY 2009, the BNAF will not affect any 

hospice’s estimated payments by more 

than 1.1 percent, and either has no 

effect on hospices with raw pre-floor, 

pre-reclassified wage index values <0.8, 

or affects them less than 1.1 percent. We 

believe that through misunderstanding, 

some in the hospice industry have 

shifted the focus of the impacts from the 

BNAF phase-out to the impact of 

fluctuations which occur in the raw prefloor, pre-reclassified hospital wage 

index every year. We have added 

Addenda C and D to show the hospitalbased wage index fluctuations for the 

last 2 years to demonstrate that they are 

a regular occurrence, and that there are 

fewer fluctuations from the prior year in 

FY 2009 than in FY 2008. 

We believe the rationale for phasing 

out the BNAF which we discussed in 

the proposed rule (72 FR 24006), 

highlights data that justify our adoption 

of our proposal. Specifically, we 

described our analysis which we believe 

shows that the negotiating committee 

adopted the BNAF to mitigate the 

negative financial impact of the 1998 

hospice wage index change. Our 

rationale in the proposed rule also 

describes our analysis of the growth in 

aggregate expenditures, the growth 

surge in the number of for-profit 

hospices, and the growth in the 

beneficiaries served that has occurred 

during the last decade. Our rationale 

also indicates a desire for parity 

between hospices and home health 

agencies since nothing in our data 

analyses indicates that hospice labor 

costs differ substantially from home 

health labor costs. We believe that these 

data, in conjunction with the impact 

analysis, show that this unique 

methodology for achieving wage index 

budget neutrality has served its purpose 

and is no longer necessary. We will 

continue to monitor the impact of the 

BNAF phase-out for any unanticipated 

effects. 

Comment: A commenter stated that 

the BNAF phase-out discriminates 

against rural providers. 

Response: We disagree that the BNAF 

phase-out discriminates against rural 

providers. As noted in our impacts, 

providers with raw pre-floor, prereclassified hospital wage index values 

of 0.8 or more are affected equally. 

These providers are estimated to 

experience a 1.1 percent reduction in 

payments in FY 2009. Providers with 

raw pre-floor, pre-reclassified wage 

index values <0.8 are protected by the 

hospice floor calculation and will either 

be less affected, or totally unaffected by 

the BNAF phase-out. Since many rural 

providers have lower raw pre-floor, prereclassified hospital wage index values, 

and therefore are eligible for the hospice 

floor calculation, we disagree that those 

rural providers eligible for the floor are 

actually less impacted on net. 

Comment: A commenter stated that 

CMS was ‘‘phasing out of the hospice 

wage index’’. 

Response: We appreciate this 

comment, as it provides the opportunity 

to clear up a misunderstanding. We are 

not phasing out the wage index, but 

rather are phasing out the BNAF, which 

is an adjustment that increases the wage 

index values. 

Comment: A commenter stated that 

CMS is focusing on that small 

percentage of hospices that have long 

lengths of stay and a surplus of 

reimbursement over expense. 

Response: The BNAF reduction is 

applied equally to every wage index 

value not subject to the hospice floor. It 

does not disproportionately affect 

hospices with long lengths of stay or 

with high margins. While there were 

good reasons for putting the adjustment 

into place, those reasons are no longer 

valid (see the proposed rule (72 FR 

24006) for a discussion of the rationale 

behind phasing out the BNAF). 

Comment: A few commenters stated 

that Congress has rejected the 

Administration’s request to reduce the 

hospice reimbursement rate, 

understanding correctly that any 

reduction in rate must necessarily 

reduce either quality of care or access to 

care. 

Response: We are unclear about what 

the commenter is referring to. Congress 

has reduced hospice reimbursements in 

the past, cutting market basket updates 

by as much as 2.5 percent. 

Comment: A commenter stated that 

the budget neutrality does not take into 

account the market basket update. 

Response: We appreciate this 

comment, as it allows us to clarify the 

above statement. The calculation to 

derive the BNAF takes the market basket 

update into account as it uses updated 

payment rates to calculate aggregate 

payments. Since we calculate aggregate 

payments using the same payment rates 

and the same utilization, and only vary 

the wage index used (the 1983 BLSbased wage index or the current raw 

pre-floor, pre-reclassified hospital wage 

index), the market basket update has no 

effect on the BNAF that results. 

Comment: A commenter 

recommended that CMS consider an 

alternative to the BNAF phase-out. The 

commenter recommended that CMS 

establish minimum staffing patterns, as 

a better staffing ratio would lead to a 

reduction in patient pain, symptom 

crises, after-hours calls, 911 calls, trips 

to the emergency room, and revocations. 

In addition, the commenter stated that 

it would reduce staff turnover and 

improve retention. 

Response: We thank the commenter 

for this recommendation. The new data 

reporting requirements from CR 5567, 

which began July 1, 2008, will enable us 

to investigate staffing patterns as part of 

any future hospice payment refinements 

analysis. However, we are not 

considering establishing minimum 

staffing patterns as an alternative to the 

BNAF phase-out. 

Comment: A commenter stated that 

reporting for CR 5567 does not include 

all disciplines. In addition, the 

commenter stated that promoting 

quality hinges on recognizing 

differences between routine home care 

and hospice care, which CR 5567 seems 

to question. The episodic nature of 

home care lends itself to per-visit 

reimbursement, while the holistic 

hospice approach is better suited to the 

current per diem reimbursement. 

Response: We appreciate the 

comment, but it is outside the scope of 

this final rule. We will, however, 

consider the comment when examining 


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visit reporting requirements in the 

future. 

Comment: A commenter stated that 

phasing out the BNAF amounted to 

‘‘taxation without representation’’. 

Response: We followed the 

requirements of the Administrative 

Procedures Act in proposing and 

finalizing this policy change, including 

providing rationale for the BNAF phaseout and the opportunity for public 

comment (73 FR 24006). 

Comment: A commenter did not want 

CMS to cut hospice payments. The 

commenter stated that Medicare was to 

help those without other sources of 

income. 

Response: We thank the commenter 

for his or her input. Medicare is a health 

insurance benefit available to people 65 

and older, some disabled people under 

age 65, and people of all ages with End 

Stage Renal Disease. While Medicare is 

certainly a help to those without much 

income, eligibility for Medicare is not 

related to income. Those who are 

Medicare beneficiaries fall into all 

income categories, from the lowest to 

the highest. 

Comment: A commenter stated that 

non-hospice care is given at end-of-life, 

and asked that CMS change physician 

practice and enhance public awareness 

rather than reducing hospice payments. 

The commenter suggested that we allow 

only the attending physician to order 

non-emergency tests and treatments in 

hospitals; that we increase physician 

oversight of hospice patients; that we 

publicize actual success rates for 

various technologies; and that we 

restructure the physician payment 

system so that doctors are paid by 

diagnosis rather than by days in hospital 

or by procedures done. 

Another commenter stated that CMS 

should evaluate the skilled benefits, as 

people that are hospice-appropriate are 

being sent to skilled facilities first, even 

though they are not rehab potentials. 

One commenter stated that the federal 

government recognizes and uses a wage 

index in determining the salaries of 

their employees. 

A different commenter recommended 

that CMS seek to limit the growth in the 

hospice benefit by requiring survey 

agencies to establish or enhance needs 

methodologies. 

Several comments recommended 

other methods of saving federal dollars 

rather than phasing out the BNAF. One 

commenter stated that CMS should cut 

extreme farm subsidies. Another 

commenter stated that CMS should cut 

programs that reward illegal status in 

the U.S. A third commenter stated that 

CMS should stop those who are using 

Medicare dollars to buy expensive 

vehicles. 

A commenter also stated that since 

Medicaid payments for hospice services 

are based on the Medicare payment 

methodology and rates, the BNAF 

phase-out will have an even greater 

effect on, and impinge on the provision 

of hospice services to Medicaid 

recipients. 

Response: We appreciate these 

comments, but they are outside the 

scope of this final rule. References to 

literature cited in this section: Medicare 

Payment Advisory Commission 

(MedPAC), Report to Congress: 

Reforming the Delivery System, June 

2008: 203–237. 

III. Provisions of the Final Regulations 

This final rule incorporates the 

provisions of the proposed rule. None of 

the provisions of this final rule differs 

from the proposed rule. 

IV. Collection of Information 

Requirements 

This document does not impose any 

information collection and 

recordkeeping requirements. 

Consequently, it does not need to be 

reviewed by the Office of Management 

and Budget under the authority of the 

Paperwork Reduction Act of 1995 (44 

U.S.C. 35). 

V. Regulatory Impact Analysis 

A. Overall Impact 

We have examined the impacts of this 

rule as required by Executive Order 

12866 (September 1993, Regulatory 

Planning and Review), the Regulatory 

Flexibility Act (RFA) (September 19, 

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

the Social Security Act, the Unfunded 

Mandates Reform Act of 1995 (Pub. L. 

104–4), Executive Order 13132 on 

Federalism, and the Congressional 

Review Act (5 U.S.C. 804(2)). We 

estimated the impact on hospices, as a 

result of the changes to the proposed FY 

2009 hospice wage index and of 

reducing the BNAF by 25 percent. As 

discussed previously, the methodology 

for computing the hospice wage index 

was determined through a negotiated 

rulemaking committee and 

implemented in the August 8, 1997 final 

rule (62 FR 42860). This rule updates to 

the hospice wage index in accordance 

with our regulation but proposes to 

revise the Negotiated Rulemaking 

Committee methodology of including a 

BNAF. 

Executive Order 12866 (as amended 

by Executive Order 13258, which 

merely reassigns responsibility of 

duties) directs agencies to assess all 

costs and benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

including potential economic, 

environmental, public health and safety 

effects, distributive impacts, and equity. 

A regulatory impact analysis (RIA) must 

be prepared for major rules with 

economically significant effects ($100 

million or more in any 1 year). We have 

determined that this final rule is an 

economically significant rule under this 

Executive Order. 

Column 4 of Table 2 shows the 

combined effects of the 25 percent 

reduction in the BNAF and of the 

updated wage data, comparing 

estimated payments for FY 2009 to 

estimated payments for FY 2008. We 

estimate that the total hospice payments 

for FY 2009 will decrease by $100 

million as a result of the application of 

the 25 percent reduction in the BNAF 

and the updated wage data. This 

estimate does not take into account the 

FY 2009 market basket update, which is 

3.6 percent, and which will be 

communicated through an 

administrative instruction. The 

estimated impact of a 3.6 percent FY 

2009 market basket update on payments 

to hospices is approximately $330 

million. If we were to take into account 

the 3.6 percent FY 2009 market basket 

update, in addition to the 25 percent 

reduction in the BNAF and the updated 

wage data, it is estimated that hospice 

payments would increase by 

approximately $230 million ($330 

million ¥ $100 million = $230 million). 

The percent change in payments to 

hospices due to the combined effects of 

the 25 percent reduction in the BNAF, 

the updated wage data, and the FY 2009 

market basket update of 3.6 percent is 

reflected in column 5 of the impact table 

(Table 2). 

The RFA requires agencies to analyze 

options for regulatory relief of small 

businesses, if a rule has a significant 

impact on a substantial number of small 

entities. The great majority of hospices 

and most other providers and suppliers 

are small entities, either by nonprofit 

status or by having revenues of less than 

$6.5 million to $31.5 million in any 1 

year (for details, see the Small Business 

Administration’s regulation at 65 FR 

69432, that sets forth size standards for 

health care industries). As indicated in 

Table 2 below, there are 3,111 hospices. 

Approximately 50.9 percent of Medicare 

certified hospices are identified as 

voluntary, government, or other 

agencies and, therefore, are considered 

small entities. Most of these and most of 

the remainder are also small hospice 

entities because their revenues fall 


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below the SBA size thresholds. We note 

that the hospice wage index 

methodology was previously guided by 

consensus, through a negotiated 

rulemaking committee that included 

representatives of national hospice 

associations, rural, urban, large and 

small hospices, multi-site hospices, and 

consumer groups. Based on all of the 

options considered, the Committee 

agreed on the methodology described in 

the Committee Statement, and after 

notice and comment, it was adopted 

into regulation in the August 8, 1997 

final rule. In developing the process for 

updating the hospice wage index in the 

1997 final rule, we considered the 

impact of this methodology on small 

hospice entities and attempted to 

mitigate any potential negative effects. 

Small hospice entities are more likely to 

be in rural areas, which are less affected 

by the BNAF reduction than entities in 

urban areas. Generally, hospices in rural 

areas are protected by the hospice floor, 

which mitigates the effect of the BNAF 

reduction. The effects of this rule on 

hospices, as illustrated in Table 2, are 

small. Overall, Medicare payments to all 

hospices will decrease by an estimated 

1.1 percent, reflecting the combined 

effects of the 25 percent reduction in the 

BNAF and the updated wage data. 

Within the hospice subgroups, Medicare 

payments will decrease by no more than 

1.6 percent. Furthermore, when 

including the FY 2009 market basket 

update of 3.6 percent into these figures, 

the combined effects of Medicare 

payment changes to all hospices will 

result in an increase of approximately 

2.5 percent. Overall average hospice 

revenue effects will be slightly less than 

these estimates since according to the 

National Hospice and Palliative Care 

Organization, about 16 percent of 

hospice caseload is non-Medicare. 

Longstanding HHS practice in 

interpreting the RFA is to consider 

effects economically ‘‘significant’’ only 

if they reach a threshold of 3 to 5 

percent or more. Accordingly, we have 

determined that this final rule does not 

create a significant economic impact on 

a substantial number of small entities. 

In addition, section 1102(b) of the Act 

requires us to prepare a regulatory 

impact analysis if a rule may have a 

significant impact on the operations of 

a substantial number of small rural 

hospitals. This analysis must conform to 

the provisions of section 604 of the 

RFA. For purposes of section 1102(b) of 

the Act, we define a small rural hospital 

as a hospital that is located outside a 

CBSA and has fewer than 100 beds. We 

have determined that this final rule will 

not have a significant impact on the 

operations of a substantial number of 

small rural hospitals. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 (UMRA) 

also requires that agencies assess 

anticipated costs and benefits before 

issuing any rule whose mandates 

require spending in any 1 year of about 

$130 million or more (the threshold in 

the statute, updated for inflation 

through 2008). This final rule will not 

have an effect on State, local, or tribal 

governments or on the private sector of 

$130 million or more. 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed rule (and subsequent final 

rule) that imposes substantial direct 

requirement costs on State and local 

governments, preempts State law, or 

otherwise has Federalism implications. 

We have reviewed this final rule under 

the threshold criteria of Executive Order 

13132, Federalism, and have 

determined that it will not have an 

impact on the rights, roles, and 

responsibilities of State, local, or tribal 

governments. 

B. Anticipated Effects 

This section discusses the impact of 

the final rule, including the estimated 

effects of the 3.6 percent FY 2009 

market basket update that will be 

communicated separately through an 

administrative instruction. The final 

rule includes continuing to use the 

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

include the clarification of New England 

‘‘deemed’’ counties and a change in the 

way that multi-campus hospital wage 

data are treated in the creation of the 

raw pre-floor, pre-reclassified hospital 

wage index), continuing the use the 

same policies for treatment of areas 

(rural and urban) without hospital wage 

data, and reducing the BNAF by 25 

percent for the first year of a 3-year 

BNAF phase-out. The final FY 2009 

hospice wage index is based upon the 

2008 raw pre-floor, pre-reclassified 

hospital wage index and the most 

complete claims data available (FY 2007 

as of March 2008) with a 25 percent 

reduction in the BNAF. 

For the purposes of our impacts, our 

baseline is estimated FY 2008 payments 

using the 2007 raw pre-floor, prereclassified hospital wage index. Our 

first comparison (column 3, Table 2) 

compares our baseline to estimated FY 

2009 payments (holding payment rates 

constant) using the updated wage data 

(2008 raw pre-floor, pre-reclassified 

hospital wage index). Consequently, the 

estimated effects illustrated in column 3 

of Table 2 are for the updated wage data 

only. The effects of using the updated 

raw pre-floor, pre-reclassified hospital 

wage index data combined with the 25 

percent reduction in the BNAF are 

illustrated in column 4 of Table 2. 

Even though the market basket update 

is not part of this final rule, we have 

included a comparison of the combined 

effects of the 25 percent BNAF 

reduction, the updated raw pre-floor, 

pre-reclassified hospital wage index, 

and the 3.6 percent FY 2009 market 

basket increase for FY 2009 (Table 2, 

column 5). Presenting these data gives 

the hospice industry a more complete 

picture of the effects of the proposed 

changes in this rule and of the market 

basket update. Certain events may limit 

the scope or accuracy of our impact 

analysis, because such an analysis is 

susceptible to forecasting errors due to 

other changes in the forecasted impact 

time period. The nature of the Medicare 

program is that the changes may 

interact, and the complexity of the 

interaction of these changes could make 

it difficult to predict accurately the full 

scope of the impact upon hospices. 


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TABLE 2—ANTICIPATED IMPACT ON MEDICARE HOSPICE PAYMENTS OF REDUCING THE BNAF, UPDATING THE RAW PREFLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX DATA, AND APPLYING A 3.6 PERCENT MARKET BASKET UPDATE

FOR THE FINAL FY 2009 HOSPICE WAGE INDEX, COMPARED TO THE PUBLISHED FINAL FY 2008 HOSPICE WAGE

INDEX

Number of 

hospices * 

Number of 

routine home 

care days in 

thousands 

Percent 

change in hospice payments 

due to FY 

2009 wage 

index change 

Percent 

change in 

hospice payments due to 

wage index 

change and 

25% 

reduction in 

budget 

neutrality 

adjustment 

factor 

Percent 

change in 

hospice 

payments due 

to wage index 

change, 25% 

reduction in 

budget neutrality adjustment factor 

and market 

basket update 

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

ALL HOSPICES ................................................................... 3,111 67,239 0.0 ¥1.1 2.5 

URBAN HOSPICES ...................................................... 2,098 57,893 0.0 ¥1.1 2.5 

RURAL HOSPICES ...................................................... 1,013 9,346 ¥0.1 ¥0.9 2.7 

BY REGION—URBAN **: 

NEW ENGLAND ........................................................... 119 2,074 0.4 ¥0.7 2.9 

MIDDLE ATLANTIC ...................................................... 209 5,971 ¥0.5 ¥1.5 2.0 

SOUTH ATLANTIC ....................................................... 310 12,950 0.0 ¥1.1 2.5 

EAST NORTH CENTRAL ............................................. 307 8,324 ¥0.2 ¥1.3 2.3 

EAST SOUTH CENTRAL ............................................. 170 4,506 ¥0.4 ¥1.3 2.3 

WEST NORTH CENTRAL ............................................ 166 3,783 0.1 ¥1.0 2.6 

WEST SOUTH CENTRAL ............................................ 348 7,588 ¥0.1 ¥1.2 2.4 

MOUNTAIN ................................................................... 201 5,054 0.0 ¥1.1 2.5 

PACIFIC ........................................................................ 234 6,692 0.8 ¥0.3 3.3 

OUTLYING .................................................................... 34 952 ¥1.1 ¥1.1 2.4 

BY REGION—RURAL **: 

NEW ENGLAND ........................................................... 26 175 ¥0.4 ¥1.4 2.1 

MIDDLE ATLANTIC ...................................................... 44 462 0.4 ¥0.6 2.9 

SOUTH ATLANTIC ....................................................... 128 1,915 0.1 ¥0.9 2.7 

EAST NORTH CENTRAL ............................................. 144 1,317 0.0 ¥1.0 2.5 

EAST SOUTH CENTRAL ............................................. 152 2,051 ¥0.4 ¥1.1 2.4 

WEST NORTH CENTRAL ............................................ 192 1,030 ¥0.2 ¥1.2 2.3 

WEST SOUTH CENTRAL ............................................ 168 1,388 ¥0.5 ¥0.8 2.8 

MOUNTAIN ................................................................... 106 601 0.2 ¥0.8 2.8 

PACIFIC ........................................................................ 52 397 1.6 0.5 4.1 

OUTLYING .................................................................... 1 9 0.0 0.0 3.6 

ROUTINE HOME CARE DAYS: 

0–3,499 DAYS (small) .................................................. 607 1,044 0.1 ¥0.8 2.7 

3,500–19,999 DAYS (medium) ..................................... 1,506 15,071 ¥0.1 ¥1.1 2.5 

20,000+ DAYS (large) .................................................. 998 51,123 0.0 ¥1.1 2.5 

TYPE OF OWNERSHIP: 

VOLUNTARY ................................................................ 1,198 29,597 ¥0.1 ¥1.2 2.4 

PROPRIETARY ............................................................ 1,528 32,903 0.0 ¥1.0 2.6 

GOVERNMENT ............................................................ 192 1,049 0.2 ¥0.8 2.8 

OTHER † ....................................................................... 193 3,690 0.1 ¥1.0 2.6 

HOSPICE BASE: 

FREESTANDING .......................................................... 1,918 49,843 0.0 ¥1.1 2.5 

HOME HEALTH AGENCY ........................................... 609 9,816 0.1 ¥1.0 2.6 

HOSPITAL .................................................................... 567 7,329 0.1 ¥1.0 2.6 

SKILLED NURSING FACILITY .................................... 17 251 ¥0.5 ¥1.6 2.0 

* As of February, 2008; for this final rule, used FY 2007 claims as of March 2008. 

** New England = Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont; Middle Atlantic = Pennsylvania, New Jersey, 

New York; South Atlantic = Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia; 

East North Central = Illinois, Indiana, Michigan, Ohio, Wisconsin; East South Central = Alabama, Kentucky, Mississippi, Tennessee; West North 

Central = Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota; West South Central = Arkansas, Louisiana, Oklahoma, 

Texas; Mountain = Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming; Pacific = Alaska, California, Hawaii, Oregon, 

Washington; Outlying = Guam, Puerto Rico, Virgin Islands. 

† This category refers to other government hospices. 

Table 2 shows the results of our 

analysis. In column 1 we indicate the 

number of hospices included in our 

analysis as of February 2008 which had 

claims in FY 2007. In column 2, we 

indicate the number of routine home 

care days that were included in our 

analysis, although the analysis was 

performed on all types of hospice care. 

Column 3 shows the percentage change 

in estimated Medicare payments from 

FY 2008 to FY 2009 due to the effects 

of the updated wage data only. Column 

4 shows the percentage change in 

estimated hospice payments from FY 

2008 to FY 2009 due to the combined 

effects of using the 2008 raw pre-floor, 

pre-reclassified hospital wage index and 


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reducing the BNAF by 25 percent. 

Column 5 shows the percentage change 

in estimated hospice payments from FY 

2008 to FY 2009 due to the combined 

effects of using updated wage data, a 25 

percent BNAF reduction, and the 3.6 

percent FY 2009 market basket update. 

Table 2 also categorizes hospices by 

various geographic and provider 

characteristics. The first row of data 

displays the aggregate result of the 

impact for all Medicare-certified 

hospices. The second and third rows of 

the table categorize hospices according 

to their geographic location (urban and 

rural). Our analysis indicated that there 

are 2,098 hospices located in urban 

areas and 1,013 hospices located in 

rural areas. The next two row groupings 

in the table indicate the number of 

hospices by census region, also broken 

down by urban and rural hospices. The 

next grouping shows the impact on 

hospices based on the size of the 

hospice’s program. We determined that 

the majority of hospice payments are 

made at the routine home care rate. 

Therefore, we based the size of each 

individual hospice’s program on the 

number of routine home care days 

provided in FY 2007. The next grouping 

shows the impact on hospices by type 

of ownership. The final grouping shows 

the impact on hospices defined by 

whether they are provider-based or 

freestanding. 

As indicated in Table 2, there are 

3,111 hospices. Approximately 50.9 

percent of Medicare-certified hospices 

are identified as voluntary, government, 

or other government agencies and, 

therefore, are considered small entities. 

Because the National Hospice and 

Palliative Care Organization estimates 

that approximately 83.7 percent of 

hospice patients are Medicare 

beneficiaries, we have not considered 

other sources of revenue in this 

analysis. As noted earlier, those CBSAs 

which had the hospice floor applied 

prior to our proposal to reduce the 

BNAF are unaffected by this proposed 

change in methodology. Those CBSAs 

that were not previously less than 0.8 

after applying the full BNAF but which 

are now less than 0.8 after applying the 

reduced BNAF will see less of a 

reduction in payments as the floor 

protects their hospice wage index value. 

As stated previously, the following 

discussions are limited to demonstrating 

trends rather than projected dollars. We 

used the raw pre-floor, pre-reclassified 

hospital wage indexes as well as the 

most complete claims data available (FY 

2007 as of March 2008) in developing 

the impact analysis. The FY 2009 

payment rates were adjusted to reflect 

the full market basket, as required by 

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

As previously noted, we publish these 

rates through administrative 

instructions rather than in a proposed 

rule. The FY 2008 update was 3.3 

percent, and the FY 2009 update is 3.6 

percent. Since the inclusion of the effect 

of a market basket increase provides a 

more complete picture of estimated 

hospice payments for FY 2009, the last 

column of Table 2 shows the combined 

impacts of the 25 percent BNAF 

reduction, the updated wage index, and 

a 3.6 percent market basket update 

factor. 

As discussed in the FY 2006 final rule 

(70 FR 45129), hospice agencies may 

use multiple hospice wage index values 

to compute their payments based on 

potentially different geographic 

locations. Before January 1, 2008, the 

location of the beneficiary was used to 

determine the CBSA for routine and 

continuous home care and the location 

of the hospice agency was used to 

determine the CBSA for respite and 

general inpatient care. Beginning 

January 1, 2008, the hospice wage index 

utilized is based on the location of the 

site of service. As the location of the 

beneficiary’s home and the location of 

the facility may vary, there will still be 

variability in geographic location for an 

individual hospice. We anticipate that 

the location of the various sites will 

usually correspond with the geographic 

location of the hospice, and thus we 

will continue to use the location of the 

hospice for our analyses of the impact 

of the proposed changes to the hospice 

wage index in this rule. For this 

analysis, we use payments to the 

hospice in the aggregate based on the 

location of the hospice. 

The impact of hospice wage index 

changes has been analyzed according to 

the type of hospice, geographic location, 

type of ownership, hospice base, and 

size. Our analysis shows that most 

hospices are in urban areas and provide 

the vast majority of routine home care 

days. Most hospices are medium-sized 

followed by large hospices. Hospices are 

almost equal in numbers by ownership 

with 1,583 designated as non-profit and 

1,528 as proprietary. The vast majority 

of hospices are freestanding. 

1. Hospice Size 

Under the Medicare hospice benefit, 

hospices can provide four different 

levels of care days. The majority of the 

days provided by a hospice are routine 

home care (RHC) days representing 

about 97 percent of the services 

provided by a hospice. Therefore, the 

number of RHC days can be used as a 

proxy for the size of the hospice, that is, 

the more days of care provided, the 

larger the hospice. As discussed in the 

August 4, 2005 final rule, we currently 

use three size designations to present 

the impact analyses. The three 

categories are: (1) Small agencies having 

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

agencies having 3,500 to 19,999 RHC 

days; and (3) large agencies having 

20,000 or more RHC days. The final FY 

2009 wage index values without the 

BNAF reduction are anticipated to have 

a 0.1 percent increase on small hospice 

providers, a 0.1 percent decrease 

anticipated for medium hospices, and 

no change anticipated for large hospices 

(column 3); the final FY 2009 wage 

index values with the 25 percent BNAF 

reduction and the updated wage data 

are anticipated to decrease estimated 

payments by 0.8 percent to small 

hospices and by 1.1 percent to medium 

and large hospices (column 4); and 

finally, the final FY 2009 wage index 

values with the 25 percent BNAF 

reduction, the updated wage data, and 

the 3.6 percent FY 2009 market basket 

update are projected to increase 

estimated payments by 2.7 percent for 

small hospices and by 2.5 percent for 

medium and large hospices (column 5). 

2. Geographic Location 

Column 3 of Table 2 shows that FY 

2009 wage index values without the 

BNAF reduction will result in little 

change in estimated payments with no 

anticipated change for urban hospices 

and an anticipated decrease of 0.1 

percent for rural hospices. For urban 

hospices, the greatest increase of 0.8 

percent is anticipated to be experienced 

by the Pacific regions, followed by an 

increase for New England of 0.4 percent, 

an increase of 0.1 percent for West 

North Central, and no change for the 

South Atlantic and Mountain regions. 

The remaining urban regions are 

anticipated to experience a decrease 

ranging from 0.1 percent in the West 

South Central region to 1.1 percent in 

Puerto Rico. 

Column 3 shows that for rural 

hospices, Puerto Rico and the East 

North Central regions are anticipated to 

experience no change. Four regions are 

anticipated to experience a decrease 

ranging from 0.2 percent for the West 

North Central region to 0.5 percent for 

West South Central region. The 

remaining regions are anticipated to 

experience an increase ranging from 0.1 

percent for the South Atlantic region to 

1.6 percent for the Pacific region. 

Column 4 shows the combined effect 

of the 25 percent BNAF reduction and 

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

on estimated payments, as compared to 

the published FY 2008 payments. 


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Overall urban hospices are anticipated 

to experience a 1.1 percent decrease in 

payments, while rural hospices can 

expect a 0.9 percent decrease. The 

estimated percent decrease in payment 

for urban hospices ranged from 0.3 

percent for Pacific hospices to 1.5 

percent for Middle Atlantic hospices. 

The estimated percent decrease in 

payment for rural hospices ranged from 

0.6 percent for Middle Atlantic hospices 

to 1.4 percent for New England 

hospices. Rural Puerto Rico’s estimated 

payments were unaffected, and the 

Pacific region saw a 0.5 percent increase 

in estimated payments. 

Column 5 shows the combined effects 

of the final FY 2009 wage index values 

with the 25 percent BNAF reduction, 

the updated wage data, and the 3.6 

percent FY 2009 market basket update 

on estimated payments as compared to 

the published FY 2008 payments. 

Overall, urban hospices are anticipated 

to experience a 2.5 percent increase in 

payments while rural hospices should 

experience a 2.7 percent increase in 

payments. Urban hospices are 

anticipated to see an increase in 

estimated payments ranging from 2.0 

percent for the Middle Atlantic region to 

3.3 percent for the Pacific region. Rural 

hospices are estimated to see an 

increase in estimated payments ranging 

from 2.1 percent for the New England 

region to 4.1 percent for the Pacific 

region. 

3. Type of Ownership 

Column 3 demonstrates the effect of 

the updated raw pre-floor, prereclassified hospital wage index on FY 

2009 estimated payments versus FY 

2008 estimated payments. We anticipate 

that using the updated raw pre-floor, 

pre-reclassified hospital wage index 

data will have no effect on proprietary 

hospices. While we estimate a slight 

decrease in estimated payments for 

voluntary (non-profit) hospices (0.1 

percent), other hospices are expected to 

experience an increase of 0.1 percent, 

and government hospices are expected 

to experience an increase of 0.2 percent. 

Column 4 demonstrates the combined 

effects of using updated raw pre-floor, 

pre-reclassified hospital wage index 

data and of incorporating a 25 percent 

BNAF reduction. Estimated payments to 

proprietary hospices are anticipated to 

decrease by 1.0 percent, while voluntary 

(non-profit), government, and other 

hospices are anticipated to experience 

decreases of 1.2 percent, 0.8 percent, 

and 1.0 percent, respectively. 

Column 5 shows the combined effects 

of the updated raw pre-floor, prereclassified hospital wage index values 

with the 25 percent BNAF reduction, 

the updated wage data, and the 3.6 

percent FY 2009 market basket update 

on estimated payments, comparing FY 

2009 to FY 2008. Estimated FY 2009 

payments are anticipated to increase for 

all hospices, regardless of ownership 

type. Estimated payments are forecast to 

increase from 2.4 percent for voluntary 

hospices to 2.8 percent for government 

hospices. 

4. Hospice Base 

Column 3 demonstrates the effect of 

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

comparing estimated payments for FY 

2009 to FY 2008. Estimated payments 

are anticipated to decrease by 0.5 

percent for skilled nursing facilities, but 

to increase for home health agency and 

hospital based facilities. Freestanding 

facilities are anticipated to experience 

no change in estimated payments. 

Column 4 shows the combined effects 

of reducing the BNAF by 25 percent and 

updating the raw pre-floor, prereclassified hospital wage index values, 

comparing FY 2009 to FY 2008 

estimated payments. Skilled nursing 

facility based hospices are estimated to 

see a 1.6 percent decline, while hospital 

based hospices and home health agency 

based hospices are each anticipated to 

experience a 1.0 percent decrease in 

payments. Freestanding hospices are 

expected to experience a 1.1 percent 

decrease. 

Column 5 shows the combined effects 

of the 25 percent BNAF reduction, the 

updated raw pre-floor, pre-reclassified 

hospital wage index, and the 3.6 percent 

FY 2009 market basket update on 

estimated payments, comparing FY 

2009 to FY 2008. Estimated increases in 

payments range from 2.0 percent for 

skilled nursing facility based hospices 

to 2.6 percent for home health agency 

based hospices and hospital based 

hospices. 

We note that the President’s budget 

includes a proposal for a zero percent 

payment update for hospices in FY 

2009. The impacts outlined in Column 

5 of Table 2 in this final rule, which 

include the effects of a 3.6 percent FY 

2009 market basket update, would need 

to change to reflect any legislation that 

the Congress might enact which would 

affect the market basket update. 

C. Accounting Statement 

As required by OMB Circular A–4 

(available at http:// 

www.whitehouse.gov/omb/circulars/ 

a004/a-4.pdf), in Table 3 below, we 

have prepared an accounting statement 

showing the classification of the 

expenditures associated with the final 

provisions of this rule. This table 

provides our best estimate of the 

decrease in Medicare payments under 

the hospice benefit as a result of the 

changes presented in this final rule on 

data for 3,111 hospices in our database. 

All expenditures are classified as 

transfers to Medicare providers (that is, 

hospices). 

TABLE 3—ACCOUNTING STATEMENT: 

CLASSIFICATION OF ESTIMATED EXPENDITURES, FROM FY 2008 TO FY 

2009 

[In millions] 

Category Transfers 

Annualized Monetized 

Transfers.

$¥100 * 

From Whom to Whom Federal Government 

to Hospices 

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

and the updated wage data. It does not include the market basket update of 3.6 percent. 

In accordance with the provisions of 

Executive Order 12866, this regulation 

was reviewed by the Office of 

Management and Budget. 

List of Subjects in 42 CFR Part 418 

Health facilities, Health professions, 

Medicare, and Reporting and 

recordkeeping requirements. 

■ For the reasons set forth in the 

preamble, the Centers for Medicare and 

Medicare Services amends 42 CFR 

chapter IV as set forth below: 

PART 418—HOSPICE CARE 

■ 1. The authority citation for part 418 

continues to read as follows: 

Authority: Secs 1102 and 1871 of the 

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

1395hh). 

Subpart G—Payment for Hospice Care 

■ 2. Section § 418.306 is amended by 

revising paragraph (c) to read as follows: 

§ 418.306 Determination of payment rates. 

* * * * * 

(c) Adjustment for wage differences. 

Each hospice’s labor market is 

determined based on definitions of 

Metropolitan Statistical Areas (MSAs) 

issued by OMB. CMS will issue 

annually, in the Federal Register, a 

hospice wage index based on the most 

current available CMS hospital wage 

data, including changes to the definition 

of MSAs. The urban and rural area 

geographic classifications are defined in 

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

chapter. The payment rates established 

by CMS are adjusted by the 

intermediary to reflect local differences 


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in wages according to the revised wage 

data. 

* * * * * 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: July 18, 2008. 

Kerry Weems, 

Acting Administrator, Centers for Medicare 

& Medicaid Services. 

Approved: July 24, 2008. 

Michael O. Leavitt, 

Secretary. 

Note: The following Addenda will not 

appear in the Code of Federal Regulations. 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

10180 ....... Abilene, TX ........................................................................................................................................................................ 0.8352 

Callahan County, TX 

Jones County, TX 

Taylor County, TX 

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

Aguada Municipio, PR 

Aguadilla Municipio, PR 

An ̃asco Municipio, PR 

Isabela Municipio, PR 

Lares Municipio, PR 

Moca Municipio, PR 

Rinco ́n Municipio, PR 

San Sebastia ́n Municipio, PR 

10420 ....... Akron, OH ......................................................................................................................................................................... 0.9231 

Portage County, OH 

Summit County, OH 

10500 ....... Albany, GA ........................................................................................................................................................................ 0.8937 

Baker County, GA 

Dougherty County, GA 

Lee County, GA 

Terrell County, GA 

Worth County, GA 

10580 ....... Albany-Schenectady-Troy, NY .......................................................................................................................................... 0.9015 

Albany County, NY 

Rensselaer County, NY 

Saratoga County, NY 

Schenectady County, NY 

Schoharie County, NY 

10740 ....... Albuquerque, NM .............................................................................................................................................................. 1.0029 

Bernalillo County, NM 

Sandoval County, NM 

Torrance County, NM 

Valencia County, NM 

10780 ....... Alexandria, LA ................................................................................................................................................................... 0.8375 

Grant Parish, LA 

Rapides Parish, LA 

10900 ....... Allentown-Bethlehem-Easton, PA-NJ ............................................................................................................................... 1.0355 

Warren County, NJ 

Carbon County, PA 

Lehigh County, PA 

Northampton County, PA 

11020 ....... Altoona, PA ....................................................................................................................................................................... 0.9046 

Blair County, PA 

11100 ....... Amarillo, TX ....................................................................................................................................................................... 0.9569 

Armstrong County, TX 

Carson County, TX 

Potter County, TX 

Randall County, TX 

11180 ....... Ames, IA ............................................................................................................................................................................ 1.0545 

Story County, IA 

11260 ....... Anchorage, AK .................................................................................................................................................................. 1.2505 

Anchorage Municipality, AK 

Matanuska-Susitna Borough, AK 

11300 ....... Anderson, IN ..................................................................................................................................................................... 0.9266 

Madison County, IN 

11340 ....... Anderson, SC .................................................................................................................................................................... 0.9537 

Anderson County, SC 

11460 ....... Ann Arbor, MI .................................................................................................................................................................... 1.1063 

Washtenaw County, MI 

11500 ....... Anniston-Oxford, AL .......................................................................................................................................................... 0.8320 


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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Calhoun County, AL 

11540 ....... Appleton, WI ...................................................................................................................................................................... 1.0075 

Calumet County, WI 

Outagamie County, WI 

11700 ....... Asheville, NC ..................................................................................................................................................................... 0.9641 

Buncombe County, NC 

Haywood County, NC 

Henderson County, NC 

Madison County, NC 

12020 ....... Athens-Clarke County, GA ................................................................................................................................................ 1.1040 

Clarke County, GA 

Madison County, GA 

Oconee County, GA 

Oglethorpe County, GA 

12060 ....... Atlanta-Sandy Springs-Marietta, GA ................................................................................................................................. 1.0316 

Barrow County, GA 

Bartow County, GA 

Butts County, GA 

Carroll County, GA 

Cherokee County, GA 

Clayton County, GA 

Cobb County, GA 

Coweta County, GA 

Dawson County, GA 

DeKalb County, GA 

Douglas County, GA 

Fayette County, GA 

Forsyth County, GA 

Fulton County, GA 

Gwinnett County, GA 

Haralson County, GA 

Heard County, GA 

Henry County, GA 

Jasper County, GA 

Lamar County, GA 

Meriwether County, GA 

Newton County, GA 

Paulding County, GA 

Pickens County, GA 

Pike County, GA 

Rockdale County, GA 

Spalding County, GA 

Walton County, GA 

12100 ....... Atlantic City, NJ ................................................................................................................................................................. 1.2804 

Atlantic County, NJ 

12220 ....... Auburn-Opelika, AL ........................................................................................................................................................... 0.8492 

Lee County, AL 

12260 ....... Augusta-Richmond County, GA-SC .................................................................................................................................. 1.0124 

Burke County, GA 

Columbia County, GA 

McDuffie County, GA 

Richmond County, GA 

Aiken County, SC 

Edgefield County, SC 

12420 ....... Austin-Round Rock, TX .................................................................................................................................................... 1.0018 

Bastrop County, TX 

Caldwell County, TX 

Hays County, TX 

Travis County, TX 

Williamson County, TX 

12540 ....... Bakersfield, CA ................................................................................................................................................................. 1.1600 

Kern County, CA 

12580 ....... Baltimore-Towson, MD ...................................................................................................................................................... 1.0638 

Anne Arundel County, MD 

Baltimore County, MD 

Carroll County, MD 

Harford County, MD 

Howard County, MD 

Queen Anne’s County, MD 

Baltimore City, MD 

12620 ....... Bangor, ME ....................................................................................................................................................................... 1.0474 


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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Penobscot County, ME 

12700 ....... Barnstable Town, MA ........................................................................................................................................................ 1.3229 

Barnstable County, MA 

12940 ....... Baton Rouge, LA ............................................................................................................................................................... 0.8433 

Ascension Parish, LA 

East Baton Rouge Parish, LA 

East Feliciana Parish, LA 

Iberville Parish, LA 

Livingston Parish, LA 

Pointe Coupee Parish, LA 

St. Helena Parish, LA 

West Baton Rouge Parish, LA 

West Feliciana Parish, LA 

12980 ....... Battle Creek, MI ................................................................................................................................................................ 1.0685 

Calhoun County, MI 

13020 ....... Bay City, MI ....................................................................................................................................................................... 0.9339 

Bay County, MI 

13140 ....... Beaumont-Port Arthur, TX ................................................................................................................................................ 0.8955 

Hardin County, TX 

Jefferson County, TX 

Orange County, TX 

13380 ....... Bellingham, WA ................................................................................................................................................................. 1.2044 

Whatcom County, WA 

13460 ....... Bend, OR .......................................................................................................................................................................... 1.1486 

Deschutes County, OR 

13644 ....... Bethesda-Frederick-Gaithersburg, MD ............................................................................................................................. 1.1033 

Frederick County, MD 

Montgomery County, MD 

13740 ....... Billings, MT ........................................................................................................................................................................ 0.9097 

Carbon County, MT 

Yellowstone County, MT 

13780 ....... Binghamton, NY ................................................................................................................................................................ 0.9394 

Broome County, NY 

Tioga County, NY 

13820 ....... Birmingham-Hoover, AL .................................................................................................................................................... 0.9340 

Bibb County, AL 

Blount County, AL 

Chilton County, AL 

Jefferson County, AL 

St. Clair County, AL 

Shelby County, AL 

Walker County, AL 

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

Burleigh County, ND 

Morton County, ND 

13980 ....... Blacksburg-Christiansburg-Radford, VA ........................................................................................................................... 0.8599 

Giles County, VA 

Montgomery County, VA 

Pulaski County, VA 

Radford City, VA 

14020 ....... Bloomington, IN ................................................................................................................................................................. 0.9358 

Greene County, IN 

Monroe County, IN 

Owen County, IN 

14060 ....... Bloomington-Normal, IL .................................................................................................................................................... 0.9788 

McLean County, IL 

14260 ....... Boise City-Nampa, ID ....................................................................................................................................................... 0.9935 

Ada County, ID 

Boise County, ID 

Canyon County, ID 

Gem County, ID 

Owyhee County, ID 

14484 ....... Boston-Quincy, MA ........................................................................................................................................................... 1.2378 

Norfolk County, MA 

Plymouth County, MA 

Suffolk County, MA 

14500 ....... Boulder, CO ...................................................................................................................................................................... 1.0944 

Boulder County, CO 

14540 ....... Bowling Green, KY ............................................................................................................................................................ 0.8564 

Edmonson County, KY 

Warren County, KY 


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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

14740 ....... Bremerton-Silverdale, WA ................................................................................................................................................. 1.1446 

Kitsap County, WA 

14860 ....... Bridgeport-Stamford-Norwalk, CT ..................................................................................................................................... 1.3368 

Fairfield County, CT 

15180 ....... Brownsville-Harlingen, TX ................................................................................................................................................. 0.9357 

Cameron County, TX 

15260 ....... Brunswick, GA ................................................................................................................................................................... 0.9946 

Brantley County, GA 

Glynn County, GA 

McIntosh County, GA 

15380 ....... Buffalo-Niagara Falls, NY ................................................................................................................................................. 1.0043 

Erie County, NY 

Niagara County, NY 

15500 ....... Burlington, NC ................................................................................................................................................................... 0.9182 

Alamance County, NC 

15540 ....... Burlington-South Burlington, VT ....................................................................................................................................... 1.0140 

Chittenden County, VT 

Franklin County, VT 

Grand Isle County, VT 

15764 ....... Cambridge-Newton-Framingham, MA ............................................................................................................................... 1.1772 

Middlesex County, MA 

15804 ....... Camden, NJ ...................................................................................................................................................................... 1.0928 

Burlington County, NJ 

Camden County, NJ 

Gloucester County, NJ 

15940 ....... Canton-Massillon, OH ....................................................................................................................................................... 0.9379 

Carroll County, OH 

Stark County, OH 

15980 ....... Cape Coral-Fort Myers, FL ............................................................................................................................................... 0.9863 

Lee County, FL 

16180 ....... Carson City, NV ................................................................................................................................................................ 1.0500 

16220 ....... Casper, WY ....................................................................................................................................................................... 0.9851 

Natrona County, WY 

16300 ....... Cedar Rapids, IA ............................................................................................................................................................... 0.9292 

Benton County, IA 

Jones County, IA 

Linn County, IA 

16580 ....... Champaign-Urbana, IL ...................................................................................................................................................... 0.9859 

Champaign County, IL 

Ford County, IL 

Piatt County, IL 

16620 ....... Charleston, WV ................................................................................................................................................................. 0.8701 

Boone County, WV 

Clay County, WV 

Kanawha County, WV 

Lincoln County, WV 

Putnam County, WV 

16700 ....... Charleston-North Charleston, SC ..................................................................................................................................... 0.9577 

Berkeley County, SC 

Charleston County, SC 

Dorchester County, SC 

16740 ....... Charlotte-Gastonia-Concord, NC-SC ................................................................................................................................ 0.9993 

Anson County, NC 

Cabarrus County, NC 

Gaston County, NC 

Mecklenburg County, NC 

Union County, NC 

York County, SC 

16820 ....... Charlottesville, VA ............................................................................................................................................................. 0.9738 

Albemarle County, VA 

Fluvanna County, VA 

Greene County, VA 

Nelson County, VA 

Charlottesville City, VA 

16860 ....... Chattanooga, TN-GA ........................................................................................................................................................ 0.9441 

Catoosa County, GA 

Dade County, GA 

Walker County, GA 

Hamilton County, TN 

Marion County, TN 

Sequatchie County, TN 


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Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46491 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

16940 ....... Cheyenne, WY .................................................................................................................................................................. 0.9771 

Laramie County, WY 

16974 ....... Chicago-Naperville-Joliet, IL ............................................................................................................................................. 1.1247 

Cook County, IL 

DeKalb County, IL 

DuPage County, IL 

Grundy County, IL 

Kane County, IL 

Kendall County, IL 

McHenry County, IL 

Will County, IL 

17020 ....... Chico, CA .......................................................................................................................................................................... 1.1851 

Butte County, CA 

17140 ....... Cincinnati-Middletown, OH-KY-IN ..................................................................................................................................... 1.0270 

Dearborn County, IN 

Franklin County, IN 

Ohio County, IN 

Boone County, KY 

Bracken County, KY 

Campbell County, KY 

Gallatin County, KY 

Grant County, KY 

Kenton County, KY 

Pendleton County, KY 

Brown County, OH 

Butler County, OH 

Clermont County, OH 

Hamilton County, OH 

Warren County, OH 

17300 ....... Clarksville, TN-KY ............................................................................................................................................................. 0.8661 

Christian County, KY 

Trigg County, KY 

Montgomery County, TN 

Stewart County, TN 

17420 ....... Cleveland, TN ................................................................................................................................................................... 0.8452 

Bradley County, TN 

Polk County, TN 

17460 ....... Cleveland-Elyria-Mentor, OH ............................................................................................................................................ 0.9803 

Cuyahoga County, OH 

Geauga County, OH 

Lake County, OH 

Lorain County, OH 

Medina County, OH 

17660 ....... Coeur d’Alene, ID .............................................................................................................................................................. 1.0006 

Kootenai County, ID 

17780 ....... College Station-Bryan, TX ................................................................................................................................................ 0.9823 

Brazos County, TX 

Burleson County, TX 

Robertson County, TX 

17820 ....... Colorado Springs, CO ....................................................................................................................................................... 1.0202 

El Paso County, CO 

Teller County, CO 

17860 ....... Columbia, MO ................................................................................................................................................................... 0.9088 

Boone County, MO 

Howard County, MO 

17900 ....... Columbia, SC .................................................................................................................................................................... 0.9237 

Calhoun County, SC 

Fairfield County, SC 

Kershaw County, SC 

Lexington County, SC 

Richland County, SC 

Saluda County, SC 

17980 ....... Columbus, GA-AL ............................................................................................................................................................. 0.9163 

Russell County, AL 

Chattahoochee County, GA 

Harris County, GA 

Marion County, GA 

Muscogee County, GA 

18020 ....... Columbus, IN .................................................................................................................................................................... 1.0011 

Bartholomew County, IN 

18140 ....... Columbus, OH ................................................................................................................................................................... 1.0586 


pwalker on PROD1PC71 with RULES4
46492 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Delaware County, OH 

Fairfield County, OH 

Franklin County, OH 

Licking County, OH 

Madison County, OH 

Morrow County, OH 

Pickaway County, OH 

Union County, OH 

18580 ....... Corpus Christi, TX ............................................................................................................................................................. 0.9015 

Aransas County, TX 

Nueces County, TX 

San Patricio County, TX 

18700 ....... Corvallis, OR ..................................................................................................................................................................... 1.1504 

Benton County, OR 

19060 ....... Cumberland, MD-WV ........................................................................................................................................................ 0.8706 

Allegany County, MD 

Mineral County, WV 

19124 ....... Dallas-Plano-Irving, TX ..................................................................................................................................................... 1.0408 

Collin County, TX 

Dallas County, TX 

Delta County, TX 

Denton County, TX 

Ellis County, TX 

Hunt County, TX 

Kaufman County, TX 

Rockwall County, TX 

19140 ....... Dalton, GA ......................................................................................................................................................................... 0.9195 

Murray County, GA 

Whitfield County, GA 

19180 ....... Danville, IL ........................................................................................................................................................................ 0.9402 

Vermilion County, IL 

19260 ....... Danville, VA ....................................................................................................................................................................... 0.8649 

Pittsylvania County, VA 

Danville City, VA 

19340 ....... Davenport-Moline-Rock Island, IA-IL ................................................................................................................................ 0.9269 

Henry County, IL 

Mercer County, IL 

Rock Island County, IL 

Scott County, IA 

19380 ....... Dayton, OH ....................................................................................................................................................................... 0.9647 

Greene County, OH 

Miami County, OH 

Montgomery County, OH 

Preble County, OH 

19460 ....... Decatur, AL ....................................................................................................................................................................... 0.8277 

Lawrence County, AL 

Morgan County, AL 

19500 ....... Decatur, IL ......................................................................................................................................................................... 0.8475 

Macon County, IL 

19660 ....... Deltona-Daytona Beach-Ormond Beach, FL .................................................................................................................... 0.9480 

Volusia County, FL 

19740 ....... Denver-Aurora, CO ........................................................................................................................................................... 1.1251 

Adams County, CO 

Arapahoe County, CO 

Broomfield County, CO 

Clear Creek County, CO 

Denver County, CO 

Douglas County, CO 

Elbert County, CO 

Gilpin County, CO 

Jefferson County, CO 

Park County, CO 

19780 ....... Des Moines-West Des Moines, IA .................................................................................................................................... 0.9684 

Dallas County, IA 

Guthrie County, IA 

Madison County, IA 

Polk County, IA 

Warren County, IA 

19804 ....... Detroit-Livonia-Dearborn, MI ............................................................................................................................................. 1.0496 

Wayne County, MI 

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


pwalker on PROD1PC71 with RULES4
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46493 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Geneva County, AL 

Henry County, AL 

Houston County, AL 

20100 ....... Dover, DE .......................................................................................................................................................................... 1.0601 

Kent County, DE 

20220 ....... Dubuque, IA ...................................................................................................................................................................... 0.9508 

Dubuque County, IA 

20260 ....... Duluth, MN-WI ................................................................................................................................................................... 1.0471 

Carlton County, MN 

St. Louis County, MN 

Douglas County, WI 

20500 ....... Durham, NC ...................................................................................................................................................................... 1.0304 

Chatham County, NC 

Durham County, NC 

Orange County, NC 

Person County, NC 

20740 ....... Eau Claire, WI ................................................................................................................................................................... 0.9946 

Chippewa County, WI 

Eau Claire County, WI 

20764 ....... Edison, NJ ......................................................................................................................................................................... 1.1737 

Middlesex County, NJ 

Monmouth County, NJ 

Ocean County, NJ 

Somerset County, NJ 

20940 ....... El Centro, CA .................................................................................................................................................................... 0.9357 

Imperial County, CA 

21060 ....... Elizabethtown, KY ............................................................................................................................................................. 0.9144 

Hardin County, KY 

Larue County, KY 

21140 ....... Elkhart-Goshen, IN ............................................................................................................................................................ 1.0089 

Elkhart County, IN 

21300 ....... Elmira, NY ......................................................................................................................................................................... 0.8675 

Chemung County, NY 

21340 ....... El Paso, TX ....................................................................................................................................................................... 0.9436 

El Paso County, TX 

21500 ....... Erie, PA ............................................................................................................................................................................. 0.8917 

Erie County, PA 

21660 ....... Eugene-Springfield, OR .................................................................................................................................................... 1.1475 

Lane County, OR 

21780 ....... Evansville, IN-KY .............................................................................................................................................................. 0.9092 

Gibson County, IN 

Posey County, IN 

Vanderburgh County, IN 

Warrick County, IN 

Henderson County, KY 

Webster County, KY 

21820 ....... Fairbanks, AK .................................................................................................................................................................... 1.1599 

Fairbanks North Star Borough, AK 

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

Ceiba Municipio, PR 

Fajardo Municipio, PR 

Luquillo Municipio, PR 

22020 ....... Fargo, ND-MN ................................................................................................................................................................... 0.8442 

Cass County, ND 

Clay County, MN 

22140 ....... Farmington, NM ................................................................................................................................................................ 1.0063 

San Juan County, NM 

22180 ....... Fayetteville, NC ................................................................................................................................................................. 0.9834 

Cumberland County, NC 

Hoke County, NC 

22220 ....... Fayetteville-Springdale-Rogers, AR-MO ........................................................................................................................... 0.9176 

Benton County, AR 

Madison County, AR 

Washington County, AR 

McDonald County, MO 

22380 ....... Flagstaff, AZ ...................................................................................................................................................................... 1.2268 

Coconino County, AZ 

22420 ....... Flint, MI ............................................................................................................................................................................. 1.1778 

Genesee County, MI 

22500 ....... Florence, SC ..................................................................................................................................................................... 0.8659 

Darlington County, SC 


pwalker on PROD1PC71 with RULES4
46494 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Florence County, SC 

22520 ....... Florence-Muscle Shoals, AL ............................................................................................................................................. 0.8062 

Colbert County, AL 

Lauderdale County, AL 

22540 ....... Fond du Lac, WI ............................................................................................................................................................... 1.0147 

Fond du Lac County, WI 

22660 ....... Fort Collins-Loveland, CO ................................................................................................................................................. 1.0389 

Larimer County, CO 

22744 ....... Fort Lauderdale-Pompano Beach-Deerfield Beach, FL .................................................................................................... 1.0737 

Broward County, FL 

22900 ....... Fort Smith, AR-OK ............................................................................................................................................................ 0.8327 

Crawford County, AR 

Franklin County, AR 

Sebastian County, AR 

Le Flore County, OK 

Sequoyah County, OK 

23020 ....... Fort Walton Beach-Crestview-Destin, FL .......................................................................................................................... 0.9177 

Okaloosa County, FL 

23060 ....... Fort Wayne, IN .................................................................................................................................................................. 0.9745 

Allen County, IN 

Wells County, IN 

Whitley County, IN 

23104 ....... Fort Worth-Arlington, TX ................................................................................................................................................... 1.0175 

Johnson County, TX 

Parker County, TX 

Tarrant County, TX 

Wise County, TX 

23420 ....... Fresno, CA ........................................................................................................................................................................ 1.1539 

Fresno County, CA 

23460 ....... Gadsden, AL ..................................................................................................................................................................... 0.8564 

Etowah County, AL 

23540 ....... Gainesville, FL .................................................................................................................................................................. 0.9653 

Alachua County, FL 

Gilchrist County, FL 

23580 ....... Gainesville, GA ................................................................................................................................................................. 0.9674 

Hall County, GA 

23844 ....... Gary, IN ............................................................................................................................................................................. 0.9682 

Jasper County, IN 

Lake County, IN 

Newton County, IN 

Porter County, IN 

24020 ....... Glens Falls, NY ................................................................................................................................................................. 0.8666 

Warren County, NY 

Washington County, NY 

24140 ....... Goldsboro, NC .................................................................................................................................................................. 0.9750 

Wayne County, NC 

24220 ....... Grand Forks, ND-MN ........................................................................................................................................................ 0.8273 

Polk County, MN 

Grand Forks County, ND 

24300 ....... Grand Junction, CO .......................................................................................................................................................... 1.0354 

Mesa County, CO 

24340 ....... Grand Rapids-Wyoming, MI .............................................................................................................................................. 0.9778 

Barry County, MI 

Ionia County, MI 

Kent County, MI 

Newaygo County, MI 

24500 ....... Great Falls, MT ................................................................................................................................................................. 0.9106 

Cascade County, MT 

24540 ....... Greeley, CO ...................................................................................................................................................................... 1.0138 

Weld County, CO 

24580 ....... Green Bay, WI .................................................................................................................................................................. 1.0210 

Brown County, WI 

Kewaunee County, WI 

Oconto County, WI 

24660 ....... Greensboro-High Point, NC .............................................................................................................................................. 0.9458 

Guilford County, NC 

Randolph County, NC 

Rockingham County, NC 

24780 ....... Greenville, NC ................................................................................................................................................................... 0.9869 

Greene County, NC 

Pitt County, NC 


pwalker on PROD1PC71 with RULES4
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46495 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

24860 ....... Greenville-Mauldin-Easley, SC ......................................................................................................................................... 1.0350 

Greenville County, SC 

Laurens County, SC 

Pickens County, SC 

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

Arroyo Municipio, PR 

Guayama Municipio, PR 

Patillas Municipio, PR 

25060 ....... Gulfport-Biloxi, MS ............................................................................................................................................................ 0.9209 

Hancock County, MS 

Harrison County, MS 

Stone County, MS 

25180 ....... Hagerstown-Martinsburg, MD–WV ................................................................................................................................... 0.9461 

Washington County, MD 

Berkeley County, WV 

Morgan County, WV 

25260 ....... Hanford-Corcoran, CA ...................................................................................................................................................... 1.1021 

Kings County, CA 

25420 ....... Harrisburg-Carlisle, PA ..................................................................................................................................................... 0.9741 

Cumberland County, PA 

Dauphin County, PA 

Perry County, PA 

25500 ....... Harrisonburg, VA ............................................................................................................................................................... 0.9308 

Rockingham County, VA 

Harrisonburg City, VA 

25540 ....... Hartford-West Hartford-East Hartford, CT ........................................................................................................................ 1.1504 

Hartford County, CT 

Middlesex County, CT 

Tolland County, CT 

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

Forrest County, MS 

Lamar County, MS 

Perry County, MS 

25860 ....... Hickory-Lenoir-Morganton, NC ......................................................................................................................................... 0.9477 

Alexander County, NC 

Burke County, NC 

Caldwell County, NC 

Catawba County, NC 

25980 ....... Hinesville-Fort Stewart, GA3 ............................................................................................................................................. 0.9644 

Liberty County, GA 

Long County, GA 

26100 ....... Holland-Grand Haven, MI ................................................................................................................................................. 0.9454 

Ottawa County, MI 

26180 ....... Honolulu, HI ...................................................................................................................................................................... 1.2130 

Honolulu County, HI 

26300 ....... Hot Springs, AR ................................................................................................................................................................ 0.9562 

Garland County, AR 

26380 ....... Houma-Bayou Cane-Thibodaux, LA ................................................................................................................................. 0.8284 

Lafourche Parish, LA 

Terrebonne Parish, LA 

26420 ....... Houston-Sugar Land-Baytown, TX ................................................................................................................................... 1.0433 

Austin County, TX 

Brazoria County, TX 

Chambers County, TX 

Fort Bend County, TX 

Galveston County, TX 

Harris County, TX 

Liberty County, TX 

Montgomery County, TX 

San Jacinto County, TX 

Waller County, TX 

26580 ....... Huntington-Ashland, WV-KY-OH ...................................................................................................................................... 0.9490 

Boyd County, KY 

Greenup County, KY 

Lawrence County, OH 

Cabell County, WV 

Wayne County, WV 

26620 ....... Huntsville, AL .................................................................................................................................................................... 0.9600 

Limestone County, AL 

Madison County, AL 

26820 ....... Idaho Falls, ID ................................................................................................................................................................... 0.9724 


pwalker on PROD1PC71 with RULES4
46496 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Bonneville County, ID 

Jefferson County, ID 

26900 ....... Indianapolis-Carmel, IN ..................................................................................................................................................... 1.0333 

Boone County, IN 

Brown County, IN 

Hamilton County, IN 

Hancock County, IN 

Hendricks County, IN 

Johnson County, IN 

Marion County, IN 

Morgan County, IN 

Putnam County, IN 

Shelby County, IN 

26980 ....... Iowa City, IA ...................................................................................................................................................................... 1.0043 

Johnson County, IA 

Washington County, IA 

27060 ....... Ithaca, NY ......................................................................................................................................................................... 1.0109 

Tompkins County, NY 

27100 ....... Jackson, MI ....................................................................................................................................................................... 0.9793 

Jackson County, MI 

27140 ....... Jackson, MS ...................................................................................................................................................................... 0.8409 

Copiah County, MS 

Hinds County, MS 

Madison County, MS 

Rankin County, MS 

Simpson County, MS 

27180 ....... Jackson, TN ...................................................................................................................................................................... 0.9107 

Chester County, TN 

Madison County, TN 

27260 ....... Jacksonville, FL ................................................................................................................................................................. 0.9469 

Baker County, FL 

Clay County, FL 

Duval County, FL 

Nassau County, FL 

St. Johns County, FL 

27340 ....... Jacksonville, NC ................................................................................................................................................................ 0.8480 

Onslow County, NC 

27500 ....... Janesville, WI .................................................................................................................................................................... 1.0184 

Rock County, WI 

27620 ....... Jefferson City, MO ............................................................................................................................................................ 0.8899 

Callaway County, MO 

Cole County, MO 

Moniteau County, MO 

Osage County, MO 

27740 ....... Johnson City, TN .............................................................................................................................................................. 0.8058 

Carter County, TN 

Unicoi County, TN 

Washington County, TN 

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

Cambria County, PA 

27860 ....... Jonesboro, AR .................................................................................................................................................................. 0.8177 

Craighead County, AR 

Poinsett County, AR 

27900 ....... Joplin, MO ......................................................................................................................................................................... 0.9396 

Jasper County, MO 

Newton County, MO 

28020 ....... Kalamazoo-Portage, MI .................................................................................................................................................... 1.0951 

Kalamazoo County, MI 

Van Buren County, MI 

28100 ....... Kankakee-Bradley, IL ........................................................................................................................................................ 1.0747 

Kankakee County, IL 

28140 ....... Kansas City, MO-KS ......................................................................................................................................................... 0.9976 

Franklin County, KS 

Johnson County, KS 

Leavenworth County, KS 

Linn County, KS 

Miami County, KS 

Wyandotte County, KS 

Bates County, MO 

Caldwell County, MO 

Cass County, MO 


pwalker on PROD1PC71 with RULES4
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46497 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Clay County, MO 

Clinton County, MO 

Jackson County, MO 

Lafayette County, MO 

Platte County, MO 

Ray County, MO 

28420 ....... Kennewick-Richland-Pasco, WA ....................................................................................................................................... 1.0576 

Benton County, WA 

Franklin County, WA 

28660 ....... Killeen-Temple-Fort Hood, TX .......................................................................................................................................... 0.8659 

Bell County, TX 

Coryell County, TX 

Lampasas County, TX 

28700 ....... Kingsport-Bristol-Bristol, TN-VA ........................................................................................................................................ 0.8039 

Hawkins County, TN 

Sullivan County, TN 

Bristol City, VA 

Scott County, VA 

Washington County, VA 

28740 ....... Kingston, NY ..................................................................................................................................................................... 1.0031 

Ulster County, NY 

28940 ....... Knoxville, TN ..................................................................................................................................................................... 0.8435 

Anderson County, TN 

Blount County, TN 

Knox County, TN 

Loudon County, TN 

Union County, TN 

29020 ....... Kokomo, IN ....................................................................................................................................................................... 1.0068 

Howard County, IN 

Tipton County, IN 

29100 ....... La Crosse, WI-MN ............................................................................................................................................................ 1.0166 

Houston County, MN 

La Crosse County, WI 

29140 ....... Lafayette, IN ...................................................................................................................................................................... 0.9310 

Benton County, IN 

Carroll County, IN 

Tippecanoe County, IN 

29180 ....... Lafayette, LA ..................................................................................................................................................................... 0.8657 

Lafayette Parish, LA 

St. Martin Parish, LA 

29340 ....... Lake Charles, LA .............................................................................................................................................................. 0.8163 

Calcasieu Parish, LA 

Cameron Parish, LA 

29404 ....... Lake County-Kenosha County, IL-WI ............................................................................................................................... 1.1130 

Lake County, IL 

Kenosha County, WI 

29420 ....... Lake Havasu City-Kingman, AZ ........................................................................................................................................ 0.9797 

Mohave County, AZ 

29460 ....... Lakeland, FL ..................................................................................................................................................................... 0.9091 

Polk County, FL 

29540 ....... Lancaster, PA .................................................................................................................................................................... 0.9712 

Lancaster County, PA 

29620 ....... Lansing-East Lansing, MI ................................................................................................................................................. 1.0622 

Clinton County, MI 

Eaton County, MI 

Ingham County, MI 

29700 ....... Laredo, TX ........................................................................................................................................................................ 0.8495 

Webb County, TX 

29740 ....... Las Cruces, NM ................................................................................................................................................................ 0.9107 

Dona Ana County, NM 

29820 ....... Las Vegas-Paradise, NV ................................................................................................................................................... 1.2385 

Clark County, NV 

29940 ....... Lawrence, KS .................................................................................................................................................................... 0.8636 

Douglas County, KS 

30020 ....... Lawton, OK ....................................................................................................................................................................... 0.8424 

Comanche County, OK 

30140 ....... Lebanon, PA ..................................................................................................................................................................... 0.8599 

Lebanon County, PA 

30300 ....... Lewiston, ID-WA ............................................................................................................................................................... 0.9924 

Nez Perce County, ID 

Asotin County, WA 


pwalker on PROD1PC71 with RULES4
46498 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

30340 ....... Lewiston-Auburn, ME ........................................................................................................................................................ 0.9650 

Androscoggin County, ME 

30460 ....... Lexington-Fayette, KY ....................................................................................................................................................... 0.9648 

Bourbon County, KY 

Clark County, KY 

Fayette County, KY 

Jessamine County, KY 

Scott County, KY 

Woodford County, KY 

30620 ....... Lima, OH ........................................................................................................................................................................... 0.9892 

Allen County, OH 

30700 ....... Lincoln, NE ........................................................................................................................................................................ 1.0550 

Lancaster County, NE 

Seward County, NE 

30780 ....... Little Rock-North Little Rock-Conway, AR ........................................................................................................................ 0.9303 

Faulkner County, AR 

Grant County, AR 

Lonoke County, AR 

Perry County, AR 

Pulaski County, AR 

Saline County, AR 

30860 ....... Logan, UT-ID ..................................................................................................................................................................... 0.9639 

Franklin County, ID 

Cache County, UT 

30980 ....... Longview, TX .................................................................................................................................................................... 0.9150 

Gregg County, TX 

Rusk County, TX 

Upshur County, TX 

31020 ....... Longview, WA ................................................................................................................................................................... 1.1365 

Cowlitz County, WA 

31084 ....... Los Angeles-Long Beach-Glendale, CA ........................................................................................................................... 1.2356 

Los Angeles County, CA 

31140 ....... Louisville, KY-IN ................................................................................................................................................................ 0.9515 

Clark County, IN 

Floyd County, IN 

Harrison County, IN 

Washington County, IN 

Bullitt County, KY 

Henry County, KY 

Jefferson County, KY 

Meade County, KY 

Nelson County, KY 

Oldham County, KY 

Shelby County, KY 

Spencer County, KY 

Trimble County, KY 

31180 ....... Lubbock, TX ...................................................................................................................................................................... 0.9111 

Crosby County, TX 

Lubbock County, TX 

31340 ....... Lynchburg, VA ................................................................................................................................................................... 0.9166 

Amherst County, VA 

Appomattox County, VA 

Bedford County, VA 

Campbell County, VA 

Bedford City, VA 

Lynchburg City, VA 

31420 ....... Macon, GA ........................................................................................................................................................................ 1.0015 

Bibb County, GA 

Crawford County, GA 

Jones County, GA 

Monroe County, GA 

Twiggs County, GA 

31460 ....... Madera, CA ....................................................................................................................................................................... 0.8470 

Madera County, CA 

31540 ....... Madison, WI ...................................................................................................................................................................... 1.1478 

Columbia County, WI 

Dane County, WI 

Iowa County, WI 

31700 ....... Manchester-Nashua, NH ................................................................................................................................................... 1.0783 

Hillsborough County, NH 

31900 ....... Mansfield, OH ................................................................................................................................................................... 0.9732 


pwalker on PROD1PC71 with RULES4
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46499 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Richland County, OH 

32420 ....... Mayagu ̈ez, PR ................................................................................................................................................................... 0.4268 

Hormigueros Municipio, PR 

Mayagu ̈ez Municipio, PR 

32580 ....... McAllen-Edinburg-Pharr, TX ............................................................................................................................................. 0.9576 

Hidalgo County, TX 

32780 ....... Medford, OR ...................................................................................................................................................................... 1.0831 

Jackson County, OR 

32820 ....... Memphis, TN-MS-AR ........................................................................................................................................................ 0.9710 

Crittenden County, AR 

DeSoto County, MS 

Marshall County, MS 

Tate County, MS 

Tunica County, MS 

Fayette County, TN 

Shelby County, TN 

Tipton County, TN 

32900 ....... Merced, CA ....................................................................................................................................................................... 1.2722 

Merced County, CA 

33124 ....... Miami-Miami Beach-Kendall, FL ....................................................................................................................................... 1.0499 

Miami-Dade County, FL 

33140 ....... Michigan City-La Porte, IN ................................................................................................................................................ 0.9357 

LaPorte County, IN 

33260 ....... Midland, TX ....................................................................................................................................................................... 1.0515 

Midland County, TX 

33340 ....... Milwaukee-Waukesha-West Allis, WI ................................................................................................................................ 1.0722 

Milwaukee County, WI 

Ozaukee County, WI 

Washington County, WI 

Waukesha County, WI 

33460 ....... Minneapolis-St. Paul-Bloomington, MN-WI ....................................................................................................................... 1.1644 

Anoka County, MN 

Carver County, MN 

Chisago County, MN 

Dakota County, MN 

Hennepin County, MN 

Isanti County, MN 

Ramsey County, MN 

Scott County, MN 

Sherburne County, MN 

Washington County, MN 

Wright County, MN 

Pierce County, WI 

St. Croix County, WI 

33540 ....... Missoula, MT ..................................................................................................................................................................... 0.9398 

Missoula County, MT 

33660 ....... Mobile, AL ......................................................................................................................................................................... 0.8432 

Mobile County, AL 

33700 ....... Modesto, CA ..................................................................................................................................................................... 1.2556 

Stanislaus County, CA 

33740 ....... Monroe, LA ........................................................................................................................................................................ 0.8221 

Ouachita Parish, LA 

Union Parish, LA 

33780 ....... Monroe, MI ........................................................................................................................................................................ 0.9882 

Monroe County, MI 

33860 ....... Montgomery, AL ................................................................................................................................................................ 0.8490 

Autauga County, AL 

Elmore County, AL 

Lowndes County, AL 

Montgomery County, AL 

34060 ....... Morgantown, WV ............................................................................................................................................................... 0.8734 

Monongalia County, WV 

Preston County, WV 

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

Grainger County, TN 

Hamblen County, TN 

Jefferson County, TN 

34580 ....... Mount Vernon-Anacortes, WA .......................................................................................................................................... 1.1052 

Skagit County, WA 

34620 ....... Muncie, IN ......................................................................................................................................................................... 0.8622 

Delaware County, IN 


pwalker on PROD1PC71 with RULES4
46500 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

34740 ....... Muskegon-Norton Shores, MI ........................................................................................................................................... 1.0325 

Muskegon County, MI 

34820 ....... Myrtle Beach-Conway-North Myrtle Beach, SC ................................................................................................................ 0.9063 

Horry County, SC 

34900 ....... Napa, CA ........................................................................................................................................................................... 1.5195 

Napa County, CA 

34940 ....... Naples-Marco Island, FL ................................................................................................................................................... 0.9958 

Collier County, FL 

34980 ....... Nashville-Davidson-Murfreesboro-Franklin, TN ................................................................................................................ 1.0170 

Cannon County, TN 

Cheatham County, TN 

Davidson County, TN 

Dickson County, TN 

Hickman County, TN 

Macon County, TN 

Robertson County, TN 

Rutherford County, TN 

Smith County, TN 

Sumner County, TN 

Trousdale County, TN 

Williamson County, TN 

Wilson County, TN 

35004 ....... Nassau-Suffolk, NY ........................................................................................................................................................... 1.3268 

Nassau County, NY 

Suffolk County, NY 

35084 ....... Newark-Union, NJ-PA ....................................................................................................................................................... 1.2451 

Essex County, NJ 

Hunterdon County, NJ 

Morris County, NJ 

Sussex County, NJ 

Union County, NJ 

Pike County, PA 

35300 ....... New Haven-Milford, CT ..................................................................................................................................................... 1.2461 

New Haven County, CT 

35380 ....... New Orleans-Metairie-Kenner, LA .................................................................................................................................... 0.9339 

Jefferson Parish, LA 

Orleans Parish, LA 

Plaquemines Parish, LA 

St. Bernard Parish, LA 

St. Charles Parish, LA 

St. John the Baptist Parish, LA 

St. Tammany Parish, LA 

35644 ....... New York-Wayne-White Plains, NY-NJ ............................................................................................................................ 1.3767 

Bergen County, NJ 

Hudson County, NJ 

Passaic County, NJ 

Bronx County, NY 

Kings County, NY 

New York County, NY 

Putnam County, NY 

Queens County, NY 

Richmond County, NY 

Rockland County, NY 

Westchester County, NY 

35660 ....... Niles-Benton Harbor, MI ................................................................................................................................................... 0.9595 

Berrien County, MI 

35980 ....... Norwich-New London, CT ................................................................................................................................................. 1.2000 

New London County, CT 

36084 ....... Oakland-Fremont-Hayward, CA ........................................................................................................................................ 1.6464 

Alameda County, CA 

Contra Costa County, CA 

36100 ....... Ocala, FL ........................................................................................................................................................................... 0.9056 

Marion County, FL 

36140 ....... Ocean City, NJ .................................................................................................................................................................. 1.1534 

Cape May County, NJ 

36220 ....... Odessa, TX ....................................................................................................................................................................... 1.0541 

Ector County, TX 

36260 ....... Ogden-Clearfield, UT ........................................................................................................................................................ 0.9447 

Davis County, UT 

Morgan County, UT 

Weber County, UT 


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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

36420 ....... Oklahoma City, OK ........................................................................................................................................................... 0.9253 

Canadian County, OK 

Cleveland County, OK 

Grady County, OK 

Lincoln County, OK 

Logan County, OK 

McClain County, OK 

Oklahoma County, OK 

36500 ....... Olympia, WA ..................................................................................................................................................................... 1.2084 

Thurston County, WA 

36540 ....... Omaha-Council Bluffs, NE-IA ........................................................................................................................................... 1.0036 

Harrison County, IA 

Mills County, IA 

Pottawattamie County, IA 

Cass County, NE 

Douglas County, NE 

Sarpy County, NE 

Saunders County, NE 

Washington County, NE 

36740 ....... Orlando, FL ....................................................................................................................................................................... 0.9684 

Lake County, FL 

Orange County, FL 

Osceola County, FL 

Seminole County, FL 

36780 ....... Oshkosh-Neenah, WI ........................................................................................................................................................ 1.0026 

Winnebago County, WI 

36980 ....... Owensboro, KY ................................................................................................................................................................. 0.9082 

Daviess County, KY 

Hancock County, KY 

McLean County, KY 

37100 ....... Oxnard-Thousand Oaks-Ventura, CA ............................................................................................................................... 1.2441 

Ventura County, CA 

37340 ....... Palm Bay-Melbourne-Titusville, FL ................................................................................................................................... 0.9788 

Brevard County, FL 

37380 ....... Palm Coast, FL ................................................................................................................................................................. 0.9389 

Flagler County, FL 

37460 ....... Panama City-Lynn Haven, FL ........................................................................................................................................... 0.8726 

Bay County, FL 

37620 ....... Parkersburg-Marietta, WV-OH .......................................................................................................................................... 0.8508 

Washington County, OH 

Pleasants County, WV 

Wirt County, WV 

Wood County, WV 

37700 ....... Pascagoula, MS ................................................................................................................................................................ 0.9077 

George County, MS 

Jackson County, MS 

37764 ....... Peabody, MA ..................................................................................................................................................................... 1.1179 

Essex County, MA 

37860 ....... Pensacola-Ferry Pass-Brent, FL ....................................................................................................................................... 0.8692 

Escambia County, FL 

Santa Rosa County, FL 

37900 ....... Peoria, IL ........................................................................................................................................................................... 0.9761 

Marshall County, IL 

Peoria County, IL 

Stark County, IL 

Tazewell County, IL 

Woodford County, IL 

37964 ....... Philadelphia, PA ................................................................................................................................................................ 1.1468 

Bucks County, PA 

Chester County, PA 

Delaware County, PA 

Montgomery County, PA 

Philadelphia County, PA 

38060 ....... Phoenix-Mesa-Scottsdale, AZ ........................................................................................................................................... 1.0774 

Maricopa County, AZ 

Pinal County, AZ 

38220 ....... Pine Bluff, AR .................................................................................................................................................................... 0.8229 

Cleveland County, AR 

Jefferson County, AR 

Lincoln County, AR 

38300 ....... Pittsburgh, PA ................................................................................................................................................................... 0.8949 


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46502 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Allegheny County, PA 

Armstrong County, PA 

Beaver County, PA 

Butler County, PA 

Fayette County, PA 

Washington County, PA 

Westmoreland County, PA 

38340 ....... Pittsfield, MA ..................................................................................................................................................................... 1.0592 

Berkshire County, MA 

38540 ....... Pocatello, ID ...................................................................................................................................................................... 0.9935 

Bannock County, ID 

Power County, ID 

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

Juana Dı ́az Municipio, PR 

Ponce Municipio, PR 

Villalba Municipio, PR 

38860 ....... Portland-South Portland-Biddeford, ME ............................................................................................................................ 1.0541 

Cumberland County, ME 

Sagadahoc County, ME 

York County, ME 

38900 ....... Portland-Vancouver-Beaverton, OR-WA .......................................................................................................................... 1.2069 

Clackamas County, OR 

Columbia County, OR 

Multnomah County, OR 

Washington County, OR 

Yamhill County, OR 

Clark County, WA 

Skamania County, WA 

38940 ....... Port St. Lucie, FL .............................................................................................................................................................. 1.0514 

Martin County, FL 

St. Lucie County, FL 

39100 ....... Poughkeepsie-Newburgh-Middletown, NY ........................................................................................................................ 1.1528 

Dutchess County, NY 

Orange County, NY 

39140 ....... Prescott, AZ ...................................................................................................................................................................... 1.0518 

Yavapai County, AZ 

39300 ....... Providence-New Bedford-Fall River, RI-MA ..................................................................................................................... 1.1099 

Bristol County, MA 

Bristol County, RI 

Kent County, RI 

Newport County, RI 

Providence County, RI 

Washington County, RI 

39340 ....... Provo-Orem, UT ................................................................................................................................................................ 1.0032 

Juab County, UT 

Utah County, UT 

39380 ....... Pueblo, CO ........................................................................................................................................................................ 0.9291 

Pueblo County, CO 

39460 ....... Punta Gorda, FL ............................................................................................................................................................... 0.9714 

Charlotte County, FL 

39540 ....... Racine, WI ......................................................................................................................................................................... 0.9970 

Racine County, WI 

39580 ....... Raleigh-Cary, NC .............................................................................................................................................................. 1.0328 

Franklin County, NC 

Johnston County, NC 

Wake County, NC 

39660 ....... Rapid City, SD .................................................................................................................................................................. 0.9249 

Meade County, SD 

Pennington County, SD 

39740 ....... Reading, PA ...................................................................................................................................................................... 0.9821 

Berks County, PA 

39820 ....... Redding, CA ...................................................................................................................................................................... 1.4214 

Shasta County, CA 

39900 ....... Reno-Sparks, NV .............................................................................................................................................................. 1.1247 

Storey County, NV 

Washoe County, NV 

40060 ....... Richmond, VA ................................................................................................................................................................... 0.9893 

Amelia County, VA 

Caroline County, VA 

Charles City County, VA 

Chesterfield County, VA 


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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

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 ............................................................................................................................. 1.1652 

Riverside County, CA 

San Bernardino County, CA 

40220 ....... Roanoke, VA ..................................................................................................................................................................... 0.9123 

Botetourt County, VA 

Craig County, VA 

Franklin County, VA 

Roanoke County, VA 

Roanoke City, VA 

Salem City, VA 

40340 ....... Rochester, MN .................................................................................................................................................................. 1.1289 

Dodge County, MN 

Olmsted County, MN 

Wabasha County, MN 

40380 ....... Rochester, NY ................................................................................................................................................................... 0.9298 

Livingston County, NY 

Monroe County, NY 

Ontario County, NY 

Orleans County, NY 

Wayne County, NY 

40420 ....... Rockford, IL ....................................................................................................................................................................... 1.0302 

Boone County, IL 

Winnebago County, IL 

40484 ....... Rockingham County-Strafford County, NH ....................................................................................................................... 1.0613 

Rockingham County, NH 

Strafford County, NH 

40580 ....... Rocky Mount, NC .............................................................................................................................................................. 0.9448 

Edgecombe County, NC 

Nash County, NC 

40660 ....... Rome, GA ......................................................................................................................................................................... 0.9491 

Floyd County, GA 

40900 ....... Sacramento—Arden-Arcade—Roseville, CA .................................................................................................................... 1.4176 

El Dorado County, CA 

Placer County, CA 

Sacramento County, CA 

Yolo County, CA 

40980 ....... Saginaw-Saginaw Township North, MI ............................................................................................................................. 0.9250 

Saginaw County, MI 

41060 ....... St. Cloud, MN .................................................................................................................................................................... 1.1073 

Benton County, MN 

Stearns County, MN 

41100 ....... St. George, UT .................................................................................................................................................................. 0.9823 

Washington County, UT 

41140 ....... St. Joseph, MO-KS ........................................................................................................................................................... 0.9197 

Doniphan County, KS 

Andrew County, MO 

Buchanan County, MO 

DeKalb County, MO 

41180 ....... St. Louis, MO-IL ................................................................................................................................................................ 0.9472 

Bond County, IL 

Calhoun County, IL 

Clinton County, IL 

Jersey County, IL 

Macoupin County, IL 

Madison County, IL 


pwalker on PROD1PC71 with RULES4
46504 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Monroe County, IL 

St. Clair County, IL 

Crawford County, MO 

Franklin County, MO 

Jefferson County, MO 

Lincoln County, MO 

St. Charles County, MO 

St. Louis County, MO 

Warren County, MO 

Washington County, MO 

St. Louis City, MO 

41420 ....... Salem, OR ......................................................................................................................................................................... 1.1097 

Marion County, OR 

Polk County, OR 

41500 ....... Salinas, CA ....................................................................................................................................................................... 1.5509 

Monterey County, CA 

41540 ....... Salisbury, MD .................................................................................................................................................................... 0.9441 

Somerset County, MD 

Wicomico County, MD 

41620 ....... Salt Lake City, UT ............................................................................................................................................................. 0.9866 

Salt Lake County, UT 

Summit County, UT 

Tooele County, UT 

41660 ....... San Angelo, TX ................................................................................................................................................................. 0.9005 

Irion County, TX 

Tom Green County, TX 

41700 ....... San Antonio, TX ................................................................................................................................................................ 0.9273 

Atascosa County, TX 

Bandera County, TX 

Bexar County, TX 

Comal County, TX 

Guadalupe County, TX 

Kendall County, TX 

Medina County, TX 

Wilson County, TX 

41740 ....... San Diego-Carlsbad-San Marcos, CA .............................................................................................................................. 1.2063 

San Diego County, CA 

41780 ....... Sandusky, OH ................................................................................................................................................................... 0.9260 

Erie County, OH 

41884 ....... San Francisco-San Mateo-Redwood City, CA .................................................................................................................. 1.5950 

Marin County, CA 

San Francisco County, CA 

San Mateo County, CA 

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

Cabo Rojo Municipio, PR 

Lajas Municipio, PR 

Sabana Grande Municipio, PR 

San Germa ́n Municipio, PR 

41940 ....... San Jose-Sunnyvale-Santa Clara, CA .............................................................................................................................. 1.6517 

San Benito County, CA 

Santa Clara County, CA 

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

Aguas Buenas Municipio, PR 

Aibonito Municipio, PR 

Arecibo Municipio, PR 

Barceloneta Municipio, PR 

Barranquitas Municipio, PR 

Bayamo ́n Municipio, PR 

Caguas Municipio, PR 

Camuy Municipio, PR 

Cano ́vanas Municipio, PR 

Carolina Municipio, PR 

Catan ̃o Municipio, PR 

Cayey Municipio, PR 

Ciales Municipio, PR 

Cidra Municipio, PR 

Comer ́ıo Municipio, PR 

Corozal Municipio, PR 

Dorado Municipio, PR 

Florida Municipio, PR 

Guaynabo Municipio, PR 


pwalker on PROD1PC71 with RULES4
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ADDENDUM A—FINAL HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

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 ................................................................................................................................... 1.3109 

San Luis Obispo County, CA 

42044 ....... Santa Ana-Anaheim-Irvine, CA ......................................................................................................................................... 1.2351 

Orange County, CA 

42060 ....... Santa Barbara-Santa Maria-Goleta, CA ........................................................................................................................... 1.2296 

Santa Barbara County, CA 

42100 ....... Santa Cruz-Watsonville, CA ............................................................................................................................................. 1.6923 

Santa Cruz County, CA 

42140 ....... Santa Fe, NM .................................................................................................................................................................... 1.1267 

Santa Fe County, NM 

42220 ....... Santa Rosa-Petaluma, CA ................................................................................................................................................ 1.5426 

Sonoma County, CA 

42260 ....... Sarasota-Bradenton-Venice, FL ........................................................................................................................................ 1.0427 

Manatee County, FL 

Sarasota County, FL 

42340 ....... Savannah, GA ................................................................................................................................................................... 0.9585 

Bryan County, GA 

Chatham County, GA 

Effingham County, GA 

42540 ....... Scranton—Wilkes-Barre, PA ............................................................................................................................................. 0.8877 

Lackawanna County, PA 

Luzerne County, PA 

Wyoming County, PA 

42644 ....... Seattle-Bellevue-Everett, WA ............................................................................................................................................ 1.2147 

King County, WA 

Snohomish County, WA 

42680 ....... Sebastian-Vero Beach, FL ................................................................................................................................................ 0.9880 

Indian River County, FL 

43100 ....... Sheboygan, WI .................................................................................................................................................................. 0.9421 

Sheboygan County, WI 

43300 ....... Sherman-Denison, TX ....................................................................................................................................................... 0.8733 

Grayson County, TX 

43340 ....... Shreveport-Bossier City, LA .............................................................................................................................................. 0.8897 

Bossier Parish, LA 

Caddo Parish, LA 

De Soto Parish, LA 

43580 ....... Sioux City, IA-NE-SD ........................................................................................................................................................ 0.9711 

Woodbury County, IA 

Dakota County, NE 

Dixon County, NE 

Union County, SD 

43620 ....... Sioux Falls, SD ................................................................................................................................................................. 1.0038 

Lincoln County, SD 

McCook County, SD 

Minnehaha County, SD 

Turner County, SD 

43780 ....... South Bend-Mishawaka, IN-MI ......................................................................................................................................... 1.0095 

St. Joseph County, IN 

Cass County, MI 


pwalker on PROD1PC71 with RULES4
46506 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

43900 ....... Spartanburg, SC ............................................................................................................................................................... 0.9890 

Spartanburg County, SC 

44060 ....... Spokane, WA .................................................................................................................................................................... 1.0975 

Spokane County, WA 

44100 ....... Springfield, IL .................................................................................................................................................................... 0.9388 

Menard County, IL 

Sangamon County, IL 

44140 ....... Springfield, MA .................................................................................................................................................................. 1.0881 

Franklin County, MA 

Hampden County, MA 

Hampshire County, MA 

44180 ....... Springfield, MO ................................................................................................................................................................. 0.9127 

Christian County, MO 

Dallas County, MO 

Greene County, MO 

Polk County, MO 

Webster County, MO 

44220 ....... Springfield, OH .................................................................................................................................................................. 0.9126 

Clark County, OH 

44300 ....... State College, PA .............................................................................................................................................................. 0.9204 

Centre County, PA 

44700 ....... Stockton, CA ..................................................................................................................................................................... 1.2444 

San Joaquin County, CA 

44940 ....... Sumter, SC ........................................................................................................................................................................ 0.9026 

Sumter County, SC 

45060 ....... Syracuse, NY .................................................................................................................................................................... 1.0402 

Madison County, NY 

Onondaga County, NY 

Oswego County, NY 

45104 ....... Tacoma, WA ..................................................................................................................................................................... 1.1604 

Pierce County, WA 

45220 ....... Tallahassee, FL ................................................................................................................................................................. 0.9473 

Gadsden County, FL 

Jefferson County, FL 

Leon County, FL 

Wakulla County, FL 

45300 ....... Tampa-St. Petersburg-Clearwater, FL .............................................................................................................................. 0.9468 

Hernando County, FL 

Hillsborough County, FL 

Pasco County, FL 

Pinellas County, FL 

45460 ....... Terre Haute, IN ................................................................................................................................................................. 0.9243 

Clay County, IN 

Sullivan County, IN 

Vermillion County, IN 

Vigo County, IN 

45500 ....... Texarkana, TX-Texarkana, AR ......................................................................................................................................... 0.8156 

Miller County, AR 

Bowie County, TX 

45780 ....... Toledo, OH ........................................................................................................................................................................ 0.9900 

Fulton County, OH 

Lucas County, OH 

Ottawa County, OH 

Wood County, OH 

45820 ....... Topeka, KS ....................................................................................................................................................................... 0.8962 

Jackson County, KS 

Jefferson County, KS 

Osage County, KS 

Shawnee County, KS 

Wabaunsee County, KS 

45940 ....... Trenton-Ewing, NJ ............................................................................................................................................................ 1.1231 

Mercer County, NJ 

46060 ....... Tucson, AZ ........................................................................................................................................................................ 0.9704 

Pima County, AZ 

46140 ....... Tulsa, OK .......................................................................................................................................................................... 0.8754 

Creek County, OK 

Okmulgee County, OK 

Osage County, OK 

Pawnee County, OK 

Rogers County, OK 

Tulsa County, OK 


pwalker on PROD1PC71 with RULES4
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ADDENDUM A—FINAL HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Wagoner County, OK 

46220 ....... Tuscaloosa, AL ................................................................................................................................................................. 0.8716 

Greene County, AL 

Hale County, AL 

Tuscaloosa County, AL 

46340 ....... Tyler, TX ............................................................................................................................................................................ 0.9567 

Smith County, TX 

46540 ....... Utica-Rome, NY ................................................................................................................................................................ 0.8908 

Herkimer County, NY 

Oneida County, NY 

46660 ....... Valdosta, GA ..................................................................................................................................................................... 0.8500 

Brooks County, GA 

Echols County, GA 

Lanier County, GA 

Lowndes County, GA 

46700 ....... Vallejo-Fairfield, CA .......................................................................................................................................................... 1.5395 

Solano County, CA 

47020 ....... Victoria, TX ........................................................................................................................................................................ 0.8715 

Calhoun County, TX 

Goliad County, TX 

Victoria County, TX 

47220 ....... Vineland-Millville-Bridgeton, NJ ........................................................................................................................................ 1.0637 

Cumberland County, NJ 

47260 ....... Virginia Beach-Norfolk-Newport News, VA-NC ................................................................................................................ 0.9256 

Currituck County, NC 

Gloucester County, VA 

Isle of Wight County, VA 

James City County, VA 

Mathews County, VA 

Surry County, VA 

York County, VA 

Chesapeake City, VA 

Hampton City, VA 

Newport News City, VA 

Norfolk City, VA 

Poquoson City, VA 

Portsmouth City, VA 

Suffolk City, VA 

Virginia Beach City, VA 

Williamsburg City, VA 

47300 ....... Visalia-Porterville, CA ....................................................................................................................................................... 1.0592 

Tulare County, CA 

47380 ....... Waco, TX .......................................................................................................................................................................... 0.8941 

McLennan County, TX 

47580 ....... Warner Robins, GA ........................................................................................................................................................... 0.9582 

Houston County, GA 

47644 ....... Warren-Troy-Farmington Hills, MI ..................................................................................................................................... 1.0498 

Lapeer County, MI 

Livingston County, MI 

Macomb County, MI 

Oakland County, MI 

St. Clair County, MI 

47894 ....... Washington-Arlington-Alexandria, DC-VA-MD-WV ........................................................................................................... 1.1394 

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 


pwalker on PROD1PC71 with RULES4
46508 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Manassas Park City, VA 

Jefferson County, WV 

47940 ....... Waterloo-Cedar Falls, IA ................................................................................................................................................... 0.8942 

Black Hawk County, IA 

Bremer County, IA 

Grundy County, IA 

48140 ....... Wausau, WI ....................................................................................................................................................................... 1.0160 

Marathon County, WI 

48260 ....... Weirton-Steubenville, WV-OH ........................................................................................................................................... 0.8318 

Jefferson County, OH 

Brooke County, WV 

Hancock County, WV 

48300 ....... Wenatchee, WA ................................................................................................................................................................ 1.2039 

Chelan County, WA 

Douglas County, WA 

48424 ....... West Palm Beach-Boca Raton-Boynton Beach, FL ......................................................................................................... 1.0211 

Palm Beach County, FL 

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

Belmont County, OH 

Marshall County, WV 

Ohio County, WV 

48620 ....... Wichita, KS ........................................................................................................................................................................ 0.9512 

Butler County, KS 

Harvey County, KS 

Sedgwick County, KS 

Sumner County, KS 

48660 ....... Wichita Falls, TX ............................................................................................................................................................... 0.8314 

Archer County, TX 

Clay County, TX 

Wichita County, TX 

48700 ....... Williamsport, PA ................................................................................................................................................................ 0.8443 

Lycoming County, PA 

48864 ....... Wilmington, DE-MD-NJ ..................................................................................................................................................... 1.1362 

New Castle County, DE 

Cecil County, MD 

Salem County, NJ 

48900 ....... Wilmington, NC ................................................................................................................................................................. 0.9878 

Brunswick County, NC 

New Hanover County, NC 

Pender County, NC 

49020 ....... Winchester, VA-WV .......................................................................................................................................................... 1.0406 

Frederick County, VA 

Winchester City, VA 

Hampshire County, WV 

49180 ....... Winston-Salem, NC ........................................................................................................................................................... 0.9571 

Davie County, NC 

Forsyth County, NC 

Stokes County, NC 

Yadkin County, NC 

49340 ....... Worcester, MA .................................................................................................................................................................. 1.1848 

Worcester County, MA 

49420 ....... Yakima, WA ...................................................................................................................................................................... 1.0777 

Yakima County, WA 

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

Gua ́nica Municipio, PR 

Guayanilla Municipio, PR 

Pen ̃uelas Municipio, PR 

Yauco Municipio, PR 

49620 ....... York-Hanover, PA ............................................................................................................................................................. 0.9824 

York County, PA 

49660 ....... Youngstown-Warren-Boardman, OH-PA .......................................................................................................................... 0.9449 

Mahoning County, OH 

Trumbull County, OH 

Mercer County, PA 

49700 ....... Yuba City, CA ................................................................................................................................................................... 1.1290 

Sutter County, CA 

Yuba County, CA 

49740 ....... Yuma, AZ .......................................................................................................................................................................... 0.9959 


pwalker on PROD1PC71 with RULES4
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46509 

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

CBSA code Urban area (constituent counties) 2 Wage 

index 1

Yuma County, AZ 

1Wage index values are based on FY 2004 hospital cost report data before reclassification. These data form the basis for the raw pre-floor, 

pre-reclassified hospital wage index. The budget neutrality adjustment or the hospice floor is then applied to the raw pre-floor, pre-reclassified 

hospital wage index to derive the hospice wage index. Wage index values greater than or equal to 0.8 are subject to a budget neutrality adjustment. The hospice floor calculation is as follows: Wage index values below 0.8 are adjusted to be the greater of either (a) the 25 percent reduced budget neutrality adjustment OR (b) the minimum of the raw pre-floor, pre-reclassified hospital wage index value × 1.15, or 0.8000. For 

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

ADDENDUM B—FINAL HOSPICE WAGE

INDEX FOR RURAL AREAS BY

CBSA—FY 2009 

CBSA 

code Nonurban area Wage index 

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

2 ........ Alaska ............................ 1.2711 

3 ........ Arizona .......................... 0.8900 

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

5 ........ California ....................... 1.2620 

6 ........ Colorado ........................ 1.0186 

7 ........ Connecticut .................... 1.1672 

8 ........ Delaware ....................... 1.0210 

10 ...... Florida ............................ 0.8886 

11 ...... Georgia .......................... 0.8040 

12 ...... Hawaii ............................ 1.1139 

13 ...... Idaho .............................. 0.8314 

14 ...... Illinois ............................. 0.8749 

15 ...... Indiana ........................... 0.9002 

16 ...... Iowa ............................... 0.8992 

17 ...... Kansas ........................... 0.8378 

18 ...... Kentucky ........................ 0.8180 

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

20 ...... Maine ............................. 0.8897 

21 ...... Maryland ........................ 0.9483 

ADDENDUM B—FINAL HOSPICE WAGE

INDEX FOR RURAL AREAS BY

CBSA—FY 2009—Continued 

CBSA 

code Nonurban area Wage index 

22 ...... Massachusetts 1 ............ 1.2164 

23 ...... Michigan ........................ 0.9398 

24 ...... Minnesota ...................... 0.9530 

25 ...... Mississippi ..................... 0.8083 

26 ...... Missouri ......................... 0.8324 

27 ...... Montana ......................... 0.8795 

28 ...... Nebraska ....................... 0.9289 

29 ...... Nevada .......................... 0.9733 

30 ...... New Hampshire ............. 1.0990 

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

32 ...... New Mexico ................... 0.9384 

33 ...... New York ....................... 0.8679 

34 ...... North Carolina ............... 0.9030 

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

36 ...... Ohio ............................... 0.9147 

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

38 ...... Oregon ........................... 1.0398 

39 ...... Pennsylvania ................. 0.8802 

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

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

ADDENDUM B—FINAL HOSPICE WAGE

INDEX FOR RURAL AREAS BY

CBSA—FY 2009—Continued 

CBSA 

code Nonurban area Wage index 

42 ...... South Carolina ............... 0.9086 

43 ...... South Dakota ................. 0.8974 

44 ...... Tennessee ..................... 0.8107 

45 ...... Texas ............................. 0.8364 

46 ...... Utah ............................... 0.8519 

47 ...... Vermont ......................... 1.0412 

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

49 ...... Virginia ........................... 0.8288 

50 ...... Washington .................... 1.0769 

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

52 ...... Wisconsin ...................... 1.0147 

53 ...... Wyoming ........................ 0.9748 

65 ...... Guam ............................. 1.0089 

1There are no hospitals in the rural areas of 

Massachusetts, so the wage index value used 

is the average wage index value for the contiguous counties. 2There are no rural areas in this state. 

3Wage index values are obtained using the 

methodology described in the rule. 

ADDENDUM C—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2008 AND FY 2009 HOSPICE WAGE INDICES

[For illustrative purposes only] 

FY2008 FY2009 FY09–

FY08 

Percent 

chng 

Rural Area 

1 ........................... Alabama ........................................................................................................ 0.7591 0.7533 ¥0.0058 ¥0.76 

2 ........................... Alaska ........................................................................................................... 1.0661 1.2109 0.1448 13.58 

3 ........................... Arizona .......................................................................................................... 0.8908 0.8479 ¥0.0429 ¥4.82 

4 ........................... Arkansas ....................................................................................................... 0.7307 0.7371 0.0064 0.88 

5 ........................... California ....................................................................................................... 1.1454 1.2023 0.0569 4.97 

6 ........................... Colorado ........................................................................................................ 0.9325 0.9704 0.0379 4.06 

7 ........................... Connecticut ................................................................................................... 1.1709 1.1119 ¥0.0590 ¥5.04 

8 ........................... Delaware ....................................................................................................... 0.9705 0.9727 0.0022 0.23 

10 ......................... Florida ........................................................................................................... 0.8594 0.8465 ¥0.0129 ¥1.50 

11 ......................... Georgia ......................................................................................................... 0.7593 0.7659 0.0066 0.87 

12 ......................... Hawaii ........................................................................................................... 1.0448 1.0612 0.0164 1.57 

13 ......................... Idaho ............................................................................................................. 0.8120 0.7920 ¥0.0200 ¥2.46 

14 ......................... Illinois ............................................................................................................ 0.8320 0.8335 0.0015 0.18 

15 ......................... Indiana .......................................................................................................... 0.8538 0.8576 0.0038 0.45 

16 ......................... Iowa ............................................................................................................... 0.8681 0.8566 ¥0.0115 ¥1.32 

17 ......................... Kansas .......................................................................................................... 0.7998 0.7981 ¥0.0017 ¥0.21 

18 ......................... Kentucky ....................................................................................................... 0.7768 0.7793 0.0025 0.32 

19 ......................... Louisiana ....................................................................................................... 0.7438 0.7373 ¥0.0065 ¥0.87 

20 ......................... Maine ............................................................................................................ 0.8443 0.8476 0.0033 0.39 

21 ......................... Maryland ....................................................................................................... 0.8926 0.9034 0.0108 1.21 

22 ......................... Massachusetts .............................................................................................. 1.1661 1.1589 ¥0.0072 ¥0.62 

23 ......................... Michigan ........................................................................................................ 0.9062 0.8953 ¥0.0109 ¥1.20 


pwalker on PROD1PC71 with RULES4
46510 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

ADDENDUM C—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2008 AND FY 2009 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2008 FY2009 FY09–

FY08 

Percent 

chng 

24 ......................... Minnesota ...................................................................................................... 0.9153 0.9079 ¥0.0074 ¥0.81 

25 ......................... Mississippi ..................................................................................................... 0.7738 0.7700 ¥0.0038 ¥0.49 

26 ......................... Missouri ......................................................................................................... 0.7927 0.7930 0.0003 0.04 

27 ......................... Montana ........................................................................................................ 0.8590 0.8379 ¥0.0211 ¥2.46 

28 ......................... Nebraska ....................................................................................................... 0.8677 0.8849 0.0172 1.98 

29 ......................... Nevada .......................................................................................................... 0.8944 0.9272 0.0328 3.67 

30 ......................... New Hampshire ............................................................................................ 1.0853 1.0470 ¥0.0383 ¥3.53 

32 ......................... New Mexico .................................................................................................. 0.8332 0.8940 0.0608 7.30 

33 ......................... New York ...................................................................................................... 0.8232 0.8268 0.0036 0.44 

34 ......................... North Carolina ............................................................................................... 0.8588 0.8603 0.0015 0.17 

35 ......................... North Dakota ................................................................................................. 0.7215 0.7182 ¥0.0033 ¥0.46 

36 ......................... Ohio ............................................................................................................... 0.8658 0.8714 0.0056 0.65 

37 ......................... Oklahoma ...................................................................................................... 0.7629 0.7492 ¥0.0137 ¥1.80 

38 ......................... Oregon .......................................................................................................... 0.9753 0.9906 0.0153 1.57 

39 ......................... Pennsylvania ................................................................................................. 0.8320 0.8385 0.0065 0.78 

40 ......................... Puerto Rico ................................................................................................... 0.4047 0.4047 0.0000 0.00 

42 ......................... South Carolina .............................................................................................. 0.8566 0.8656 0.0090 1.05 

43 ......................... South Dakota ................................................................................................ 0.8480 0.8549 0.0069 0.81 

44 ......................... Tennessee .................................................................................................... 0.7827 0.7723 ¥0.0104 ¥1.33 

45 ......................... Texas ............................................................................................................ 0.7965 0.7968 0.0003 0.04 

46 ......................... Utah ............................................................................................................... 0.8140 0.8116 ¥0.0024 ¥0.29 

47 ......................... Vermont ......................................................................................................... 0.9744 0.9919 0.0175 1.80 

48 ......................... Virgin Islands ................................................................................................ 0.8467 0.6830 ¥0.1637 ¥19.33 

49 ......................... Virginia .......................................................................................................... 0.7940 0.7896 ¥0.0044 ¥0.55 

50 ......................... Washington ................................................................................................... 1.0263 1.0259 ¥0.0004 ¥0.04 

51 ......................... West Virginia ................................................................................................. 0.7607 0.7454 ¥0.0153 ¥2.01 

52 ......................... Wisconsin ...................................................................................................... 0.9553 0.9667 0.0114 1.19 

53 ......................... Wyoming ....................................................................................................... 0.9295 0.9287 ¥0.0008 ¥0.09 

65 ......................... Guam ............................................................................................................ 0.9611 0.9611 0.0000 0.00 

CBSA ................... Urban Area 

10180 ................... Abilene, TX ................................................................................................... 0.8000 0.7957 ¥0.0043 ¥0.54 

10380 ................... Aguadilla-Isabela-San Sebastia ́n, PR ........................................................... 0.3915 0.3448 ¥0.0467 ¥11.93 

10420 ................... Akron, OH ..................................................................................................... 0.8654 0.8794 0.0140 1.62 

10500 ................... Albany, GA .................................................................................................... 0.8991 0.8514 ¥0.0477 ¥5.31 

10580 ................... Albany-Schenectady-Troy, NY ...................................................................... 0.8720 0.8588 ¥0.0132 ¥1.51 

10740 ................... Albuquerque, NM .......................................................................................... 0.9458 0.9554 0.0096 1.02 

10780 ................... Alexandria, LA ............................................................................................... 0.8006 0.7979 ¥0.0027 ¥0.34 

10900 ................... Allentown-Bethlehem-Easton, PA-NJ ........................................................... 0.9947 0.9865 ¥0.0082 ¥0.82 

11020 ................... Altoona, PA ................................................................................................... 0.8812 0.8618 ¥0.0194 ¥2.20 

11100 ................... Amarillo, TX .................................................................................................. 0.9169 0.9116 ¥0.0053 ¥0.58 

11180 ................... Ames, IA ....................................................................................................... 0.9760 1.0046 0.0286 2.93 

11260 ................... Anchorage, AK .............................................................................................. 1.2023 1.1913 ¥0.0110 ¥0.91 

11300 ................... Anderson, IN ................................................................................................. 0.8681 0.8827 0.0146 1.68 

11340 ................... Anderson, SC ................................................................................................ 0.9017 0.9086 0.0069 0.77 

11460 ................... Ann Arbor, MI ................................................................................................ 1.0826 1.0539 ¥0.0287 ¥2.65 

11500 ................... Anniston-Oxford, AL ...................................................................................... 0.7770 0.7926 0.0156 2.01 

11540 ................... Appleton, WI ................................................................................................. 0.9455 0.9598 0.0143 1.51 

11700 ................... Asheville, NC ................................................................................................ 0.9216 0.9185 ¥0.0031 ¥0.34 

12020 ................... Athens-Clarke County, GA ........................................................................... 0.9856 1.0517 0.0661 6.71 

12060 ................... Atlanta-Sandy Springs-Marietta, GA ............................................................. 0.9762 0.9828 0.0066 0.68 

12100 ................... Atlantic City, NJ ............................................................................................ 1.1831 1.2198 0.0367 3.10 

12220 ................... Auburn-Opelika, AL ....................................................................................... 0.8096 0.8090 ¥0.0006 ¥0.07 

12260 ................... Augusta-Richmond County, GA-SC ............................................................. 0.9667 0.9645 ¥0.0022 ¥0.23 

12420 ................... Austin-Round Rock, TX ................................................................................ 0.9344 0.9544 0.0200 2.14 

12540 ................... Bakersfield, CA ............................................................................................. 1.0725 1.1051 0.0326 3.04 

12580 ................... Baltimore-Towson, MD ................................................................................. 1.0088 1.0134 0.0046 0.46 

12620 ................... Bangor, ME ................................................................................................... 0.9711 0.9978 0.0267 2.75 

12700 ................... Barnstable Town, MA ................................................................................... 1.2539 1.2603 0.0064 0.51 

12940 ................... Baton Rouge, LA .......................................................................................... 0.8084 0.8034 ¥0.0050 ¥0.62 

12980 ................... Battle Creek, MI ............................................................................................ 0.9762 1.0179 0.0417 4.27 

13020 ................... Bay City, MI .................................................................................................. 0.9251 0.8897 ¥0.0354 ¥3.83 

13140 ................... Beaumont-Port Arthur, TX ............................................................................ 0.8595 0.8531 ¥0.0064 ¥0.74 

13380 ................... Bellingham, WA ............................................................................................ 1.1104 1.1474 0.0370 3.33 

13460 ................... Bend, OR ...................................................................................................... 1.0743 1.0942 0.0199 1.85 

13644 ................... Bethesda-Gaithersburg-Frederick, MD ......................................................... 1.0903 1.0511 ¥0.0392 ¥3.60 

13740 ................... Billings, MT ................................................................................................... 0.8712 0.8666 ¥0.0046 ¥0.53 

13780 ................... Binghamton, NY ............................................................................................ 0.8786 0.8949 0.0163 1.86 


pwalker on PROD1PC71 with RULES4
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46511 

ADDENDUM C—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2008 AND FY 2009 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2008 FY2009 FY09–

FY08 

Percent 

chng 

13820 ................... Birmingham-Hoover, AL ................................................................................ 0.8894 0.8898 0.0004 0.04 

13900 ................... Bismarck, ND ................................................................................................ 0.7240 0.7225 ¥0.0015 ¥0.21 

13980 ................... Blacksburg-Christiansburg-Radford, VA ....................................................... 0.8213 0.8192 ¥0.0021 ¥0.26 

14020 ................... Bloomington, IN ............................................................................................ 0.8533 0.8915 0.0382 4.48 

14060 ................... Bloomington-Normal, IL ................................................................................ 0.8944 0.9325 0.0381 4.26 

14260 ................... Boise City-Nampa, ID ................................................................................... 0.9401 0.9465 0.0064 0.68 

14484 ................... Boston-Quincy, MA ....................................................................................... 1.1679 1.1792 0.0113 0.97 

14500 ................... Boulder, CO .................................................................................................. 1.0350 1.0426 0.0076 0.73 

14540 ................... Bowling Green, KY ....................................................................................... 0.8148 0.8159 0.0011 0.14 

14740 ................... Bremerton-Silverdale, WA ............................................................................ 1.0913 1.0904 ¥0.0009 ¥0.08 

14860 ................... Bridgeport-Stamford-Norwalk, CT ................................................................. 1.2659 1.2735 0.0076 0.60 

15180 ................... Brownsville-Harlingen, TX ............................................................................. 0.9430 0.8914 ¥0.0516 ¥5.47 

15260 ................... Brunswick, GA .............................................................................................. 1.0164 0.9475 ¥0.0689 ¥6.78 

15380 ................... Buffalo-Niagara Falls, NY ............................................................................. 0.9424 0.9568 0.0144 1.53 

15500 ................... Burlington, NC ............................................................................................... 0.8674 0.8747 0.0073 0.84 

15540 ................... Burlington-South Burlington, VT ................................................................... 0.9474 0.9660 0.0186 1.96 

15764 ................... Cambridge-Newton-Framingham, MA .......................................................... 1.0970 1.1215 0.0245 2.23 

15804 ................... Camden, NJ .................................................................................................. 1.0392 1.0411 0.0019 0.18 

15940 ................... Canton-Massillon, OH ................................................................................... 0.9031 0.8935 ¥0.0096 ¥1.06 

15980 ................... Cape Coral-Fort Myers, FL ........................................................................... 0.9342 0.9396 0.0054 0.58 

16180 ................... Carson City, NV ............................................................................................ 1.0025 1.0003 ¥0.0022 ¥0.22 

16220 ................... Casper, WY ................................................................................................... 0.9145 0.9385 0.0240 2.62 

16300 ................... Cedar Rapids, IA .......................................................................................... 0.8888 0.8852 ¥0.0036 ¥0.41 

16580 ................... Champaign-Urbana, IL .................................................................................. 0.9644 0.9392 ¥0.0252 ¥2.61 

16620 ................... Charleston, WV ............................................................................................. 0.8542 0.8289 ¥0.0253 ¥2.96 

16700 ................... Charleston-North Charleston, SC ................................................................. 0.9145 0.9124 ¥0.0021 ¥0.23 

16740 ................... Charlotte-Gastonia-Concord, NC-SC ............................................................ 0.9554 0.9520 ¥0.0034 ¥0.36 

16820 ................... Charlottesville, VA ......................................................................................... 1.0125 0.9277 ¥0.0848 ¥8.38 

16860 ................... Chattanooga, TN-GA .................................................................................... 0.8948 0.8994 0.0046 0.51 

16940 ................... Cheyenne, WY .............................................................................................. 0.9060 0.9308 0.0248 2.74 

16974 ................... Chicago-Naperville-Joliet, IL ......................................................................... 1.0751 1.0715 ¥0.0036 ¥0.33 

17020 ................... Chico, CA ...................................................................................................... 1.1053 1.1290 0.0237 2.14 

17140 ................... Cincinnati-Middletown, OH-KY-IN ................................................................. 0.9601 0.9784 0.0183 1.91 

17300 ................... Clarksville, TN-KY ......................................................................................... 0.8436 0.8251 ¥0.0185 ¥2.19 

17420 ................... Cleveland, TN ............................................................................................... 0.8109 0.8052 ¥0.0057 ¥0.70 

17460 ................... Cleveland-Elyria-Mentor, OH ........................................................................ 0.9400 0.9339 ¥0.0061 ¥0.65 

17660 ................... Coeur d’Alene, ID ......................................................................................... 0.9344 0.9532 0.0188 2.01 

17780 ................... College Station-Bryan, TX ............................................................................ 0.9045 0.9358 0.0313 3.46 

17820 ................... Colorado Springs, CO ................................................................................... 0.9701 0.9719 0.0018 0.19 

17860 ................... Columbia, MO ............................................................................................... 0.8542 0.8658 0.0116 1.36 

17900 ................... Columbia, SC ................................................................................................ 0.8933 0.8800 ¥0.0133 ¥1.49 

17980 ................... Columbus, GA-AL ......................................................................................... 0.8239 0.8729 0.0490 5.95 

18020 ................... Columbus, IN ................................................................................................ 0.9318 0.9537 0.0219 2.35 

18140 ................... Columbus, OH .............................................................................................. 1.0107 1.0085 ¥0.0022 ¥0.22 

18580 ................... Corpus Christi, TX ........................................................................................ 0.8564 0.8588 0.0024 0.28 

18700 ................... Corvallis, OR ................................................................................................. 1.1546 1.0959 ¥0.0587 ¥5.08 

19060 ................... Cumberland, MD-WV .................................................................................... 0.8446 0.8294 ¥0.0152 ¥1.80 

19124 ................... Dallas-Plano-Irving, TX ................................................................................. 1.0075 0.9915 ¥0.0160 ¥1.59 

19140 ................... Dalton, GA .................................................................................................... 0.9093 0.8760 ¥0.0333 ¥3.66 

19180 ................... Danville, IL .................................................................................................... 0.9266 0.8957 ¥0.0309 ¥3.33 

19260 ................... Danville, VA .................................................................................................. 0.8451 0.8240 ¥0.0211 ¥2.50 

19340 ................... Davenport-Moline-Rock Island, IA-IL ............................................................ 0.8846 0.8830 ¥0.0016 ¥0.18 

19380 ................... Dayton, OH ................................................................................................... 0.9037 0.9190 0.0153 1.69 

19460 ................... Decatur, AL ................................................................................................... 0.8159 0.7885 ¥0.0274 ¥3.36 

19500 ................... Decatur, IL .................................................................................................... 0.8172 0.8074 ¥0.0098 ¥1.20 

19660 ................... Deltona-Daytona Beach-Ormond Beach, FL ................................................ 0.9263 0.9031 ¥0.0232 ¥2.50 

19740 ................... Denver-Aurora, CO ....................................................................................... 1.0930 1.0718 ¥0.0212 ¥1.94 

19780 ................... Des Moines-West Des Moines, IA ................................................................ 0.9214 0.9226 0.0012 0.13 

19804 ................... Detroit-Livonia-Dearborn, MI ......................................................................... 1.0281 0.9999 ¥0.0282 ¥2.74 

20020 ................... Dothan, AL .................................................................................................... 0.7381 0.7270 ¥0.0111 ¥1.50 

20100 ................... Dover, DE ..................................................................................................... 0.9847 1.0099 0.0252 2.56 

20220 ................... Dubuque, IA .................................................................................................. 0.9133 0.9058 ¥0.0075 ¥0.82 

20260 ................... Duluth, MN-WI .............................................................................................. 1.0042 0.9975 ¥0.0067 ¥0.67 

20500 ................... Durham, NC .................................................................................................. 0.9826 0.9816 ¥0.0010 ¥0.10 

20740 ................... Eau Claire, WI ............................................................................................... 0.9630 0.9475 ¥0.0155 ¥1.61 

20764 ................... Edison, NJ ..................................................................................................... 1.1190 1.1181 ¥0.0009 ¥0.08 

20940 ................... El Centro, CA ................................................................................................ 0.9076 0.8914 ¥0.0162 ¥1.78 

21060 ................... Elizabethtown, KY ......................................................................................... 0.8697 0.8711 0.0014 0.16 

21140 ................... Elkhart-Goshen, IN ....................................................................................... 0.9426 0.9611 0.0185 1.96 


pwalker on PROD1PC71 with RULES4
46512 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

ADDENDUM C—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2008 AND FY 2009 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2008 FY2009 FY09–

FY08 

Percent 

chng 

21300 ................... Elmira, NY ..................................................................................................... 0.8240 0.8264 0.0024 0.29 

21340 ................... El Paso, TX ................................................................................................... 0.9053 0.8989 ¥0.0064 ¥0.71 

21500 ................... Erie, PA ......................................................................................................... 0.8827 0.8495 ¥0.0332 ¥3.76 

21604 ................... Essex County, MA ........................................................................................ 1.0418 ................ ................ ................

21660 ................... Eugene-Springfield, OR ................................................................................ 1.0876 1.0932 0.0056 0.51 

21780 ................... Evansville, IN-KY .......................................................................................... 0.9071 0.8662 ¥0.0409 ¥4.51 

21820 ................... Fairbanks, AK ............................................................................................... 1.1059 1.1050 ¥0.0009 ¥0.08 

21940 ................... Fajardo, PR ................................................................................................... 0.4036 0.4375 0.0339 8.40 

22020 ................... Fargo, ND-MN ............................................................................................... 0.8250 0.8042 ¥0.0208 ¥2.52 

22140 ................... Farmington, NM ............................................................................................ 0.8589 0.9587 0.0998 11.62 

22180 ................... Fayetteville, NC ............................................................................................. 0.8945 0.9368 0.0423 4.73 

22220 ................... Fayetteville-Springdale-Rogers, AR-MO ....................................................... 0.8865 0.8742 ¥0.0123 ¥1.39 

22380 ................... Flagstaff, AZ .................................................................................................. 1.1601 1.1687 0.0086 0.74 

22420 ................... Flint, MI ......................................................................................................... 1.0969 1.1220 0.0251 2.29 

22500 ................... Florence, SC ................................................................................................. 0.8388 0.8249 ¥0.0139 ¥1.66 

22520 ................... Florence-Muscle Shoals, AL ......................................................................... 0.7843 0.7680 ¥0.0163 ¥2.08 

22540 ................... Fond du Lac, WI ........................................................................................... 1.0063 0.9667 ¥0.0396 ¥3.94 

22660 ................... Fort Collins-Loveland, CO ............................................................................ 0.9544 0.9897 0.0353 3.70 

22744 ................... Ft Lauderdale-Pompano Beach-Deerfield, FL .............................................. 1.0133 1.0229 0.0096 0.95 

22900 ................... Fort Smith, AR-OK ........................................................................................ 0.7731 0.7933 0.0202 2.61 

23020 ................... Fort Walton Beach-Crestview-Destin, FL ..................................................... 0.8643 0.8743 0.0100 1.16 

23060 ................... Fort Wayne, IN .............................................................................................. 0.9517 0.9284 ¥0.0233 ¥2.45 

23104 ................... Fort Worth-Arlington, TX ............................................................................... 0.9569 0.9693 0.0124 1.30 

23420 ................... Fresno, CA .................................................................................................... 1.0943 1.0993 0.0050 0.46 

23460 ................... Gadsden, AL ................................................................................................. 0.8066 0.8159 0.0093 1.15 

23540 ................... Gainesville, FL .............................................................................................. 0.9277 0.9196 ¥0.0081 ¥0.87 

23580 ................... Gainesville, GA ............................................................................................. 0.8958 0.9216 0.0258 2.88 

23844 ................... Gary, IN ......................................................................................................... 0.9334 0.9224 ¥0.0110 ¥1.18 

24020 ................... Glens Falls, NY ............................................................................................. 0.8324 0.8256 ¥0.0068 ¥0.82 

24140 ................... Goldsboro, NC .............................................................................................. 0.9171 0.9288 0.0117 1.28 

24220 ................... Grand Forks, ND-MN .................................................................................... 0.7949 0.7881 ¥0.0068 ¥0.86 

24300 ................... Grand Junction, CO ...................................................................................... 0.9668 0.9864 0.0196 2.03 

24340 ................... Grand Rapids-Wyoming, MI ......................................................................... 0.9455 0.9315 ¥0.0140 ¥1.48 

24500 ................... Great Falls, MT ............................................................................................. 0.8598 0.8675 0.0077 0.90 

24540 ................... Greeley, CO .................................................................................................. 0.9602 0.9658 0.0056 0.58 

24580 ................... Green Bay, WI .............................................................................................. 0.9787 0.9727 ¥0.0060 ¥0.61 

24660 ................... Greensboro-High Point, NC .......................................................................... 0.8866 0.9010 0.0144 1.62 

24780 ................... Greenville, NC ............................................................................................... 0.9432 0.9402 ¥0.0030 ¥0.32 

24860 ................... Greenville, SC ............................................................................................... 0.9804 0.9860 0.0056 0.57 

25020 ................... Guayama, PR ............................................................................................... 0.3235 0.3064 ¥0.0171 ¥5.29 

25060 ................... Gulfport-Biloxi, MS ........................................................................................ 0.8915 0.8773 ¥0.0142 ¥1.59 

25180 ................... Hagerstown-Martinsburg, MD-WV ................................................................ 0.9038 0.9013 ¥0.0025 ¥0.28 

25260 ................... Hanford-Corcoran, CA .................................................................................. 1.0282 1.0499 0.0217 2.11 

25420 ................... Harrisburg-Carlisle, PA ................................................................................. 0.9402 0.9280 ¥0.0122 ¥1.30 

25500 ................... Harrisonburg, VA .......................................................................................... 0.9073 0.8867 ¥0.0206 ¥2.27 

25540 ................... Hartford-West Hartford-East Hartford, CT .................................................... 1.0894 1.0959 0.0065 0.60 

25620 ................... Hattiesburg, MS ............................................................................................ 0.7430 0.7366 ¥0.0064 ¥0.86 

25860 ................... Hickory-Lenoir-Morganton, NC ..................................................................... 0.9010 0.9028 0.0018 0.20 

25980 ................... Hinesville-Fort Stewart, GA .......................................................................... 0.9178 0.9187 0.0009 0.10 

26100 ................... Holland-Grand Haven, MI ............................................................................. 0.9163 0.9006 ¥0.0157 ¥1.71 

26180 ................... Honolulu, HI .................................................................................................. 1.1096 1.1556 0.0460 4.15 

26300 ................... Hot Springs, AR ............................................................................................ 0.8782 0.9109 0.0327 3.72 

26380 ................... Houma-Bayou Cane-Thibodaux, LA ............................................................. 0.8082 0.7892 ¥0.0190 ¥2.35 

26420 ................... Houston-Sugar Land-Baytown, TX ............................................................... 1.0008 0.9939 ¥0.0069 ¥0.69 

26580 ................... Huntington-Ashland, WV-KY-OH .................................................................. 0.8997 0.9041 0.0044 0.49 

26620 ................... Huntsville, AL ................................................................................................ 0.9007 0.9146 0.0139 1.54 

26820 ................... Idaho Falls, ID ............................................................................................... 0.9088 0.9264 0.0176 1.94 

26900 ................... Indianapolis-Carmel, IN ................................................................................ 0.9895 0.9844 ¥0.0051 ¥0.52 

26980 ................... Iowa City, IA .................................................................................................. 0.9714 0.9568 ¥0.0146 ¥1.50 

27060 ................... Ithaca, NY ..................................................................................................... 0.9928 0.9630 ¥0.0298 ¥3.00 

27100 ................... Jackson, MI ................................................................................................... 0.9560 0.9329 ¥0.0231 ¥2.42 

27140 ................... Jackson, MS ................................................................................................. 0.8271 0.8011 ¥0.0260 ¥3.14 

27180 ................... Jackson, TN .................................................................................................. 0.8853 0.8676 ¥0.0177 ¥2.00 

27260 ................... Jacksonville, FL ............................................................................................ 0.9165 0.9021 ¥0.0144 ¥1.57 

27340 ................... Jacksonville, NC ........................................................................................... 0.8231 0.8079 ¥0.0152 ¥1.85 

27500 ................... Janesville, WI ................................................................................................ 0.9655 0.9702 0.0047 0.49 

27620 ................... Jefferson City, MO ........................................................................................ 0.8332 0.8478 0.0146 1.75 

27740 ................... Johnson City, TN .......................................................................................... 0.8043 0.7677 ¥0.0366 ¥4.55 

27780 ................... Johnstown, PA .............................................................................................. 0.8620 0.7543 ¥0.1077 ¥12.49 


pwalker on PROD1PC71 with RULES4
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46513 

ADDENDUM C—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2008 AND FY 2009 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2008 FY2009 FY09–

FY08 

Percent 

chng 

27860 ................... Jonesboro, AR .............................................................................................. 0.7662 0.7790 0.0128 1.67 

27900 ................... Joplin, MO ..................................................................................................... 0.8605 0.8951 0.0346 4.02 

28020 ................... Kalamazoo-Portage, MI ................................................................................ 1.0704 1.0433 ¥0.0271 ¥2.53 

28100 ................... Kankakee-Bradley, IL .................................................................................... 1.0083 1.0238 0.0155 1.54 

28140 ................... Kansas City, MO-KS ..................................................................................... 0.9495 0.9504 0.0009 0.09 

28420 ................... Kennewick-Richland-Pasco, WA .................................................................. 1.0343 1.0075 ¥0.0268 ¥2.59 

28660 ................... Killeen-Temple-Fort Hood, TX ...................................................................... 0.8901 0.8249 ¥0.0652 ¥7.33 

28700 ................... Kingsport-Bristol, TN-VA ............................................................................... 0.7985 0.7658 ¥0.0327 ¥4.10 

28740 ................... Kingston, NY ................................................................................................. 0.9367 0.9556 0.0189 2.02 

28940 ................... Knoxville, TN ................................................................................................. 0.8249 0.8036 ¥0.0213 ¥2.58 

29020 ................... Kokomo, IN ................................................................................................... 0.9669 0.9591 ¥0.0078 ¥0.81 

29100 ................... La Crosse, WI-MN ........................................................................................ 0.9426 0.9685 0.0259 2.75 

29140 ................... Lafayette, IN .................................................................................................. 0.8931 0.8869 ¥0.0062 ¥0.69 

29180 ................... Lafayette, LA ................................................................................................. 0.8289 0.8247 ¥0.0042 ¥0.51 

29340 ................... Lake Charles, LA .......................................................................................... 0.7914 0.7777 ¥0.0137 ¥1.73 

29404 ................... Lake County-Kenosha County, IL-WI ........................................................... 1.0570 1.0603 0.0033 0.31 

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

29460 ................... Lakeland, FL ................................................................................................. 0.8879 0.8661 ¥0.0218 ¥2.46 

29540 ................... Lancaster, PA ............................................................................................... 0.9589 0.9252 ¥0.0337 ¥3.51 

29620 ................... Lansing-East Lansing, MI ............................................................................. 1.0088 1.0119 0.0031 0.31 

29700 ................... Laredo, TX .................................................................................................... 0.7811 0.8093 0.0282 3.61 

29740 ................... Las Cruces, NM ............................................................................................ 0.9273 0.8676 ¥0.0597 ¥6.44 

29820 ................... Las Vegas-Paradise, NV .............................................................................. 1.1430 1.1799 0.0369 3.23 

29940 ................... Lawrence, KS ................................................................................................ 0.8365 0.8227 ¥0.0138 ¥1.65 

30020 ................... Lawton, OK ................................................................................................... 0.8065 0.8025 ¥0.0040 ¥0.50 

30140 ................... Lebanon, PA ................................................................................................. 0.8679 0.8192 ¥0.0487 ¥5.61 

30300 ................... Lewiston, ID-WA ........................................................................................... 0.9853 0.9454 ¥0.0399 ¥4.05 

30340 ................... Lewiston-Auburn, ME .................................................................................... 0.9126 0.9193 0.0067 0.73 

30460 ................... Lexington-Fayette, KY .................................................................................. 0.9181 0.9191 0.0010 0.11 

30620 ................... Lima, OH ....................................................................................................... 0.9042 0.9424 0.0382 4.22 

30700 ................... Lincoln, NE .................................................................................................... 1.0092 1.0051 ¥0.0041 ¥0.41 

30780 ................... Little Rock-North Little Rock, AR .................................................................. 0.8890 0.8863 ¥0.0027 ¥0.30 

30860 ................... Logan, UT-ID ................................................................................................ 0.9022 0.9183 0.0161 1.78 

30980 ................... Longview, TX ................................................................................................ 0.8788 0.8717 ¥0.0071 ¥0.81 

31020 ................... Longview, WA ............................................................................................... 1.0011 1.0827 0.0816 8.15 

31084 ................... Los Angeles-Long Beach-Santa Ana, CA .................................................... 1.1760 1.1771 0.0011 0.09 

31140 ................... Louisville-Jefferson County, KY-IN ............................................................... 0.9118 0.9065 ¥0.0053 ¥0.58 

31180 ................... Lubbock, TX .................................................................................................. 0.8613 0.8680 0.0067 0.78 

31340 ................... Lynchburg, VA .............................................................................................. 0.8694 0.8732 0.0038 0.44 

31420 ................... Macon, GA .................................................................................................... 0.9519 0.9541 0.0022 0.23 

31460 ................... Madera, CA ................................................................................................... 0.8154 0.8069 ¥0.0085 ¥1.04 

31540 ................... Madison, WI .................................................................................................. 1.0840 1.0935 0.0095 0.88 

31700 ................... Manchester-Nashua, NH .............................................................................. 1.0243 1.0273 0.0030 0.29 

31900 ................... Mansfield, OH ............................................................................................... 0.9271 0.9271 0.0000 0.00 

32420 ................... Mayagu ̈ez, PR .............................................................................................. 0.3848 0.3711 ¥0.0137 ¥3.56 

32580 ................... McAllen-Edinburg-Mission, TX ...................................................................... 0.8773 0.9123 0.0350 3.99 

32780 ................... Medford, OR ................................................................................................. 1.0818 1.0318 ¥0.0500 ¥4.62 

32820 ................... Memphis, TN-MS-AR .................................................................................... 0.9373 0.9250 ¥0.0123 ¥1.31 

32900 ................... Merced, CA ................................................................................................... 1.1471 1.2120 0.0649 5.66 

33124 ................... Miami-Miami Beach-Kendall, FL ................................................................... 0.9812 1.0002 0.0190 1.94 

33140 ................... Michigan City-La Porte, IN ............................................................................ 0.9118 0.8914 ¥0.0204 ¥2.24 

33260 ................... Midland, TX ................................................................................................... 0.9786 1.0017 0.0231 2.36 

33340 ................... Milwaukee-Waukesha-West Allis, WI ........................................................... 1.0218 1.0214 ¥0.0004 ¥0.04 

33460 ................... Minneapolis-St. Paul-Bloomington, MN-WI .................................................. 1.0946 1.1093 0.0147 1.34 

33540 ................... Missoula, MT ................................................................................................. 0.8928 0.8953 0.0025 0.28 

33660 ................... Mobile, AL ..................................................................................................... 0.7913 0.8033 0.0120 1.52 

33700 ................... Modesto, CA ................................................................................................. 1.1729 1.1962 0.0233 1.99 

33740 ................... Monroe, LA ................................................................................................... 0.7997 0.7832 ¥0.0165 ¥2.06 

33780 ................... Monroe, MI .................................................................................................... 0.9707 0.9414 ¥0.0293 ¥3.02 

33860 ................... Montgomery, AL ............................................................................................ 0.8009 0.8088 0.0079 0.99 

34060 ................... Morgantown, WV .......................................................................................... 0.8423 0.8321 ¥0.0102 ¥1.21 

34100 ................... Morristown, TN .............................................................................................. 0.7933 0.7388 ¥0.0545 ¥6.87 

34580 ................... Mount Vernon-Anacortes, WA ...................................................................... 1.0517 1.0529 0.0012 0.11 

34620 ................... Muncie, IN ..................................................................................................... 0.8562 0.8214 ¥0.0348 ¥4.06 

34740 ................... Muskegon-Norton Shores, MI ....................................................................... 0.9941 0.9836 ¥0.0105 ¥1.06 

34820 ................... Myrtle Beach-Conway-North Myrtle Beach, SC ........................................... 0.8810 0.8634 ¥0.0176 ¥2.00 

34900 ................... Napa, CA ...................................................................................................... 1.3374 1.4476 0.1102 8.24 

34940 ................... Naples-Marco Island, FL ............................................................................... 0.9941 0.9487 ¥0.0454 ¥4.57 

34980 ................... Nashville-Davidson-Murfreesboro, TN .......................................................... 0.9847 0.9689 ¥0.0158 ¥1.60 


pwalker on PROD1PC71 with RULES4
46514 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

ADDENDUM C—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2008 AND FY 2009 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2008 FY2009 FY09–

FY08 

Percent 

chng 

35004 ................... Nassau-Suffolk, NY ....................................................................................... 1.2662 1.2640 ¥0.0022 ¥0.17 

35084 ................... Newark-Union, NJ-PA ................................................................................... 1.1892 1.1862 ¥0.0030 ¥0.25 

35300 ................... New Haven-Milford, CT ................................................................................ 1.1953 1.1871 ¥0.0082 ¥0.69 

35380 ................... New Orleans-Metairie-Kenner, LA ................................................................ 0.8831 0.8897 0.0066 0.75 

35644 ................... New York-White Plains-Wayne, NY-NJ ........................................................ 1.3177 1.3115 ¥0.0062 ¥0.47 

35660 ................... Niles-Benton Harbor, MI ............................................................................... 0.8915 0.9141 0.0226 2.54 

35980 ................... Norwich-New London, CT ............................................................................. 1.1932 1.1432 ¥0.0500 ¥4.19 

36084 ................... Oakland-Fremont-Hayward, CA .................................................................... 1.5819 1.5685 ¥0.0134 ¥0.85 

36100 ................... Ocala, FL ...................................................................................................... 0.8867 0.8627 ¥0.0240 ¥2.71 

36140 ................... Ocean City, NJ .............................................................................................. 1.0472 1.0988 0.0516 4.93 

36220 ................... Odessa, TX ................................................................................................... 1.0073 1.0042 ¥0.0031 ¥0.31 

36260 ................... Ogden-Clearfield, UT .................................................................................... 0.8995 0.9000 0.0005 0.06 

36420 ................... Oklahoma City, OK ....................................................................................... 0.8843 0.8815 ¥0.0028 ¥0.32 

36500 ................... Olympia, WA ................................................................................................. 1.1081 1.1512 0.0431 3.89 

36540 ................... Omaha-Council Bluffs, NE-IA ....................................................................... 0.9450 0.9561 0.0111 1.17 

36740 ................... Orlando-Kissimmee, FL ................................................................................ 0.9452 0.9226 ¥0.0226 ¥2.39 

36780 ................... Oshkosh-Neenah, WI .................................................................................... 0.9315 0.9551 0.0236 2.53 

36980 ................... Owensboro, KY ............................................................................................. 0.8748 0.8652 ¥0.0096 ¥1.10 

37100 ................... Oxnard-Thousand Oaks-Ventura, CA ........................................................... 1.1546 1.1852 0.0306 2.65 

37340 ................... Palm Bay-Melbourne-Titusville, FL ............................................................... 0.9443 0.9325 ¥0.0118 ¥1.25 

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

37460 ................... Panama City-Lynn Haven, FL ...................................................................... 0.8027 0.8313 0.0286 3.56 

37620 ................... Parkersburg-Marietta-Vienna, WV-OH ......................................................... 0.7977 0.8105 0.0128 1.60 

37700 ................... Pascagoula, MS ............................................................................................ 0.8215 0.8647 0.0432 5.26 

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

37860 ................... Pensacola-Ferry Pass-Brent, FL .................................................................. 0.8000 0.8281 0.0281 3.51 

37900 ................... Peoria, IL ....................................................................................................... 0.8982 0.9299 0.0317 3.53 

37964 ................... Philadelphia, PA ............................................................................................ 1.0996 1.0925 ¥0.0071 ¥0.65 

38060 ................... Phoenix-Mesa-Scottsdale, AZ ...................................................................... 1.0287 1.0264 ¥0.0023 ¥0.22 

38220 ................... Pine Bluff, AR ............................................................................................... 0.8383 0.7839 ¥0.0544 ¥6.49 

38300 ................... Pittsburgh, PA ............................................................................................... 0.8674 0.8525 ¥0.0149 ¥1.72 

38340 ................... Pittsfield, MA ................................................................................................. 1.0266 1.0091 ¥0.0175 ¥1.70 

38540 ................... Pocatello, ID .................................................................................................. 0.9400 0.9465 0.0065 0.69 

38660 ................... Ponce, PR ..................................................................................................... 0.4842 0.4450 ¥0.0392 ¥8.10 

38860 ................... Portland-South Portland-Biddeford, ME ....................................................... 0.9908 1.0042 0.0134 1.35 

38900 ................... Portland-Vancouver-Beaverton, OR-WA ...................................................... 1.1416 1.1498 0.0082 0.72 

38940 ................... Port St. Lucie-Fort Pierce, FL ....................................................................... 0.9833 1.0016 0.0183 1.86 

39100 ................... Poughkeepsie-Newburgh-Middletown, NY ................................................... 1.0911 1.0982 0.0071 0.65 

39140 ................... Prescott, AZ .................................................................................................. 0.9836 1.0020 0.0184 1.87 

39300 ................... Providence-New Bedford-Fall River, RI-MA ................................................. 1.0783 1.0574 ¥0.0209 ¥1.94 

39340 ................... Provo-Orem, UT ............................................................................................ 0.9537 0.9557 0.0020 0.21 

39380 ................... Pueblo, CO ................................................................................................... 0.8753 0.8851 0.0098 1.12 

39460 ................... Punta Gorda, FL ........................................................................................... 0.9405 0.9254 ¥0.0151 ¥1.61 

39540 ................... Racine, WI .................................................................................................... 0.9356 0.9498 0.0142 1.52 

39580 ................... Raleigh-Cary, NC .......................................................................................... 0.9864 0.9839 ¥0.0025 ¥0.25 

39660 ................... Rapid City, SD .............................................................................................. 0.8833 0.8811 ¥0.0022 ¥0.25 

39740 ................... Reading, PA .................................................................................................. 0.9622 0.9356 ¥0.0266 ¥2.76 

39820 ................... Redding, CA .................................................................................................. 1.3198 1.3541 0.0343 2.60 

39900 ................... Reno-Sparks, NV .......................................................................................... 1.1963 1.0715 ¥0.1248 ¥10.43 

40060 ................... Richmond, VA ............................................................................................... 0.9177 0.9425 0.0248 2.70 

40140 ................... Riverside-San Bernardino-Ontario, CA ......................................................... 1.0904 1.1100 0.0196 1.80 

40220 ................... Roanoke, VA ................................................................................................. 0.8647 0.8691 0.0044 0.51 

40340 ................... Rochester, MN .............................................................................................. 1.1408 1.0755 ¥0.0653 ¥5.72 

40380 ................... Rochester, NY ............................................................................................... 0.8994 0.8858 ¥0.0136 ¥1.51 

40420 ................... Rockford, IL ................................................................................................... 0.9989 0.9814 ¥0.0175 ¥1.75 

40484 ................... Rockingham County, NH .............................................................................. 1.0159 1.0111 ¥0.0048 ¥0.47 

40580 ................... Rocky Mount, NC .......................................................................................... 0.8854 0.9001 0.0147 1.66 

40660 ................... Rome, GA ..................................................................................................... 0.9193 0.9042 ¥0.0151 ¥1.64 

40900 ................... Sacramento—Arden-Arcade—Roseville, CA ................................................ 1.3372 1.3505 0.0133 0.99 

40980 ................... Saginaw-Saginaw Township North, MI ......................................................... 0.8874 0.8812 ¥0.0062 ¥0.70 

41060 ................... St. Cloud, MN ............................................................................................... 1.0362 1.0549 0.0187 1.80 

41100 ................... St. George, UT .............................................................................................. 0.9265 0.9358 0.0093 1.00 

41140 ................... St. Joseph, MO-KS ....................................................................................... 1.0118 0.8762 ¥0.1356 ¥13.40 

41180 ................... St. Louis, MO-IL ............................................................................................ 0.9005 0.9024 0.0019 0.21 

41420 ................... Salem, OR .................................................................................................... 1.0438 1.0572 0.0134 1.28 

41500 ................... Salinas, CA ................................................................................................... 1.4337 1.4775 0.0438 3.06 

41540 ................... Salisbury, MD ................................................................................................ 0.8953 0.8994 0.0041 0.46 

41620 ................... Salt Lake City, UT ......................................................................................... 0.9402 0.9399 ¥0.0003 ¥0.03 

41660 ................... San Angelo, TX ............................................................................................. 0.8362 0.8579 0.0217 2.60 


pwalker on PROD1PC71 with RULES4
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46515 

ADDENDUM C—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2008 AND FY 2009 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2008 FY2009 FY09–

FY08 

Percent 

chng 

41700 ................... San Antonio, TX ............................................................................................ 0.8844 0.8834 ¥0.0010 ¥0.11 

41740 ................... San Diego-Carlsbad-San Marcos, CA .......................................................... 1.1354 1.1492 0.0138 1.22 

41780 ................... Sandusky, OH ............................................................................................... 0.9302 0.8822 ¥0.0480 ¥5.16 

41884 ................... San Francisco-San Mateo-Redwood City, CA ............................................. 1.5165 1.5195 0.0030 0.20 

41900 ................... San Germa ́n-Cabo Rojo, PR ........................................................................ 0.4885 0.4729 ¥0.0156 ¥3.19 

41940 ................... San Jose-Sunnyvale-Santa Clara, CA ......................................................... 1.5543 1.5735 0.0192 1.24 

41980 ................... San Juan-Caguas-Guaynabo, PR ................................................................ 0.4452 0.4528 0.0076 1.71 

42020 ................... San Luis Obispo-Paso Robles, CA .............................................................. 1.1598 1.2488 0.0890 7.67 

42044 ................... Santa Ana-Anaheim-Irvine, CA ..................................................................... 1.1473 1.1766 0.0293 2.55 

42060 ................... Santa Barbara-Santa Maria, CA ................................................................... 1.1091 1.1714 0.0623 5.62 

42100 ................... Santa Cruz-Watsonville, CA ......................................................................... 1.5457 1.6122 0.0665 4.30 

42140 ................... Santa Fe, NM ................................................................................................ 1.0824 1.0734 ¥0.0090 ¥0.83 

42220 ................... Santa Rosa-Petaluma, CA ............................................................................ 1.4464 1.4696 0.0232 1.60 

42260 ................... Sarasota-Bradenton-Venice, FL ................................................................... 0.9868 0.9933 0.0065 0.66 

42340 ................... Savannah, GA ............................................................................................... 0.9351 0.9131 ¥0.0220 ¥2.35 

42540 ................... Scranton—Wilkes-Barre, PA ......................................................................... 0.8347 0.8457 0.0110 1.32 

42644 ................... Seattle-Bellevue-Everett, WA ....................................................................... 1.1434 1.1572 0.0138 1.21 

42680 ................... Sebastian-Vero Beach, FL ............................................................................ 0.9573 0.9412 ¥0.0161 ¥1.68 

43100 ................... Sheboygan, WI ............................................................................................. 0.9026 0.8975 ¥0.0051 ¥0.57 

43300 ................... Sherman-Denison, TX .................................................................................. 0.8502 0.8320 ¥0.0182 ¥2.14 

43340 ................... Shreveport-Bossier City, LA ......................................................................... 0.8865 0.8476 ¥0.0389 ¥4.39 

43580 ................... Sioux City, IA-NE-SD .................................................................................... 0.9200 0.9251 0.0051 0.55 

43620 ................... Sioux Falls, SD ............................................................................................. 0.9559 0.9563 0.0004 0.04 

43780 ................... South Bend-Mishawaka, IN-MI ..................................................................... 0.9842 0.9617 ¥0.0225 ¥2.29 

43900 ................... Spartanburg, SC ........................................................................................... 0.9174 0.9422 0.0248 2.70 

44060 ................... Spokane, WA ................................................................................................ 1.0447 1.0455 0.0008 0.08 

44100 ................... Springfield, IL ................................................................................................ 0.8890 0.8944 0.0054 0.61 

44140 ................... Springfield, MA .............................................................................................. 1.0079 1.0366 0.0287 2.85 

44180 ................... Springfield, MO ............................................................................................. 0.8469 0.8695 0.0226 2.67 

44220 ................... Springfield, OH .............................................................................................. 0.8593 0.8694 0.0101 1.18 

44300 ................... State College, PA ......................................................................................... 0.8784 0.8768 ¥0.0016 ¥0.18 

44700 ................... Stockton, CA ................................................................................................. 1.1442 1.1855 0.0413 3.61 

44940 ................... Sumter, SC ................................................................................................... 0.8083 0.8599 0.0516 6.38 

45060 ................... Syracuse, NY ................................................................................................ 0.9691 0.9910 0.0219 2.26 

45104 ................... Tacoma, WA ................................................................................................. 1.0789 1.1055 0.0266 2.47 

45220 ................... Tallahassee, FL ............................................................................................ 0.8942 0.9025 0.0083 0.93 

45300 ................... Tampa-St. Petersburg-Clearwater, FL .......................................................... 0.9144 0.9020 ¥0.0124 ¥1.36 

45460 ................... Terre Haute, IN ............................................................................................. 0.8765 0.8805 0.0040 0.46 

45500 ................... Texarkana, TX-Texarkana, AR ..................................................................... 0.8104 0.7770 ¥0.0334 ¥4.12 

45780 ................... Toledo, OH .................................................................................................... 0.9586 0.9431 ¥0.0155 ¥1.62 

45820 ................... Topeka, KS ................................................................................................... 0.8730 0.8538 ¥0.0192 ¥2.20 

45940 ................... Trenton-Ewing, NJ ........................................................................................ 1.0835 1.0699 ¥0.0136 ¥1.26 

46060 ................... Tucson, AZ .................................................................................................... 0.9202 0.9245 0.0043 0.47 

46140 ................... Tulsa, OK ...................................................................................................... 0.8103 0.8340 0.0237 2.92 

46220 ................... Tuscaloosa, AL ............................................................................................. 0.8542 0.8303 ¥0.0239 ¥2.80 

46340 ................... Tyler, TX ....................................................................................................... 0.8811 0.9114 0.0303 3.44 

46540 ................... Utica-Rome, NY ............................................................................................ 0.8396 0.8486 0.0090 1.07 

46660 ................... Valdosta, GA ................................................................................................. 0.8369 0.8098 ¥0.0271 ¥3.24 

46700 ................... Vallejo-Fairfield, CA ...................................................................................... 1.5137 1.4666 ¥0.0471 ¥3.11 

47020 ................... Victoria, TX ................................................................................................... 0.8560 0.8302 ¥0.0258 ¥3.01 

47220 ................... Vineland-Millville-Bridgeton, NJ .................................................................... 0.9832 1.0133 0.0301 3.06 

47260 ................... Virginia Beach-Norfolk-Newport News, VA .................................................. 0.8790 0.8818 0.0028 0.32 

47300 ................... Visalia-Porterville, CA ................................................................................... 0.9968 1.0091 0.0123 1.23 

47380 ................... Waco, TX ...................................................................................................... 0.8633 0.8518 ¥0.0115 ¥1.33 

47580 ................... Warner Robins, GA ....................................................................................... 0.8380 0.9128 0.0748 8.93 

47644 ................... Warren-Troy-Farmington Hills, MI ................................................................ 1.0054 1.0001 ¥0.0053 ¥0.53 

47894 ................... Washington-Arlington-Alexandria, DC-VA .................................................... 1.1054 1.0855 ¥0.0199 ¥1.80 

47940 ................... Waterloo-Cedar Falls, IA .............................................................................. 0.8408 0.8519 0.0111 1.32 

48140 ................... Wausau, WI .................................................................................................. 0.9722 0.9679 ¥0.0043 ¥0.44 

48260 ................... Weirton-Steubenville, WV-OH ...................................................................... 0.8063 0.7924 ¥0.0139 ¥1.72 

48300 ................... Wenatchee, WA ............................................................................................ 1.0346 1.1469 0.1123 10.85 

48424 ................... West Palm Beach-Boca Raton-Boynton, FL ................................................ 0.9649 0.9728 0.0079 0.82 

48540 ................... Wheeling, WV-OH ......................................................................................... 0.7010 0.6961 ¥0.0049 ¥0.70 

48620 ................... Wichita, KS ................................................................................................... 0.9063 0.9062 ¥0.0001 ¥0.01 

48660 ................... Wichita Falls, TX ........................................................................................... 0.8311 0.7920 ¥0.0391 ¥4.70 

48700 ................... Williamsport, PA ............................................................................................ 0.8139 0.8043 ¥0.0096 ¥1.18 

48864 ................... Wilmington, DE-MD-NJ ................................................................................. 1.0684 1.0824 0.0140 1.31 

48900 ................... Wilmington, NC ............................................................................................. 0.9835 0.9410 ¥0.0425 ¥4.32 

49020 ................... Winchester, VA-WV ...................................................................................... 1.0091 0.9913 ¥0.0178 ¥1.76 


pwalker on PROD1PC71 with RULES4
46516 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

ADDENDUM C—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2008 AND FY 2009 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2008 FY2009 FY09–

FY08 

Percent 

chng 

49180 ................... Winston-Salem, NC ...................................................................................... 0.9276 0.9118 ¥0.0158 ¥1.70 

49340 ................... Worcester, MA .............................................................................................. 1.0722 1.1287 0.0565 5.27 

49420 ................... Yakima, WA .................................................................................................. 0.9847 1.0267 0.0420 4.27 

49500 ................... Yauco, PR ..................................................................................................... 0.3854 0.3284 ¥0.0570 ¥14.79 

49620 ................... York-Hanover, PA ......................................................................................... 0.9397 0.9359 ¥0.0038 ¥0.40 

49660 ................... Youngstown-Warren-Boardman, OH-PA ...................................................... 0.8802 0.9002 0.0200 2.27 

49700 ................... Yuba City, CA ............................................................................................... 1.0730 1.0756 0.0026 0.24 

49740 ................... Yuma, AZ ...................................................................................................... 0.9109 0.9488 0.0379 4.16 

ADDENDUM D—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2007 AND FY 2008 HOSPICE WAGE INDICES

[For illustrative purposes only] 

FY2007 FY2008 FY08–

FY07 

Percent 

chng 

Rural Area 

1 ........................... Alabama ........................................................................................................ 0.7446 0.7591 0.0145 1.95 

2 ........................... Alaska ........................................................................................................... 1.1977 1.0661 ¥0.1316 ¥10.99 

3 ........................... Arizona .......................................................................................................... 0.8768 0.8908 0.0140 1.60 

4 ........................... Arkansas ....................................................................................................... 0.7466 0.7307 ¥0.0159 ¥2.13 

5 ........................... California ....................................................................................................... 1.1054 1.1454 0.0400 3.62 

6 ........................... Colorado ........................................................................................................ 0.9380 0.9325 ¥0.0055 ¥0.59 

7 ........................... Connecticut ................................................................................................... 1.1730 1.1709 ¥0.0021 ¥0.18 

8 ........................... Delaware ....................................................................................................... 0.9579 0.9705 0.0126 1.32 

10 ......................... Florida ........................................................................................................... 0.8568 0.8594 0.0026 0.30 

11 ......................... Georgia ......................................................................................................... 0.7662 0.7593 ¥0.0069 ¥0.90 

12 ......................... Hawaii ........................................................................................................... 1.0551 1.0448 ¥0.0103 ¥0.98 

13 ......................... Idaho ............................................................................................................. 0.8037 0.8120 0.0083 1.03 

14 ......................... Illinois ............................................................................................................ 0.8271 0.8320 0.0049 0.59 

15 ......................... Indiana .......................................................................................................... 0.8624 0.8538 ¥0.0086 ¥1.00 

16 ......................... Iowa ............................................................................................................... 0.8509 0.8681 0.0172 2.02 

17 ......................... Kansas .......................................................................................................... 0.8035 0.7998 ¥0.0037 ¥0.46 

18 ......................... Kentucky ....................................................................................................... 0.7766 0.7768 0.0002 0.03 

19 ......................... Louisiana ....................................................................................................... 0.7411 0.7438 0.0027 0.36 

20 ......................... Maine ............................................................................................................ 0.8843 0.8443 ¥0.0400 ¥4.52 

21 ......................... Maryland ....................................................................................................... 0.9353 0.8926 ¥0.0427 ¥4.57 

22 ......................... Massachusetts .............................................................................................. 1.0216 1.1661 0.1445 14.14 

23 ......................... Michigan ........................................................................................................ 0.8895 0.9062 0.0167 1.88 

24 ......................... Minnesota ...................................................................................................... 0.9132 0.9153 0.0021 0.23 

25 ......................... Mississippi ..................................................................................................... 0.7674 0.7738 0.0064 0.83 

26 ......................... Missouri ......................................................................................................... 0.7900 0.7927 0.0027 0.34 

27 ......................... Montana ........................................................................................................ 0.8762 0.8590 ¥0.0172 ¥1.96 

28 ......................... Nebraska ....................................................................................................... 0.8657 0.8677 0.0020 0.23 

29 ......................... Nevada .......................................................................................................... 0.9065 0.8944 ¥0.0121 ¥1.33 

30 ......................... New Hampshire ............................................................................................ 1.0817 1.0853 0.0036 0.33 

32 ......................... New Mexico .................................................................................................. 0.8635 0.8332 ¥0.0303 ¥3.51 

33 ......................... New York ...................................................................................................... 0.8154 0.8232 0.0078 0.96 

34 ......................... North Carolina ............................................................................................... 0.8540 0.8588 0.0048 0.56 

35 ......................... North Dakota ................................................................................................. 0.7261 0.7215 ¥0.0046 ¥0.63 

36 ......................... Ohio ............................................................................................................... 0.8826 0.8658 ¥0.0168 ¥1.90 

37 ......................... Oklahoma ...................................................................................................... 0.7581 0.7629 0.0048 0.63 

38 ......................... Oregon .......................................................................................................... 0.9826 0.9753 ¥0.0073 ¥0.74 

39 ......................... Pennsylvania ................................................................................................. 0.8291 0.8320 0.0029 0.35 

40 ......................... Puerto Rico ................................................................................................... 0.4047 0.4047 0.0000 0.00 

42 ......................... South Carolina .............................................................................................. 0.8638 0.8566 ¥0.0072 ¥0.83 

43 ......................... South Dakota ................................................................................................ 0.8560 0.8480 ¥0.0080 ¥0.93 

44 ......................... Tennessee .................................................................................................... 0.7895 0.7827 ¥0.0068 ¥0.86 

45 ......................... Texas ............................................................................................................ 0.8003 0.7965 ¥0.0038 ¥0.47 

46 ......................... Utah ............................................................................................................... 0.8118 0.8140 0.0022 0.27 

47 ......................... Vermont ......................................................................................................... 0.9830 0.9744 ¥0.0086 ¥0.87 

48 ......................... Virgin Islands ................................................................................................ 0.7615 0.8467 0.0852 11.19 

49 ......................... Virginia .......................................................................................................... 0.8013 0.7940 ¥0.0073 ¥0.91 

50 ......................... Washington ................................................................................................... 1.0510 1.0263 ¥0.0247 ¥2.35 

51 ......................... West Virginia ................................................................................................. 0.7717 0.7607 ¥0.0110 ¥1.43 

52 ......................... Wisconsin ...................................................................................................... 0.9509 0.9553 0.0044 0.46 


pwalker on PROD1PC71 with RULES4
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46517 

ADDENDUM D—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2007 AND FY 2008 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2007 FY2008 FY08–

FY07 

Percent 

chng 

53 ......................... Wyoming ....................................................................................................... 0.9257 0.9295 0.0038 0.41 

65 ......................... Guam ............................................................................................................ 0.9611 0.9611 0.0000 0.00 

CBSA ................... Urban Area 

10180 ................... Abilene, TX ................................................................................................... 0.7896 0.8000 0.0104 1.32 

10380 ................... Aguadilla-Isabela-San Sebastia ́n, PR ........................................................... 0.4738 0.3915 ¥0.0823 ¥17.37 

10420 ................... Akron, OH ..................................................................................................... 0.8982 0.8654 ¥0.0328 ¥3.65 

10500 ................... Albany, GA .................................................................................................... 0.8628 0.8991 0.0363 4.21 

10580 ................... Albany-Schenectady-Troy, NY ...................................................................... 0.8589 0.8720 0.0131 1.53 

10740 ................... Albuquerque, NM .......................................................................................... 0.9684 0.9458 ¥0.0226 ¥2.33 

10780 ................... Alexandria, LA ............................................................................................... 0.8033 0.8006 ¥0.0027 ¥0.34 

10900 ................... Allentown-Bethlehem-Easton, PA-NJ ........................................................... 0.9818 0.9947 0.0129 1.31 

11020 ................... Altoona, PA ................................................................................................... 0.8944 0.8812 ¥0.0132 ¥1.48 

11100 ................... Amarillo, TX .................................................................................................. 0.9156 0.9169 0.0013 0.14 

11180 ................... Ames, IA ....................................................................................................... 0.9536 0.9760 0.0224 2.35 

11260 ................... Anchorage, AK .............................................................................................. 1.1895 1.2023 0.0128 1.08 

11300 ................... Anderson, IN ................................................................................................. 0.8586 0.8681 0.0095 1.11 

11340 ................... Anderson, SC ................................................................................................ 0.8997 0.9017 0.0020 0.22 

11460 ................... Ann Arbor, MI ................................................................................................ 1.0859 1.0826 ¥0.0033 ¥0.30 

11500 ................... Anniston-Oxford, AL ...................................................................................... 0.7682 0.7770 0.0088 1.15 

11540 ................... Appleton, WI ................................................................................................. 0.9288 0.9455 0.0167 1.80 

11700 ................... Asheville, NC ................................................................................................ 0.9285 0.9216 ¥0.0069 ¥0.74 

12020 ................... Athens-Clarke County, GA ........................................................................... 0.9855 0.9856 0.0001 0.01 

12060 ................... Atlanta-Sandy Springs-Marietta, GA ............................................................. 0.9793 0.9762 ¥0.0031 ¥0.32 

12100 ................... Atlantic City, NJ ............................................................................................ 1.1615 1.1831 0.0216 1.86 

12220 ................... Auburn-Opelika, AL ....................................................................................... 0.8100 0.8096 ¥0.0004 ¥0.05 

12260 ................... Augusta-Richmond County, GA-SC ............................................................. 0.9748 0.9667 ¥0.0081 ¥0.83 

12420 ................... Austin-Round Rock, TX ................................................................................ 0.9437 0.9344 ¥0.0093 ¥0.99 

12540 ................... Bakersfield, CA ............................................................................................. 1.0470 1.0725 0.0255 2.44 

12580 ................... Baltimore-Towson, MD ................................................................................. 0.9897 1.0088 0.0191 1.93 

12620 ................... Bangor, ME ................................................................................................... 0.9993 0.9711 ¥0.0282 ¥2.82 

12700 ................... Barnstable Town, MA ................................................................................... 1.2600 1.2539 ¥0.0061 ¥0.48 

12940 ................... Baton Rouge, LA .......................................................................................... 0.8593 0.8084 ¥0.0509 ¥5.92 

12980 ................... Battle Creek, MI ............................................................................................ 0.9508 0.9762 0.0254 2.67 

13020 ................... Bay City, MI .................................................................................................. 0.9343 0.9251 ¥0.0092 ¥0.98 

13140 ................... Beaumont-Port Arthur, TX ............................................................................ 0.8412 0.8595 0.0183 2.18 

13380 ................... Bellingham, WA ............................................................................................ 1.1731 1.1104 ¥0.0627 ¥5.34 

13460 ................... Bend, OR ...................................................................................................... 1.0786 1.0743 ¥0.0043 ¥0.40 

13644 ................... Bethesda-Gaithersburg-Frederick, MD ......................................................... 1.1483 1.0903 ¥0.0580 ¥5.05 

13740 ................... Billings, MT ................................................................................................... 0.8834 0.8712 ¥0.0122 ¥1.38 

13780 ................... Binghamton, NY ............................................................................................ 0.8562 0.8786 0.0224 2.62 

13820 ................... Birmingham-Hoover, AL ................................................................................ 0.8959 0.8894 ¥0.0065 ¥0.73 

13900 ................... Bismarck, ND ................................................................................................ 0.7574 0.7240 ¥0.0334 ¥4.41 

13980 ................... Blacksburg-Christiansburg-Radford, VA ....................................................... 0.7954 0.8213 0.0259 3.26 

14020 ................... Bloomington, IN ............................................................................................ 0.8447 0.8533 0.0086 1.02 

14060 ................... Bloomington-Normal, IL ................................................................................ 0.9075 0.8944 ¥0.0131 ¥1.44 

14260 ................... Boise City-Nampa, ID ................................................................................... 0.9052 0.9401 0.0349 3.86 

14484 ................... Boston-Quincy, MA ....................................................................................... 1.1558 1.1679 0.0121 1.05 

14500 ................... Boulder, CO .................................................................................................. 0.9734 1.0350 0.0616 6.33 

14540 ................... Bowling Green, KY ....................................................................................... 0.8211 0.8148 ¥0.0063 ¥0.77 

14740 ................... Bremerton-Silverdale, WA ............................................................................ 1.0675 1.0913 0.0238 2.23 

14860 ................... Bridgeport-Stamford-Norwalk, CT ................................................................. 1.2592 1.2659 0.0067 0.53 

15180 ................... Brownsville-Harlingen, TX ............................................................................. 0.9804 0.9430 ¥0.0374 ¥3.81 

15260 ................... Brunswick, GA .............................................................................................. 0.9311 1.0164 0.0853 9.16 

15380 ................... Buffalo-Niagara Falls, NY ............................................................................. 0.9511 0.9424 ¥0.0087 ¥0.91 

15500 ................... Burlington, NC ............................................................................................... 0.8905 0.8674 ¥0.0231 ¥2.59 

15540 ................... Burlington-South Burlington, VT ................................................................... 0.9410 0.9474 0.0064 0.68 

15764 ................... Cambridge-Newton-Framingham, MA .......................................................... 1.1172 1.0970 ¥0.0202 ¥1.81 

15804 ................... Camden, NJ .................................................................................................. 1.0517 1.0392 ¥0.0125 ¥1.19 

15940 ................... Canton-Massillon, OH ................................................................................... 0.8935 0.9031 0.0096 1.07 

15980 ................... Cape Coral-Fort Myers, FL ........................................................................... 0.9356 0.9342 ¥0.0014 ¥0.15 

16180 ................... Carson City, NV ............................................................................................ 1.0234 1.0025 ¥0.0209 ¥2.04 

16220 ................... Casper, WY ................................................................................................... 0.9026 0.9145 0.0119 1.32 

16300 ................... Cedar Rapids, IA .......................................................................................... 0.8825 0.8888 0.0063 0.71 

16580 ................... Champaign-Urbana, IL .................................................................................. 0.9594 0.9644 0.0050 0.52 

16620 ................... Charleston, WV ............................................................................................. 0.8445 0.8542 0.0097 1.15 

16700 ................... Charleston-North Charleston, SC ................................................................. 0.9245 0.9145 ¥0.0100 ¥1.08 

16740 ................... Charlotte-Gastonia-Concord, NC-SC ............................................................ 0.9750 0.9554 ¥0.0196 ¥2.01 


pwalker on PROD1PC71 with RULES4
46518 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

ADDENDUM D—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2007 AND FY 2008 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2007 FY2008 FY08–

FY07 

Percent 

chng 

16820 ................... Charlottesville, VA ......................................................................................... 1.0187 1.0125 ¥0.0062 ¥0.61 

16860 ................... Chattanooga, TN-GA .................................................................................... 0.9088 0.8948 ¥0.0140 ¥1.54 

16940 ................... Cheyenne, WY .............................................................................................. 0.8775 0.9060 0.0285 3.25 

16974 ................... Chicago-Naperville-Joliet, IL ......................................................................... 1.0790 1.0751 ¥0.0039 ¥0.36 

17020 ................... Chico, CA ...................................................................................................... 1.0511 1.1053 0.0542 5.16 

17140 ................... Cincinnati-Middletown, OH-KY-IN ................................................................. 0.9615 0.9601 ¥0.0014 ¥0.15 

17300 ................... Clarksville, TN-KY ......................................................................................... 0.8284 0.8436 0.0152 1.83 

17420 ................... Cleveland, TN ............................................................................................... 0.8139 0.8109 ¥0.0030 ¥0.37 

17460 ................... Cleveland-Elyria-Mentor, OH ........................................................................ 0.9213 0.9400 0.0187 2.03 

17660 ................... Coeur d’Alene, ID ......................................................................................... 0.9647 0.9344 ¥0.0303 ¥3.14 

17780 ................... College Station-Bryan, TX ............................................................................ 0.8900 0.9045 0.0145 1.63 

17820 ................... Colorado Springs, CO ................................................................................... 0.9468 0.9701 0.0233 2.46 

17860 ................... Columbia, MO ............................................................................................... 0.8345 0.8542 0.0197 2.36 

17900 ................... Columbia, SC ................................................................................................ 0.9057 0.8933 ¥0.0124 ¥1.37 

17980 ................... Columbus, GA-AL ......................................................................................... 0.8560 0.8239 ¥0.0321 ¥3.75 

18020 ................... Columbus, IN ................................................................................................ 0.9588 0.9318 ¥0.0270 ¥2.82 

18140 ................... Columbus, OH .............................................................................................. 0.9860 1.0107 0.0247 2.51 

18580 ................... Corpus Christi, TX ........................................................................................ 0.8550 0.8564 0.0014 0.16 

18700 ................... Corvallis, OR ................................................................................................. 1.0729 1.1546 0.0817 7.61 

19060 ................... Cumberland, MD-WV .................................................................................... 0.9317 0.8446 ¥0.0871 ¥9.35 

19124 ................... Dallas-Plano-Irving, TX ................................................................................. 1.0228 1.0075 ¥0.0153 ¥1.50 

19140 ................... Dalton, GA .................................................................................................... 0.9079 0.9093 0.0014 0.15 

19180 ................... Danville, IL .................................................................................................... 0.9028 0.9266 0.0238 2.64 

19260 ................... Danville, VA .................................................................................................. 0.8489 0.8451 ¥0.0038 ¥0.45 

19340 ................... Davenport-Moline-Rock Island, IA-IL ............................................................ 0.8724 0.8846 0.0122 1.40 

19380 ................... Dayton, OH ................................................................................................... 0.9064 0.9037 ¥0.0027 ¥0.30 

19460 ................... Decatur, AL ................................................................................................... 0.8469 0.8159 ¥0.0310 ¥3.66 

19500 ................... Decatur, IL .................................................................................................... 0.8067 0.8172 0.0105 1.30 

19660 ................... Deltona-Daytona Beach-Ormond Beach, FL ................................................ 0.9299 0.9263 ¥0.0036 ¥0.39 

19740 ................... Denver-Aurora, CO ....................................................................................... 1.0723 1.0930 0.0207 1.93 

19780 ................... Des Moines-West Des Moines, IA ................................................................ 0.9669 0.9214 ¥0.0455 ¥4.71 

19804 ................... Detroit-Livonia-Dearborn, MI ......................................................................... 1.0424 1.0281 ¥0.0143 ¥1.37 

20020 ................... Dothan, AL .................................................................................................... 0.7721 0.7381 ¥0.0340 ¥4.40 

20100 ................... Dover, DE ..................................................................................................... 0.9776 0.9847 0.0071 0.73 

20220 ................... Dubuque, IA .................................................................................................. 0.9024 0.9133 0.0109 1.21 

20260 ................... Duluth, MN-WI .............................................................................................. 1.0213 1.0042 ¥0.0171 ¥1.67 

20500 ................... Durham, NC .................................................................................................. 1.0244 0.9826 ¥0.0418 ¥4.08 

20740 ................... Eau Claire, WI ............................................................................................... 0.9201 0.9630 0.0429 4.66 

20764 ................... Edison, NJ ..................................................................................................... 1.1249 1.1190 ¥0.0059 ¥0.52 

20940 ................... El Centro, CA ................................................................................................ 0.8906 0.9076 0.0170 1.91 

21060 ................... Elizabethtown, KY ......................................................................................... 0.8802 0.8697 ¥0.0105 ¥1.19 

21140 ................... Elkhart-Goshen, IN ....................................................................................... 0.9627 0.9426 ¥0.0201 ¥2.09 

21300 ................... Elmira, NY ..................................................................................................... 0.8250 0.8240 ¥0.0010 ¥0.12 

21340 ................... El Paso, TX ................................................................................................... 0.8977 0.9053 0.0076 0.85 

21500 ................... Erie, PA ......................................................................................................... 0.8737 0.8827 0.0090 1.03 

21604 ................... Essex County, MA ........................................................................................ 1.0538 1.0418 ¥0.0120 ¥1.14 

21660 ................... Eugene-Springfield, OR ................................................................................ 1.0818 1.0876 0.0058 0.54 

21780 ................... Evansville, IN-KY .......................................................................................... 0.8713 0.9071 0.0358 4.11 

21820 ................... Fairbanks, AK ............................................................................................... 1.1408 1.1059 ¥0.0349 ¥3.06 

21940 ................... Fajardo, PR ................................................................................................... 0.4153 0.4036 ¥0.0117 ¥2.82 

22020 ................... Fargo, ND-MN ............................................................................................... 0.8486 0.8250 ¥0.0236 ¥2.78 

22140 ................... Farmington, NM ............................................................................................ 0.8509 0.8589 0.0080 0.94 

22180 ................... Fayetteville, NC ............................................................................................. 0.9416 0.8945 ¥0.0471 ¥5.00 

22220 ................... Fayetteville-Springdale-Rogers, AR-MO ....................................................... 0.8661 0.8865 0.0204 2.36 

22380 ................... Flagstaff, AZ .................................................................................................. 1.2092 1.1601 ¥0.0491 ¥4.06 

22420 ................... Flint, MI ......................................................................................................... 1.0655 1.0969 0.0314 2.95 

22500 ................... Florence, SC ................................................................................................. 0.8947 0.8388 ¥0.0559 ¥6.25 

22520 ................... Florence-Muscle Shoals, AL ......................................................................... 0.8272 0.7843 ¥0.0429 ¥5.19 

22540 ................... Fond du Lac, WI ........................................................................................... 0.9640 1.0063 0.0423 4.39 

22660 ................... Fort Collins-Loveland, CO ............................................................................ 1.0122 0.9544 ¥0.0578 ¥5.71 

22744 ................... Ft Lauderdale-Pompano Beach-Deerfield, FL .............................................. 1.0432 1.0133 ¥0.0299 ¥2.87 

22900 ................... Fort Smith, AR-OK ........................................................................................ 0.8230 0.7731 ¥0.0499 ¥6.06 

23020 ................... Fort Walton Beach-Crestview-Destin, FL ..................................................... 0.8872 0.8643 ¥0.0229 ¥2.58 

23060 ................... Fort Wayne, IN .............................................................................................. 0.9793 0.9517 ¥0.0276 ¥2.82 

23104 ................... Fort Worth-Arlington, TX ............................................................................... 0.9486 0.9569 0.0083 0.87 

23420 ................... Fresno, CA .................................................................................................... 1.0538 1.0943 0.0405 3.84 

23460 ................... Gadsden, AL ................................................................................................. 0.7938 0.8066 0.0128 1.61 

23540 ................... Gainesville, FL .............................................................................................. 0.9388 0.9277 ¥0.0111 ¥1.18 

23580 ................... Gainesville, GA ............................................................................................. 0.8874 0.8958 0.0084 0.95 


pwalker on PROD1PC71 with RULES4
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46519 

ADDENDUM D—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2007 AND FY 2008 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2007 FY2008 FY08–

FY07 

Percent 

chng 

23844 ................... Gary, IN ......................................................................................................... 0.9395 0.9334 ¥0.0061 ¥0.65 

24020 ................... Glens Falls, NY ............................................................................................. 0.8559 0.8324 ¥0.0235 ¥2.75 

24140 ................... Goldsboro, NC .............................................................................................. 0.8775 0.9171 0.0396 4.51 

24220 ................... Grand Forks, ND-MN .................................................................................... 0.7901 0.7949 0.0048 0.61 

24300 ................... Grand Junction, CO ...................................................................................... 0.9550 0.9668 0.0118 1.24 

24340 ................... Grand Rapids-Wyoming, MI ......................................................................... 0.9390 0.9455 0.0065 0.69 

24500 ................... Great Falls, MT ............................................................................................. 0.9052 0.8598 ¥0.0454 ¥5.02 

24540 ................... Greeley, CO .................................................................................................. 0.9570 0.9602 0.0032 0.33 

24580 ................... Green Bay, WI .............................................................................................. 0.9483 0.9787 0.0304 3.21 

24660 ................... Greensboro-High Point, NC .......................................................................... 0.9104 0.8866 ¥0.0238 ¥2.61 

24780 ................... Greenville, NC ............................................................................................... 0.9425 0.9432 0.0007 0.07 

24860 ................... Greenville, SC ............................................................................................... 1.0027 0.9804 ¥0.0223 ¥2.22 

25020 ................... Guayama, PR ............................................................................................... 0.3181 0.3235 0.0054 1.70 

25060 ................... Gulfport-Biloxi, MS ........................................................................................ 0.8929 0.8915 ¥0.0014 ¥0.16 

25180 ................... Hagerstown-Martinsburg, MD-WV ................................................................ 0.9489 0.9038 ¥0.0451 ¥4.75 

25260 ................... Hanford-Corcoran, CA .................................................................................. 1.0036 1.0282 0.0246 2.45 

25420 ................... Harrisburg-Carlisle, PA ................................................................................. 0.9313 0.9402 0.0089 0.96 

25500 ................... Harrisonburg, VA .......................................................................................... 0.9088 0.9073 ¥0.0015 ¥0.17 

25540 ................... Hartford-West Hartford-East Hartford, CT .................................................... 1.1073 1.0894 ¥0.0179 ¥1.62 

25620 ................... Hattiesburg, MS ............................................................................................ 0.7601 0.7430 ¥0.0171 ¥2.25 

25860 ................... Hickory-Lenoir-Morganton, NC ..................................................................... 0.8921 0.9010 0.0089 1.00 

25980 ................... Hinesville-Fort Stewart, GA .......................................................................... 0.9198 0.9178 ¥0.0020 ¥0.22 

26100 ................... Holland-Grand Haven, MI ............................................................................. 0.9055 0.9163 0.0108 1.19 

26180 ................... Honolulu, HI .................................................................................................. 1.1214 1.1096 ¥0.0118 ¥1.05 

26300 ................... Hot Springs, AR ............................................................................................ 0.9005 0.8782 ¥0.0223 ¥2.48 

26380 ................... Houma-Bayou Cane-Thibodaux, LA ............................................................. 0.7894 0.8082 0.0188 2.38 

26420 ................... Houston-Sugar Land-Baytown, TX ............................................................... 0.9996 1.0008 0.0012 0.12 

26580 ................... Huntington-Ashland, WV-KY-OH .................................................................. 0.9477 0.8997 ¥0.0480 ¥5.06 

26620 ................... Huntsville, AL ................................................................................................ 0.9146 0.9007 ¥0.0139 ¥1.52 

26820 ................... Idaho Falls, ID ............................................................................................... 0.9420 0.9088 ¥0.0332 ¥3.52 

26900 ................... Indianapolis-Carmel, IN ................................................................................ 0.9920 0.9895 ¥0.0025 ¥0.25 

26980 ................... Iowa City, IA .................................................................................................. 0.9747 0.9714 ¥0.0033 ¥0.34 

27060 ................... Ithaca, NY ..................................................................................................... 0.9793 0.9928 0.0135 1.38 

27100 ................... Jackson, MI ................................................................................................... 0.9304 0.9560 0.0256 2.75 

27140 ................... Jackson, MS ................................................................................................. 0.8311 0.8271 ¥0.0040 ¥0.48 

27180 ................... Jackson, TN .................................................................................................. 0.8964 0.8853 ¥0.0111 ¥1.24 

27260 ................... Jacksonville, FL ............................................................................................ 0.9290 0.9165 ¥0.0125 ¥1.35 

27340 ................... Jacksonville, NC ........................................................................................... 0.8236 0.8231 ¥0.0005 ¥0.06 

27500 ................... Janesville, WI ................................................................................................ 0.9538 0.9655 0.0117 1.23 

27620 ................... Jefferson City, MO ........................................................................................ 0.8387 0.8332 ¥0.0055 ¥0.66 

27740 ................... Johnson City, TN .......................................................................................... 0.7937 0.8043 0.0106 1.34 

27780 ................... Johnstown, PA .............................................................................................. 0.8354 0.8620 0.0266 3.18 

27860 ................... Jonesboro, AR .............................................................................................. 0.7911 0.7662 ¥0.0249 ¥3.15 

27900 ................... Joplin, MO ..................................................................................................... 0.8582 0.8605 0.0023 0.27 

28020 ................... Kalamazoo-Portage, MI ................................................................................ 1.0381 1.0704 0.0323 3.11 

28100 ................... Kankakee-Bradley, IL .................................................................................... 1.0721 1.0083 ¥0.0638 ¥5.95 

28140 ................... Kansas City, MO-KS ..................................................................................... 0.9476 0.9495 0.0019 0.20 

28420 ................... Kennewick-Richland-Pasco, WA .................................................................. 1.0619 1.0343 ¥0.0276 ¥2.60 

28660 ................... Killeen-Temple-Fort Hood, TX ...................................................................... 0.8526 0.8901 0.0375 4.40 

28700 ................... Kingsport-Bristol-Bristol, TN-VA .................................................................... 0.8054 0.7985 ¥0.0069 ¥0.86 

28740 ................... Kingston, NY ................................................................................................. 0.9255 0.9367 0.0112 1.21 

28940 ................... Knoxville, TN ................................................................................................. 0.8441 0.8249 ¥0.0192 ¥2.27 

29020 ................... Kokomo, IN ................................................................................................... 0.9508 0.9669 0.0161 1.69 

29100 ................... La Crosse, WI-MN ........................................................................................ 0.9564 0.9426 ¥0.0138 ¥1.44 

29140 ................... Lafayette, IN .................................................................................................. 0.8736 0.8931 0.0195 2.23 

29180 ................... Lafayette, LA ................................................................................................. 0.8428 0.8289 ¥0.0139 ¥1.65 

29340 ................... Lake Charles, LA .......................................................................................... 0.7833 0.7914 0.0081 1.03 

29404 ................... Lake County-Kenosha County, IL-WI ........................................................... 1.0429 1.0570 0.0141 1.35 

29460 ................... Lakeland, FL ................................................................................................. 0.8912 0.8879 ¥0.0033 ¥0.37 

29540 ................... Lancaster, PA ............................................................................................... 0.9694 0.9589 ¥0.0105 ¥1.08 

29620 ................... Lansing-East Lansing, MI ............................................................................. 0.9794 1.0088 0.0294 3.00 

29700 ................... Laredo, TX .................................................................................................... 0.8068 0.7811 ¥0.0257 ¥3.19 

29740 ................... Las Cruces, NM ............................................................................................ 0.8467 0.9273 0.0806 9.52 

29820 ................... Las Vegas-Paradise, NV .............................................................................. 1.1437 1.1430 ¥0.0007 ¥0.06 

29940 ................... Lawrence, KS ................................................................................................ 0.8537 0.8365 ¥0.0172 ¥2.01 

30020 ................... Lawton, OK ................................................................................................... 0.7872 0.8065 0.0193 2.45 

30140 ................... Lebanon, PA ................................................................................................. 0.8459 0.8679 0.0220 2.60 

30300 ................... Lewiston, ID-WA ........................................................................................... 0.9886 0.9853 ¥0.0033 ¥0.33 

30340 ................... Lewiston-Auburn, ME .................................................................................... 0.9331 0.9126 ¥0.0205 ¥2.20 


pwalker on PROD1PC71 with RULES4
46520 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

ADDENDUM D—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2007 AND FY 2008 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2007 FY2008 FY08–

FY07 

Percent 

chng 

30460 ................... Lexington-Fayette, KY .................................................................................. 0.9075 0.9181 0.0106 1.17 

30620 ................... Lima, OH ....................................................................................................... 0.9225 0.9042 ¥0.0183 ¥1.98 

30700 ................... Lincoln, NE .................................................................................................... 1.0214 1.0092 ¥0.0122 ¥1.19 

30780 ................... Little Rock-North Little Rock, AR .................................................................. 0.8747 0.8890 0.0143 1.63 

30860 ................... Logan, UT-ID ................................................................................................ 0.9164 0.9022 ¥0.0142 ¥1.55 

30980 ................... Longview, TX ................................................................................................ 0.8730 0.8788 0.0058 0.66 

31020 ................... Longview, WA ............................................................................................... 0.9579 1.0011 0.0432 4.51 

31084 ................... Los Angeles-Long Beach-Santa Ana, CA .................................................... 1.1783 1.1760 ¥0.0023 ¥0.20 

31140 ................... Louisville-Jefferson County, KY-IN ............................................................... 0.9251 0.9118 ¥0.0133 ¥1.44 

31180 ................... Lubbock, TX .................................................................................................. 0.8783 0.8613 ¥0.0170 ¥1.94 

31340 ................... Lynchburg, VA .............................................................................................. 0.8691 0.8694 0.0003 0.03 

31420 ................... Macon, GA .................................................................................................... 0.9443 0.9519 0.0076 0.80 

31460 ................... Madera, CA ................................................................................................... 0.8713 0.8154 ¥0.0559 ¥6.42 

31540 ................... Madison, WI .................................................................................................. 1.0659 1.0840 0.0181 1.70 

31700 ................... Manchester-Nashua, NH .............................................................................. 1.0354 1.0243 ¥0.0111 ¥1.07 

31900 ................... Mansfield, OH ............................................................................................... 0.9891 0.9271 ¥0.0620 ¥6.27 

32420 ................... Mayagu ̈ez, PR .............................................................................................. 0.4020 0.3848 ¥0.0172 ¥4.28 

32580 ................... McAllen-Edinburg-Mission, TX ...................................................................... 0.8934 0.8773 ¥0.0161 ¥1.80 

32780 ................... Medford, OR ................................................................................................. 1.0225 1.0818 0.0593 5.80 

32820 ................... Memphis, TN-MS-AR .................................................................................... 0.9397 0.9373 ¥0.0024 ¥0.26 

32900 ................... Merced, CA ................................................................................................... 1.1109 1.1471 0.0362 3.26 

33124 ................... Miami-Miami Beach-Kendall, FL ................................................................... 0.9750 0.9812 0.0062 0.64 

33140 ................... Michigan City-La Porte, IN ............................................................................ 0.9399 0.9118 ¥0.0281 ¥2.99 

33260 ................... Midland, TX ................................................................................................... 0.9514 0.9786 0.0272 2.86 

33340 ................... Milwaukee-Waukesha-West Allis, WI ........................................................... 1.0146 1.0218 0.0072 0.71 

33460 ................... Minneapolis-St. Paul-Bloomington, MN-WI .................................................. 1.1075 1.0946 ¥0.0129 ¥1.16 

33540 ................... Missoula, MT ................................................................................................. 0.9473 0.8928 ¥0.0545 ¥5.75 

33660 ................... Mobile, AL ..................................................................................................... 0.7891 0.7913 0.0022 0.28 

33700 ................... Modesto, CA ................................................................................................. 1.1885 1.1729 ¥0.0156 ¥1.31 

33740 ................... Monroe, LA ................................................................................................... 0.8031 0.7997 ¥0.0034 ¥0.42 

33780 ................... Monroe, MI .................................................................................................... 0.9468 0.9707 0.0239 2.52 

33860 ................... Montgomery, AL ............................................................................................ 0.8618 0.8009 ¥0.0609 ¥7.07 

34060 ................... Morgantown, WV .......................................................................................... 0.8420 0.8423 0.0003 0.04 

34100 ................... Morristown, TN .............................................................................................. 0.7961 0.7933 ¥0.0028 ¥0.35 

34580 ................... Mount Vernon-Anacortes, WA ...................................................................... 1.0454 1.0517 0.0063 0.60 

34620 ................... Muncie, IN ..................................................................................................... 0.8930 0.8562 ¥0.0368 ¥4.12 

34740 ................... Muskegon-Norton Shores, MI ....................................................................... 0.9664 0.9941 0.0277 2.87 

34820 ................... Myrtle Beach-Conway-North Myrtle Beach, SC ........................................... 0.8934 0.8810 ¥0.0124 ¥1.39 

34900 ................... Napa, CA ...................................................................................................... 1.2643 1.3374 0.0731 5.78 

34940 ................... Naples-Marco Island, FL ............................................................................... 1.0139 0.9941 ¥0.0198 ¥1.95 

34980 ................... Nashville-Davidson—Murfreesboro, TN ....................................................... 0.9790 0.9847 0.0057 0.58 

35004 ................... Nassau-Suffolk, NY ....................................................................................... 1.2719 1.2662 ¥0.0057 ¥0.45 

35084 ................... Newark-Union, NJ-PA ................................................................................... 1.1883 1.1892 0.0009 0.08 

35300 ................... New Haven-Milford, CT ................................................................................ 1.1887 1.1953 0.0066 0.56 

35380 ................... New Orleans-Metairie-Kenner, LA ................................................................ 0.8995 0.8831 ¥0.0164 ¥1.82 

35644 ................... New York-White Plains-Wayne, NY-NJ ........................................................ 1.3188 1.3177 ¥0.0011 ¥0.08 

35660 ................... Niles-Benton Harbor, MI ............................................................................... 0.8879 0.8915 0.0036 0.41 

35980 ................... Norwich-New London, CT ............................................................................. 1.1345 1.1932 0.0587 5.17 

36084 ................... Oakland-Fremont-Hayward, CA .................................................................... 1.5346 1.5819 0.0473 3.08 

36100 ................... Ocala, FL ...................................................................................................... 0.8925 0.8867 ¥0.0058 ¥0.65 

36140 ................... Ocean City, NJ .............................................................................................. 1.1011 1.0472 ¥0.0539 ¥4.90 

36220 ................... Odessa, TX ................................................................................................... 0.9884 1.0073 0.0189 1.91 

36260 ................... Ogden-Clearfield, UT .................................................................................... 0.9029 0.8995 ¥0.0034 ¥0.38 

36420 ................... Oklahoma City, OK ....................................................................................... 0.9031 0.8843 ¥0.0188 ¥2.08 

36500 ................... Olympia, WA ................................................................................................. 1.0927 1.1081 0.0154 1.41 

36540 ................... Omaha-Council Bluffs, NE-IA ....................................................................... 0.9560 0.9450 ¥0.0110 ¥1.15 

36740 ................... Orlando-Kissimmee, FL ................................................................................ 0.9464 0.9452 ¥0.0012 ¥0.13 

36780 ................... Oshkosh-Neenah, WI .................................................................................... 0.9183 0.9315 0.0132 1.44 

36980 ................... Owensboro, KY ............................................................................................. 0.8780 0.8748 ¥0.0032 ¥0.36 

37100 ................... Oxnard-Thousand Oaks-Ventura, CA ........................................................... 1.1622 1.1546 ¥0.0076 ¥0.65 

37340 ................... Palm Bay-Melbourne-Titusville, FL ............................................................... 0.9839 0.9443 ¥0.0396 ¥4.02 

37460 ................... Panama City-Lynn Haven, FL ...................................................................... 0.8005 0.8027 0.0022 0.27 

37620 ................... Parkersburg-Marietta-Vienna, WV-OH ......................................................... 0.8270 0.7977 ¥0.0293 ¥3.54 

37700 ................... Pascagoula, MS ............................................................................................ 0.8156 0.8215 0.0059 0.72 

37860 ................... Pensacola-Ferry Pass-Brent, FL .................................................................. 0.8096 0.8000 ¥0.0096 ¥1.19 

37900 ................... Peoria, IL ....................................................................................................... 0.8870 0.8982 0.0112 1.26 

37964 ................... Philadelphia, PA ............................................................................................ 1.1038 1.0996 ¥0.0042 ¥0.38 

38060 ................... Phoenix-Mesa-Scottsdale, AZ ...................................................................... 1.0127 1.0287 0.0160 1.58 

38220 ................... Pine Bluff, AR ............................................................................................... 0.8680 0.8383 ¥0.0297 ¥3.42 


pwalker on PROD1PC71 with RULES4
Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 46521 

ADDENDUM D—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2007 AND FY 2008 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2007 FY2008 FY08–

FY07 

Percent 

chng 

38300 ................... Pittsburgh, PA ............................................................................................... 0.8845 0.8674 ¥0.0171 ¥1.93 

38340 ................... Pittsfield, MA ................................................................................................. 1.0181 1.0266 0.0085 0.83 

38540 ................... Pocatello, ID .................................................................................................. 0.9351 0.9400 0.0049 0.52 

38660 ................... Ponce, PR ..................................................................................................... 0.4939 0.4842 ¥0.0097 ¥1.96 

38860 ................... Portland-South Portland-Biddeford, ME ....................................................... 1.0382 0.9908 ¥0.0474 ¥4.57 

38900 ................... Portland-Vancouver-Beaverton, OR-WA ...................................................... 1.1266 1.1416 0.0150 1.33 

38940 ................... Port St. Lucie-Fort Pierce, FL ....................................................................... 1.0123 0.9833 ¥0.0290 ¥2.86 

39100 ................... Poughkeepsie-Newburgh-Middletown, NY ................................................... 1.0891 1.0911 0.0020 0.18 

39140 ................... Prescott, AZ .................................................................................................. 0.9869 0.9836 ¥0.0033 ¥0.33 

39300 ................... Providence-New Bedford-Fall River, RI-MA ................................................. 1.0966 1.0783 ¥0.0183 ¥1.67 

39340 ................... Provo-Orem, UT ............................................................................................ 0.9500 0.9537 0.0037 0.39 

39380 ................... Pueblo, CO ................................................................................................... 0.8623 0.8753 0.0130 1.51 

39460 ................... Punta Gorda, FL ........................................................................................... 0.9255 0.9405 0.0150 1.62 

39540 ................... Racine, WI .................................................................................................... 0.8997 0.9356 0.0359 3.99 

39580 ................... Raleigh-Cary, NC .......................................................................................... 0.9691 0.9864 0.0173 1.79 

39660 ................... Rapid City, SD .............................................................................................. 0.8987 0.8833 ¥0.0154 ¥1.71 

39740 ................... Reading, PA .................................................................................................. 0.9686 0.9622 ¥0.0064 ¥0.66 

39820 ................... Redding, CA .................................................................................................. 1.2203 1.3198 0.0995 8.15 

39900 ................... Reno-Sparks, NV .......................................................................................... 1.0982 1.1963 0.0981 8.93 

40060 ................... Richmond, VA ............................................................................................... 0.9328 0.9177 ¥0.0151 ¥1.62 

40140 ................... Riverside-San Bernardino-Ontario, CA ......................................................... 1.1027 1.0904 ¥0.0123 ¥1.12 

40220 ................... Roanoke, VA ................................................................................................. 0.8374 0.8647 0.0273 3.26 

40340 ................... Rochester, MN .............................................................................................. 1.1131 1.1408 0.0277 2.49 

40380 ................... Rochester, NY ............................................................................................... 0.9121 0.8994 ¥0.0127 ¥1.39 

40420 ................... Rockford, IL ................................................................................................... 0.9984 0.9989 0.0005 0.05 

40484 ................... Rockingham County, NH .............................................................................. 1.0374 1.0159 ¥0.0215 ¥2.07 

40580 ................... Rocky Mount, NC .......................................................................................... 0.8915 0.8854 ¥0.0061 ¥0.68 

40660 ................... Rome, GA ..................................................................................................... 0.9414 0.9193 ¥0.0221 ¥2.35 

40900 ................... Sacramento—Arden-Arcade—Roseville, CA ................................................ 1.2969 1.3372 0.0403 3.11 

40980 ................... Saginaw-Saginaw Township North, MI ......................................................... 0.9088 0.8874 ¥0.0214 ¥2.35 

41060 ................... St. Cloud, MN ............................................................................................... 0.9965 1.0362 0.0397 3.98 

41100 ................... St. George, UT .............................................................................................. 0.9392 0.9265 ¥0.0127 ¥1.35 

41140 ................... St. Joseph, MO-KS ....................................................................................... 0.9519 1.0118 0.0599 6.29 

41180 ................... St. Louis, MO-IL ............................................................................................ 0.8954 0.9005 0.0051 0.57 

41420 ................... Salem, OR .................................................................................................... 1.0442 1.0438 ¥0.0004 ¥0.04 

41500 ................... Salinas, CA ................................................................................................... 1.4128 1.4337 0.0209 1.48 

41540 ................... Salisbury, MD ................................................................................................ 0.9064 0.8953 ¥0.0111 ¥1.22 

41620 ................... Salt Lake City, UT ......................................................................................... 0.9421 0.9402 ¥0.0019 ¥0.20 

41660 ................... San Angelo, TX ............................................................................................. 0.8271 0.8362 0.0091 1.10 

41700 ................... San Antonio, TX ............................................................................................ 0.8980 0.8844 ¥0.0136 ¥1.51 

41740 ................... San Diego-Carlsbad-San Marcos, CA .......................................................... 1.1413 1.1354 ¥0.0059 ¥0.52 

41780 ................... Sandusky, OH ............................................................................................... 0.9019 0.9302 0.0283 3.14 

41884 ................... San Francisco-San Mateo-Redwood City,CA .............................................. 1.4994 1.5165 0.0171 1.14 

41900 ................... San Germa ́n-Cabo Rojo, PR ........................................................................ 0.4650 0.4885 0.0235 5.05 

41940 ................... San Jose-Sunnyvale-Santa Clara, CA ......................................................... 1.5099 1.5543 0.0444 2.94 

41980 ................... San Juan-Caguas-Guaynabo, PR ................................................................ 0.4621 0.4452 ¥0.0169 ¥3.66 

42020 ................... San Luis Obispo-Paso Robles, CA .............................................................. 1.1349 1.1598 0.0249 2.19 

42044 ................... Santa Ana-Anaheim-Irvine, CA ..................................................................... 1.1559 1.1473 ¥0.0086 ¥0.74 

42060 ................... Santa Barbara-Santa Maria, CA ................................................................... 1.1694 1.1091 ¥0.0603 ¥5.16 

42100 ................... Santa Cruz-Watsonville, CA ......................................................................... 1.5166 1.5457 0.0291 1.92 

42140 ................... Santa Fe, NM ................................................................................................ 1.0920 1.0824 ¥0.0096 ¥0.88 

42220 ................... Santa Rosa-Petaluma, CA ............................................................................ 1.3493 1.4464 0.0971 7.20 

42260 ................... Sarasota-Bradenton-Venice, FL ................................................................... 0.9639 0.9868 0.0229 2.38 

42340 ................... Savannah, GA ............................................................................................... 0.9461 0.9351 ¥0.0110 ¥1.16 

42540 ................... Scranton—Wilkes-Barre, PA ......................................................................... 0.8540 0.8347 ¥0.0193 ¥2.26 

42644 ................... Seattle-Bellevue-Everett, WA ....................................................................... 1.1577 1.1434 ¥0.0143 ¥1.24 

42680 ................... Sebastian-Vero Beach, FL ............................................................................ ................ 0.9573 0.9573 ................

43100 ................... Sheboygan, WI ............................................................................................. 0.8911 0.9026 0.0115 1.29 

43300 ................... Sherman-Denison, TX .................................................................................. 0.9507 0.8502 ¥0.1005 ¥10.57 

43340 ................... Shreveport-Bossier City, LA ......................................................................... 0.8760 0.8865 0.0105 1.20 

43580 ................... Sioux City, IA-NE-SD .................................................................................... 0.9381 0.9200 ¥0.0181 ¥1.93 

43620 ................... Sioux Falls, SD ............................................................................................. 0.9635 0.9559 ¥0.0076 ¥0.79 

43780 ................... South Bend-Mishawaka, IN-MI ..................................................................... 0.9788 0.9842 0.0054 0.55 

43900 ................... Spartanburg, SC ........................................................................................... 0.9172 0.9174 0.0002 0.02 

44060 ................... Spokane, WA ................................................................................................ 1.0905 1.0447 ¥0.0458 ¥4.20 

44100 ................... Springfield, IL ................................................................................................ 0.8792 0.8890 0.0098 1.11 

44140 ................... Springfield, MA .............................................................................................. 1.0248 1.0079 ¥0.0169 ¥1.65 

44180 ................... Springfield, MO ............................................................................................. 0.8237 0.8469 0.0232 2.82 

44220 ................... Springfield, OH .............................................................................................. 0.8396 0.8593 0.0197 2.35 


pwalker on PROD1PC71 with RULES4
46522 Federal Register / Vol. 73, No. 154 / Friday, August 8, 2008 / Rules and Regulations 

ADDENDUM D—COMPARISON OF RAW PRE-FLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX VALUES USED AS INPUT

VALUES TO DERIVE THE FY 2007 AND FY 2008 HOSPICE WAGE INDICES—Continued 

[For illustrative purposes only] 

FY2007 FY2008 FY08–

FY07 

Percent 

chng 

44300 ................... State College, PA ......................................................................................... 0.8356 0.8784 0.0428 5.12 

44700 ................... Stockton, CA ................................................................................................. 1.1307 1.1442 0.0135 1.19 

44940 ................... Sumter, SC ................................................................................................... 0.8377 0.8083 ¥0.0294 ¥3.51 

45060 ................... Syracuse, NY ................................................................................................ 0.9574 0.9691 0.0117 1.22 

45104 ................... Tacoma, WA ................................................................................................. 1.0742 1.0789 0.0047 0.44 

45220 ................... Tallahassee, FL ............................................................................................ 0.8688 0.8942 0.0254 2.92 

45300 ................... Tampa-St. Petersburg-Clearwater, FL .......................................................... 0.9233 0.9144 ¥0.0089 ¥0.96 

45460 ................... Terre Haute, IN ............................................................................................. 0.8304 0.8765 0.0461 5.55 

45500 ................... Texarkana, TX-Texarkana, AR ..................................................................... 0.8283 0.8104 ¥0.0179 ¥2.16 

45780 ................... Toledo, OH .................................................................................................... 0.9574 0.9586 0.0012 0.13 

45820 ................... Topeka, KS ................................................................................................... 0.8920 0.8730 ¥0.0190 ¥2.13 

45940 ................... Trenton-Ewing, NJ ........................................................................................ 1.0834 1.0835 0.0001 0.01 

46060 ................... Tucson, AZ .................................................................................................... 0.9007 0.9202 0.0195 2.16 

46140 ................... Tulsa, OK ...................................................................................................... 0.8543 0.8103 ¥0.0440 ¥5.15 

46220 ................... Tuscaloosa, AL ............................................................................................. 0.8645 0.8542 ¥0.0103 ¥1.19 

46340 ................... Tyler, TX ....................................................................................................... 0.9168 0.8811 ¥0.0357 ¥3.89 

46540 ................... Utica-Rome, NY ............................................................................................ 0.8358 0.8396 0.0038 0.45 

46660 ................... Valdosta, GA ................................................................................................. 0.8866 0.8369 ¥0.0497 ¥5.61 

46700 ................... Vallejo-Fairfield, CA ...................................................................................... 1.4936 1.5137 0.0201 1.35 

46940 ................... Vero Beach, FL ............................................................................................. 0.9434 ................ ¥0.9434 ................

47020 ................... Victoria, TX ................................................................................................... 0.8160 0.8560 0.0400 4.90 

47220 ................... Vineland-Millville-Bridgeton, NJ .................................................................... 0.9827 0.9832 0.0005 0.05 

47260 ................... Virginia Beach-Norfolk-Newport News, VA .................................................. 0.8799 0.8790 ¥0.0009 ¥0.10 

47300 ................... Visalia-Porterville, CA ................................................................................... 1.0123 0.9968 ¥0.0155 ¥1.53 

47380 ................... Waco, TX ...................................................................................................... 0.8518 0.8633 0.0115 1.35 

47580 ................... Warner Robins, GA ....................................................................................... 0.8645 0.8380 ¥0.0265 ¥3.07 

47644 ................... Warren-Troy-Farmington Hills, MI ................................................................ 0.9871 1.0054 0.0183 1.85 

47894 ................... Washington-Arlington-Alexandria, DC-VA .................................................... 1.0926 1.1054 0.0128 1.17 

47940 ................... Waterloo-Cedar Falls, IA .............................................................................. 0.8557 0.8408 ¥0.0149 ¥1.74 

48140 ................... Wausau, WI .................................................................................................. 0.9590 0.9722 0.0132 1.38 

48260 ................... Weirton-Steubenville, WV-OH ...................................................................... 0.7819 0.8063 0.0244 3.12 

48300 ................... Wenatchee, WA ............................................................................................ 1.0070 1.0346 0.0276 2.74 

48424 ................... West Palm Beach-Boca Raton-Boynton, FL ................................................ 1.0067 0.9649 ¥0.0418 ¥4.15 

48540 ................... Wheeling, WV-OH ......................................................................................... 0.7161 0.7010 ¥0.0151 ¥2.11 

48620 ................... Wichita, KS ................................................................................................... 0.9153 0.9063 ¥0.0090 ¥0.98 

48660 ................... Wichita Falls, TX ........................................................................................... 0.8285 0.8311 0.0026 0.31 

48700 ................... Williamsport, PA ............................................................................................ 0.8364 0.8139 ¥0.0225 ¥2.69 

48864 ................... Wilmington, DE-MD-NJ ................................................................................. 1.0471 1.0684 0.0213 2.03 

48900 ................... Wilmington, NC ............................................................................................. 0.9582 0.9835 0.0253 2.64 

49020 ................... Winchester, VA-WV ...................................................................................... 1.0214 1.0091 ¥0.0123 ¥1.20 

49180 ................... Winston-Salem, NC ...................................................................................... 0.8944 0.9276 0.0332 3.71 

49340 ................... Worcester, MA .............................................................................................. 1.1028 1.0722 ¥0.0306 ¥2.77 

49420 ................... Yakima, WA .................................................................................................. 1.0155 0.9847 ¥0.0308 ¥3.03 

49500 ................... Yauco, PR ..................................................................................................... 0.4408 0.3854 ¥0.0554 ¥12.57 

49620 ................... York-Hanover, PA ......................................................................................... 0.9347 0.9397 0.0050 0.53 

49660 ................... Youngstown-Warren-Boardman, OH-PA ...................................................... 0.8603 0.8802 0.0199 2.31 

49700 ................... Yuba City, CA ............................................................................................... 1.0921 1.0730 ¥0.0191 ¥1.75 

49740 ................... Yuma, AZ ...................................................................................................... 0.9126 0.9109 ¥0.0017 ¥0.19 

[FR Doc. E8–17795 Filed 7–31–08; 4:15 pm] 

BILLING CODE 4120–01–P 


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