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 Department of Health and Human Services Centers for Medicare & Medicaid Services 42 CFR Part 412
[CMS-1554-F]
RIN 0938-AP19
 AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
 ACTION: Final rule.
 SUMMARY: This final rule updates the prospective payment rates for inpatient rehabilitation facilities (IRFs) for Federal fiscal year (FY) 2009 (for discharges occurring on or after October 1, 2008 and on or before September 30, 2009) as required under section 1886(j)(3)(C) of the Social Security Act (the Act). Section 1886(j)(5) of the Act requires the Secretary to publish in the 
                            **Federal Register**
                             on or before the August 1 that precedes the start of each fiscal year, the classification and weighting factors for the IRF prospective payment system's (PPS) case-mix groups and a description of the methodology and data used in computing the prospective payment rates for that fiscal year. We are revising existing policies regarding the PPS within the authority granted under section 1886(j) of the Act.
 DATES: These regulations are effective October 1, 2008. The updated IRF prospective payment rates are applicable for discharges on or after October 1, 2008 and on or before September 30, 2009 (FY 2009).
 FOR FURTHER INFORMATION CONTACT: Susanne Seagrave, (410) 786-0044, for information regarding the payment policies. Jeanette Kranacs, (410) 786-9385, for information regarding the wage index.


SUPPLEMENTARY INFORMATION: Table of Contents I. Background A. Historical Overview of the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) B. Operational Overview of the Current IRF PPS II. Provisions of the Proposed Rule III. Analysis of and Responses to Public Comments IV. Update to the Case-Mix Group (CMG) Relative Weights and Average Length of Stay Values for FY 2009 V. FY 2009 IRF PPS Federal Prospective Payment Rates A. Increase Factor and Labor-Related Share for FY 2009 B. Area Wage Adjustment C. Description of the IRF Standard Payment Conversion Factor and Payment Rates for FY 2009 D. Example of the Methodology for Adjusting the Federal Prospective Payment Rates VI. Update to Payments for High-Cost Outliers Under the IRF PPS A. Update to the Outlier Threshold Amount for FY 2009 B. Update to the IRF Cost-to-Charge Ratio Ceilings VII. Revisions to the Regulation Text in Response to the Medicare, Medicaid, and SCHIP Extension Act of 2007 VIII. Post Acute Care Payment Reform IX. Miscellaneous Comments X. Provisions of the Final Rule XI. Collection of Information Requirements XII. Regulatory Impact Statement Regulation Text Addendum Acronyms Because of the many terms to which we refer by acronym in this final rule, we are listing the acronyms used and their corresponding terms in alphabetical order below. ASCA Administrative Simplification Compliance Act, Public Law 107-105 BBA Balanced Budget Act of 1997, Public Law 105-33 BBRA Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999, Public Law 106-113 BIPA Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act of 2000, Public Law 106-554 CBSA Core-Based Statistical Area CCR Cost-to-Charge Ratio CFR Code of Federal Regulations CMG Case-Mix Group DRA Deficit Reduction Act of 2005, Public Law 109-171 DSH Disproportionate Share Hospital ECI Employment Cost Index FI Fiscal Intermediary FR 
                            **Federal Register** FY Federal Fiscal Year GDP Gross Domestic Product HHH Hubert H. Humphrey Building HIPAA Health Insurance Portability and Accountability Act, Public Law 104-191 IFMC Iowa Foundation for Medical Care IPF Inpatient Psychiatric Facility IPPS Inpatient Prospective Payment System IRF Inpatient Rehabilitation Facility IRF-PAI Inpatient Rehabilitation Facility-Patient Assessment Instrument IRF PPS Inpatient Rehabilitation Facility Prospective Payment System IRVEN Inpatient Rehabilitation Validation and Entry LIP Low-Income Percentage LTCH Long-Term Care Hospital MAC Medicare Administrative Contractor MEDPAR Medicare Provider Analysis and Review MMA Medicare Prescription Drug, Improvement, and  Modernization Act of 2003, Public Law 108-173 MMSEA Medicare, Medicaid, and SCHIP Extension Act of 2007, Public Law 110-173 MSA Metropolitan Statistical Area NAICS North American Industrial Classification System OMB Office of Management and Budget PAI Patient Assessment Instrument PPS Prospective Payment System RAND RAND Corporation RFA Regulatory Flexibility Act, Public Law 96-354 RIA Regulatory Impact Analysis RIC Rehabilitation Impairment Category RPL Rehabilitation, Psychiatric, and Long-Term Care Hospital Market Basket SCHIP State Children's Health Insurance Program SIC Standard Industrial Code TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Public Law 97-248 I. Background A. Historical Overview of the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Section 4421 of the Balanced Budget Act of 1997 (BBA), Public Law 105-33, as amended by section 125 of the Medicare, Medicaid, and SCHIP (State Children's Health Insurance Program) Balanced Budget Refinement Act of 1999 (BBRA), Public Law 106-113, and by section 305 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), Public Law 106-554, provides for the implementation of a per discharge prospective payment system (PPS) under section 1886(j) of the Social Security Act (the Act) for inpatient rehabilitation hospitals and inpatient rehabilitation units of a hospital (hereinafter referred to as IRFs). Payments under the IRF PPS encompass inpatient operating and capital costs of furnishing covered rehabilitation services (that is, routine, ancillary, and capital costs) but not direct graduate medical education costs, costs of approved nursing and allied health education activities, bad debts, and other services or items outside the scope of the IRF PPS. Although a complete discussion of the IRF PPS provisions appears in the original FY 2002 IRF PPS final rule (66 FR 41316) and the FY 2006 IRF PPS final rule (70 FR 47880), we are providing below a general description of the IRF PPS for fiscal years (FYs) 2002 through 2008. Under the IRF PPS from FY 2002 through FY 2005, as described in the FY 2002 IRF PPS final rule (66 FR 41316), the Federal prospective payment rates were computed across 100 distinct case-mix groups (CMGs). We constructed 95 CMGs using rehabilitation impairment 
                        ( print page 46371)
                        categories (RICs), functional status (both motor and cognitive), and age (in some cases, cognitive status and age may not be a factor in defining a CMG). In addition, we constructed five special CMGs to account for very short stays and for patients who expire in the IRF. For each of the CMGs, we developed relative weighting factors to account for a patient's clinical characteristics and expected resource needs. Thus, the weighting factors accounted for the relative difference in resource use across all CMGs. Within each CMG, we created tiers based on the estimated effects that certain comorbidities would have on resource use. We established the Federal PPS rates using a standardized payment conversion factor (formerly referred to as the budget neutral conversion factor). For a detailed discussion of the budget neutral conversion factor, please refer to our FY 2004 IRF PPS final rule (68 FR 45684 through 45685). In the FY 2006 IRF PPS final rule (70 FR 47880), we discussed in detail the methodology for determining the standard payment conversion factor. We applied the relative weighting factors to the standard payment conversion factor to compute the unadjusted Federal prospective payment rates under the IRF PPS from FYs 2002 through 2005. Within the structure of the payment system, we then made adjustments to account for interrupted stays, transfers, short stays, and deaths. Finally, we applied the applicable adjustments to account for geographic variations in wages (wage index), the percentage of low-income patients, location in a rural area (if applicable), and outlier payments (if applicable) to the IRF's unadjusted Federal prospective payment rates. For cost reporting periods that began on or after January 1, 2002 and before October 1, 2002, we determined the final prospective payment amounts using the transition methodology prescribed in section 1886(j)(1) of the Act. Under this provision, IRFs transitioning into the PPS were paid a blend of the Federal IRF PPS rate and the payment that the IRF would have received had the IRF PPS not been implemented. This provision also allowed IRFs to elect to bypass this blended payment and immediately be paid 100 percent of the Federal IRF PPS rate. The transition methodology expired as of cost reporting periods beginning on or after October 1, 2002 (FY 2003), and payments for all IRFs now consist of 100 percent of the Federal IRF PPS rate. We established a CMS Web site as a primary information resource for the IRF PPS. The Web site URL is 
                        *http://www.cms.hhs.gov/​InpatientRehabFacPPS/​*
                         and may be accessed to download or view publications, software, data specifications, educational materials, and other information pertinent to the IRF PPS. Section 1886(j) of the Act confers broad statutory authority upon the Secretary to propose refinements to the IRF PPS. In the FY 2006 IRF PPS final rule (70 FR 47880) and in correcting amendments to the FY 2006 IRF PPS final rule (70 FR 57166) that we published on September 30, 2005, we finalized a number of refinements to the IRF PPS case-mix classification system (the CMGs and the corresponding relative weights) and the case-level and facility-level adjustments. These refinements included the adoption of OMB's Core-Based Statistical Area (CBSA) market definitions, modifications to the CMGs, tier comorbidities, and CMG relative weights, implementation of a new teaching status adjustment for IRFs, revision and rebasing of the IRF market basket, and updates to the rural, low-income percentage (LIP), and high-cost outlier adjustments. Any reference to the FY 2006 IRF PPS final rule in this final rule also includes the provisions effective in the correcting amendments. For a detailed discussion of the final key policy changes for FY 2006, please refer to the FY 2006 IRF PPS final rule (70 FR 47880 and 70 FR 57166). In the FY 2007 IRF PPS final rule (71 FR 48354), we further refined the IRF PPS case-mix classification system (the CMG relative weights) and the case-level adjustments, to ensure that IRF PPS payments continue to reflect as accurately as possible the costs of care. For a detailed discussion of the FY 2007 policy revisions, please refer to the FY 2007 IRF PPS final rule (71 FR 48354). In the FY 2008 IRF PPS final rule (72 FR 44284), we updated the Federal prospective payment rates and the outlier threshold, revised the IRF wage index policy, and clarified how we determine high-cost outlier payments for transfer cases. For more information on the policy changes implemented for FY 2008, please refer to the FY 2008 IRF PPS final rule (72 FR 44284), in which we published the final FY 2008 IRF Federal prospective payment rates. After publication of the FY 2008 IRF PPS final rule (72 FR 44284), section 115 of the Medicare, Medicaid, and SCHIP Extension Act of 2007, Public Law 110-173 (MMSEA), amended section 1886(j)(3)(C) of the Act to apply a zero percent increase factor for FYs 2008 and 2009, effective for IRF discharges occurring on or after April 1, 2008. Section 1886(j)(3)(C) of the Act requires the Secretary to develop an increase factor to update the IRF Federal prospective payment rates for each FY. Based on the legislative change to the increase factor, we revised the FY 2008 Federal prospective payment rates for IRF discharges occurring on or after April 1, 2008. Thus, the final FY 2008 IRF Federal prospective payment rates that were published in the FY 2008 IRF PPS final rule (72 FR 44284) were effective for discharges occurring on or after October 1, 2007 and on or before March 31, 2008; and the revised FY 2008 IRF Federal prospective payment rates are effective for discharges occurring on or after April 1, 2008 and on or before September 30, 2008. The revised FY 2008 Federal prospective payment rates are available on the CMS Web site at 
                        *http://www.cms.hhs.gov/​InpatientRehabFacPPS/​07_​DataFiles.asp#TopOfPage*. B. Operational Overview of the Current IRF PPS As described in the FY 2002 IRF PPS final rule, upon the admission and discharge of a Medicare Part A fee-for-service patient, the IRF is required to complete the appropriate sections of a patient assessment instrument, the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI). All required data must be electronically encoded into the IRF-PAI software product. Generally, the software product includes patient classification programming called the GROUPER software. The GROUPER software uses specific IRF-PAI data elements to classify (or group) patients into distinct CMGs and account for the existence of any relevant comorbidities. The GROUPER software produces a five-digit CMG number. The first digit is an alpha-character that indicates the comorbidity tier. The last four digits represent the distinct CMG number. Free downloads of the Inpatient Rehabilitation Validation and Entry (IRVEN) software product, including the GROUPER software, are available on the CMS Web site at 
                        *http://www.cms.hhs.gov/​InpatientRehabFacPPS/​06_​Software.asp.* Once a patient is discharged, the IRF submits a Medicare claim as a Health Insurance Portability and Accountability Act (HIPAA), Public Law 104-191, compliant electronic claim or, if the Administrative Compliance Act (ASCA), Public Law 107-105, permits, a paper claim, a UB-04 or a CMS-1450, (as appropriate) using the five-digit CMG number and sends it to the 
                        ( print page 46372)
                        appropriate Medicare fiscal intermediary (FI) or Medicare Administrative Contractor (MAC). Claims submitted to Medicare must comply with both ASCA and HIPAA. Section 3 of the ASCA amends section 1862(a) of the Act by adding paragraph (22) which requires the Medicare program, subject to section 1862(h) of the Act, to deny payment under Part A or Part B for any expenses for items or services “for which a claim is submitted other than in an electronic form specified by the Secretary.” Section 1862(h) of the Act, in turn, provides that the Secretary shall waive such denial in situations in which there is no method available for the submission of claims in an electronic form or the entity submitting the claim is a small provider. In addition, the Secretary also has the authority to waive such denial “in such unusual cases as the Secretary finds appropriate.” We refer the reader to the final rule, “Medicare Program; Electronic Submission of Medicare Claims” (70 FR 71008, November 25, 2005). Section 3 of the ASCA operates in the context of the administrative simplification provisions of HIPAA, which include, among others, the requirements for transaction standards and code sets codified in 45 CFR, parts 160 and 162, subparts A and I through R (generally known as the Transactions Rule). The Transactions Rule requires covered entities, including covered healthcare providers, to conduct covered electronic transactions according to the applicable transaction standards. (See the program claim memoranda issued and published by CMS at: 
                        *http://www.cms.hhs.gov/​ElectronicBillingEDITrans/​*
                         and listed in the addenda to the Medicare Intermediary Manual, Part 3, section 3600. CMS instructions for the limited number of Medicare claims submitted on paper are available at: 
                        *http://www.cms.hhs.gov/​manuals/​downloads/​clm104c25.pdf*.) The Medicare FI or MAC processes the claim through its software system. This software system includes pricing programming called the “PRICER” software. The PRICER software uses the CMG number, along with other specific claim data elements and provider-specific data, to adjust the IRF's prospective payment for interrupted stays, transfers, short stays, and deaths, and then applies the applicable adjustments to account for the IRF's wage index, percentage of low-income patients, rural location, and outlier payments. For discharges occurring on or after October 1, 2005, the IRF PPS payment also reflects the new teaching status adjustment that became effective as of FY 2006, as discussed in the FY 2006 IRF PPS final rule (70 FR 47880). II. Provisions of the Proposed Rule As discussed in the FY 2009 IRF PPS proposed rule (73 FR 22674), we proposed to make revisions to the regulation text in response to section 115 of the MMSEA. Specifically, we proposed to revise 42 CFR part 412. We discuss these proposed revisions and others in detail below. A. Section 412.23 Excluded Hospitals: Classifications We proposed to revise the regulation text in paragraph (b)(2)(i) and remove paragraph (b)(2)(ii) in response to section 115 of the MMSEA. To summarize, for cost reporting periods— (1) Beginning on or after July 1, 2005, the hospital has served an inpatient population of whom at least 60 percent require intensive rehabilitation services for treatment of one or more of the conditions specified at paragraph (b)(2)(ii) of this section (as amended by removing former (b)(2)(ii) and redesignating former (b)(2)(iii) as the new (b)(2)(ii)). (2) A comorbidity that meets the criteria as specified in § 412.23(b)(2)(i) may continue to be used to determine the compliance threshold. B. Additional Proposed Changes Update the FY 2009 IRF PPS relative weights and average length of stay values using the most current and complete Medicare claims and cost report data, as discussed in section II of the FY 2009 IRF PPS proposed rule (73 FR 22674, 22676 through 22680).
                    Update the FY 2009 IRF PPS payment rates by the proposed wage index and labor related share in a budget neutral manner, as discussed in sections III.A and B of the FY 2009 IRF PPS proposed rule (73 FR 22674, 22680 through 22686).
                    Update the outlier threshold amount for FY 2009, as discussed in section IV.A of the FY 2009 IRF PPS proposed rule (73 FR 22674, 22686 through 22687).
                    Update the cost-to-charge ratio ceiling and the national average urban and rural cost-to-charge ratios for purposes of determining outlier payments under the IRF PPS, as discussed in section IV.B of the FY 2009 IRF PPS proposed rule (73 FR 22674 at 22687). III. Analysis of and Responses to Public Comments We received approximately 17 timely items of correspondence containing multiple comments on the FY 2009 IRF PPS proposed rule (73 FR 22674) from the public. We received comments from various trade associations, inpatient rehabilitation facilities, health care industry organizations, and health care consulting firms. The following discussion, arranged by subject area, includes a summary of the public comments that we received, and our responses to the comments appear under the appropriate subject heading. IV. Update to the CMG Relative Weights and Average Length of Stay Values for FY 2009 As specified in 42 CFR 412.620(b)(1), we calculate a relative weight for each CMG that is proportional to the resources needed by an average inpatient rehabilitation case in that CMG. For example, cases in a CMG with a relative weight of 2, on average, will cost twice as much as cases in a CMG with a relative weight of 1. Relative weights account for the variance in cost per discharge due to the variance in resource utilization among the payment groups, and their use helps to ensure that IRF PPS payments support beneficiary access to care as well as provider efficiency. In the FY 2009 IRF PPS proposed rule (73 FR 22674, 22676 through 22680), we proposed updates to the CMG relative weights and average length of stay values using the most recent available data (FY 2006 IRF claims, FY 2006 IRF-PAI, and FY 2006 IRF cost report data) to ensure that IRF PPS payments continue to reflect as accurately as possible the costs of care in IRFs. We proposed to do this using the same methodology, with one change, that was described in the original, FY 2002 IRF PPS final rule (66 FR 41316) and the FY 2006 IRF PPS final rule (70 FR 47880, 47887 through 47888). The proposed change to the methodology involves using new, more detailed cost-to-charge ratio (CCR) data from the cost reports of IRF subprovider units of primary acute care hospitals, instead of CCR data from the associated primary acute care hospitals, to calculate IRFs' average costs per case. In general, we proposed to make this change in the methodology because the more detailed CCR data from the IRF subprovider cost reports are now available in sufficient detail, and the relationship between costs and charge in the primary acute care hospital could differ from the relationship between costs and charges in the IRF subprovider units, making the data from the IRF subprovider units potentially more accurate for estimating the average costs per case in these units. For freestanding IRFs, we proposed to continue using CCR data from the 
                        ( print page 46373)
                        freestanding IRF's cost report. We also noted that in future years we would continue to estimate the CMG relative weights using both the primary acute care hospital CCRs and the IRF subprovider unit CCRs to ensure that we continue to use the most appropriate data in updating the CMG relative weights. In addition, we proposed to make changes to the CMG relative weights for FY 2009 in such a way that total estimated aggregate payments to IRFs for FY 2009 would be the same with or without the proposed changes (that is, in a budget neutral manner) by applying a budget neutrality factor to the standard payment amount, as described in section II of the FY 2009 IRF PPS proposed rule (73 FR 22674 at 22677). To compute the budget neutrality factor used to update the CMG relative weights, we proposed to use the following steps: *Step 1.*
                         Calculate the estimated total amount of IRF PPS payments for FY 2009 (with no proposed changes to the CMG relative weights). *Step 2.*
                         Apply the proposed changes to the CMG relative weights (as discussed above) to calculate the estimated total amount of IRF PPS payments for FY 2009. *Step 3.*
                         Divide the amount calculated in step 1 by the amount calculated in step 2 to determine the budget neutrality factor that would maintain the same total estimated aggregate payments in FY 2009 with and without the proposed changes to the CMG relative weights. *Step 4.*
                         Apply the proposed budget neutrality factor to the FY 2008 IRF PPS standard payment amount after the application of the budget-neutral wage adjustment factor. Note that the budget neutrality factor that we use to update the CMG relative weights for FY 2009 changed from 0.9969 in the proposed rule to 0.9939 in this final rule due to the use of updated FY 2007 IRF claims data in this final rule. We received five comments on the proposed updates to the CMG relative weights and average length of stay values, which are summarized below. *Comment:*
                         Several commenters supported the proposed update to the CMG relative weights for FY 2009, with one commenter referring to the proposed update as a “step in the right direction.” However, several commenters specifically suggested that we analyze the FY 2007 IRF claims and cost report data in computing the CMG relative weights for FY 2009, as these data would reflect more of the impact of recent changes in the 75 percent rule and the IRF medical necessity reviews than the FY 2006 IRF claims and cost report data. Further, one commenter recommended that we seek additional cost information to use to compute the CMG relative weights, including nursing staff time data, ancillary cost data, and other alternatives to the IRF claims and cost report data that we currently use to compute the CMG relative weights. Finally, a couple of commenters recommended that we recalibrate the CMG relative weights more frequently, with one commenter specifically asking that we recalibrate the CMG relative weights again next year (for FY 2010) using the most recent available data. *Response:*
                         We agree with the commenters that we should analyze the most recent available IRF data to compute the CMG relative weights for FY 2009 in order to ensure that IRF PPS payments continue to reflect as accurately as possible the costs of care in IRFs. For the proposed rule, we used data from FY 2006 IRF claims, FY 2006 IRF-PAI, and FY 2006 IRF cost reports because that was the best available data at the time. For this final rule, we have updated the IRF claims data used in our analysis of the CMG relative weights and average length of stay values from FY 2006 to FY 2007. We note that we used FY 2006 IRF-PAI data for analyzing the CMG relative weights in the proposed rule because we implemented some minor adjustments to the classification system for FY 2007 in the FY 2007 IRF PPS final rule (71 FR 48354, 48360 through 48370). Accordingly, some of the CMGs that appeared on the FY 2006 IRF claims data would not be the same CMGs that would be assigned under the current, post-FY 2007 IRF classification system. We therefore used the FY 2006 IRF-PAI data for the proposed rule to ensure that the appropriate current CMG was assigned for all of the FY 2006 claims. However, use of the IRF-PAI data was no longer necessary when we used the FY 2007 IRF claims data for this final rule because the CMG information on the FY 2007 IRF claims data incorporated all of the changes to the IRF classification system that were implemented in the FY 2007 IRF PPS final rule (71 FR 48354, 48360 through 48370). We did not implement any changes to the IRF classification system in the FY 2008 IRF PPS final rule (72 FR 44284). The results of our analysis of the FY 2007 IRF claims data are reflected in the CMG relative weights and average length of stay values presented in Table 1 in this final rule. We further note that we have not updated the IRF cost report data used in this final rule. Although we agree with the commenter that it is important to analyze the most recent available cost report data to reflect as fully as possible the changes in IRF patient populations that may have occurred as a result of changes in the 75 percent rule and the IRF medical necessity reviews, only a small portion of the FY 2007 IRF cost reports are available for analysis at this time. Accordingly, we have continued to use the FY 2006 cost report data for analyzing IRFs' costs per case in this final rule because these are the most complete IRF cost report data available at this time. However, we will continue to evaluate the need for further updates and refinements to the CMG relative weights and average length of stay values in future years and would update the cost report data, as appropriate, when the data become available. We appreciate the commenter's suggestions regarding alternative data to use in analyzing the costs of caring for IRF patients, and we will carefully consider the commenter's suggestions for future refinements to the methodology for computing the CMG relative weights. Finally, we agree with the commenters that we may need to update the CMG relative weight and average length of stay analysis frequently to ensure that IRF payments continue to reflect the costs of caring for IRF patients, especially in light of recent changes resulting from changes to the 75 percent rule and the IRF medical necessity reviews. We intend to continue analyzing the most recent available data, and will propose future refinements to the IRF classification and weighting system based on that analysis, as appropriate. *Comment:*
                         One commenter stated a concern that the methodology used to revise the IRF classification system in the FY 2006 IRF PPS final rule (70 FR 47880) may have reduced the overall IRF case mix weights. This commenter asked CMS to re-examine this issue. *Response:*
                         As discussed in the FY 2006 IRF PPS final rule (70 FR 47880, 47886 through 47904), the FY 2007 IRF PPS final rule (71 FR 48354, 48373 through 48374), and the FY 2008 IRF PPS final rule (72 FR 44284 at 44293), we have analyzed the data and it continues to show that the FY 2006 refinements to the IRF classification system did not cause a reduction in the overall IRF case mix weights or in aggregate IRF payments. We have met with industry representatives several times in order to understand their concerns. We have also discussed the results of our analysis with them, which continues to show that we implemented the FY 2006 refinements to the IRF 
                        ( print page 46374)
                        classification system in a budget neutral manner, so that estimated aggregate payments to providers would not increase or decrease as a result of these refinements. *Comment:*
                         One commenter questioned why only 141 (40 percent) of the proposed FY 2009 CMG relative weight values increased compared with the FY 2008 CMG relative weight values, while 212 (60 percent) of the proposed FY 2009 CMG relative weight values decreased compared with the FY 2008 CMG relative weight values. This commenter generally expressed surprise at the proposed FY 2009 CMG relative weights values, but indicated that certain changes appeared to be correct, particularly the increases in the CMG relative weights for some of the orthopedic conditions. However, the commenter questioned why the CMG relative weight values for other types of cases decreased. *Response:*
                         As we discussed in the proposed rule (73 FR 22674 at 22680), updates to the CMG relative weights will result in some increases and some decreases to the CMG relative weight values. This is due to the distributional nature of CMG relative weight changes. However, our updated analysis of the CMG relative weight values presented in Table 1 of this final rule (which is based on more recent data than that used in the proposed rule, as explained previously in this section) now shows that more than half of the CMG relative weights will increase and, further, that more than half of beneficiaries are in payment groups for which the CMG relative weight will increase between FY 2008 and FY 2009. Specifically, our analysis shows that 57 percent of patients are classified into one of the 177 payment groups (that is, the combination of CMG and tier) that will experience an increase in the CMG relative weight value between FYs 2008 and 2009, and 43 percent of patients are classified into one of the 176 classification groups that will experience a decrease in the CMG relative weight value between FYs 2008 and 2009. *Final Decision:*
                         We received only positive comments in support of the proposal to change the methodology for determining IRFs' average costs per case by using more detailed cost-to-charge ratio (CCR) data from the cost reports of IRF subprovider units of primary acute care hospitals to calculate the IRF subprovider units' average costs per case. Thus, after carefully considering all of the comments that we received on the proposed updates to the CMG relative weights and average length of stay values, we are finalizing this change to the methodology for the reasons explained previously and as described in more detail in the proposed rule (73 FR 22674, 22676 through 22677). For freestanding IRFs, we will continue to use the CCR data from the freestanding IRFs' cost reports. Consistent with the methodology that we used to compute the CMG relative weights for FYs 2002 through 2008, with the one change described above, we are implementing the updates to the CMG relative weights and average length of stay values presented in Table 1 below. As recommended by the commenters, we have updated the CMG relative weights and average length of stay values in Table 1 using FY 2007 IRF claims data for this final rule. Further, as noted previously, we have continued to use FY 2006 IRF cost report data for this final rule because it is the best available cost report data at this time. Table 1—Relative Weights and Average Lengths of Stay for Case-Mix Groups
CMG
CMG
                                 description 
                                 (M=motor, 
                                 C=cognitive, 
                                 A=age)
Relative weight
Average length of stayTier 1
Tier 2
Tier 3
None
Tier 1
Tier 2
Tier 3
None0101
Stroke: M>51.05
0.7712
0.7108
0.6381
0.6059
9
10
9
80102
Stroke: M>44.45 and M<51.05 and C>18.5
0.9694
0.8936
0.8021
0.7617
11
11
11
100103
Stroke: M>44.45 and M<51.05 and C<18.5
1.1478
1.0580
0.9496
0.9018
14
14
12
120104
Stroke: M>38.85 and M<44.45
1.2192
1.1238
1.0087
0.9579
13
14
13
130105
Stroke: M>34.25 and M<38.85
1.4320
1.3199
1.1848
1.1251
16
18
15
150106
Stroke: M>30.05 and M<34.25
1.6632
1.5330
1.3761
1.3067
19
19
17
170107
Stroke: M>26.15 and M<30.05
1.8970
1.7485
1.5695
1.4904
20
21
19
190108
Stroke: M<26.15 and A>84.5
2.2795
2.1011
1.8860
1.7910
27
26
23
220109
Stroke: M>22.35 and M<26.15 and A<84.5
2.1786
2.0081
1.8025
1.7117
22
23
21
220110
Stroke: M<22.35 and A<84.5
2.7217
2.5087
2.2518
2.1384
30
30
27
260201
Traumatic brain injury: M>53.35 and C>23.5
0.7556
0.6464
0.5818
0.5295
10
10
8
80202
Traumatic brain injury: M>44.25 and M<53.35 and C>23.5
1.0305
0.8817
0.7935
0.7222
13
11
10
100203
Traumatic brain injury: M>44.25 and C<23.5
1.1487
0.9828
0.8846
0.8051
12
13
12
110204
Traumatic brain injury: M>40.65 and M<44.25
1.2934
1.1066
0.9959
0.9064
15
14
13
120205
Traumatic brain injury: M>28.75 and M<40.65
1.5739
1.3466
1.2119
1.1030
17
17
16
140206
Traumatic brain injury: M>22.05 and M<28.75
1.9530
1.6709
1.5039
1.3687
21
21
18
180207
Traumatic brain injury: M<22.05
2.6307
2.2508
2.0257
1.8437
36
28
24
22( print page 46375)0301
Non-traumatic brain injury: M>41.05
1.1084
0.9308
0.8358
0.7650
12
12
11
100302
Non-traumatic brain injury: M>35.05 and M<41.05
1.4120
1.1857
1.0647
0.9746
14
15
13
130303
Non-traumatic brain injury: M>26.15 and M<35.05
1.6938
1.4224
1.2772
1.1691
17
17
16
150304
Non-traumatic brain injury: M<26.15
2.3130
1.9424
1.7441
1.5966
27
23
21
200401
Traumatic spinal cord injury: M>48.45
0.9255
0.7883
0.7732
0.6566
12
12
11
90402
Traumatic spinal cord injury: M>30.35 and M<48.45
1.3933
1.1868
1.1640
0.9886
17
15
16
130403
Traumatic spinal cord injury: M>16.05 and M<30.35
2.2823
1.9440
1.9067
1.6194
28
23
23
210404
Traumatic spinal cord injury: M<16.05 and A>63.5
3.9766
3.3872
3.3222
2.8215
53
40
37
340405
Traumatic spinal cord injury: M<16.05 and A<63.5
.0347
2.5850
2.5354
2.1532
42
30
29
270501
Non-traumatic spinal cord injury: M>51.35
0.8107
0.6397
0.5945
0.5245
9
9
8
80502
Non-traumatic spinal cord injury: M>40.15 and M<51.35
1.0994
0.8675
0.8062
0.7113
13
11
11
100503
Non-traumatic spinal cord injury: M>31.25 and M<40.15
1.4315
1.1296
1.0497
0.9261
16
14
13
130504
Non-traumatic spinal cord injury: M>29.25 and M<31.25
1.7229
1.3596
1.2634
1.1147
21
17
16
150505
Non-traumatic spinal cord injury: M>23.75 and M<29.25
2.0360
1.6066
1.4930
1.3173
23
21
19
170506
Non-traumatic spinal cord injury: M<23.75
2.8325
2.2351
2.0770
1.8325
32
27
25
230601
Neurological: M>47.75
0.9245
0.7546
0.7174
0.6542
11
9
10
90602
Neurological: M>37.35 and M<47.75
1.2366
1.0094
0.9596
0.8750
12
13
12
120603
Neurological: M>25.85 and M<37.35
1.5763
1.2866
1.2232
1.1154
16
16
15
140604
Neurological: M<25.85
2.0887
1.7049
1.6208
1.4780
24
21
20
180701
Fracture of lower extremity: M>42.15
0.9187
0.7742
0.7300
0.6563
11
10
10
90702
Fracture of lower extremity: M>34.15 and M<42.15
1.2116
1.0209
0.9627
0.8655
14
14
12
120703
Fracture of lower extremity: M>28.15 and M<34.15
1.4846
1.2510
1.1797
1.0606
16
16
15
140704
Fracture of lower extremity: M<28.15
1.8994
1.6005
1.5093
1.3569
20
20
19
170801
Replacement of lower extremity joint: M>49.55
0.7000
0.5704
0.5172
0.4714
8
7
8
70802
Replacement of lower extremity joint: M>37.05 and M<49.55
0.9380
0.7643
0.6931
0.6317
10
10
9
90803
Replacement of lower extremity joint: M>28.65 and M<37.05 and A>83.5
1.3383
1.0905
0.9889
0.9013
14
13
13
120804
Replacement of lower extremity joint: M>28.65 and M<37.05 and A<83.5
1.1745
0.9571
0.8679
0.7910
13
12
11
100805
Replacement of lower extremity joint: M>22.05 and M<28.65
1.4661
1.1947
1.0833
0.9874
16
16
13
130806
Replacement of lower extremity joint: M<22.05
1.8139
1.4780
1.3403
1.2215
18
18
17
150901
Other orthopedic: M>44.75
0.8584
0.7574
0.6829
0.6041
10
10
9
90902
Other orthopedic: M>34.35 and M<44.75
1.1473
1.0122
0.9127
0.8074
13
13
12
11( print page 46376)0903
Other orthopedic: M>24.15 and M<34.35
1.4840
1.3093
1.1806
1.0443
16
16
15
140904
Other orthopedic: M<24.15
1.9620
1.7310
1.5608
1.3807
22
22
19
181001
Amputation, lower extremity: M>47.65
0.9356
0.9061
0.7797
0.7137
11
12
11
101002
Amputation, lower extremity: M>36.25 and M<47.65
1.2522
1.2127
1.0435
0.9552
14
15
13
121003
Amputation, lower extremity: M<36.25
1.8193
1.7619
1.5161
1.3877
19
21
19
171101
Amputation, non-lower extremity: M>36.35
1.1846
0.9851
0.9851
0.8558
12
12
13
111102
Amputation, non-lower extremity: M<36.35
1.7288
1.4377
1.4377
1.2490
17
18
17
151201
Osteoarthritis: M>37.65
1.0319
0.9668
0.8483
0.7541
11
12
11
101202
Osteoarthritis: M>30.75 and M<37.65
1.3034
1.2212
1.0715
0.9525
14
15
13
131203
Osteoarthritis: M<30.75
1.6379
1.5346
1.3465
1.1969
16
18
17
151301
Rheumatoid, other arthritis: M>36.35
1.0983
0.9874
0.8499
0.7648
12
12
11
101302
Rheumatoid, other arthritis: M>26.15 and M<36.35
1.4790
1.3296
1.1445
1.0299
15
16
14
131303
Rheumatoid, other arthritis: M<26.15
1.9140
1.7208
1.4812
1.3329
24
22
18
171401
Cardiac: M>48.85
0.8003
0.7221
0.6388
0.5667
10
11
9
81402
Cardiac: M>38.55 and M<48.85
1.1095
1.0010
0.8856
0.7856
13
13
12
111403
Cardiac: M>31.15 and M<38.55
1.3578
1.2251
1.0838
0.9615
15
15
13
131404
Cardiac: M<31.15
1.7628
1.5905
1.4071
1.2483
20
20
17
161501
Pulmonary: M>49.25
0.9603
0.8386
0.7413
0.7038
11
12
10
91502
Pulmonary: M>39.05 and M<49.25
1.2297
1.0739
0.9494
0.9013
13
13
12
111503
Pulmonary: M>29.15 and M<39.05
1.5640
1.3658
1.2074
1.1463
16
17
14
141504
Pulmonary: M<29.15
1.9525
1.7051
1.5073
1.4310
22
19
17
171601
Pain syndrome: M>37.15
1.1094
0.8968
0.7667
0.7068
13
13
10
101602
Pain syndrome: M>26.75 and M<37.15
1.4978
1.2108
1.0351
0.9543
16
16
13
131603
Pain syndrome: M<26.75
1.9287
1.5590
1.3328
1.2287
22
19
17
161701
Major multiple trauma without brain or spinal cord injury: M>39.25
1.0454
0.9189
0.8461
0.7419
11
12
11
101702
Major multiple trauma without brain or spinal cord injury: M>31.05 and M<39.25
1.3777
1.2110
1.1151
0.9778
14
15
14
131703
Major multiple trauma without brain or spinal cord injury: M>25.55 and M<31.05
1.6566
1.4561
1.3408
1.1757
18
17
16
151704
Major multiple trauma without brain or spinal cord injury: M<25.55
2.0776
1.8261
1.6815
1.4744
23
24
21
191801
Major multiple trauma with brain or spinal cord injury: M>40.85
1.2189
0.9629
0.9044
0.7757
15
13
13
101802
Major multiple trauma with brain or spinal cord injury: M>23.05 and M<40.85
1.8398
1.4533
1.3651
1.1708
19
17
16
151803
Major multiple trauma with brain or spinal cord injury: M<23.05
3.1442
2.4838
2.3329
2.0009
37
31
26
241901
Guillian Barre: M>35.95
1.1582
0.9288
0.9288
0.8782
15
11
11
121902
Guillian Barre: M>18.05 and M<35.95
2.3408
1.8772
1.8772
1.7749
26
22
25
221903
Guillian Barre: M<18.05
3.5944
2.8825
2.8825
2.7254
33
35
41
312001
Miscellaneous: M>49.15
0.8820
0.7282
0.6614
0.5928
11
9
9
8( print page 46377)2002
Miscellaneous: M>38.75 and M<49.15
1.1873
0.9803
0.8904
0.7980
12
13
11
112003
Miscellaneous: M>27.85 and M<38.75
1.5231
1.2575
1.1422
1.0237
16
16
14
132004
Miscellaneous: M<27.85
2.0363
1.6812
1.5271
1.3686
22
20
19
172101
Burns: M>0
2.3666
2.3666
2.1481
1.7454
25
25
25
175001
Short-stay cases, length of stay is 3 days or fewer



0.1476



35101
Expired, orthopedic, length of stay is 13 days or fewer



0.6783



85102
Expired, orthopedic, length of stay is 14 days or more



1.5432



195103
Expired, not orthopedic, length of stay is 15 days or fewer



0.7086



95104
Expired, not orthopedic, length of stay is 16 days or more



1.9586



23
 V. FY 2009 IRF PPS Federal Prospective Payment Rates A. Increase Factor and Labor-Related Share for FY 2009 Section 1886(j)(3)(C) of the Act requires the Secretary to establish an increase factor that reflects changes over time in the prices of an appropriate mix of goods and services included in the covered IRF services, which is referred to as a market basket index. According to section 1886(j)(3)(A)(i) of the Act, the increase factor shall be used to update the IRF Federal prospective payment rates for each FY. However, section 115 of the MMSEA, amended section 1886(j)(3)(C) of the Act to apply a zero percent increase factor for FYs 2008 and 2009, effective for IRF discharges occurring on or after April 1, 2008. Thus, we are applying an increase factor of zero percent to update the IRF Federal prospective payment rates for FY 2009 in this final rule. We continue to use the methodology described in the FY 2006 IRF PPS final rule to update the IRF labor-related share for FY 2009 (70 FR 47880, 47908 through 47917). The IRF labor-related share for FY 2009 is the sum of the FY 2009 relative importance of each labor-related cost category, and reflects the different rates of price change for these cost categories between the base year (FY 2002) and FY 2009. Consistent with our proposal to update the labor-related share with the most recent available data, the labor-related share for this final rule reflects Global Insight's second quarter 2008 forecast. (Global Insight is a nationally recognized economic and financial forecasting firm that contracts with CMS to forecast the components of providers' market baskets.) As shown in Table 2, the total FY 2009 Rehabilitation, Psychiatric, and Long-Term Care Hospital Market Basket (RPL) labor-related share in this final rule is 75.464 percent. Table 2—FY 2009 IRF RPL Labor-Related Share Relative Importance
Cost category
FY 2009 IRF 
                                 labor-related share relative 
                                 importanceWages and salaries
52.552Employee benefits
13.982Professional fees
2.890All other labor intensive services
2.120Subtotal
71.544Labor-related share of capital costs (.46)
3.920Total
75.464*SOURCE:*
                             GLOBAL INSIGHT, INC, 2nd QTR, 2008; @USMACRO/CONTROL0508 @CISSIM/TL0508.SIM Historical Data through 1st QTR, 2008.
 We received five comments on the increase factor and labor-related share for FY 2009, which are summarized below. *Comment:*
                         Two commenters expressed concern that the zero percent increase factor that we are applying to the IRF Federal prospective payment rates for FY 2009, would impose a financial burden on IRFs. These commenters noted that the zero percent increase factor for FY 2009 was required by section 115 of the MMSEA, which also made revisions to the 60 percent rule. The commenters requested that any future legislative changes to the 60 percent rule also be considered in combination with updates to the IRF Federal prospective payment rates. *Response:*
                         As we discussed in the FY 2009 IRF PPS proposed rule (73 FR 22674, 22680 through 22681), section 115 of the MMSEA amended section 1886(j)(3)(C) of the Act to apply a zero percent increase factor for FYs 2008 and 2009, effective for IRF discharges occurring on or after April 1, 2008. While we understand that the effect of the zero percent increase factor is to maintain FY 2009 IRF PPS payment rates at FY 2008 levels, the statute does not give CMS the discretion to implement an increase factor other than zero percent for FY 2009. We will respond to any future legislative changes to the 60 percent rule accordingly. *Comment:*
                         One commenter requested that CMS calculate the IRF PPS market basket estimates using more current market basket data. This commenter stated that the FY 2009 market basket estimate is based on data from FY 2002, and that the FY 2002 data underestimate the increase in costs, especially labor costs, that IRFs have experienced. The commenter suggested that CMS use Medicare cost report data to compute the market basket estimate, rather than data from the Bureau of Labor Statistics, in order to make the estimate more current. *Response:*
                         The IRF PPS market basket, which is a fixed weight, Laspeyres-type price index, is constructed in three 
                        ( print page 46378)
                        steps. First, a base period is selected (FY 2002 in the current market basket) and total base period expenditures are estimated for a set of mutually exclusive and exhaustive spending categories based upon type of expenditure. The proportion of total operating costs that each category represents is called a cost or expenditure weight. Medicare Cost Report (MCR) data are used to derive the primary cost weights for the market basket. We monitor the stability of these cost weights and have determined that they do not tend to fluctuate over short periods of time (such as a period of less than 5 years). In general, we have typically rebased (recalculated market basket cost weights) approximately every 5 years. We note that we last revised and rebased the market basket in the FY 2006 IRF PPS final rule (70 FR 47880, 47915 through 47917). Second, the FY 2002 expenditure weight for each cost category is matched to an appropriate price or wage variable, referred to as a price proxy. These price proxies are selected to reflect the rate-of-price change for each expenditure category and are primarily obtained from the Bureau of Labor Statistics (BLS). Finally, each FY 2002 cost weight is multiplied by the level of its respective price proxy. The sum of these products (that is, the expenditure weights multiplied by their price levels) for all cost categories yields the composite index level of the market basket in a given period. Repeating this step for other periods produces a series of market basket levels over time. The final IRF market basket update for FY 2009 is calculated using the market basket levels from the second quarter of 2008 (2008Q2) forecast prepared by Global Insight, Inc. (GII). These levels reflect the most recent price data available (historical price data through 2008Q1 and forecasted price data for 2008Q2 and beyond). Given the methodology described above, the current market basket estimate is not based solely on FY 2002 data, but rather is calculated by applying the most recent available price data for each quarter to the FY 2002 cost weights. Thus, the current FY 2009 market basket estimate does in fact reflect recent price increases experienced by IRFs. *Comment:*
                         Several commenters expressed concern about the methodology for computing the labor-related share. One commenter requested that we begin updating the labor-related share more frequently using the most recent available data. The commenter stated that the current calculation of the labor-related share is based on 2002 data. Another commenter said that the methodology does not adequately reflect the difficulty IRFs have in recruiting a skilled labor force. *Response:*
                         The FY 2009 labor-related share is intended to reflect those costs that are related to, influenced by, or vary with the local labor market. Accordingly, the share is calculated as the sum of the relative importance of the appropriate categories which include wages and salaries, fringe benefits, professional fees, labor-intensive services, and a portion of capital costs. We calculate this share based on the RPL market basket, which we believe adequately captures the current cost structures of Medicare-participating IRFs. By following a four-step process to estimate the labor-related relative importance for FY 2009, we are making use of up-to-date data that reflect current trends. As a result, the labor-related share appropriately reflects current labor market price pressures experienced by IRFs. The process is as follows: First, we compute the FY 2009 price index level for the total market basket and each cost category of the market basket. Second, we calculate a ratio for each cost category by dividing the FY 2009 price index level for that cost category by the total market basket price index level. Third, we determine the FY 2009 relative importance for each cost category by multiplying this ratio by the base year (FY 2002) weight. Finally, we sum the FY 2009 relative importance for each of the labor-related categories to produce the FY 2009 labor-related relative importance. The price proxies that move the different cost categories in the market basket do not necessarily change at the same rate, and the relative importance captures these potential differential growth rates. Accordingly, the relative importance figure more closely reflects the cost share weights for FY 2009 when compared to the base year weights from the 2002-based RPL market basket. We revised and rebased the market basket and labor-related share in FY 2006 and expect to conduct additional updates on a regular basis. *Final Decision:*
                         We will continue to apply a zero percent increase factor to the IRF Federal prospective payment rates for FY 2009, in accordance with section 115 of the MMSEA. Further, we will continue to update the IRF labor-related share using our current methodology, which reflects the most recent available data. Thus, for this final rule, the labor-related share is 75.464 percent. This is based on the GII's forecast for the second quarter of 2008 (2008Q2) with historical data through the first quarter of 2008 (2008Q1). B. Area Wage Adjustment Section 1886(j)(6) of the Act requires the Secretary to adjust the proportion (as estimated by the Secretary from time to time) of rehabilitation facilities' costs attributable to wages and wage-related costs by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the rehabilitation facility compared to the national average wage level for those facilities. The Secretary is required to update the IRF PPS wage index on the basis of information available to the Secretary on the wages and wage-related costs to furnish rehabilitation services. Any adjustments or updates made under section 1886(j)(6) of the Act for a FY are made in a budget neutral manner. In the FY 2008 IRF PPS final rule (72 FR 44284 at 44299), we maintained the methodology described in the FY 2006 IRF PPS final rule to determine the wage index, labor market area definitions, and hold harmless policy consistent with the rationale outlined in the FY 2006 IRF PPS final rule (70 FR 47880, 47917 through 47933). For FY 2009, we proposed to and will maintain the policies and methodologies described in the FY 2008 IRF PPS final rule relating to the labor market area definitions and the wage index methodology for areas with wage data. Therefore, this final rule continues to use the Core-Based Statistical Area (CBSA) labor market area definitions and the pre-reclassification and pre-floor hospital wage index data based on 2004 cost report data. When adopting new labor market designations made by the Office of Management and Budget (OMB), we identified some geographic areas where there were no hospitals and, thus, no hospital wage index data on which to base the calculation of the IRF PPS wage index. We continue to use the same methodology discussed in the FY 2008 IRF PPS final rule (72 FR 44284 at 44299) to address those geographic areas where there are no hospitals and, thus, no hospital wage index data on which to base the calculation of the FY 2009 IRF PPS wage index. Additionally, this final rule incorporates the CBSA changes published in the most recent OMB bulletin that applies to the hospital wage data used to determine the current IRF PPS wage index. The changes were nomenclature and did not represent substantive changes to the CBSA-based designations. Specifically, OMB added or deleted certain CBSA numbers and revised certain titles. The OMB bulletins 
                        ( print page 46379)
                        are available online at 
                        *http://www.whitehouse.gov/​omb/​bulletins/​index.html.* 1. Clarification of New England Deemed Counties We are taking this opportunity to address the change in the treatment of “New England deemed counties” (that is, those counties in New England listed in § 412.64(b)(1)(ii)(B) of the regulations that were deemed to be parts of urban areas under section 601(g) of the Social Security Amendments of 1983) that was made in the FY 2008 Inpatient Prospective Payment System (IPPS) final rule with comment period (72 FR 47337). These counties include the following: Litchfield County, CT; York County, ME; Sagadahoc County, ME; Merrimack County, NH; and Newport County, RI. Of these five “New England deemed counties,” three (York County, ME, Sagadahoc County, ME, and Newport County, RI) are also included in metropolitan statistical areas (MSAs) defined by OMB and are considered urban under both the current IPPS and IRF PPS labor market area definitions in § 412.64(b)(1)(ii)(A). The remaining two, Litchfield County, CT and Merrimack County, NH, are 
                        *geographically*
                         located in areas that are considered rural under the current IPPS (and IRF PPS) labor market area definitions, but have been previously deemed urban under the IPPS in certain circumstances, as discussed below. In the FY 2008 IPPS final rule with comment period, (72 FR 47337 through 47338), § 412.64(b)(1)(ii)(B) was revised that the two “New England deemed counties” that are still considered rural under the OMB definitions (Litchfield County, CT and Merrimack County, NH), are no longer considered urban, effective for discharges occurring on or after October 1, 2007, and, therefore, are considered rural in accordance with § 412.64(b)(1)(ii)(C). However, for purposes of payment under the IPPS, acute care hospitals located within those areas are treated as being reclassified to their deemed urban area effective for discharges occurring on or after October 1, 2007 (see 72 FR 47337 through 47338). We note that the IRF PPS does not provide for geographic reclassification. Also, in the FY 2008 IPPS final rule with comment period (72 FR 47338), we explained that we limited this policy change for the “New England deemed counties” only to IPPS hospitals, and any change to non-IPPS provider wage indexes would be addressed in the respective payment system rules. Accordingly, as stated above, we are taking this opportunity to clarify the treatment of “New England deemed counties” under the IRF PPS in this final rule. As discussed above, the IRF PPS has consistently used the IPPS definition of “urban” and “rural” with regard to the wage index used in the IRF PPS. Under existing § 412.602, an IRF's wage index is determined based on the location of the IRF in an urban or rural area as defined in §§ 412.64(b)(1)(ii)(A) through (C). Historical changes to the labor market area/geographic classifications and annual updates to the wage index values under the IRF PPS are made effective October 1 each year. When we established the most recent IRF PPS payment rate update, effective for discharges occurring on or after October 1, 2007 through September 30, 2008, we considered the “New England deemed counties” (including Litchfield County, CT and Merrimack County, NH) as urban for FY 2008, as evidenced by the inclusion of Litchfield County, CT as one of the constituent counties of urban CBSA 25540 (Hartford-West Hartford-East Hartford, CT), and the inclusion of Merrimack County, NH as one of the constituent counties of urban CBSA 31700 (Manchester-Nashua, NH). As noted above, § 412.602 indicates that the terms “rural” and “urban” are defined according to the definitions of those terms in §§ 412.64(b)(1)(ii)(A) through (C). Applying the IPPS definitions, Litchfield County, CT and Merrimack County, NH are not considered “urban” under §§ 412.64(b)(1)(ii)(A) and (B) as revised under the FY 2008 IPPS final rule and, therefore, are considered “rural” under § 412.64(b)(1)(ii)(C). Accordingly, reflecting our policy to use the IPPS definitions of “urban” and “rural”, these two counties would be considered “rural” under the IRF PPS effective with the next update of the IRF PPS payment rates, October 1, 2008, and would no longer be included in urban CBSA 25540 (Hartford-West Hartford-East Hartford, CT) and urban CBSA 31700 (Manchester-Nashua, NH), respectively. We note that this policy is consistent with our policy of not taking into account IPPS geographic reclassifications in determining payments under the IRF PPS. We do not need to make any changes to our regulations to effectuate this change. There is one IRF (in Merrimack County, NH) that greatly benefits from treating these counties as rural. This IRF would begin to receive a higher wage index value and the 21.3 percent adjustment that is applied to IRF PPS payments for rural facilities. Currently, there are no IRFs in the following areas: Litchfield County, CT; rural Connecticut; or rural New Hampshire. 2. Multi-Campus Hospital Wage Index Data In the FY 2008 IRF PPS final rule (72 FR 44284, August 7, 2007), we established IRF PPS wage index values for FY 2008 calculated from the same data (collected from cost reports submitted by hospitals for cost reporting periods beginning during FY 2003) used to compute the FY 2007 acute care hospital inpatient wage index, without taking into account geographic reclassification under sections 1886(d)(8) and (d)(10) of the Act. The IRF PPS wage index values applicable for discharges occurring on or after October 1, 2007 through September 30, 2008 are shown in Table 1 (for urban areas) and Table 2 (for rural areas) in the addendum to the FY 2008 IRF PPS final rule (72 FR 44284, 44312 through 44335). We are continuing to use IPPS wage data for the FY 2009 IRF PPS Wage Index, because we believe that using the hospital inpatient wage data is appropriate and reasonable for the IRF PPS. We note that the IPPS wage data used to determine the FY 2009 IRF wage index values reflect our policy that was adopted under the IPPS beginning in FY 2008. The wage data for multi-campus hospitals located in different labor market areas (CBSAs) are apportioned to each CBSA where the campuses are located (see the FY 2008 IPPS final rule with comment period (72 FR 47317 through 47320)). We computed the FY 2009 IRF PPS wage index values presented in this final rule consistent with our pre-reclassified IPPS wage index policy (that is, our historical policy of not taking into account IPPS geographic reclassifications in determining payments under the IRF PPS). For the FY 2009 IRF PPS, we computed the wage index from IPPS wage data (submitted by hospitals for cost reporting periods beginning in FY 2004 and used in the FY 2008 IPPS wage index), which allocated salaries and hours to the campuses of two multi-campus hospitals with campuses that are located in different labor areas, one in Massachusetts and another in Illinois. Thus, the FY 2009 IRF PPS wage index values for the following CBSAs are affected by this policy: Boston-Quincy, MA (CBSA 14484), Providence-New Bedford-Falls River, RI-MA (CBSA 39300), Chicago-Naperville-Joliet, IL (CBSA 16974) and Lake County-Kenosha County, IL-WI (CBSA 29404) (please refer to Table 1 in the addendum of this final rule).
                        ( print page 46380) 3. Methodology for Applying the Revisions to the Area Wage Adjustment for FY 2009 in a Budget-Neutral Manner To calculate the wage-adjusted facility payment for the payment rates set forth in this final rule, we multiply the unadjusted Federal prospective payment by the FY 2009 RPL labor-related share (75.464 percent) to determine the labor-related portion of the Federal prospective payments. We then multiply this labor-related portion by the applicable IRF wage index shown in Table 1 for urban areas and Table 2 for rural areas in the addendum. Adjustments or updates to the IRF wage index made under section 1886(j)(6) of the Act must be made in a budget neutral manner; therefore, we calculated a budget neutral wage adjustment factor as established in the FY 2004 IRF PPS final rule (68 FR 45674 at 45689), codified at § 412.624(e)(1), and described in the steps below. We proposed to use (and have used for this final rule) the following steps to ensure that the FY 2009 IRF standard payment conversion factor reflects the update to the proposed wage indexes (based on the FY 2004 pre-reclassified and pre-floor hospital wage data) and the labor-related share in a budget neutral manner: *Step 1.*
                         Determine the total amount of the estimated FY 2008 IRF PPS rates, using the FY 2008 standard payment conversion factor and the labor-related share and the wage indexes from FY 2008 (as published in the FY 2008 IRF PPS final rule (72 FR 44284 at 44301, 44298, and 44312 through 44335, respectively)). *Step 2.*
                         Calculate the total amount of estimated IRF PPS payments, using the FY 2008 standard payment conversion factor and the FY 2009 labor-related share and CBSA urban and rural wage indexes. *Step 3.*
                         Divide the amount calculated in step 1 by the amount calculated in step 2, which equals the final FY 2009 budget neutral wage adjustment factor of 1.0003. (Note that this final budget neutral wage adjustment factor differs from the one we proposed in the proposed rule (1.0004) because of the use of updated data to calculate the labor-related share for this final rule and the use of updated FY 2007 IRF claims data for this final rule.) *Step 4.*
                         Apply the FY 2009 budget neutral wage adjustment factor from step 3 to the FY 2008 IRF PPS standard payment conversion factor after the application of the estimated market basket update to determine the FY 2009 standard payment conversion factor. We received 4 comments on the proposed FY 2009 IRF PPS wage index, which are summarized below. *Comment:*
                         Several commenters recommended that we consider wage index policies under the acute IPPS because IRFs compete in a similar labor pool as acute care hospitals. The IPPS wage index policies would allow IRFs to benefit from the IPPS reclassification and/or floor policies. Several commenters also recommended that CMS conduct further analysis of the wage index methodology to ensure that fluctuations in the annual wage index for hospitals are minimized, that all future updates match the costs of labor in the market, that IRF's occupational mix is appropriately recognized, and that payments are “smoothed” across geography and across time. Further, one provider requested that the same wage index policies be used for all healthcare providers, to maintain consistency. *Response:*
                         We do not believe IPPS wage index policies should be applied to IRFs. We note the IRF PPS does not account for geographic reclassification under sections 1886(d)(8) and (d)(10) of the Act and does not apply the “rural floor” under section 4410 of Public Law 105-33(BBA). Because we do not have an IRF specific wage index we are unable to determine at this time the degree, if any, to which a geographic reclassification adjustment under the IRF PPS is appropriate. Furthermore, we believe the “rural floor” is applicable only to the acute care hospital payment system. The rationale for our current wage index policies is fully described in the FY 2006 final rule (70 FR 47880, 47926 through 47928). In addition, we reviewed the Medicare Payment Advisory Commission's (MedPAC) wage index recommendations as discussed in MedPAC's June 2007 report titled, “Report to Congress: Promoting Greater Efficiency in Medicare.” Although some commenters recommended that we adopt the IPPS wage index policies such as reclassification and floor policies, we note that MedPAC's June 2007 report to Congress recommends that Congress “repeal the existing hospital wage index statute, including reclassification and exceptions, and give the Secretary authority to establish new wage index systems.” We believe that adopting the IPPS wage index policies, such as reclassification or floor, would not be prudent at this time because MedPAC suggests that the reclassification and exception policies in the IPPS wage index alters the wage index values for one-third of IPPS hospitals. In addition, MedPAC found that the exceptions may lead to anomalies in the wage index. By adopting the IPPS reclassification and exceptions at this time, the IRF PPS wage index may be vulnerable to similar issues that MedPAC identified in their June 2007 Report to Congress. However, we will continue to review and consider MedPAC's recommendations on a refined or an alternative wage index methodology for the IRF PPS in future years. We would also like to inform the commenter about our current research with respect to wage index methodology, including the issues the commenter mentioned about ensuring that the wage index minimizes fluctuations, matches the costs of labor in the market, and provides for a single wage index policy. Section 106(b)(2) of the MIEA-TRHCA instructed the Secretary of Health and Human Services, to take into account MedPAC's recommendations on the Medicare wage index classification system, to include in the FY 2009 IPPS proposed rule one or more proposals to revise the wage index adjustment applied under section 1886(d)(3)(E) of the Act for purposes of the IPPS. The proposal (or proposals) must consider each of the following: Problems associated with the definition of labor markets for the wage index adjustment.
                    The modification or elimination of geographic reclassifications and other adjustments.
                    The use of Bureau of Labor of Statistics data or other data or methodologies to calculate relative wages for each geographic area.
                    Minimizing variations in wage index adjustments between and within MSAs and statewide rural areas.
                    The feasibility of applying all components of CMS's proposal to other settings.
                    Methods to minimize the volatility of wage index adjustments while maintaining the principle of budget neutrality.
                    The effect that the implementation of the proposal would have on health care providers on each region of the country.
                    Methods for implementing the proposal(s) including methods to phase in such implementations.
                    Issues relating to occupational mix such as staffing practices and any evidence on quality of care and patient safety including any recommendation for alternative calculations to the occupational mix. To assist us in meeting the requirements of section 106(b)(2) of Public Law 109-432, in February 2008, we awarded a Task Order under its Expedited Research and Demonstration Contract, to Acumen, LLC. A 
                        ( print page 46381)
                        comparison of the current IPPS wage index and MedPAC's recommendations will be presented in the FY 2009 IPPS final rule. We plan to monitor these efforts and the impact or influence they may have to the IRF PPS wage index. *Comment:*
                         One commenter requested that the IRF wage index values for FY 2009 be capped at plus or minus 2 percent of the IRF wage index values for FY 2008 to provide for more stable, and thus more predictable, changes in the IRF wage index between FY 2008 and FY 2009. *Response:*
                         We will take the commenter's suggestion into account for the future. However, we do not believe that the IRF wage index would accurately reflect geographic variations in the costs of labor, which is the purpose of the IRF wage index, if we were to constrain changes in the wage index adjustment from year to year. Thus, we believe it is best at this point to continue the analysis of the wage index methodology, as described above, and to consider developing wage index policies that are consistent across settings as noted in the previous response. *Final Decision:*
                         We will continue to use the policies and methodologies described in the FY 2008 IRF PPS final rule relating to the labor market area definitions and the wage index methodology for areas with wage data. Therefore, this final rule continues to use the Core-Based Statistical Area (CBSA) labor market area definitions and the pre-reclassification and pre-floor hospital wage index data based on 2004 cost report data. We discuss the final standard payment conversion factor for FY 2009 in the next section below. C. Description of the IRF Standard Payment Conversion Factor and Payment Rates for FY 2009 To calculate the standard payment conversion factor for FY 2009, as illustrated in Table 4 below, we begin with the standard payment conversion factor for FY 2008. To explain how we determined the standard payment conversion factor for FY 2008, we include Table 3 below. The final FY 2008 IRF standard payment conversion factor that we show in Tables 3 and 4 below is different than the IRF standard payment conversion factor that we published in the FY 2008 IRF PPS final rule (72 FR 44284 at 44301) due to a legislative change. We adjusted the IRF standard payment conversion factor for IRF discharges occurring on or after April 1, 2008 to reflect the changes codified in section 115 of the MMSEA that require the Secretary to apply a zero percent increase factor for FYs 2008 and 2009, effective for discharges occurring on or after April 1, 2008. In the FY 2008 IRF PPS final rule (72 FR 44284, 44300 through 44301), we used the RPL market basket estimate described in that final rule (3.2 percent) to update the IRF standard payment conversion factor. As shown in Table 3 of the FY 2008 IRF PPS final rule (72 FR 44284 at 44301), applying this market basket estimate to the standard payment amount resulted in a final standard payment conversion factor for FY 2008 of $13,451. However, section 115 of the MMSEA had the effect of changing the increase factor for FY 2008 from 3.2 percent to zero percent for discharges occurring on or after April 1, 2008. This, in turn, had the effect of decreasing the IRF standard payment conversion factor for discharges occurring on or after April 1, 2008. As shown in Table 3 below, to develop the FY 2008 standard payment conversion factor for discharges beginning on or after April 1, 2008, we started with the FY 2007 standard payment conversion factor that was finalized in the FY 2007 IRF PPS final rule (71 FR 48354 at 48378). We then multiplied this by the zero percent increase factor, as described above. Then, we applied the same FY 2008 budget neutrality factor (1.0041) for the Wage Index, Labor-Related Share, and the Hold Harmless Provision that was published in the FY 2008 IRF PPS Final Rule (72 FR 44284 at 44301). This resulted in the final FY 2008 standard payment conversion factor, effective for discharges occurring on or after April 1, 2008, of $13,034. Table 3—Calculations To Determine the FY 2008 IRF Standard Payment Conversion Factor for Discharges Beginning on or After April 1, 2008
Explanation for adjustment
CalculationsFY 2007 Standard Payment Conversion Factor (published in the FY 2007 IRF PPS Final Rule (71 FR 48354))
$12,981Zero Percent Increase Factor for Discharges Occurring on or after April 1, 2008
×  1.0000Budget Neutrality Factor for the Wage Index, Labor-Related Share, and the Hold Harmless Provision that was published in the FY 2008 IRF PPS Final Rule (72 FR 44284)
×  1.0041Standard Payment Conversion Factor for Discharges Occurring on or after April 1, 2008
= $13,034
 As a result, the IRF standard payment conversion factor changed from $13,451 for discharges occurring on or after October 1, 2007 to $13,034 for discharges occurring on or after April 1, 2008. Further, as required by section 115 of the MMSEA, we apply an increase factor of zero percent to the standard payment conversion factor for FY 2009, meaning that it does not change from the current value of $13,034. Next, we apply the combined final budget neutrality factor for the FY 2009 wage index and labor related share of 1.0003, which results in a standard payment amount of $13,038. Finally, we apply the final budget neutrality factor for the revised CMG relative weights of 0.9939, which results in the final FY 2009 standard payment conversion factor of $12,958. As stated previously, we note that the budget neutrality factor for the FY 2009 wage index and labor related share changed from 1.0004 in the proposed rule to 1.0003 in this final rule due to the use of updated FY 2007 IRF claims data in this final rule and the update to the FY 2009 labor-related share for this final rule using the most recent available data. Similarly, the budget neutrality factor used to update the CMG relative weights and average length of stay values changed from 0.9969 in the proposed rule to 0.9939 in this final rule due to the use of updated FY 2007 IRF claims data in this final rule. Furthermore, the methodology that we used to compute the final budget neutrality factors for this final rule is the same methodology (as discussed above and in section IV of this final rule) that we used to compute the proposed budget neutrality factors in the proposed rule (73 FR 22674 at 22677 and 22683).
                        ( print page 46382) Table 4—Calculations To Determine the FY 2009 Standard Payment Conversion Factor
Explanation for adjustment
CalculationsStandard Payment Conversion Factor for Discharges Occurring on or after April 1, 2008
$13,034Zero Percent Increase Factor for FY 2009
× 1.0000Budget Neutrality Factor for the Wage Index and Labor-Related Share
× 1.0003Budget Neutrality Factor for the Revisions to the CMG Relative Weights
× 0.9939FY 2009 Standard Payment Conversion Factor
= $12,958
 After the application of the CMG relative weights described in section IV of this final rule, the resulting unadjusted IRF prospective payment rates for FY 2009 are shown below in Table 5, “FY 2009 Payment Rates.” Table 5—FY 2009 Payment Rates
CMG
Payment rate tier 1
Payment rate tier 2
Payment rate tier 3
Payment rate no comorbidity0101
$9,993.21
$9,210.55
$8,268.50
$7,851.250102
12,561.49
11,579.27
10,393.61
9,870.110103
14,873.19
13,709.56
12,304.92
11,685.520104
15,798.39
14,562.20
13,070.73
12,412.470105
18,555.86
17,103.26
15,352.64
14,579.050106
21,551.75
19,864.61
17,831.50
16,932.220107
24,581.33
22,657.06
20,337.58
19,312.600108
29,537.76
27,226.05
24,438.79
23,207.780109
28,230.30
26,020.96
23,356.80
22,180.210110
35,267.79
32,507.73
29,178.82
27,709.390201
9,791.06
8,376.05
7,538.96
6,861.260202
13,353.22
11,425.07
10,282.17
9,358.270203
14,884.85
12,735.12
11,462.65
10,432.490204
16,759.88
14,339.32
12,904.87
11,745.130205
20,394.60
17,449.24
15,703.80
14,292.670206
25,306.97
21,651.52
19,487.54
17,735.610207
34,088.61
29,165.87
26,249.02
23,890.660301
14,362.65
12,061.31
10,830.30
9,912.870302
18,296.70
15,364.30
13,796.38
12,628.870303
21,948.26
18,431.46
16,549.96
15,149.200304
29,971.85
25,169.62
22,600.05
20,688.740401
11,992.63
10,214.79
10,019.13
8,508.220402
18,054.38
15,378.55
15,083.11
12,810.280403
29,574.04
25,190.35
24,707.02
20,984.190404
51,528.78
43,891.34
43,049.07
36,561.000405
39,323.64
33,496.43
32,853.71
27,901.170501
10,505.05
8,289.23
7,703.53
6,796.470502
14,246.03
11,241.07
10,446.74
9,217.030503
18,549.38
14,637.36
13,602.01
12,000.400504
22,325.34
17,617.70
16,371.14
14,444.280505
26,382.49
20,818.32
19,346.29
17,069.570506
36,703.54
28,962.43
26,913.77
23,745.540601
11,979.67
9,778.11
9,296.07
8,477.120602
16,023.86
13,079.81
12,434.50
11,338.250603
20,425.70
16,671.76
15,850.23
14,453.350604
27,065.37
22,092.09
21,002.33
19,151.920701
11,904.51
10,032.08
9,459.34
8,504.340702
15,699.91
13,228.82
12,474.67
11,215.150703
19,237.45
16,210.46
15,286.55
13,743.250704
24,612.43
20,739.28
19,557.51
17,582.710801
9,070.60
7,391.24
6,701.88
6,108.400802
12,154.60
9,903.80
8,981.19
8,185.570803
17,341.69
14,130.70
12,814.17
11,679.050804
15,219.17
12,402.10
11,246.25
10,249.780805
18,997.72
15,480.92
14,037.40
12,794.730806
23,504.52
19,151.92
17,367.61
15,828.200901
11,123.15
9,814.39
8,849.02
7,827.930902
14,866.71
13,116.09
11,826.77
10,462.290903
19,229.67
16,965.91
15,298.21
13,532.040904
25,423.60
22,430.30
20,224.85
17,891.111001
12,123.50
11,741.24
10,103.35
9,248.121002
16,226.01
15,714.17
13,521.67
12,377.481003
23,574.49
22,830.70
19,645.62
17,981.821101
15,350.05
12,764.93
12,764.93
11,089.461102
22,401.79
18,629.72
18,629.72
16,184.54( print page 46383)1201
13,371.36
12,527.79
10,992.27
9,771.631202
16,889.46
15,824.31
13,884.50
12,342.501203
21,223.91
19,885.35
17,447.95
15,509.431301
14,231.77
12,794.73
11,013.00
9,910.281302
19,164.88
17,228.96
14,830.43
13,345.441303
24,801.61
22,298.13
19,193.39
17,271.721401
10,370.29
9,356.97
8,277.57
7,343.301402
14,376.90
12,970.96
11,475.60
10,179.801403
17,594.37
15,874.85
14,043.88
12,459.121404
22,842.36
20,609.70
18,233.20
16,175.471501
12,443.57
10,866.58
9,605.77
9,119.841502
15,934.45
13,915.60
12,302.33
11,679.051503
20,266.31
17,698.04
15,645.49
14,853.761504
25,300.50
22,094.69
19,531.59
18,542.901601
14,375.61
11,620.73
9,934.90
9,158.711602
19,408.49
15,689.55
13,412.83
12,365.821603
24,992.09
20,201.52
17,270.42
15,921.491701
13,546.29
11,907.11
10,963.76
9,613.541702
17,852.24
15,692.14
14,449.47
12,670.331703
21,466.22
18,868.14
17,374.09
15,234.721704
26,921.54
23,662.60
21,788.88
19,105.281801
15,794.51
12,477.26
11,719.22
10,051.521802
23,840.13
18,831.86
17,688.97
15,171.231803
40,742.54
32,185.08
30,229.72
25,927.661901
15,007.96
12,035.39
12,035.39
11,379.721902
30,332.09
24,324.76
24,324.76
22,999.151903
46,576.24
37,351.44
37,351.44
35,315.732001
11,428.96
9,436.02
8,570.42
7,681.502002
15,385.03
12,702.73
11,537.80
10,340.482003
19,736.33
16,294.69
14,800.63
13,265.102004
26,386.38
21,784.99
19,788.16
17,734.322101
30,666.40
30,666.40
27,835.08
22,616.895001
0.00
0.00
0.00
1,912.605101
0.00
0.00
0.00
8,789.415102
0.00
0.00
0.00
19,996.795103
0.00
0.00
0.00
9,182.045104
0.00
0.00
0.00
25,379.54
 We received 3 comments on the proposed standard payment conversion factor and the proposed unadjusted IRF prospective payment rates for FY 2009, which are summarized below. *Comment:*
                         One commenter recommended that CMS use the most recent available data in computing the FY 2009 CMG relative weights, because these have an impact on the FY 2009 IRF prospective payment rates and the budget neutrality factors used in computing the FY 2009 standard payment conversion factor. *Response:*
                         We agree that we should use the most recent available data in computing the FY 2009 CMG relative weights. We typically update the data we use in our analysis each year between the proposed and final rules in order to ensure that we are using the most current available data. Specifically, in the proposed rule (73 FR 22674 at 22677), we proposed to update our analysis for this final rule using more current data. Thus, we updated our data analysis using FY 2007 IRF claims data for the final rule, whereas we had used FY 2006 IRF claims data in conducting the analysis for the FY 2009 IRF PPS proposed rule (73 FR 22674 at 22677). As discussed in detail in section IV of this final rule, we did not use IRF-PAI data for this final rule because the CMG information on the FY 2007 IRF claims data incorporated all of the most recent changes to the IRF classification system that were implemented in the FY 2007 IRF PPS final rule (71 FR 48354). Moreover, we did not implement any changes to the IRF classification system in the FY 2008 IRF PPS final rule (72 FR 44284). The revised final budget neutrality factors for FY 2009 reflect the updated FY 2009 IRF labor-related share and the revised CMG relative weights and average length of stay values described above. *Comment:*
                         Several commenters requested that we keep the same standard payment conversion factor of $13,034 for FY 2009 that was used for determining IRF PPS payments in FY 2008, for discharges occurring on or after April 1, 2008. In effect, we believe that these commenters were asking us not to apply the combined budget neutrality factor for the wage index and labor-related share or the budget neutrality factor for the revisions to the CMG relative weights to the FY 2008 standard payment conversion factor in determining the FY 2009 standard payment conversion factor. Another commenter asked us to provide a more extensive explanation of the methodology that we use to compute the budget neutrality factors, including any background studies on the methodology and calculations for the budget neutrality factors. *Response:*
                         Section 1886(j)(6) of the Act requires CMS to make any adjustments or updates to the IRF wage index in a budget neutral manner. To do this, we ensure that estimated aggregate payments to IRFs in the FY are not greater or less than estimated aggregate payments would have been without such adjustments or updates to the wage index. Thus, in accordance with the statute and using the same general methodology that was described and 
                        ( print page 46384)
                        finalized in the FY 2004 IRF PPS final rule (68 FR 45674 at 45689), we are required to adjust the FY 2008 standard payment conversion factor of $13,034 by the combined final budget neutrality factor for the FY 2009 wage index and labor related share of 1.0003, which results in a standard payment amount of $13,038. Further, in accordance with the regulations at § 412.624(d)(4), as discussed in the FY 2006 IRF PPS final rule (70 FR 47880 at 47937), we apply an additional budget neutrality factor to make the updates to the CMG relative weights and average length of stay values budget neutral. The final budget neutrality factor used to update the CMG relative weights and average length of stay values for this final rule is 0.9939, which results in a standard payment amount of $12,958. As discussed above, the budget neutrality factor used to update the CMG relative weights and average length of stay values changed from 0.9969 in the proposed rule to 0.9939 in this final rule due to the use of updated FY 2007 IRF claims data in this final rule. Although the standard payment conversion factor for FY 2009 of $12,958 is lower than the standard payment conversion factor applicable for discharges occurring on or after April 1, 2008, of $13,034, estimated aggregate IRF payments for FY 2009, excluding outlier payments, are the same. This is because we estimate that aggregate IRF payments would have increased by about $37 million, due to the update to the CMG relative weights for FY 2009, if we had not applied the budget-neutrality factor used to update the CMG relative weights and average length of stay values. We have consistently implemented any revisions to the IRF classification and weighting factors in a budget-neutral manner, such that estimated aggregate payments to IRFs remain the same with and without the revisions. The methodology for computing the budget neutrality factor is the same general methodology that we have consistently used to ensure that the changes to the classification and weighting factors that we implemented in the FY 2006 IRF PPS final rule (70 FR 47880) and in the FY 2007 IRF PPS final rule (71 FR 48354) were done in a budget-neutral manner. (Note that we did not implement any changes to the IRF classification or weighting factors in the FY 2008 IRF PPS final rule (72 FR 44284)). The methodology that we are using in this final rule to compute the budget neutrality factor for the updates to the CMG relative weights is the same general methodology that we have used to ensure that updates to the IRF wage index are implemented in a budget-neutral manner, as discussed above and as finalized in the FY 2004 IRF PPS final rule (68 FR 45674 at 45689). The methodology, as proposed in the FY 2009 IRF PPS proposed rule (73 FR 22674 at 22677) and finalized in this final rule, applied to the update to the CMG relative weights for FY 2009 involves the following steps: *Step 1.*
                         Calculate the estimated total amount of IRF PPS payments for FY 2009 (with no changes to the CMG relative weights). *Step 2.*
                         Apply the changes to the CMG relative weights (as discussed in section IV of this final rule) to calculate the estimated total amount of IRF PPS payments for FY 2009 (with the changes). *Step 3.*
                         Divide the amount calculated in step 1 ($6,003,947,007) by the amount calculated in step 2 ($6,040,824,839) to determine the factor (0.9939) that maintains the same total estimated aggregate payments in FY 2009 with and without the changes to the CMG relative weights. *Step 4.*
                         Apply the final budget neutrality factor (0.9939) to the FY 2008 IRF PPS standard payment amount after the application of the budget-neutral wage adjustment factor. The FY 2004 IRF PPS final rule (68 FR 45674 at 45689) contains additional information on the methodology for computing the budget neutrality factor for the IRF wage index and labor-related share, and the FY 2006 IRF PPS final rule (70 FR 47880, 47937 through 47938) contains additional information on the methodology for computing the budget neutrality factor for the updates to the CMG relative weights and average length of stay values. *Final Decision:*
                         After reviewing the comments that we received on the proposed methodology for calculating the budget neutrality factors for the wage index and labor-related share and for the CMG relative weights and average length of stay values, we are finalizing the proposed methodology. We are also finalizing the FY 2009 standard payment conversion factor at $12,958. This differs from the standard payment conversion factor of $12,999 that we had proposed in the proposed rule because of the use of updated FY 2007 IRF claims data for analyzing the final CMG relative weights and average length of stay values for this final rule, as discussed in section IV of this final rule. D. Example of the Methodology for Adjusting the Federal Prospective Payment Rates Table 6 illustrates the methodology for adjusting the Federal prospective payments (as described in sections III.A through III.C of the FY 2009 proposed rule (73 FR 22674, 22680 through 22685)). The examples below are based on two hypothetical Medicare beneficiaries, both classified into CMG 0110 (without comorbidities). The unadjusted Federal prospective payment rate for CMG 0110 (without comorbidities) appears in Table 5 above. One beneficiary is in Facility A, an IRF located in rural Spencer County, Indiana, and another beneficiary is in Facility B, an IRF located in urban Harrison County, Indiana. Facility A, a non-teaching hospital, has a disproportionate share hospital (DSH) percentage of 5 percent (which results in a low-income percentage (LIP) adjustment of 1.0309), a wage index of 0.8576, and an applicable rural adjustment of 21.3 percent. Facility B, a teaching hospital, has a DSH percentage of 15 percent (which results in a LIP adjustment of 1.0910), a wage index of 0.9065, and an applicable teaching status adjustment of 0.109. To calculate each IRF's labor and non-labor portion of the Federal prospective payment, we begin by taking the unadjusted Federal prospective payment rate for CMG 0110 (without comorbidities) from Table 5 above. Then, we multiply the estimated labor-related share (75.464) described in section V.A of this final rule by the unadjusted Federal prospective payment rate. To determine the non-labor portion of the Federal prospective payment rate, we subtract the labor portion of the Federal payment from the unadjusted Federal prospective payment. To compute the wage-adjusted Federal prospective payment, we multiply the result of the labor portion of the Federal payment by the appropriate wage index found in the addendum in Tables 1 and 2, which would result in the wage-adjusted amount. Next, we compute the wage-adjusted Federal payment by adding the wage-adjusted amount to the non-labor portion. Adjusting the Federal prospective payment by the facility-level adjustments involves several steps. First, we take the wage-adjusted Federal prospective payment and multiply it by the appropriate rural and LIP adjustments (if applicable). Second, to determine the appropriate amount of additional payment for the teaching 
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                        status adjustment (if applicable), we multiply the teaching status adjustment (0.109, in this example) by the wage-adjusted and rural-adjusted amount (if applicable). Finally, we add the additional teaching status payments (if applicable) to the wage, rural, and LIP-adjusted Federal prospective payment rates. Table 6 illustrates the components of the adjusted payment calculation. Table 6—Example of Computing an IRF FY 2009 Federal Prospective Payment
Steps
Rural facility A (Spencer Co., IN)
Urban Facility B (Harrison Co., IN)1. Unadjusted Federal Prospective Payment
$27,709.39
$27,709.392. Labor Share
× 0.75464
× 0.754643. Labor Portion of Federal Payment
= $20,910.61
= $20,910.614. CBSA Based Wage Index (shown in the Addendum, Tables 1 and 2)
× 0.8576
× 0.90655. Wage-Adjusted Amount
= $17,932.94
= $18,955.476. Non-labor Amount
+ $6,798.78
+ $6,798.787. Wage-Adjusted Federal Payment
= $24,731.72
= $25,754.258. Rural Adjustment
× 1.213
× 1.0009. Wage- and Rural-Adjusted Federal Payment
= $29,999.57
= $25,754.2510. LIP Adjustment
× 1.0309
× 1.091011. FY 2009 Wage-, Rural- and LIP-Adjusted Federal Prospective Payment Rate
= $30,926.56
= $28,097.8812. FY 2009 Wage- and Rural-Adjusted Federal Prospective Payment
$29,999.57
$25,754.2513. Teaching Status Adjustment
× 0.000
× 0.10914. Teaching Status Adjustment Amount
= $0.00
= $2,807.2115. FY 2009 Wage-, Rural-, and LIP-Adjusted Federal Prospective Payment Rate
+ $30,926.56
+ $28,097.8816. Total FY 2009 Adjusted Federal Prospective Payment
= $30,926.56
= $30,905.10
 Thus, the adjusted payment for Facility A would be $30,926.56 and the adjusted payment for Facility B would be $30,905.10. VI. Update to Payments for High-Cost Outliers Under the IRF PPS A. Update to the Outlier Threshold Amount for FY 2009 Section 1886(j)(4) of the Act provides the Secretary with the authority to make payments in addition to the basic IRF prospective payments for cases incurring extraordinarily high costs. A case qualifies for an outlier payment if the estimated cost of the case exceeds the adjusted outlier threshold. We calculate the adjusted outlier threshold by adding the IRF PPS payment for the case (that is, the CMG payment adjusted by all of the relevant facility-level adjustments) and the adjusted threshold amount (also adjusted by all of the relevant facility-level adjustments). Then, we calculate the estimated cost of a case by multiplying the IRF's overall CCR by the Medicare allowable covered charge. If the estimated cost of the case is higher than the adjusted outlier threshold, we make an outlier payment for the case equal to 80 percent of the difference between the estimated cost of the case and the outlier threshold. In the FY 2002 IRF PPS final rule (66 FR 41316, 41362 through 41363), we discussed our rationale for setting the outlier threshold amount for the IRF PPS so that estimated outlier payments would equal 3 percent of total estimated payments. Subsequently, we updated the IRF outlier threshold amount in the FYs 2006, 2007, and 2008 IRF PPS final rules (70 FR 47880, 70 FR 57166, 71 FR 48354, and 72 FR 44284, respectively) to maintain estimated outlier payments at 3 percent of total estimated payments. We also stated that we would continue to analyze the estimated outlier payments for subsequent years and adjust the outlier threshold amount as appropriate to maintain the 3 percent target. As was proposed, for this final rule, we used updated data for calculating the high-cost outlier threshold amount. Specifically, we performed an updated analysis using FY 2007 claims data using the same methodology that we used to set the initial outlier threshold amount in the FY 2002 IRF PPS final rule (66 FR 41316, 41362 through 41363), which is also the same methodology that we used to update the outlier threshold amounts for FYs 2006, 2007, and 2008. (Note: the methodology that we use to calculate the appropriate outlier threshold amount for each FY requires us to simulate Medicare payments for that FY, using the most recent available IRF claims data from a previous FY. If the previous FY's data that we are using for the analysis does not contain exactly the same CMGs as the future FY for which we are calculating the update to the outlier threshold, then we cannot rely on the CMGs from the previous FY's IRF claims data and must instead use IRF-PAI data to assign the appropriate CMG for each IRF claim.) The CMGs and tiers in effect for FY 2009 would be slightly different than those that were in effect for FY 2006, due to revisions that were implemented in the FY 2007 IRF PPS final rule (71 FR 48354, 48360 through 48370). Use of the IRF-PAI data was no longer necessary when we used the updated FY 2007 IRF claims data for this final rule because the CMG information on the FY 2007 IRF claims data incorporated all of the changes to the IRF classification system that were implemented in the FY 2007 IRF PPS final rule (71 FR 48354, 48360 through 48370). We did not implement any changes to the IRF classification system in the FY 2008 IRF PPS final rule (72 FR 44284). For FY 2009, based on an analysis of updated FY 2007 claims data, we estimate that IRF outlier payments as a percentage of total estimated payments would be 4.2 percent without the change to the outlier threshold amount. The need to revise the high-cost outlier 
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                        threshold is discussed in detail in section IV.A of the FY 2009 proposed rule (73 FR 22674, 22686 through 22687). Generally, we note that the zero percent IRF increase factor for FYs 2008 and 2009, for discharges occurring on or after April 1, 2008, implemented by section 115 of the MMSEA resulted in lower IRF PPS payments for FYs 2008 and 2009 than would otherwise have been implemented. In addition, IRF charges found in the FY 2007 IRF claims data were higher than those in the FY 2006 IRF claims data, resulting in higher estimated outlier payments for FY 2009. Based on the updated analysis of FY 2007 claims data (for the reasons discussed previously, IRF-PAI data was not needed in this analysis), we are updating the outlier threshold amount to $10,250 to maintain estimated outlier payments at 3 percent of total estimated aggregate IRF payments for FY 2009. B. Update to the IRF Cost-to-Charge Ratio Ceilings In accordance with the methodology stated in the FY 2004 IRF PPS final rule (68 FR 45674, 45692 through 45694), we apply a ceiling to IRFs' CCRs. Using the methodology described in that final rule, as discussed in more detail in section IV.B of the FY 2009 proposed rule (73 FR 22674 at 22687), we are updating the national urban and rural CCRs for IRFs. As was proposed, the national average rural and urban CCRs and our estimate of the national CCR ceiling are changing in this final rule based on the analysis of updated data. We apply the national urban and rural CCRs in the following situations: New IRFs that have not yet submitted their first Medicare cost report.
                    IRFs whose overall CCR is in excess of the national CCR ceiling for FY 2009, as discussed below.
                    Other IRFs for which accurate data to calculate an overall CCR are not available. Specifically, for FY 2009, we estimate a national average CCR of 0.619 for rural IRFs and 0.490 for urban IRFs based on the most recent available IRF cost report data. For this final rule, we have used FY 2006 IRF cost report data, updated through March 31, 2008. If, for any IRF, the FY 2006 cost report was missing or had an “as submitted” status, we use data from a previous fiscal year's report for that IRF. However, we do not use cost report data from before FY 2003 for any IRF. For new IRFs, we use these national CCRs until the facility's actual CCR can be computed using the first settled cost report (either tentative or final, whichever is earlier). In addition, we estimate the national CCR ceiling at 1.60 for FY 2009. This means that, if an individual IRF's CCR exceeds this ceiling of 1.60 for FY 2009, we would replace the IRF's CCR with the appropriate national average CCR (either rural or urban, depending on the geographic location of the IRF). For a complete description of the methodology used to calculate the national CCR ceiling for this final rule, see section IV.B of the FY 2009 proposed rule (73 FR 22674 at 22687). We received seven comments on the proposed high-cost outlier updates under the IRF PPS, which are summarized below. *Comment:*
                         Most commenters supported our proposal to increase the outlier threshold amount to maintain estimated outlier payments at 3 percent of total estimated payments. However, several other commenters expressed concerns that the change would mean that fewer cases would qualify for outlier payments and that it would affect IRFs' ability to provide care to Medicare beneficiaries. Several commenters asked that we further explain the reasons behind the increase in the IRF outlier threshold amount and provide proof that we would be paying more than 3 percent in outliers without the change. Finally, one commenter said that the increases in the outlier threshold amount in recent years appear excessive and recommended that CMS look more closely to determine if there are anomalies in the IRF outlier data or institutional practices that may be causing the changes. *Response:*
                         Based on our analysis of FY 2007 IRF claims and FY 2006 IRF cost report data (as previously discussed, we did not need to use IRF-PAI data in conjunction with the FY 2007 IRF claims data), we need to increase the IRF outlier threshold amount to maintain estimated outlier payments at 3 percent of total estimated payments for FY 2009 for the following reasons. First, as discussed in detail in the FY 2009 IRF PPS proposed rule (73 FR 22674, 22686 through 22687), section 115 of the MMSEA, which amended section 1886(j)(3)(C) of the Social Security Act, required the Secretary to apply a zero percent increase factor for FYs 2008 and 2009, effective for discharges occurring on or after April 1, 2008. The effect of this change was to decrease projected IRF PPS payments. As a direct result of a zero percent update, we would exceed our projected 3 percent target for the proportion of estimated IRF outlier payment to estimated IRF total payments. Second, because the average charges per case in the FY 2007 data are significantly higher than the average charges per case in the FY 2006 data, we believe that our increase to the outlier threshold amount for FY 2009 is warranted. Specifically, higher charges directly result in more cases being estimated to qualify for outlier payments and higher estimated outlier payments, which in turn lead to higher estimates of outlier payments as a percentage of total estimated payments. In this case, higher charges result in estimated outlier payments as a percentage of total estimated payments in FY 2009 of 4.2 percent, well above the 3 percent target. To decrease estimated outlier payments as a percentage of total estimated payments from 4.2 percent to 3 percent, we must increase the outlier threshold. The higher charges in the FY 2007 may be due to several factors, including the “75 percent” rule and the IRF medical review activities, which have led to declines in the number of IRF discharges and may have led to increases in the complexity of IRF cases. Thus, based on our analysis of updated data (that is, FY 2007 IRF claims data), we now project that estimated IRF outlier payments as a percentage of total estimated payments for FY 2008 increased from 3.0 percent to 3.7 percent. Thus, given the recent changes in IRF aggregate payments resulting from section 115 of the MMSEA and recent increases in IRFs' charges that are being reflected in the IRF claims data for FY 2007, we believe that it is necessary to adjust the outlier threshold amount for FY 2009 to maintain estimated IRF outlier payments equal to 3 percent of estimated total payments. As several of the commenters suggested, increasing the outlier threshold amount for FY 2009 would mean that fewer cases would qualify for IRF outlier payments. As discussed above, this is necessary to maintain estimated IRF outlier payments at 3 percent of estimated total payments. However, we do not believe that this will affect IRFs' ability to provide care to Medicare beneficiaries because the IRF outlier policy is designed to reduce the financial risk to IRFs, which could be substantial for many smaller IRFs, of admitting unusually high-cost cases. The additional IRF outlier payments reduce the financial losses caused by treating these patients and, therefore, reduce the incentives to underserve these patients. As discussed at length in the FY 2002 IRF PPS final rule (66 FR 41316 at 41362), we considered various options for setting the target percentage of estimated outlier payments as a percentage of total payments. In that 
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                        final rule, we finalized our proposal to set an outlier policy of 3 percent of total estimated payments because we believed (and continue to believe) that this option optimizes the extent to which we protect vulnerable IRFs for treating unusually high-cost cases, while still providing adequate payment for all other IRF cases. If we were to increase the percentage of total estimated IRF payments that we paid in IRF outlier payments, then we would have to reduce IRF PPS payments for all other IRF cases in order to implement this change in a budget neutral manner. This could negatively affect the adequacy of IRF PPS payments for other, non-outlier IRF cases. Thus, we continue to believe that the 3 percent outlier policy ensures that all IRF cases, outlier and non-outlier, continue to be reimbursed appropriately. As one of the commenters suggested, we will continue to analyze IRF outliers to determine if there are any anomalies in the IRF outlier data or any institutional practices which may be affecting our analysis of IRF outliers. To the extent that we find any such anomalies, we would propose to implement future refinements to the IRF outlier policies to ensure that IRF outlier payments continue to fulfill their intended purpose of reducing the risks to IRFs of treating unusually high-cost cases and ensuring access to care for all patients who require and can benefit from an IRF level of care. *Comment:*
                         One commenter recommended that we continue to refine our methodology for calculating the outlier threshold amount, and that we use the most accurate CCR data available. *Response:*
                         The CCR data that we use in our analyses comes directly from the Medicare cost reports submitted to Medicare by IRFs and is continually updated each time a more recent cost report is tentatively settled. Therefore, we believe that it is the most accurate and most recent CCR data available. However, we agree with the commenter about the need to continually examine our methodology and the CCR data to ensure that we are setting the IRF outlier threshold at the appropriate level to maintain estimated outlier payments at 3 percent of total estimated payments. *Comment:*
                         One commenter requested that we conduct an analysis of IRF outlier payments to ensure that we are not rewarding IRFs with outlier payments for the “wrong” reasons, such as the cost effects of declines in patient volume. This commenter suggested that we should either “hold back” outlier payments from facilities if we find that the outlier payments were paid for the “wrong” reasons, or that we should reduce the outlier pool from 3 percent to 1.5 percent. *Response:*
                         We are continuing to analyze IRF outlier payments to ensure that they continue to compensate IRFs for treating unusually high-cost patients and promote access to care for patients who are likely to require unusually high-cost care. At this time, we do not have indications to suggest that any IRF outlier payments are being paid for the “wrong” reasons. Further, we do not have indications to suggest that the outlier pool would be better set at 1.5 percent than at 3 percent. However, we will carefully consider this commenter's suggestions, and will consider proposing additional refinements to the IRF outlier policies in the future if we find that such refinements are necessary. *Comment:*
                         Several commenters requested that CMS provide additional data and information to the public to allow the IRF industry and external researchers to conduct a more thorough review of CMS's proposed updates to the outlier threshold amount and to verify our estimates of outlier payments as a percentage of total payments for FY 2009. Specifically, one commenter asked that we provide information on actual charge increases and CCR declines that have been utilized in the outlier threshold calculation, a discussion of the data sources and time periods used in computing the outlier threshold, an IRF Medpar file (including total payments, outlier payments, and actual, estimated, and proposed CMGs), historical information on IRF facility-level payment factors (specifically CCRs), and actual levels and percentages of outlier payments. The commenter also asked that we provide data on actual outlier payments and the percentage of outlier payments by FY. *Response:*
                         We will carefully consider all of the commenter's suggestions in updating the IRF rate setting files that we post on the IRF PPS Web site in conjunction with each IRF PPS proposed and final rule. These files are available for download from the IRF PPS Web site at 
                        *http://www.cms.hhs.gov/​InpatientRehabFacPPS/​07_​DataFiles.asp#TopOfPage*. These files already contain much of the facility-level payment data requested by the commenter, including the CCRs used to compute the IRF outlier threshold amount. For this final rule, we used FY 2007 IRF claims data to conduct patient-level payment simulations to estimate the outlier threshold amount for FY 2009. This data file contains information that can be used to identify individual Medicare beneficiaries and is therefore not publicly available. We obtained the provider-level CCR data used in this analysis from the Provider-Specific Files, which contain historical CCR data and are available for download from the CMS Web site at 
                        *http://www.cms.hhs.gov/​ProspMedicareFeeSvcPmtGen/​03_​psf.asp*. The modified Medpar data files that CMS provides to IPPS hospitals already contain IRF stay data. However, we have recently discovered that these files do not include the CMGs, and we recognize that there may be other limitations to the usefulness of these files for analyzing IRF payments. Based on the commenters' requests, we will carefully consider the usefulness and feasibility of including additional variables, such as actual IRF outlier payments and the percentage of outlier payments, on the Medpar file in the future to facilitate IRF analyses. *Comment:*
                         One commenter suggested that CMS utilize the same concepts that the IPPS uses for modeling charge increases and cost-to-charge ratio (CCR) changes in estimating the outlier threshold amount, as noted in the methodology implemented for IPPS hospitals in the FY 2007 IPPS final rule (71 FR 47870, 48150 through 48151). *Response:*
                         We considered proposing the same methodology described in the FY 2007 IPPS final rule (71 FR 47870, 48150 through 48151) for projecting cost and charge growth in estimating the FY 2008 and FY 2009 IRF outlier threshold amount. However, we discovered that the accuracy of the projections depends on the case mix of patients in the facilities remaining similar from year to year, as it does in IPPS hospitals. With the recent phase in of the enforcement of the 75 percent rule criteria and increases in IRF medical review activities, we find evidence of relatively large changes in the case mix of patients in IRFs, especially in recent years (FYs 2004 through 2007). In performing our analysis, we noted that, if we based future projections of cost and charge growth on data from years in which IRFs were experiencing abnormal fluctuations in case mix, the results appeared dramatically skewed. Rather than implementing an outlier threshold amount for FY 2009 based on such skewed results, we thought a better approach would be to wait until we could further analyze the interactions between case mix changes and IRF cost and charge growth. We are encouraged that IRF case mix may stabilize in the near future now that the IRF compliance percentage is set at 
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                        60 percent for FY 2009. However, as recently as FY 2007, we are still observing large shifts in IRFs' patient populations, and we believe it is prudent at this time to defer adopting a methodology for projecting cost and charge growth in IRFs until the patient populations have stabilized. *Final Decision:*
                         Based on careful consideration of the comments that we received on the proposed update to the outlier threshold amount for FY 2009 and based on updated analysis of the FY 2007 data explained previously in this section and for the reasons explained in the proposed rule (73 FR 22674, 22686 through 22687), we are finalizing our decision to update the outlier threshold amount for FY 2009. Based on our proposed policy, the outlier threshold amount for FY 2009 is $10,250. In addition, we did not receive any comments on the IRF cost-to-charge ratio ceiling. Based on our proposed policy and the reasons set forth in the proposed rule (73 FR 22674 at 22687), we are finalizing the national average urban CCR at 0.490 and the national average rural CCR at 0.619. We are also finalizing our estimate of the IRF national CCR ceiling at 1.60 for FY 2009. VII. Revisions to the Regulation Text in Response to the Medicare, Medicaid, and SCHIP Extension Act of 2007 Section 115 of the MMSEA amended section 5005 of the Deficit Reduction Act of 2005 (DRA, Pub. L. 109-171) to revise the following elements of the 75 percent rule that are used to classify IRFs: The compliance rate that IRFs must meet to be excluded from the IPPS and to be paid under the IRF PPS shall be no greater than the 60 percent compliance rate that became effective for cost reporting periods beginning on or after July 1, 2006.
                    Patient comorbidities that satisfy the criteria specified in42 CFR 412.23(b)(2)(i) shall be included in the calculations used to determine whether an IRF meets the 60 percent compliance percentage for cost reporting periods beginning on or after July 1, 2007. Although section 115 of the MMSEA grants the Secretary broad discretion to implement compliance criteria up to 60 percent, we are setting the compliance rate at 60 percent, the highest level possible within current statutory authority, for the reasons discussed in detail in the proposed rule (73 FR 22674, 22687 through 22688). Generally, we are setting the compliance rate at 60 percent because we believe that it implements the provisions of the statute with minimal disruption to IRF operations, thus allowing us to more effectively analyze changes in IRF operations and admissions patterns over time as well as helping us to ensure that IRFs predominantly treat patients who benefit most from this level of care. Specifically, we proposed the following revisions to the regulation text in § 412.23(b). We proposed to remove the following phrases from the first sentence of § 412.23(b)(2)(i): “and before July 1, 2007;” and
                    “and for cost reporting periods beginning on or after July 1, 2007 and before July 1, 2008, the hospital has served an inpatient population of whom at least 65 percent,” We also proposed to remove § 412.23(b)(2)(ii) in its entirety, redesignate the existing § 412.23(b)(2)(iii) to § 412.23(b)(2)(ii), and revise all references to the previously numbered § 412.23(b)(2)(iii) accordingly. We received 3 comments on the proposed revisions to the regulation text in response to section 115 of the MMSEA, which are summarized below. *Comment:*
                         Although several commenters supported the revisions to the regulation text in response to section 115 of the MMSEA, one commenter was concerned that CMS was confusing the 75 percent rule policies, hereinafter referred to as the 60 percent rule policies, and the IRF medical necessity policies. *Response:*
                         We agree with the commenter that the IRF 60 percent rule policies and the IRF medical necessity policies are different. While both policies relate to ensuring that patients who need the intensive rehabilitation services provided in IRFs have access to this level of care, the two policies serve different functions and are applied differently. The Medicare statute excludes payment for services that “* * * are not reasonable and necessary” (see section 1862(a) of the Social Security Act). This applies to all Medicare settings of care, including IRFs, and it applies to all Medicare beneficiaries receiving treatment in those settings. Thus, all IRF discharges for which providers seek payment from Medicare must meet the criteria for establishing the medical necessity of the treatment, regardless of whether the patient's condition is one of the conditions listed in § 412.23(b)(2)(iii), herein redesignated as § 412.23(b)(2)(ii), or not. CMS has specifically instructed its contractors to make medical review determinations based on reviews of individual medical records by qualified clinicians, not on the basis of diagnosis alone. In addition, we do not believe that the 60 percent rule should be used to make individual medical review claim determinations. Conversely, the IRF 60 percent rule is intended to distinguish IRFs from other inpatient hospital settings of care, including acute care hospitals and traditional post-acute care settings (such as skilled nursing facilities). The 60 percent rule specifies that an IRF's patient population must consist of at least 60 percent of the patients who need intensive rehabilitation services for one or more of 13 specified conditions. The remaining 40 percent of patients in an IRF may be admitted for treatment of conditions not included on the list of qualifying conditions. We recognize that the list of 13 conditions does not identify all possible conditions for which it would generally be considered reasonable and necessary for a patient to be treated in an IRF, and thus we believe that it is appropriate to allow some percentage of an IRF's patient population to be made up of patients with other conditions. However, every patient must meet the medical necessity criteria. We believe that it is particularly important to ensure that all patients being treated in IRFs meet the medical necessity criteria, so that the data on which we base IRF PPS payments is as accurate as possible. *Comment:*
                         One commenter expressed a number of concerns about Medicare's policies concerning IRF medical necessity. This commenter indicated that IRFs are confused about the interpretation of the medical necessity policies. The commenter also expressed concerns that the data that CMS uses to analyze and update IRF PPS payment rates may not be as accurate as it could be because it may include patients who do not meet medical necessity requirements for receiving care in IRFs. The commenter suggested that this could lead to inaccuracies in CMS's rate setting for IRFs. *Response:*
                         We note that we did not propose anything regarding the IRF medical necessity policies in the proposed rule. However, we will carefully consider the commenter's concerns and suggestions and will consider refinements to the IRF medical necessity criteria in the future. *Comment:*
                         Several commenters requested that CMS implement changes to the operational policies used in determining IRFs' compliance with the 60 percent rule, to correspond with the statutory changes to the compliance percentage and the continued use of comorbidites. For example, several commenters asked CMS to revise its policies to include Medicare Advantage patients in determining whether at least 
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                        50 percent of an IRF's patient population is made up of Medicare patients. In addition, one commenter asked that CMS revise its policies to allow individual IRFs to view the same IRF-PAI database information that the fiscal intermediaries use in determining the IRFs' compliance using the presumptive methodology. *Response:*
                         We appreciate the suggestions provided by the commenters and are considering making future changes to some of the operational policies for determining compliance with the 60 percent rule, including changes to some of the policies mentioned by the commenters. We are currently evaluating whether we could include Medicare Advantage patients in determining whether 50 percent of an IRF's patient population is made up of Medicare patients, including our statutory authority for doing so. We are also currently evaluating whether modifications to the current system for collecting and compiling IRF-PAI data could be made to allow individual IRFs to view copies of the reports that the Medicare contractors use in determining the individual IRF's compliance using the presumptive methodology. Our goal is to continue to ensure that the 60 percent rule compliance determinations are as transparent and equitable as possible both for providers and for Medicare contractors. We are continuing to work toward this end. *Comment:*
                         One commenter suggested that we remove the phrase “(b)(2)(ii)” from the end of the paragraph in the regulations at § 412.23(b)(2), as the original § 412.23(b)(2)(ii) to which the paragraph referred will no longer exist. *Response:*
                         We agree with the commenter's suggestion and will make the suggested revision. *Final Decision:*
                         As all of the commenters supported the proposed revisions to the regulation text, we are finalizing our revisions to the regulation text at § 412.23(b) by removing the following phrases from the first sentence of § 412.23(b)(2)(i): “and before July 1, 2007;” and
                    “and for cost reporting periods beginning on or after July 1, 2007 and before July 1, 2008, the hospital has served an inpatient population of whom at least 65 percent,” We are also removing § 412.23(b)(2)(ii) in its entirety, redesignating the existing § 412.23(b)(2)(iii) to § 412.23(b)(2)(ii), and revising all references to the previously numbered § 412.23(b)(2)(iii) accordingly. In response to a comment, we are also deleting the phrase “or (b)(2)(ii)” from the end of the paragraph in section § 412.23(b)(2). VIII. Post Acute Care Payment Reform In the proposed rule, we discussed our ongoing examination of possible steps toward achieving a more seamless system for the delivery and payment of post-acute care (PAC) services in various care settings. These include the PAC Payment Reform Demonstration (PAC-PRD) and its standardized patient assessment tool, the Continuity Assessment Record and Evaluation (CARE) tool. In the related area of value-based purchasing (VBP) initiatives, we described the IPPS preventable hospital-acquired conditions (HAC) payment provision, which is designed to ensure that the occurrence of selected, preventable conditions during hospitalization does not have the unintended effect of generating higher Medicare payments under the IPPS. We then discussed the potential application of this same underlying principle to other care settings in addition to IPPS hospitals. For a full and complete discussion of this issue as it pertains to the IRF setting, please refer to the FY 2009 IRF PPS proposed rule (73 FR 22674, 22688 through 22689). We received 12 responses to our request for comments on the post acute care payment reform. *Comment:*
                         We received several comments concerning the use of the CARE tool. While most of these comments acknowledged that the CARE tool holds long-term promise in terms of potentially facilitating the efficient flow of secure electronic patient information, they also cautioned that it would be far too premature at this point in time to draw any definitive conclusions about its use, given the very early stage of the research currently being conducted in this area. *Response:*
                         We agree with the commenters' observations about the CARE tool, both in terms of its significant future potential and the need to await the results of ongoing research before reaching any specific conclusions about its use. We will continue to evaluate the CARE tool closely during the remainder of the current demonstration, and we plan to keep the commenters' concerns in mind as we proceed with our research in this area. *Comment:*
                         A number of commenters stressed the need for external research in the area of PAC payment reform, as well as the importance of obtaining input from the stakeholder community. *Response:*
                         We agree with the commenters regarding the value of obtaining stakeholder input, and believe that this is, in fact, crucial to the success of our PAC payment reform efforts. We also recognize the importance of obtaining the benefit of findings from research that is currently underway. We note that our own activities in this regard primarily involve applied research through our demonstration projects and internal analysis of changes in program policy. However, while our limited resources in this area preclude us from sponsoring any external research projects on PAC payment reform, we strongly favor such activity and encourage interested parties to engage in it. *Comment:*
                         We received a number of comments regarding the HAC payment provision under the IPPS, and the possible adoption of a similar approach in care settings other than IPPS hospitals. The commenters urged us to conduct a thorough evaluation of the HAC policy's implementation under the IPPS to determine its actual impact and efficacy prior to considering whether to adopt this type of approach in other care settings. Some also questioned the legal authority under existing Medicare law to expand the HAC payment provision beyond the IPPS hospital setting. Others raised concerns about the specific implications of applying this type of policy to the IRF setting. They cited “falls” as an example of something that might be less appropriately characterized as “never events” in the IRF setting than in the acute care hospital setting. They also argued that it would be unfair to penalize an IRF financially for a condition that actually developed during the preceding hospital stay but was not detected until after transfer to the IRF. In addition, they indicated that it might be difficult to differentiate a preventable healthcare-acquired complication from a normal, unavoidable aspect of a terminal illness. *Response:*
                         We appreciate the commenters' thoughtful input about application of the principal embodied in the IPPS HAC payment provision to the IRF setting. While we acknowledge that “falls” are among the selected HACs in the IPPS acute care setting that potentially have significant implications for the IRF setting, we agree that these and other conditions may have different implications in the IRF setting. We agree with the commenters that it would be unfair to penalize an IRF financially for a condition that developed in another care setting. We note that the IPPS HAC payment provision uses Present on Admission (POA) indicator data to exclude from payment consequences conditions that develop outside of the IPPS acute care stay, and a similar mechanism would be needed to apply this type of payment provision to the IRF setting. Regarding the commenters' concerns about the difficulty in 
                        ( print page 46390)
                        differentiating a preventable healthcare-acquired complication from a normal, unavoidable aspect of a terminal illness, we would expect to work closely with stakeholders to determine which conditions could reasonably be prevented through the application of evidence-based guidelines. Finally, with regard to the comments that questioned the existing legal authority for expanding the HAC payment provision beyond the IPPS hospital setting, we note that in this final rule, we are not establishing any new Medicare policies in this area. However, we will keep the commenters' concerns in mind as our implementation of value-based purchasing for all Medicare payment systems proceeds, and we look forward to working with stakeholders in continuing to explore possible ways to reduce the occurrence of these preventable conditions in various care settings. IX. Miscellaneous Comments *Comment:*
                         One commenter recommended that CMS update the IRF facility-level adjustments, including the rural adjustment, the low-income percentage adjustment, and the teaching status adjustment, as these adjustments were last updated in FY 2006 based on analysis of FY 2003 data. This commenter also suggested a number of methodological changes to the way that CMS computes the facility-level adjustments, including standardizing cost-per-case by outlier payments and computing three-year moving averages of the adjustments to promote added stability and predictability in the payment system. *Response:*
                         We note that we did not propose any refinements to the IRF facility-level adjustment for FY 2009. However, we are in the process of analyzing the data to determine whether future updates to the IRF facility-level adjustments are needed. At the same time, we are also analyzing the commenter's suggested revisions to the methodology for computing these adjustments to determine whether these revisions would improve the precision of our estimates of the appropriate facility-level adjustment parameters. We will consider proposing to update the IRF facility-level adjustments in future rules if our analysis indicates that such updates are necessary to ensure that IRF PPS payments continue to reflect the costs of caring for IRF patients appropriately. *Comment:*
                         One commenter recommended that CMS re-examine the weights used to compute the weighted motor score for classifying IRF patients. The weights that are currently being used to compute patients' motor scores were finalized in the FY 2006 IRF PPS final rule (70 FR 47880 at 47900) and were based on FY 2003 data. The commenter expressed concerns that the appropriate weights may change over time and may need to be updated using more recent data. *Response:*
                         We did not propose any changes to the weighted motor score in the proposed rule. However, we will consider the commenter's suggestions for future updates to the weighted motor score methodology. *Comment:*
                         Several commenters expressed interest in assisting CMS in the development of the IRF Report to Congress that was mandated in section 115 of the MMSEA. *Response:*
                         We appreciate the commenters' interest in this important project and, as required by statute, we will consult with interested parties and stakeholders in developing this report. *Comment:*
                         Several commenters noted that we reported IRF spending estimates of $6.4 billion for FY 2008 in the proposed rule (73 FR 22674 at 22686) and IRF spending projections of $5.6 billion for FY 2009 in the press release that was issued in conjunction with the proposed rule. We believe that these commenters mistakenly interpreted these spending estimates to mean that a 12.5 percent decrease in IRF PPS payments is estimated to occur between FY 2008 and FY 2009. *Response:*
                         The IRF spending estimate of $6.4 billion for FY 2008 that was reported in the proposed rule (73 FR 22674 at 22686) did not account for any changes in IRF utilization that might occur between FYs 2006 and 2008. It was based on an analysis of simulated IRF payments using IRF claims data from FY 2006 (that is, the number and types of patients that were being treated in IRFs in FY 2006) and the policies that were being proposed for FY 2009 with IRF utilization held constant. The $6.4 billion spending estimate should not be compared with the $5.6 billion IRF spending projection developed by the Office of the Actuary for FY 2008, which accounts for expected changes in IRF utilization between FYs 2006 and 2008. The Office of the Actuary projects that total IRF spending for both FY 2008 and FY 2009 will be $5.6 billion under both the FY 2009 IRF PPS proposed and final rules. Thus, for this final rule, we estimate only a $40 million decrease in IRF PPS spending between FY 2008 and FY 2009, which is equal to only 0.7 percent of total estimated IRF PPS payments. We note that this is different than the $20 million decrease in IRF PPS spending that we had estimated for the proposed rule due to the use of updated data (that is, FY 2007 IRF claims data). The estimated $40 million decrease for this final rule is entirely due to the adjustment to the outlier threshold amount for FY 2009 to set estimated IRF outlier payments at 3 percent of total estimated payments, as discussed in detail in section XII of this final rule. X. Provisions of the Final Rule In this final rule, we are adopting the provisions as set forth in the FY 2009 IRF PPS proposed rule (73 FR 22674), except as noted elsewhere in the preamble. Specifically: We will update the pre-reclassified and pre-floor wage indexes based on the CBSA changes published in the most recent OMB bulletins that apply to the hospital wage data used to determine the current IRF PPS wage index, as discussed in section V.B of this final rule.
                    We will update the FY 2009 IRF PPS relative weights and average length of stay values using the most current and complete Medicare claims and cost report data, as discussed in section IV of this final rule.
                    We will update the FY 2009 IRF PPS payment rates by the wage index and labor related share in a budget neutral manner, as discussed in section V.A and B of this final rule.
                    We will update the outlier threshold amount for FY 2009, as discussed in section VI.A of this final rule.
                    We will update the cost-to-charge ratio ceiling and the national average urban and rural cost-to-charge ratios for purposes of determining outlier payments under the IRF PPS, as discussed in section VI.B of this final rule.
                    With respect to § 412.23, we will revise the regulation text in paragraph (b)(2) and (b)(2)(i) and remove paragraph (b)(2)(ii) to reflect section 115 of the MMSEA, as discussed in section VII of this final rule. XI. Collection of Information Requirements This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995. XII. Regulatory Impact Statement We have examined the impact of this final rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review), the Regulatory Flexibility Act (RFA, 
                        ( print page 46391)
                        September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), Executive Order 13132 on Federalism, and the Congressional Review Act (5 U.S.C. 804(2)). Executive Order 12866, as amended, directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any one year). This final rule does not reach the $100 million economic threshold and thus is not considered a major rule. We estimate that the total impact of the changes in this final rule would be a decrease of approximately $40 million or 0.7 percent of total IRF PPS payments (this reflects a $40 million decrease due to the update to the outlier threshold amount to decrease estimated outlier payments from approximately 3.7 percent in FY 2008 to 3 percent in FY 2009). The RFA requires agencies to analyze options for regulatory relief of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Most IRFs and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $6.5 million to $31.5 million in any one year. (For details, see the Small Business Administration's final rule that set forth size standards for health care industries, at 65 FR 69432, November 17, 2000.) Because we lack data on individual hospital receipts, we cannot determine the number of small proprietary IRFs or the proportion of IRFs' revenue that is derived from Medicare payments. Therefore, we assume that all IRFs (an approximate total of 1,200 IRFs, of which approximately 60 percent are nonprofit facilities) are considered small entities and that Medicare payment constitutes the majority of their revenues. The Department of Health and Human Services generally uses a revenue impact of 3 to 5 percent as a significance threshold under the RFA. Medicare fiscal intermediaries and carriers are not considered to be small entities. Individuals and States are not included in the definition of a small entity. The Secretary has determined that this final rule (which we estimate will result in a decrease in total estimated payments to IRFs of 0.7 percent) would not have a significant economic impact on a substantial number of small entities and therefore an analysis as outlined by the RFA was not prepared. In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a Metropolitan Statistical Area and has fewer than 100 beds. The Secretary has determined that this final rule would not have a significant impact on the operations of a substantial number of small rural hospitals and therefore an analysis for section 1102(b) of the Act was not prepared. Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any one year of $100 million in 1995 dollars, updated annually for inflation. That threshold level is currently approximately $130 million. This final rule would not mandate any cost requirements on State, local, or tribal governments in the aggregate, or by the private sector, of $130 million. Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. As stated above, this final rule would not have a substantial effect on State and local governments. We received one comment on the regulatory impact statement included in the proposed rule, which is summarized below. *Comment:*
                         One commenter expressed concern that the regulatory impact information provided in the proposed rule was not sufficient to calculate the projected impact to individual providers, and that data on FY 2007 actual payments, FY 2008 estimated payments, and FY 2009 proposed payments would be required to fully estimate the effects on individual IRFs. The commenter requested that CMS make information available to allow interested parties to recreate CMS's impact table and to make projections on a facility-specific basis. *Response:*
                         As discussed above, we did not prepare a regulatory impact analysis for this final rule (or for the proposed rule) because this final rule does not reach the $100 million economic threshold and thus is not considered a major rule. However, we provided an IRF rate setting file in conjunction with the proposed rule to allow interested parties to calculate the payment effects of the proposed policies for individual IRFs. In addition, we will carefully consider all of the commenter's suggestions in updating the final FY 2009 IRF rate setting file that will be posted on the IRF PPS Web site in conjunction with this final rule. This file will be available for download from the IRF PPS Web site soon after publication of this final rule at 
                        *http://www.cms.hhs.gov/​InpatientRehabFacPPS/​07_​DataFiles.asp#TopOfPage*. The IRF rate setting files posted in conjunction with each proposed and final rule already contain much of the facility-level payment data needed to allow interested parties to recreate CMS's analysis and to make projections on a facility-specific basis. In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the Office of Management and Budget. List of Subjects in 42 CFR Part 412 Administrative practice and procedure
Health facilities
Medicare
Puerto Rico
Reporting and recordkeeping requirements
 For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services amends 42 CFR chapter IV as follows: PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES
 1.The authority citation for part 412 continues to read as follows: Authority:
                            Sections 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). Subpart B—Hospital Services Subject to and Excluded From the Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital—Related Costs
 2.Section 412.23 is amended by— A. Revising introductory text of paragraph (b)(2). B. Revising introductory text of paragraph (b)(2)(i). C. Revising paragraphs (b)(2)(i)(A) and (B). D. Removing paragraph (b)(2)(ii).
                            ( print page 46392) E. Redesignating paragraph (b)(2)(iii) as (b)(2)(ii). The revision reads as follows: § 412.23
  
 (b) * * * (2) Except in the case of a newly participating hospital seeking classification under this paragraph as a rehabilitation hospital for its first 12-month cost reporting period, as described in paragraph (b)(8) of this section, a hospital must show that during its most recent, consecutive, and appropriate 12-month time period (as defined by CMS or the fiscal intermediary), it served an inpatient population that meets the criteria under paragraph (b)(2)(i) of this section. (i) For cost reporting periods beginning on or after July 1, 2004 and before July 1, 2005, the hospital has served an inpatient population of whom at least 50 percent, and for cost reporting periods beginning on or after July 1, 2005, the hospital has served an inpatient population of whom at least 60 percent required intensive rehabilitation services for treatment of one or more of the conditions specified at paragraph (b)(2)(ii) of this section. A patient with a comorbidity, as defined at § 412.602, may be included in the inpatient population that counts toward the required applicable percentage if— (A) The patient is admitted for inpatient rehabilitation for a condition that is not one of the conditions specified in paragraph (b)(2)(ii) of this section; (B) The patient has a comorbidity that falls in one of the conditions specified in paragraph (b)(2)(ii) of this section; and 
 (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare—Hospital Insurance; and Program No. 93.774, Medicare—Supplemental Medical Insurance Program).
 Dated: July 18, 2008. Kerry Weems, Acting Administrator, Centers for Medicare & Medicaid Services. Approved: July 25, 2008. Michael O. Leavitt, Secretary.
 The following addendum will not appear in the Code of Federal Regulations. Addendum This addendum contains the tables referred to throughout the preamble of this final rule. The tables presented below are as follows: Table 1.—Inpatient Rehabilitation Facility Wage Index for Urban Areas for Discharges Occurring from October 1, 2008 through September 30, 2009 Table 2.—Inpatient Rehabilitation Facility Wage Index for Rural Areas for Discharges Occurring from October 1, 2008 through September 30, 2009 Table 1—Inpatient Rehabilitation Facility Wage Index for Urban Areas for Discharges Occurring From October 1, 2008 Through September 30, 2009
CBSA code
Urban area (constituent counties)
Wage index10180
Abilene, TX
0.7957Callahan County, TXJones County, TXTaylor County, TX10380
Aguadilla-Isabela-San Sebastián, PR
0.3448Aguada Municipio, PRAguadilla Municipio, PRAñasco Municipio, PRIsabela Municipio, PRLares Municipio, PRMoca Municipio, PRRincón Municipio, PRSan Sebastián Municipio, PR10420
Akron, OH
0.8794Portage County, OHSummit County, OH10500
Albany, GA
0.8514Baker County, GADougherty County, GALee County, GATerrell County, GAWorth County, GA10580
Albany-Schenectady-Troy, NY
0.8588Albany County, NYRensselaer County, NYSaratoga County, NYSchenectady County, NYSchoharie County, NY10740
Albuquerque, NM
0.9554Bernalillo County, NMSandoval County, NMTorrance County, NMValencia County, NM10780
Alexandria, LA
0.7979Grant Parish, LARapides Parish, LA10900
Allentown-Bethlehem-Easton, PA-NJ
0.9865Warren County, NJCarbon County, PALehigh County, PANorthampton County, PA11020
Altoona, PA
0.8618( print page 46393)Blair County, PA11100
Amarillo, TX
0.9116Armstrong County, TXCarson County, TXPotter County, TXRandall County, TX11180
Ames, IA
1.0046Story County, IA11260
Anchorage, AK
1.1913Anchorage Municipality, AKMatanuska-Susitna Borough, AK11300
Anderson, IN
0.8827Madison County, IN11340
Anderson, SC
0.9086Anderson County, SC11460
Ann Arbor, MI
1.0539Washtenaw County, MI11500
Anniston-Oxford, AL
0.7926Calhoun County, AL11540
Appleton, WI
0.9598Calumet County, WIOutagamie County, WI11700
Asheville, NC
0.9185Buncombe County, NCHaywood County, NCHenderson County, NCMadison County, NC12020
Athens-Clarke County, GA
1.0517Clarke County, GAMadison County, GAOconee County, GAOglethorpe County, GA12060
Atlanta-Sandy Springs-Marietta, GA
0.9828Barrow County, GABartow County, GAButts County, GACarroll County, GACherokee County, GAClayton County, GACobb County, GACoweta County, GADawson County, GADeKalb County, GADouglas County, GAFayette County, GAForsyth County, GAFulton County, GAGwinnett County, GAHaralson County, GAHeard County, GAHenry County, GAJasper County, GALamar County, GAMeriwether County, GANewton County, GAPaulding County, GAPickens County, GAPike County, GARockdale County, GASpalding County, GAWalton County, GA12100
Atlantic City, NJ
1.2198Atlantic County, NJ12220
Auburn-Opelika, AL
0.8090Lee County, AL12260
Augusta-Richmond County, GA-SC
0.9645Burke County, GAColumbia County, GAMcDuffie County, GARichmond County, GAAiken County, SC( print page 46394)Edgefield County, SC12420
Austin-Round Rock, TX
0.9544Bastrop County, TXCaldwell County, TXHays County, TXTravis County, TXWilliamson County, TX12540
Bakersfield, CA
1.1051Kern County, CA12580
Baltimore-Towson, MD
1.0134Anne Arundel County, MDBaltimore County, MDCarroll County, MDHarford County, MDHoward County, MDQueen Anne's County, MDBaltimore City, MD12620
Bangor, ME
0.9978Penobscot County, ME12700
Barnstable Town, MA
1.2603Barnstable County, MA12940
Baton Rouge, LA
0.8034Ascension Parish, LAEast Baton Rouge Parish, LAEast Feliciana Parish, LAIberville Parish, LALivingston Parish, LAPointe Coupee Parish, LASt. Helena Parish, LAWest Baton Rouge Parish, LAWest Feliciana Parish, LA12980
Battle Creek, MI
1.0179Calhoun County, MI13020
Bay City, MI
0.8897Bay County, MI13140
Beaumont-Port Arthur, TX
0.8531Hardin County, TXJefferson County, TXOrange County, TX13380
Bellingham, WA
1.1474Whatcom County, WA13460
Bend, OR
1.0942Deschutes County, OR13644
Bethesda-Gaithersburg-Frederick, MD
1.0511Frederick County, MDMontgomery County, MD13740
Billings, MT
0.8666Carbon County, MTYellowstone County, MT13780
Binghamton, NY
0.8949Broome County, NYTioga County, NY13820
Birmingham-Hoover, AL
0.8898Bibb County, ALBlount County, ALChilton County, ALJefferson County, ALSt. Clair County, ALShelby County, ALWalker County, AL13900
Bismarck, ND
0.7225Burleigh County, NDMorton County, ND13980
Blacksburg-Christiansburg-Radford, VA
0.8192Giles County, VAMontgomery County, VAPulaski County, VARadford City, VA14020
Bloomington, IN
0.8915Greene County, INMonroe County, IN( print page 46395)Owen County, IN14060
Bloomington-Normal, IL
0.9325McLean County, IL14260
Boise City-Nampa, ID
0.9465Ada County, IDBoise County, IDCanyon County, IDGem County, IDOwyhee County, ID14484
Boston-Quincy, MA
1.1792Norfolk County, MAPlymouth County, MASuffolk County, MA14500
Boulder, CO
1.0426Boulder County, CO14540
Bowling Green, KY
0.8159Edmonson County, KYWarren County, KY14740
Bremerton-Silverdale, WA
1.0904Kitsap County, WA14860
Bridgeport-Stamford-Norwalk, CT
1.2735Fairfield County, CT15180
Brownsville-Harlingen, TX
0.8914Cameron County, TX15260
Brunswick, GA
0.9475Brantley County, GAGlynn County, GAMcIntosh County, GA15380
Buffalo-Niagara Falls, NY
0.9568Erie County, NYNiagara County, NY15500
Burlington, NC
0.8747Alamance County, NC15540
Burlington-South Burlington, VT
0.9660Chittenden County, VTFranklin County, VTGrand Isle County, VT15764
Cambridge-Newton-Framingham, MA
1.1215Middlesex County, MA15804
Camden, NJ
1.0411Burlington County, NJCamden County, NJGloucester County, NJ15940
Canton-Massillon, OH
0.8935Carroll County, OHStark County, OH15980
Cape Coral-Fort Myers, FL
0.9396Lee County, FL16180
Carson City, NV
1.0003Carson City, NV16220
Casper, WY
0.9385Natrona County, WY16300
Cedar Rapids, IA
0.8852Benton County, IAJones County, IALinn County, IA16580
Champaign-Urbana, IL
0.9392Champaign County, ILFord County, ILPiatt County, IL16620
Charleston, WV
0.8289Boone County, WVClay County, WVKanawha County, WVLincoln County, WVPutnam County, WV16700
Charleston-North Charleston, SC
0.9124Berkeley County, SCCharleston County, SCDorchester County, SC16740
Charlotte-Gastonia-Concord, NC-SC
0.9520( print page 46396)Anson County, NCCabarrus County, NCGaston County, NCMecklenburg County, NCUnion County, NCYork County, SC16820
Charlottesville, VA
0.9277Albemarle County, VAFluvanna County, VAGreene County, VANelson County, VACharlottesville City, VA16860
Chattanooga, TN-GA
0.8994Catoosa County, GADade County, GAWalker County, GAHamilton County, TNMarion County, TNSequatchie County, TN16940
Cheyenne, WY
0.9308Laramie County, WY16974
Chicago-Naperville-Joliet, IL
1.0715Cook County, ILDeKalb County, ILDuPage County, ILGrundy County, ILKane County, ILKendall County, ILMcHenry County, ILWill County, IL17020
Chico, CA
1.1290Butte County, CA17140
Cincinnati-Middletown, OH-KY-IN
0.9784Dearborn County, INFranklin County, INOhio County, INBoone County, KYBracken County, KYCampbell County, KYGallatin County, KYGrant County, KYKenton County, KYPendleton County, KYBrown County, OHButler County, OHClermont County, OHHamilton County, OHWarren County, OH17300
Clarksville, TN-KY
0.8251Christian County, KYTrigg County, KYMontgomery County, TNStewart County, TN17420
Cleveland, TN
0.8052Bradley County, TNPolk County, TN17460
Cleveland-Elyria-Mentor, OH
0.9339Cuyahoga County, OHGeauga County, OHLake County, OHLorain County, OHMedina County, OH17660
Coeur d'Alene, ID
0.9532Kootenai County, ID17780
College Station-Bryan, TX
0.9358Brazos County, TXBurleson County, TXRobertson County, TX17820
Colorado Springs, CO
0.9719El Paso County, COTeller County, CO( print page 46397)17860
Columbia, MO
0.8658Boone County, MOHoward County, MO17900
Columbia, SC
0.8800Calhoun County, SCFairfield County, SCKershaw County, SCLexington County, SCRichland County, SCSaluda County, SC17980
Columbus, GA-AL
0.8729Russell County, ALChattahoochee County, GAHarris County, GAMarion County, GAMuscogee County, GA18020
Columbus, IN
0.9537Bartholomew County, IN18140
Columbus, OH
1.0085Delaware County, OHFairfield County, OHFranklin County, OHLicking County, OHMadison County, OHMorrow County, OHPickaway County, OHUnion County, OH18580
Corpus Christi, TX
0.8588Aransas County, TXNueces County, TXSan Patricio County, TX18700
Corvallis, OR
1.0959Benton County, OR19060
Cumberland, MD-WV
0.8294Allegany County, MDMineral County, WV19124
Dallas-Plano-Irving, TX
0.9915Collin County, TXDallas County, TXDelta County, TXDenton County, TXEllis County, TXHunt County, TXKaufman County, TXRockwall County, TX19140
Dalton, GA
0.8760Murray County, GAWhitfield County, GA19180
Danville, IL
0.8957Vermilion County, IL19260
Danville, VA
0.8240Pittsylvania County, VADanville City, VA19340
Davenport-Moline-Rock Island, IA-IL
0.8830Henry County, ILMercer County, ILRock Island County, ILScott County, IA19380
Dayton, OH
0.9190Greene County, OHMiami County, OHMontgomery County, OHPreble County, OH19460
Decatur, AL
0.7885Lawrence County, ALMorgan County, AL19500
Decatur, IL
0.8074Macon County, IL19660
Deltona-Daytona Beach-Ormond Beach, FL
0.9031Volusia County, FL19740
Denver-Aurora, CO
1.0718( print page 46398)Adams County, COArapahoe County, COBroomfield County, COClear Creek County, CODenver County, CODouglas County, COElbert County, COGilpin County, COJefferson County, COPark County, CO19780
Des Moines-West Des Moines, IA
0.9226Dallas County, IAGuthrie County, IAMadison County, IAPolk County, IAWarren County, IA19804
Detroit-Livonia-Dearborn, MI
0.9999Wayne County, MI20020
Dothan, AL
0.7270Geneva County, ALHenry County, ALHouston County, AL20100
Dover, DE
1.0099Kent County, DE20220
Dubuque, IA
0.9058Dubuque County, IA20260
Duluth, MN-WI
0.9975Carlton County, MNSt. Louis County, MNDouglas County, WI20500
Durham, NC
0.9816Chatham County, NCDurham County, NCOrange County, NCPerson County, NC20740
Eau Claire, WI
0.9475Chippewa County, WIEau Claire County, WI20764
Edison, NJ
1.1181Middlesex County, NJMonmouth County, NJOcean County, NJSomerset County, NJ20940
El Centro, CA
0.8914Imperial County, CA21060
Elizabethtown, KY
0.8711Hardin County, KYLarue County, KY21140
Elkhart-Goshen, IN
0.9611Elkhart County, IN21300
Elmira, NY
0.8264Chemung County, NY21340
El Paso, TX
0.8989El Paso County, TX21500
Erie, PA
0.8495Erie County, PA21660
Eugene-Springfield, OR
1.0932Lane County, OR21780
Evansville, IN-KY
0.8662Gibson County, INPosey County, INVanderburgh County, INWarrick County, INHenderson County, KYWebster County, KY21820
Fairbanks, AK
1.1050Fairbanks North Star Borough, AK21940
Fajardo, PR
0.4375Ceiba Municipio, PRFajardo Municipio, PRLuquillo Municipio, PR( print page 46399)22020
Fargo, ND-MN
0.8042Cass County, NDClay County, MN22140
Farmington, NM
0.9587San Juan County, NM22180
Fayetteville, NC
0.9368Cumberland County, NCHoke County, NC22220
Fayetteville-Springdale-Rogers, AR-MO
0.8742Benton County, ARMadison County, ARWashington County, ARMcDonald County, MO22380
Flagstaff, AZ
1.1687Coconino County, AZ22420
Flint, MI
1.1220Genesee County, MI22500
Florence, SC
0.8249Darlington County, SCFlorence County, SC22520
Florence-Muscle Shoals, AL
0.7680Colbert County, ALLauderdale County, AL22540
Fond du Lac, WI
0.9667Fond du Lac County, WI22660
Fort Collins-Loveland, CO
0.9897Larimer County, CO22744
Fort Lauderdale-Pompano Beach-Deerfield Beach, FL
1.0229Broward County, FL22900
Fort Smith, AR-OK
0.7933Crawford County, ARFranklin County, ARSebastian County, ARLe Flore County, OKSequoyah County, OK23020
Fort Walton Beach-Crestview-Destin, FL
0.8743Okaloosa County, FL23060
Fort Wayne, IN
0.9284Allen County, INWells County, INWhitley County, IN23104
Fort Worth-Arlington, TX
0.9693Johnson County, TXParker County, TXTarrant County, TXWise County, TX23420
Fresno, CA
1.0993Fresno County, CA23460
Gadsden, AL
0.8159Etowah County, AL23540
Gainesville, FL
0.9196Alachua County, FLGilchrist County, FL23580
Gainesville, GA
0.9216Hall County, GA23844
Gary, IN
0.9224Jasper County, INLake County, INNewton County, INPorter County, IN24020
Glens Falls, NY
0.8256Warren County, NYWashington County, NY24140
Goldsboro, NC
0.9288Wayne County, NC24220
Grand Forks, ND-MN
0.7881Polk County, MNGrand Forks County, ND24300
Grand Junction, CO
0.9864Mesa County, CO24340
Grand Rapids-Wyoming, MI
0.9315( print page 46400)Barry County, MIIonia County, MIKent County, MINewaygo County, MI24500
Great Falls, MT
0.8675Cascade County, MT24540
Greeley, CO
0.9658Weld County, CO24580
Green Bay, WI
0.9727Brown County, WIKewaunee County, WIOconto County, WI24660
Greensboro-High Point, NC
0.9010Guilford County, NCRandolph County, NCRockingham County, NC24780
Greenville, NC
0.9402Greene County, NCPitt County, NC24860
Greenville-Mauldin-Easley, SC
0.9860Greenville County, SCLaurens County, SCPickens County, SC25020
Guayama, PR
0.3064Arroyo Municipio, PRGuayama Municipio, PRPatillas Municipio, PR25060
Gulfport-Biloxi, MS
0.8773Hancock County, MSHarrison County, MSStone County, MS25180
Hagerstown-Martinsburg, MD-WV
0.9013Washington County, MDBerkeley County, WVMorgan County, WV25260
Hanford-Corcoran, CA
1.0499Kings County, CA25420
Harrisburg-Carlisle, PA
0.9280Cumberland County, PADauphin County, PAPerry County, PA25500
Harrisonburg, VA
0.8867Rockingham County, VAHarrisonburg City, VA25540
Hartford-West Hartford-East Hartford, CT
1.0959Hartford County, CTMiddlesex County, CTTolland County, CT25620
Hattiesburg, MS
0.7366Forrest County, MSLamar County, MSPerry County, MS25860
Hickory-Lenoir-Morganton, NC
0.9028Alexander County, NCBurke County, NCCaldwell County, NCCatawba County, NC25980
Hinesville-Fort Stewart, GA 1
0.9187Liberty County, GALong County, GA26100
Holland-Grand Haven, MI
0.9006Ottawa County, MI26180
Honolulu, HI
1.1556Honolulu County, HI26300
Hot Springs, AR
0.9109Garland County, AR26380
Houma-Bayou Cane-Thibodaux, LA
0.7892Lafourche Parish, LATerrebonne Parish, LA26420
Houston-Sugar Land-Baytown, TX
0.9939Austin County, TX( print page 46401)Brazoria County, TXChambers County, TXFort Bend County, TXGalveston County, TXHarris County, TXLiberty County, TXMontgomery County, TXSan Jacinto County, TXWaller County, TX26580
Huntington-Ashland, WV-KY-OH
0.9041Boyd County, KYGreenup County, KYLawrence County, OHCabell County, WVWayne County, WV26620
Huntsville, AL
0.9146Limestone County, ALMadison County, AL26820
Idaho Falls, ID
0.9264Bonneville County, IDJefferson County, ID26900
Indianapolis-Carmel, IN
0.9844Boone County, INBrown County, INHamilton County, INHancock County, INHendricks County, INJohnson County, INMarion County, INMorgan County, INPutnam County, INShelby County, IN26980
Iowa City, IA
0.9568Johnson County, IAWashington County, IA27060
Ithaca, NY
0.9630Tompkins County, NY27100
Jackson, MI
0.9329Jackson County, MI27140
Jackson, MS
0.8011Copiah County, MSHinds County, MSMadison County, MSRankin County, MSSimpson County, MS27180
Jackson, TN
0.8676Chester County, TNMadison County, TN27260
Jacksonville, FL
0.9021Baker County, FLClay County, FLDuval County, FLNassau County, FLSt. Johns County, FL27340
Jacksonville, NC
0.8079Onslow County, NC27500
Janesville, WI
0.9702Rock County, WI27620
Jefferson City, MO
0.8478Callaway County, MOCole County, MOMoniteau County, MOOsage County, MO27740
Johnson City, TN
0.7677Carter County, TNUnicoi County, TNWashington County, TN27780
Johnstown, PA
0.7543Cambria County, PA27860
Jonesboro, AR
0.7790Craighead County, AR( print page 46402)Poinsett County, AR27900
Joplin, MO
0.8951Jasper County, MONewton County, MO28020
Kalamazoo-Portage, MI
1.0433Kalamazoo County, MIVan Buren County, MI28100
Kankakee-Bradley, IL
1.0238Kankakee County, IL28140
Kansas City, MO-KS
0.9504Franklin County, KSJohnson County, KSLeavenworth County, KSLinn County, KSMiami County, KSWyandotte County, KSBates County, MOCaldwell County, MOCass County, MOClay County, MOClinton County, MOJackson County, MOLafayette County, MOPlatte County, MORay County, MO28420
Kennewick-Richland-Pasco, WA
1.0075Benton County, WAFranklin County, WA28660
Killeen-Temple-Fort Hood, TX
0.8249Bell County, TXCoryell County, TXLampasas County, TX28700
Kingsport-Bristol-Bristol, TN-VA
0.7658Hawkins County, TNSullivan County, TNBristol City, VAScott County, VAWashington County, VA28740
Kingston, NY
0.9556Ulster County, NY28940
Knoxville, TN
0.8036Anderson County, TNBlount County, TNKnox County, TNLoudon County, TNUnion County, TN29020
Kokomo, IN
0.9591Howard County, INTipton County, IN29100
La Crosse, WI-MN
0.9685Houston County, MNLa Crosse County, WI29140
Lafayette, IN
0.8869Benton County, INCarroll County, INTippecanoe County, IN29180
Lafayette, LA
0.8247Lafayette Parish, LASt. Martin Parish, LA29340
Lake Charles, LA
0.7777Calcasieu Parish, LACameron Parish, LA29404
Lake County-Kenosha County, IL-WI
1.0603Lake County, ILKenosha County, WI29420
Lake Havasu City-Kingman, AZ
0.9333Mohave County, AZ29460
Lakeland, FL
0.8661Polk County, FL29540
Lancaster, PA
0.9252Lancaster County, PA( print page 46403)29620
Lansing-East Lansing, MI
1.0119Clinton County, MIEaton County, MIIngham County, MI29700
Laredo, TX
0.8093Webb County, TX29740
Las Cruces, NM
0.8676Dona Ana County, NM29820
Las Vegas-Paradise, NV
1.1799Clark County, NV29940
Lawrence, KS
0.8227Douglas County, KS30020
Lawton, OK
0.8025Comanche County, OK30140
Lebanon, PA
0.8192Lebanon County, PA30300
Lewiston, ID-WA
0.9454Nez Perce County, IDAsotin County, WA30340
Lewiston-Auburn, ME
0.9193Androscoggin County, ME30460
Lexington-Fayette, KY
0.9191Bourbon County, KYClark County, KYFayette County, KYJessamine County, KYScott County, KYWoodford County, KY30620
Lima, OH
0.9424Allen County, OH30700
Lincoln, NE
1.0051Lancaster County, NESeward County, NE30780
Little Rock-North Little Rock-Conway, AR
0.8863Faulkner County, ARGrant County, ARLonoke County, ARPerry County, ARPulaski County, ARSaline County, AR30860
Logan, UT-ID
0.9183Franklin County, IDCache County, UT30980
Longview, TX
0.8717Gregg County, TXRusk County, TXUpshur County, TX31020
Longview, WA
1.0827Cowlitz County, WA31084
Los Angeles-Long Beach-Santa Ana, CA
1.1771Los Angeles County, CA31140
Louisville-Jefferson County, KY-IN
0.9065Clark County, INFloyd County, INHarrison County, INWashington County, INBullitt County, KYHenry County, KYMeade County, KYNelson County, KYOldham County, KYShelby County, KYSpencer County, KYTrimble County, KY31180
Lubbock, TX
0.8680Crosby County, TXLubbock County, TX31340
Lynchburg, VA
0.8732Amherst County, VAAppomattox County, VABedford County, VA( print page 46404)Campbell County, VABedford City, VALynchburg City, VA31420
Macon, GA
0.9541Bibb County, GACrawford County, GAJones County, GAMonroe County, GATwiggs County, GA31460
Madera, CA
0.8069Madera County, CA31540
Madison, WI
1.0935Columbia County, WIDane County, WIIowa County, WI31700
Manchester-Nashua, NH
1.0273Hillsborough County, NH31900
Mansfield, OH 1
0.9271Richland County, OH32420
Mayagüez, PR
0.3711Hormigueros Municipio, PRMayagüez Municipio, PR32580
McAllen-Edinburg-Mission, TX
0.9123Hidalgo County, TX32780
Medford, OR
1.0318Jackson County, OR32820
Memphis, TN-MS-AR
0.9250Crittenden County, ARDeSoto County, MSMarshall County, MSTate County, MSTunica County, MSFayette County, TNShelby County, TNTipton County, TN32900
Merced, CA
1.2120Merced County, CA33124
Miami-Miami Beach-Kendall, FL
1.0002Miami-Dade County, FL33140
Michigan City-La Porte, IN
0.8914LaPorte County, IN33260
Midland, TX
1.0017Midland County, TX33340
Milwaukee-Waukesha-West Allis, WI
1.0214Milwaukee County, WIOzaukee County, WIWashington County, WIWaukesha County, WI33460
Minneapolis-St. Paul—Bloomington, MN-WI
1.1093Anoka County, MNCarver County, MNChisago County, MNDakota County, MNHennepin County, MNIsanti County, MNRamsey County, MNScott County, MNSherburne County, MNWashington County, MNWright County, MNPierce County, WISt. Croix County, WI33540
Missoula, MT
0.8953Missoula County, MT33660
Mobile, AL
0.8033Mobile County, AL33700
Modesto, CA
1.1962Stanislaus County, CA33740
Monroe, LA
0.7832Ouachita Parish, LAUnion Parish, LA( print page 46405)33780
Monroe, MI
0.9414Monroe County, MI33860
Montgomery, AL
0.8088Autauga County, ALElmore County, ALLowndes County, ALMontgomery County, AL34060
Morgantown, WV
0.8321Monongalia County, WVPreston County, WV34100
Morristown, TN
0.7388Grainger County, TNHamblen County, TNJefferson County, TN34580
Mount Vernon-Anacortes, WA
1.0529Skagit County, WA34620
Muncie, IN
0.8214Delaware County, IN34740
Muskegon-Norton Shores, MI
0.9836Muskegon County, MI34820
Myrtle Beach-Conway-North Myrtle Beach, SC
0.8634Horry County, SC34900
Napa, CA
1.4476Napa County, CA34940
Naples-Marco Island, FL
0.9487Collier County, FL34980
Nashville-Davidson-Murfreesboro-Franklin, TN
0.9689Cannon County, TNCheatham County, TNDavidson County, TNDickson County, TNHickman County, TNMacon County, TNRobertson County, TNRutherford County, TNSmith County, TNSumner County, TNTrousdale County, TNWilliamson County, TNWilson County, TN35004
Nassau-Suffolk, NY
1.2640Nassau County, NYSuffolk County, NY35084
Newark-Union, NJ-PA
1.1862Essex County, NJHunterdon County, NJMorris County, NJSussex County, NJUnion County, NJPike County, PA35300
New Haven-Milford, CT
1.1871New Haven County, CT35380
New Orleans-Metairie-Kenner, LA
0.8897Jefferson Parish, LAOrleans Parish, LAPlaquemines Parish, LASt. Bernard Parish, LASt. Charles Parish, LASt. John the Baptist Parish, LASt. Tammany Parish, LA35644
New York-White Plains-Wayne, NY-NJ
1.3115Bergen County, NJHudson County, NJPassaic County, NJBronx County, NYKings County, NYNew York County, NYPutnam County, NYQueens County, NYRichmond County, NYRockland County, NY( print page 46406)Westchester County, NY35660
Niles-Benton Harbor, MI
0.9141Berrien County, MI35980
Norwich-New London, CT
1.1432New London County, CT36084
Oakland-Fremont-Hayward, CA
1.5685Alameda County, CAContra Costa County, CA36100
Ocala, FL
0.8627Marion County, FL36140
Ocean City, NJ
1.0988Cape May County, NJ36220
Odessa, TX
1.0042Ector County, TX36260
Ogden-Clearfield, UT
0.9000Davis County, UTMorgan County, UTWeber County, UT36420
Oklahoma City, OK
0.8815Canadian County, OKCleveland County, OKGrady County, OKLincoln County, OKLogan County, OKMcClain County, OKOklahoma County, OK36500
Olympia, WA
1.1512Thurston County, WA36540
Omaha-Council Bluffs, NE-IA
0.9561Harrison County, IAMills County, IAPottawattamie County, IACass County, NEDouglas County, NESarpy County, NESaunders County, NEWashington County, NE36740
Orlando-Kissimmee, FL
0.9226Lake County, FLOrange County, FLOsceola County, FLSeminole County, FL36780
Oshkosh-Neenah, WI
0.9551Winnebago County, WI36980
Owensboro, KY
0.8652Daviess County, KYHancock County, KYMcLean County, KY37100
Oxnard-Thousand Oaks-Ventura, CA
1.1852Ventura County, CA37340
Palm Bay-Melbourne-Titusville, FL
0.9325Brevard County, FL37380
Palm Coast, FL
0.8945Flagler County, FL37460
Panama City-Lynn Haven, FL
0.8313Bay County, FL37620
Parkersburg-Marietta-Vienna, WV-OH
0.8105Washington County, OHPleasants County, WVWirt County, WVWood County, WV37700
Pascagoula, MS
0.8647George County, MSJackson County, MS37764
Peabody, MA
1.0650Essex County, MA37860
Pensacola-Ferry Pass-Brent, FL
0.8281Escambia County, FLSanta Rosa County, FL37900
Peoria, IL
0.9299Marshall County, IL( print page 46407)Peoria County, ILStark County, ILTazewell County, ILWoodford County, IL37964
Philadelphia, PA
1.0925Bucks County, PAChester County, PADelaware County, PAMontgomery County, PAPhiladelphia County, PA38060
Phoenix-Mesa-Scottsdale, AZ
1.0264Maricopa County, AZPinal County, AZ38220
Pine Bluff, AR
0.7839Cleveland County, ARJefferson County, ARLincoln County, AR38300
Pittsburgh, PA
0.8525Allegheny County, PAArmstrong County, PABeaver County, PAButler County, PAFayette County, PAWashington County, PAWestmoreland County, PA38340
Pittsfield, MA
1.0091Berkshire County, MA38540
Pocatello, ID
0.9465Bannock County, IDPower County, ID38660
Ponce, PR
0.4450Juana Díaz Municipio, PRPonce Municipio, PRVillalba Municipio, PR38860
Portland-South Portland-Biddeford, ME
1.0042Cumberland County, MESagadahoc County, MEYork County, ME38900
Portland-Vancouver-Beaverton, OR-WA
1.1498Clackamas County, ORColumbia County, ORMultnomah County, ORWashington County, ORYamhill County, ORClark County, WASkamania County, WA38940
Port St. Lucie, FL
1.0016Martin County, FLSt. Lucie County, FL39100
Poughkeepsie-Newburgh-Middletown, NY
1.0982Dutchess County, NYOrange County, NY39140
Prescott, AZ
1.0020Yavapai County, AZ39300
Providence-New Bedford-Fall River, RI-MA
1.0574Bristol County, MABristol County, RIKent County, RINewport County, RIProvidence County, RIWashington County, RI39340
Provo-Orem, UT
0.9557Juab County, UTUtah County, UT39380
Pueblo, CO
0.8851Pueblo County, CO39460
Punta Gorda, FL
0.9254Charlotte County, FL39540
Racine, WI
0.9498Racine County, WI39580
Raleigh-Cary, NC
0.9839( print page 46408)Franklin County, NCJohnston County, NCWake County, NC39660
Rapid City, SD
0.8811Meade County, SDPennington County, SD39740
Reading, PA
0.9356Berks County, PA39820
Redding, CA
1.3541Shasta County, CA39900
Reno-Sparks, NV
1.0715Storey County, NVWashoe County, NV40060
Richmond, VA
0.9425Amelia County, VACaroline County, VACharles City County, VAChesterfield County, VACumberland County, VADinwiddie County, VAGoochland County, VAHanover County, VAHenrico County, VAKing and Queen County, VAKing William County, VALouisa County, VANew Kent County, VAPowhatan County, VAPrince George County, VASussex County, VAColonial Heights City, VAHopewell City, VAPetersburg City, VARichmond City, VA40140
Riverside-San Bernardino-Ontario, CA
1.1100Riverside County, CASan Bernardino County, CA40220
Roanoke, VA
0.8691Botetourt County, VACraig County, VAFranklin County, VARoanoke County, VARoanoke City, VASalem City, VA40340
Rochester, MN
1.0755Dodge County, MNOlmsted County, MNWabasha County, MN40380
Rochester, NY
0.8858Livingston County, NYMonroe County, NYOntario County, NYOrleans County, NYWayne County, NY40420
Rockford, IL
0.9814Boone County, ILWinnebago County, IL40484
Rockingham County, NH
1.0111Rockingham County, NHStrafford County, NH40580
Rocky Mount, NC
0.9001Edgecombe County, NCNash County, NC40660
Rome, GA
0.9042Floyd County, GA40900
Sacramento—Arden-Arcade—Roseville, CA
1.3505El Dorado County, CAPlacer County, CASacramento County, CAYolo County, CA40980
Saginaw-Saginaw Township North, MI
0.8812( print page 46409)Saginaw County, MI41060
St. Cloud, MN
1.0549Benton County, MNStearns County, MN41100
St. George, UT
0.9358Washington County, UT41140
St. Joseph, MO-KS
0.8762Doniphan County, KSAndrew County, MOBuchanan County, MODeKalb County, MO41180
St. Louis, MO-IL
0.9024Bond County, ILCalhoun County, ILClinton County, ILJersey County, ILMacoupin County, ILMadison County, ILMonroe County, ILSt. Clair County, ILCrawford County, MOFranklin County, MOJefferson County, MOLincoln County, MOSt. Charles County, MOSt. Louis County, MOWarren County, MOWashington County, MOSt. Louis City, MO41420
Salem, OR
1.0572Marion County, ORPolk County, OR41500
Salinas, CA
1.4775Monterey County, CA41540
Salisbury, MD
0.8994Somerset County, MDWicomico County, MD41620
Salt Lake City, UT
0.9399Salt Lake County, UTSummit County, UTTooele County, UT41660
San Angelo, TX
0.8579Irion County, TXTom Green County, TX41700
San Antonio, TX
0.8834Atascosa County, TXBandera County, TXBexar County, TXComal County, TXGuadalupe County, TXKendall County, TXMedina County, TXWilson County, TX41740
San Diego-Carlsbad-San Marcos, CA
1.1492San Diego County, CA41780
Sandusky, OH
0.8822Erie County, OH41884
San Francisco-San Mateo-Redwood City, CA
1.5195Marin County, CASan Francisco County, CASan Mateo County, CA41900
San Germán-Cabo Rojo, PR
0.4729Cabo Rojo Municipio, PRLajas Municipio, PRSabana Grande Municipio, PRSan Germán Municipio, PR41940
San Jose-Sunnyvale-Santa Clara, CA
1.5735San Benito County, CASanta Clara County, CA41980
San Juan-Caguas-Guaynabo, PR
0.4528Aguas Buenas Municipio, PR( print page 46410)Aibonito Municipio, PRArecibo Municipio, PRBarceloneta Municipio, PRBarranquitas Municipio, PRBayamón Municipio, PRCaguas Municipio, PRCamuy Municipio, PRCanóvanas Municipio, PRCarolina Municipio, PRCataño Municipio, PRCayey Municipio, PRCiales Municipio, PRCidra Municipio, PRComerío Municipio, PRCorozal Municipio, PRDorado Municipio, PRFlorida Municipio, PRGuaynabo Municipio, PRGurabo Municipio, PRHatillo Municipio, PRHumacao Municipio, PRJuncos Municipio, PRLas Piedras Municipio, PRLoíza Municipio, PRManatí Municipio, PRMaunabo Municipio, PRMorovis Municipio, PRNaguabo Municipio, PRNaranjito Municipio, PROrocovis Municipio, PRQuebradillas Municipio, PRRío Grande Municipio, PRSan Juan Municipio, PRSan Lorenzo Municipio, PRToa Alta Municipio, PRToa Baja Municipio, PRTrujillo Alto Municipio, PRVega Alta Municipio, PRVega Baja Municipio, PRYabucoa Municipio, PR42020
San Luis Obispo-Paso Robles, CA
1.2488San Luis Obispo County, CA42044
Santa Ana-Anaheim-Irvine, CA
1.1766Orange County, CA42060
Santa Barbara-Santa Maria-Goleta, CA
1.1714Santa Barbara County, CA42100
Santa Cruz-Watsonville, CA
1.6122Santa Cruz County, CA42140
Santa Fe, NM
1.0734Santa Fe County, NM42220
Santa Rosa-Petaluma, CA
1.4696Sonoma County, CA42260
Sarasota-Bradenton-Venice, FL
0.9933Manatee County, FLSarasota County, FL42340
Savannah, GA
0.9131Bryan County, GAChatham County, GAEffingham County, GA42540
Scranton—Wilkes-Barre, PA
0.8457Lackawanna County, PALuzerne County, PAWyoming County, PA42644
Seattle-Bellevue-Everett, WA
1.1572King County, WASnohomish County, WA42680
Sebastian-Vero Beach, FL
0.9412Indian River County, FL43100
Sheboygan, WI
0.8975Sheboygan County, WI43300
Sherman-Denison, TX
0.8320( print page 46411)Grayson County, TX43340
Shreveport-Bossier City, LA
0.8476Bossier Parish, LACaddo Parish, LADe Soto Parish, LA43580
Sioux City, IA-NE-SD
0.9251Woodbury County, IADakota County, NEDixon County, NEUnion County, SD43620
Sioux Falls, SD
0.9563Lincoln County, SDMcCook County, SDMinnehaha County, SDTurner County, SD43780
South Bend-Mishawaka, IN-MI
0.9617St. Joseph County, INCass County, MI43900
Spartanburg, SC
0.9422Spartanburg County, SC44060
Spokane, WA
1.0455Spokane County, WA44100
Springfield, IL
0.8944Menard County, ILSangamon County, IL44140
Springfield, MA
1.0366Franklin County, MAHampden County, MAHampshire County, MA44180
Springfield, MO
0.8695Christian County, MODallas County, MOGreene County, MOPolk County, MOWebster County, MO44220
Springfield, OH
0.8694Clark County, OH44300
State College, PA
0.8768Centre County, PA44700
Stockton, CA
1.1855San Joaquin County, CA44940
Sumter, SC
0.8599Sumter County, SC45060
Syracuse, NY
0.9910Madison County, NYOnondaga County, NYOswego County, NY45104
Tacoma, WA
1.1055Pierce County, WA45220
Tallahassee, FL
0.9025Gadsden County, FLJefferson County, FLLeon County, FLWakulla County, FL45300
Tampa-St. Petersburg-Clearwater, FL
0.9020Hernando County, FLHillsborough County, FLPasco County, FLPinellas County, FL45460
Terre Haute, IN
0.8805Clay County, INSullivan County, INVermillion County, INVigo County, IN45500
Texarkana, TX-Texarkana, AR
0.7770Miller County, ARBowie County, TX45780
Toledo, OH
0.9431Fulton County, OHLucas County, OHOttawa County, OH( print page 46412)Wood County, OH45820
Topeka, KS
0.8538Jackson County, KSJefferson County, KSOsage County, KSShawnee County, KSWabaunsee County, KS45940
Trenton-Ewing, NJ
1.0699Mercer County, NJ46060
Tucson, AZ
0.9245Pima County, AZ46140
Tulsa, OK
0.8340Creek County, OKOkmulgee County, OKOsage County, OKPawnee County, OKRogers County, OKTulsa County, OKWagoner County, OK46220
Tuscaloosa, AL
0.8303Greene County, ALHale County, ALTuscaloosa County, AL46340
Tyler, TX
0.9114Smith County, TX46540
Utica-Rome, NY
0.8486Herkimer County, NYOneida County, NY46660
Valdosta, GA
0.8098Brooks County, GAEchols County, GALanier County, GALowndes County, GA46700
Vallejo-Fairfield, CA
1.4666Solano County, CA47020
Victoria, TX
0.8302Calhoun County, TXGoliad County, TXVictoria County, TX47220
Vineland-Millville-Bridgeton, NJ
1.0133Cumberland County, NJ47260
Virginia Beach-Norfolk-Newport News, VA-NC
0.8818Currituck County, NCGloucester County, VAIsle of Wight County, VAJames City County, VAMathews County, VASurry County, VAYork County, VAChesapeake City, VAHampton City, VANewport News City, VANorfolk City, VAPoquoson City, VAPortsmouth City, VASuffolk City, VAVirginia Beach City, VAWilliamsburg City, VA47300
Visalia-Porterville, CA
1.0091Tulare County, CA47380
Waco, TX
0.8518McLennan County, TX47580
Warner Robins, GA
0.9128Houston County, GA47644
Warren-Troy-Farmington Hills, MI
1.0001Lapeer County, MILivingston County, MIMacomb County, MIOakland County, MISt. Clair County, MI47894
Washington-Arlington-Alexandria, DC-VA-MD-WV
1.0855( print page 46413)District of Columbia, DCCalvert County, MDCharles County, MDPrince George's County, MDArlington County, VAClarke County, VAFairfax County, VAFauquier County, VALoudoun County, VAPrince William County, VASpotsylvania County, VAStafford County, VAWarren County, VAAlexandria City, VAFairfax City, VAFalls Church City, VAFredericksburg City, VAManassas City, VAManassas Park City, VAJefferson County, WV47940
Waterloo-Cedar Falls, IA
0.8519Black Hawk County, IABremer County, IAGrundy County, IA48140
Wausau, WI
0.9679Marathon County, WI48260
Weirton-Steubenville, WV-OH
0.7924Jefferson County, OHBrooke County, WVHancock County, WV48300
Wenatchee, WA
1.1469Chelan County, WADouglas County, WA48424
West Palm Beach-Boca Raton-Boynton Beach, FL
0.9728Palm Beach County, FL48540
Wheeling, WV-OH
0.6961Belmont County, OHMarshall County, WVOhio County, WV48620
Wichita, KS
0.9062Butler County, KSHarvey County, KSSedgwick County, KSSumner County, KS48660
Wichita Falls, TX
0.7920Archer County, TXClay County, TXWichita County, TX48700
Williamsport, PA
0.8043Lycoming County, PA48864
Wilmington, DE-MD-NJ
1.0824New Castle County, DECecil County, MDSalem County, NJ48900
Wilmington, NC
0.9410Brunswick County, NCNew Hanover County, NCPender County, NC49020
Winchester, VA-WV
0.9913Frederick County, VAWinchester City, VAHampshire County, WV49180
Winston-Salem, NC
0.9118Davie County, NCForsyth County, NCStokes County, NCYadkin County, NC49340
Worcester, MA
1.1287Worcester County, MA49420
Yakima, WA
1.0267Yakima County, WA( print page 46414)49500
Yauco, PR
0.3284Guánica Municipio, PRGuayanilla Municipio, PRPeñuelas Municipio, PRYauco Municipio, PR49620
York-Hanover, PA
0.9359York County, PA49660
Youngstown-Warren-Boardman, OH-PA
0.9002Mahoning County, OHTrumbull County, OHMercer County, PA49700
Yuba City, CA
1.0756Sutter County, CAYuba County, CA49740
Yuma, AZ
0.9488Yuma County, AZ1
                             At this time, there are no hospitals located in this urban area on which to base a wage index.
 Table 2—Inpatient Rehabilitation Facility Wage Index for Rural Areas for Discharges Occurring From October 1, 2008 Through September 30, 2009
CBSA code
Nonurban area
Wage index1
Alabama
0.75332
Alaska
1.21093
Arizona
0.84794
Arkansas
0.73715
California
1.20236
Colorado
0.97047
Connecticut
1.11198
Delaware
0.972710
Florida
0.846511
Georgia
0.765912
Hawaii
1.061213
Idaho
0.792014
Illinois
0.833515
Indiana
0.857616
Iowa
0.856617
Kansas
0.798118
Kentucky
0.779319
Louisiana
0.737320
Maine
0.847621
Maryland
0.903422
Massachusetts 1
1.158923
Michigan
0.895324
Minnesota
0.907925
Mississippi
0.770026
Missouri
0.793027
Montana
0.837928
Nebraska
0.884929
Nevada
0.927230
New Hampshire
0.047031
New Jersey 1
—32
New Mexico
0.894033
New York
0.826834
North Carolina
0.860335
North Dakota
0.718236
Ohio
0.871437
Oklahoma
0.749238
Oregon
0.990639
Pennsylvania
0.838540
Puerto Rico 1
0.404741
Rhode Island 1
—42
South Carolina
0.865643
South Dakota
0.854944
Tennessee
0.772345
Texas
0.796846
Utah
0.811647
Vermont
0.991948
Virgin Islands
0.683049
Virginia
0.789650
Washington
1.025951
West Virginia
0.745452
Wisconsin
0.966753
Wyoming
0.928765
Guam
0.96111
                             All counties within the State are classified as urban, with the exception of Massachusetts and Puerto Rico. Massachusetts and Puerto Rico have areas designated as rural; however, no short-term, acute care hospitals are located in the area(s) for FY 2009. The rural Massachusetts wage index is calculated as the average of all contiguous CBSAs. The Puerto Rico wage index is the same as FY 2008.


[FR Doc. E8-17797 Filed 7-31-08; 4:15 pm] BILLING CODE 4120-01-P