Medicare Program; Schedule of Prospectively Determined Payment Rates for Skilled Nursing Facility Inpatient Routine Service Costs

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

[BPD-842-NC]

RIN 0938-AH70

Medicare Program; Schedule of Prospectively Determined Payment

Rates for Skilled Nursing Facility Inpatient Routine Service Costs

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Final notice with comment period.

-----------------------------------------------------------------------

SUMMARY: This final notice with comment period sets forth the schedule

of payment rates for low Medicare volume skilled nursing facilities for

prospective payments for routine service costs for Federal fiscal year

1997 (cost reporting periods beginning on or after October 1, 1996 and

before October 1, 1997). Section 1888(d) of the Social Security Act

requires the Secretary to establish and publish the prospectively

determined payment rates 90 days prior to the beginning of the affected

Federal fiscal year.

DATES: Effective date: The schedule of payment rates is effective for

cost reporting periods beginning on or after October 1, 1996.

Comment date: Written comments will be considered if we receive

them at the appropriate address, as provided below, no later than 5:00

p.m. on November 4, 1996.

ADDRESSES: Mail written comments (an original and three copies) to the

following address: Health Care Financing Administration, Department of

Health and Human Services, Attention: BPD-842-NC, P.O. Box 7517,

Baltimore, MD 21244-0517.

If you prefer, you may deliver your written comments (an original

and three copies) to one of the following addresses: Room 309-G, Hubert

H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC

20201, or C5-09-26, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Comments may also be submitted electronically to the following e-

mail address: [email protected] E-mail comments must include the

full name and address of the sender and must be submitted to the

referenced address in order to be considered. All comments must be

incorporated in the e-mail message because we may not be able to access

attachments. Electronically submitted comments will be available for

public inspection at the Independence Avenue address, below.

Because of staffing and resource limitations, we cannot accept

comments by facsimile (FAX) transmission. In

[[Page 46467]]

commenting, please refer to file code BPD-842-NC. Comments received

timely will be available for public inspection as they are received,

generally beginning approximately 3 weeks after publication of a

document, in Room 309-G of the Department's offices at 200 Independence

Avenue, SW, Washington, DC, on Monday through Friday of each week from

8:30 a.m. to 5 p.m. (phone: (202) 690-7890).

Copies: To order copies of the Federal Register containing this

document, send your request to: New Orders, Superintendent of

Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date

of the issue requested and enclose a check or money order payable to

the Superintendent of Documents, or enclose your Visa or Master Card

number and expiration date. Credit card orders can also be placed by

calling the order desk at (202) 512-1800 or by faxing to (202) 512-

2250. The cost for each copy is $8.00. As an alternative, you can view

and photocopy the Federal Register document at most libraries

designated as Federal Depository Libraries and at many other public and

academic libraries throughout the country that receive the Federal

Register.

FOR FURTHER INFORMATION CONTACT: Joseph Menning (410) 786-4594.

SUPPLEMENTARY INFORMATION:

I. Background

Section 1888 of the Social Security Act (the Act) sets forth the

statutory requirements concerning Medicare payments to skilled nursing

facilities (SNFs) for their routine service costs for services

furnished to Medicare beneficiaries. Most SNFs are paid on a reasonable

cost basis up to a schedule of routine service per diem cost limits

established in accordance with the general reasonable cost provisions

of section 1861(v)(1) of the Act and the specific SNF payment

provisions of section 1888 of the Act. However, under the provision at

section 1888(d) of the Act, for cost reporting periods beginning on or

after October 1, 1986, a SNF with fewer than 1,500 Medicare covered

days in a given cost reporting period may choose to receive payment

based on a prospectively determined payment rate in the subsequent cost

reporting period. The prospectively determined payment rates for low

Medicare volume SNFs are established on a per diem basis and include

payment for the cost of furnishing general inpatient routine services

and capital-related costs associated with routine services.

The per diem amounts may not exceed the limit on routine service

costs set forth in section 1888(a) of the Act with respect to the

facility, adjusted to take into account average capital-related costs

with respect to the type and location of the facility. The limit used

for this purpose is the applicable routine service cost limit in effect

when the provider elects to be paid under the prospectively determined

payment rates.

For SNFs located in an urban area, the prospectively determined

payment amount is equal to 105 percent of the mean of the per diem

reasonable routine service and routine capital-related costs of

services for SNFs in urban areas within the same census region. The

mean per diem is determined without regard to the limitations of

section 1888(a) of the Act and is adjusted for different area wage

levels.

For SNFs located in a rural area, the prospectively determined

payment amount is equal to 105 percent of the mean of the per diem

reasonable routine service and routine capital-related costs of covered

services for SNFs in rural areas within the same census region. The

mean per diem is determined without regard to the limitations of

section 1888(a) of the Act and is adjusted for different area wage

levels.

Prior to the enactment of the Omnibus Budget Reconciliation Act of

1993 (OBRA 1993; Public Law 103-66), we published guidelines specifying

the methodology and data used and the actual prospectively determined

payment rates annually in the Medicare Provider Reimbursement Manual

(HCFA Pub. 15-1). The general requirements for the rates were included

under sections 2820 and 2821 of the manual and the actual rates, the

most recent effective for Federal fiscal year 1993, were in section

2828 of the manual.

Section 13503(b) of OBRA 1993 prohibited changes to the Federal

fiscal year 1993 prospectively determined payment rates paid under

section 1888(d) of the Act for services furnished during cost reporting

periods beginning in Federal fiscal year 1994 and in Federal fiscal

year 1995, except as may be necessary to take into account the

amendments made by section 13503(c). Section 13503(c) of OBRA 1993

amended sections 1861(v)(1)(B) and 1878(f)(2) of the Act by eliminating

return on owner's equity for services furnished on or after October 1,

1993.

On July 21, 1995, we published in the Federal Register a final rule

(60 FR 37590) that codified in the Code of Federal Regulations the

statutory requirements for the optional prospectively determined

payment system for low Medicare volume SNFs and the guidelines on the

methodology and data used that were in the Provider Reimbursement

Manual. These implementing regulations, effective on August 21, 1995,

appear at 42 CFR 413.1, 413.24 and 413.300 through 413.321.

Under the provisions of Sec. 413.312(a)(1), to calculate the

prospectively determined payment rates, we use the SNF cost data that

were used to develop the applicable SNF inpatient routine service cost

limits, a wage index to adjust for area wage differences, and the most

recent projections of increases in the costs from the SNF market basket

(inflation factors). Section 413.312(a)(2) provides that we will

announce in the Federal Register the wage index and the annual

percentage increases in the market basket used in the calculation of

the rates. In addition, Sec. 413.320 provides that at least 90 days

before the beginning of a Federal fiscal year to which revised

prospectively determined payment rates are to be applied, HCFA will

publish a notice in the Federal Register establishing the rates for

routine services and explaining the basis on which the rates are

calculated.

This notice announces the schedule of payment rates for prospective

payments for routine service costs in Federal fiscal year 1997 (cost

reporting periods beginning on or after October 1, 1996 and before

October 1, 1997) for low Medicare volume SNFs that elect this method of

payment. This notice represents the first schedule of prospectively

determined payment rates published in a Federal Register notice after

the effective date of the July 1995 implementing regulations. In

addition, this notice includes the inflation factors to update the

routine service cost limits applicable for Federal fiscal year 1997,

which are necessary to compute a SNF's prospectively determined payment

rate.

II. Update of the Schedule of Prospectively Determined Payment Rates

As mentioned earlier, the statute provided that both the SNF

routine service cost limits and the prospectively determined payment

rates be frozen at the Federal fiscal year 1993 amounts for cost

reporting periods beginning in Federal fiscal year 1994 and in Federal

fiscal year 1995. As a result of these rates and limits remaining at

the Federal fiscal year 1993 levels, the Medicare program experienced a

savings in Medicare trust funds. We had anticipated that, because of

these prior years' savings, we would have legislative support to

preserve these program savings for Federal fiscal year 1996 and later.

We expected to do this

[[Page 46468]]

by trending the Federal fiscal year 1993 limits and rates to cost

reporting periods beginning in Federal fiscal year 1996, except that

the inflation factors for Federal fiscal year 1994 and Federal fiscal

year 1995 would not be included. However, such legislation has not been

enacted. Therefore, in the interim for Federal fiscal year 1996, we

provided the Medicare intermediaries with updated Federal fiscal year

1996 limits and rates by trending the Federal fiscal 1993 data to

Federal fiscal 1996 by using the projected inflation factors and the

methodology described in the October 7, 1992 Federal Register notice

(57 FR 46177) that announced the Federal fiscal year 1993 limits

(including the inflation factors for Federal fiscal years 1994 and

1995).

In addition, in May 1996, we provided all Medicare intermediaries

with revisions to the Federal fiscal year 1993 cost limits and

prospectively determined payment rates that reflected corrections to

the projected inflation factors used in the October 7, 1992 notice. (An

explanation of the circumstances under which HCFA corrects projected

inflation factors is in the October 7, 1992 notice (57 FR 46179 through

46180).) These revised Federal fiscal year 1993 limits and rates were

also used to compute updated limits and rates for cost reporting

periods beginning in Federal fiscal year 1996. However, these revisions

did not affect prospectively determined payment rates issued before the

May 1996 notification to the intermediaries.

In developing the prospectively determined payment rates effective

with this notice, we are using the basic methodology and cost report

data specified in Sec. 413.312 of the regulations (and described in

section 2828 of the Provider Reimbursement Manual). We will continue to

use the same wage indexes and the same urban and rural designations

used to compute the Federal fiscal year 1993 cost limits and

prospectively determined rates, as specified in the October 7, 1992

Federal Register notice and described in section 2828 of the Provider

Reimbursement Manual, respectively. In addition, we will continue to

provide a per diem add-on to the prospectively determined payment rates

to account for costs incurred by SNFs in complying with the nursing

home reform provisions specified in section 1819 of the Act (enacted by

OBRA 1987), including the costs of conducting nurse aide training and

competency evaluations, and for costs associated with the Occupational

Safety and Health Administration (OSHA) universal precaution

requirements.

Tables I and II under section IV. of this notice contain the

Federal fiscal year 1997 prospectively determined payment rates. Table

III under section IV. of this notice contains the Federal fiscal year

1997 routine service cost limits. Table IV under section IV. of this

notice contains the monthly inflation factors to be applied to full 12

month cost reporting periods beginning in Federal fiscal year 1997.

III. Methodology for Determining Prospectively Determined Per Diem

Payment Rates

The schedule of rates set forth in Tables I and II under section

IV. of this notice applies to all SNFs that qualify and request to

receive the optional prospective payment rate for routine services

under the provisions of subpart I of part 413. Under Sec. 413.314(d), a

SNF's prospective payment rate, excluding capital-related costs, cannot

exceed its actual routine service cost limit (without regard to

exceptions, exemptions, or retroactive adjustments) in effect at the

time of the election to be paid a prospectively determined payment

rate. The prospectively determined payment rate is in place of payment

that would otherwise be made for routine service costs and associated

capital-related costs under section 1861(v) of the Act. There are no

retroactive adjustments to these rates and under Sec. 413.308(c), an

SNF may not revoke its request to be paid under this provision after it

has received the initial determination of eligibility from the

intermediary and the cost reporting period has begun.

A. Data

The actual cost data used to develop the prospectively determined

payment rates for cost reporting periods beginning in FY 1993 were

obtained from settled freestanding SNF Medicare cost reports for

periods ending on or after June 30, 1989, and through May 31, 1990.

Comparable data for hospital-based SNFs were obtained from settled

Medicare cost reports for periods ending on or after October 31, 1988,

and through September 30, 1989. We are continuing to use the same cost

report data to develop the prospectively determined payment rates in

this notice.

B. Use of the Most Recent Available Inflation Factors

We are continuing to use the SNF input price market basket index

(inflation factor) to adjust the cost report data to the initial cost

reporting period to which the prospectively determined payment rates

apply. The inflation factors are comprised of a ``market basket'' of

the most commonly used categories of SNF routine service expenses. The

categories used are based primarily on those used in the National

Center for Health Statistics in its National Nursing Home Surveys. The

categories are weighted according to the estimated proportion of SNF

routine service cost attributable to each category. The Appendix to

this notice specifies the weights used in each category.

We are adjusting the cost report data described above using the

most recent available inflation factors shown below. These inflation

factors are similar to those used in the May 1996 notification to the

intermediaries described in section II. of this notice. These inflation

factors, representing the annual percentage increases in the market

basket over the previous year, are:

1988................................................................5.1

1989................................................................6.6

1990................................................................6.3

1991................................................................4.4

1992................................................................3.8

1993................................................................3.7

1994................................................................3.4

1995................................................................2.9

1996................................................................2.9

1997................................................................3.2

1998................................................................3.4

If a facility has a cost reporting period beginning in a month

after October 1, 1996, the intermediary increases the adjusted routine

operating portion of the rate that otherwise apply to the SNF by the

factor from Table IV of this notice that corresponds to the month and

year in which the cost reporting period begins. Each factor represents

the compounded monthly increase derived from the annual increase in the

market basket index and is used to account for inflation in costs that

occur after the date on which the prospective payment rates are

effective.

If a facility uses a cost reporting period that is not 12 months in

duration, a special adjustment factor will be calculated. This is

necessary because market basket increases are computed to the midpoint

of a cost reporting period and the adjustment factors in Table IV of

this notice are based on an assumed 12-month cost reporting period. For

cost reporting periods of other than 12 months, the calculation is done

for the midpoint of the specific cost reporting period. The SNF's

intermediary obtains this adjustment factor from HCFA central office.

C. Use of Wage Index to Adjust Labor-Related Cost

We are continuing to use the hospital industry wage index to

account for area

[[Page 46469]]

wage differences. We are continuing to apply the wage index to five

categories of labor-related costs: wages, employee benefits, health

service costs, business service costs, and other miscellaneous costs.

The portion of labor-related costs remains at the level of 83.1

percent. In addition, the same wage index values and urban/rural

designations, as shown in Tables V and VI of this notice, are to be

applied to the labor-related portion of the prospectively determined

payment rates in this notice. (These are the same wage index values and

urban/rural designations shown in the October 7, 1992 cost limit notice

and section 2828 of the Provider Reimbursement Manual.)

D. Use of Classification System

We will retain the classification system based on grouping SNFs by

census regions and by urban or rural area designation within the

region. As required by sections 1888(d)(3) and 1886(d)(2)(D) of the

Act, the term ``region'' means one of the nine census divisions,

comprising the fifty States and the District of Columbia, established

by the Bureau of Census for statistical and reporting purposes. The

term ``urban area'' means an area within a Metropolitan Statistical

Area (MSA) (as defined by the Office of Management and Budget (OMB),

with exceptions for certain New England County Metropolitan Areas

(NECMAs), as described in a notice published in the Federal Register on

April 1, 1991 (56 FR 13319)). The term ``rural area'' means an area

outside of an MSA.

E. Use of OBRA 1987 and OSHA Per Diem Add-on

Section 1861(v)(1)(E) of the Act provides for payment for costs

incurred by SNFs in complying with the nursing home reform provisions

specified in section 1819 of the Act, including the costs of conducting

nurse aide training and competency evaluations (referred to as the OBRA

1987 nursing home reform). Since the cost report data used in this

notice does not account for the costs of implementing the OBRA 1987

nursing home reform provisions, we will continue to provide a per diem

add-on for these costs. In addition, we will continue to provide a per

diem add-on for the costs associated with the Occupational Safety and

Health Administration (OSHA) universal precaution requirements. A

detailed description of the derivation of the per diem add-on is

contained in section 2828 of the Provider Reimbursement Manual. The

amount of the OBRA/OSHA per diem add-on to determine prospectively

determined payment rates for cost reporting periods beginning in

Federal fiscal year 1997 is $2.06. (For cost limit purposes, the per

diem add-on is $2.20 for Federal fiscal year 1997.)

F. Comparison of Provider's Prospective Payment Rate with Provider's

Cost Limit

Below is an example of the calculation of the prospectively

determined payment rate for a provider including the comparison of the

adjusted routine operating portion of the rate with the applicable

routine operating cost limit applicable to the specific provider. The

capital-related component of the rate is added to the lower of the

SNF's specific cost limit or its adjusted routine operating portion of

the rate to arrive at the provider's actual prospectively determined

payment rate.

Example: In this case, the adjusted cost limit is less than the

adjusted routine operating portion of the rate for a freestanding SNF

located in Providence, Rhode Island (MSA Region 1), with a cost

reporting period beginning January 1, 1997. Therefore, the

prospectively determined payment rate for this SNF is the adjusted cost

limit plus the capital-related component of the rate ($126.12).

----------------------------------------------------------------------------------------------------------------

Labor- Non-labor Capital-

related related related

component component component

----------------------------------------------------------------------------------------------------------------

Limit (From Table III)................................................... $88.45 $18.99 ...........

Rate (From Table I)...................................................... $116.46 $22.21 $10.00

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Calculation of Prospective Payment Rate

----------------------------------------------------------------------------------------------------------------

Limit Rate Rate source

----------------------------------------------------------------------------------------------------------------

Labor-Related Component............................. $88.45 $116.46 (Table I).

Wage Index.......................................... x 1.0630 x 1.0630 (Table V).

Adjusted Labor Component............................ $94.02 $123.80 --

Non-Labor Component................................. $18.99 22.21 (Table I).

OBRA/OSHA Per Diem Add-on........................... +$2.20 +$2.06 (Sec III.E).

Adjusted Limit/Rate................................. $115.21 $148.07 --

Cost Reporting Year Adjustment Factor............... x 1.00796 x 1.00796 (Table IV).

Applicable Limit and Operating Rate Portion......... $116.12 $149.25 --

Capital-Related Component........................... +10.00 -- (Table I).

Prospectively Determined Payment Rate............... $126.12 -- --

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Table I.--Prospective Rates--MSA Locations, Effective for Cost Reporting Periods Beginning in FY 1997

----------------------------------------------------------------------------------------------------------------

Labor- Nonlabor- Capital-

Region \1\ related related related

----------------------------------------------------------------------------------------------------------------

1. New England (CT, ME, MA, NH, RI, VT).................................. $116.46 $22.21 $10.00

2. Middle Atlantic (PA, NJ, NY).......................................... 112.33 20.30 9.79

3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)................... 100.69 16.19 9.81

4. East North Central (IL, IN, MI, OH, WI)............................... 95.68 15.90 9.18

5. East South Central (AL, KY, MS, TN)................................... 96.25 14.16 7.32

6. West North Central (IA, KS, MN, MO, NB, ND, SD)....................... 102.64 17.05 10.23

7. West South Central (AR, LA, OK, TX)................................... 89.81 14.03 10.06

[[Page 46470]]

8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............................. 106.86 18.25 13.04

9. Pacific (AK, CA, HI, OR, WA).......................................... 97.24 19.93 8.40

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\1\ There are 16 MSAs that have counties in two or more regions. For each of these MSAs, the region in which a

majority of the SNFs are located determines the regional rate that is paid as shown below. This is the same

methodology as that used to implement the requirements of section 1886(d)(2)(D) of the Act as they apply to

the hospital prospective payment.

The MSAs are as follows:

------------------------------------------------------------------------

MSA Region

------------------------------------------------------------------------

Chattanooga, TN-GA............................................ 5

Cincinnati, OH-KY-IN.......................................... 4

Columbus, GA-AL............................................... 3

Davenport-Rock Island-Moline, IA-IL........................... 4

Duluth-Superior, MN-WI........................................ 6

Evansville-Henderson, IN-KY................................... 4

Huntington-Ashland, WV-KY-OH.................................. 3

Johnson City-Kingsport-Bristol, TN-VA......................... 5

Louisville, KY-IN............................................. 5

Memphis, TN-AR-MS............................................. 5

Minneapolis-St. Paul, MN-WI................................... 6

Parkersburg-Marietta, WV-OH................................... 3

St. Louis, MO-IL.............................................. 6

Steubenville-Weirton, OH-WV................................... 4

Wheeling, WV-OH............................................... 3

Wilmington-Newark, DE-NJ-MD................................... 3

------------------------------------------------------------------------

Table II.--Prospective Rates--Non-MSA Locations Effective for Cost Reporting Periods Beginning in FY 1997

----------------------------------------------------------------------------------------------------------------

Labor- Nonlabor- Capital-

Region related related related

----------------------------------------------------------------------------------------------------------------

1. New England (CT, ME, MA, NH, RI, VT).................................. $125.72 $20.96 $10.58

2. Middle Atlantic (PA, NJ, NY).......................................... 117.44 16.86 7.94

3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)................... 111.02 15.09 9.19

4. East North Central (IL, IN, MI, OH, WI)............................... 104.72 14.62 8.28

5. East South Central (AL, KY, MS, TN)................................... 105.49 13.28 6.77

6. West North Central (IA, KS, MN, MO, NB, ND, SD)....................... 108.01 14.37 6.66

7. West South Central (AR, LA, OK, TX)................................... 102.51 13.03 9.22

8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............................. 107.03 15.69 8.36

9. Pacific (AK, CA, HI, OR, WA).......................................... 119.77 20.11 10.16

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Table III.--Routine Service Cost Limits in Effect for Cost Reporting Periods Beginning in Federal Fiscal Year

1997

----------------------------------------------------------------------------------------------------------------

Labor- Non-labor-

Provider type/location related related OBRA/OSHA

component component add-ons

----------------------------------------------------------------------------------------------------------------

Freestanding: ........... ........... $2.20

MSA.................................................................. $88.45 $18.99

Non-MSA.............................................................. 89.81 15.16

Hospital based: ........... ........... 2.20

MSA limit............................................................ 124.76 26.45

Non-MSA limit........................................................ 114.31 19.01

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[[Page 46471]]

Table IV.--Cost Reporting Year Adjustment Factors \1\ Effective for Cost

Reporting Periods Beginning in FY 1997

------------------------------------------------------------------------

The

If an SNF cost reporting period begins: adjustment

factor is:

------------------------------------------------------------------------

November 1, 1996............................................ 1.00268

December 1, 1996............................................ 1.00528

January 1, 1997............................................. 1.00796

February 1, 1997............................................ 1.01083

March 1, 1997............................................... 1.01343

April 1, 1997............................................... 1.01631

May 1, 1997................................................. 1.01910

June 1, 1997................................................ 1.02200

July 1, 1997................................................ 1.02481

August 1, 1997.............................................. 1.02773

September 1, 1997........................................... 1.03066

------------------------------------------------------------------------

\1\ Based on compounded actual market basket inflation rates of 3.70

percent for 1993, 3.40 percent for 1994 and projected rates of 2.90

percent for 1995, 2.90 percent for 1996, 3.20 percent for 1997, and

3.40 percent for 1998.

Table V--Wage Index for Urban Areas

------------------------------------------------------------------------

Wage

Urban area (constituent counties or county equivalents) index

------------------------------------------------------------------------

Abilene TX................................................... 0.9220

Taylor, TX

Aguadilla, PR................................................ 0.4568

Aguada, PR

Aguadilla, PR

Isabella, PR

Moca, PR

Akron, OH.................................................... 0.9493

Portage, OH

Summit, OH

Albany, GA................................................... 0.8050

Dougherty, GA

Lee, GA

Albany-Schenectady-Troy, NY.................................. 0.8922

Albany, NY

Greene, NY

Montgomery, NY

Rensselaer, NY

Saratoga, NY

Schenectady, NY

Albuquerque, NM.............................................. 1.0123

Bernalillo, NM

Alexandria, LA............................................... 0.8275

Rapides, LA

Allentown-Bethlehem, PA-NJ................................... 0.9857

Warren, NJ

Carbon, PA

Lehigh, PA

Northampton, PA

Altoona, PA.................................................. 0.9238

Blair, PA

Amarillo, TX................................................. 0.8739

Potter, TX

Randall, TX

Anaheim-Santa Ana, CA........................................ 1.2130

Orange, CA

Anchorage, AK................................................ 1.4176

Anchorage, AK

Anderson, IN................................................. 0.9583

Madison, IN

Anderson, SC................................................. 0.7258

Anderson, SC

Ann Arbor, MI................................................ 1.1384

Washtenaw, MI

Anniston, AL................................................. 0.7931

Calhoun, AL

Appleton-Oshkosh-Neenah, WI.................................. 0.9179

Calumet, WI

Outagamie, WI

Winnebago, WI

Arecibo, PR.................................................. 0.3953

Arecibo, PR

Camuy, PR

Hatillo, PR

Quebradillas, PR

Asheville, NC................................................ 0.8739

Buncombe, NC

Athens, GA................................................... 0.8209

Clarke, GA

Jackson, GA

Madison, GA

Oconee, GA

Atlanta, GA.................................................. 0.9596

Barrow, GA

Butts, GA

Cherokee, GA

Clayton, GA

Cobb, GA

Coweta, GA

De Kalb, GA

Douglas, GA

Fayette, GA

Forsyth, GA

Fulton, GA

Gwinnett, GA

Henry, GA

Newton, GA

Paulding, GA

Rockdale, GA

Spalding, GA

Walton, GA

Atlantic City, NJ............................................ 1.0507

Atlantic City , NJ

Cape May, NJ

Augusta, GA-SC............................................... 0.9401

Columbia, GA

McDuffie, GA

Richmond, GA

Aiken, SC

Aurora-Elgin, IL............................................. 0.9665

Kane, IL

Kendall, IL

Austin, TX................................................... 0.9599

Hays, TX

Travis, TX

Williamson, TX

Bakersfield, CA.............................................. 1.0868

Kern, CA

Baltimore, MD................................................ 1.0156

Anne Arundel, MD

Baltimore, MD

Baltimore City, MD

Carroll, MD

Harford, MD

Howard, MD

Queen Annes, MD

Bangor, ME................................................... 0.9064

Penobscot, ME

Baton Rouge, LA.............................................. 0.9089

Ascension, LA

East Baton Rouge, LA

Livingston, LA

West Baton Rouge, LA

Battle Creek, MI............................................. 0.9465

Calhoun, MI

Beaumont-Port Arthur, TX..................................... 0.9604

Hardin, TX

Jefferson, TX

Orange, TX

Beaver County, PA............................................ 1.0165

Beaver, PA

Bellingham, WA............................................... 1.0497

Whatcom, WA

Benton Harbor, MI............................................ 0.8406

Berrien, MI

Bergen-Passaic, NJ........................................... 1.0295

Bergen, NJ

Passaic, NJ

Billings, MT................................................. 0.9325

Yellowstone, MT

Biloxi-Gulfport, MS.......................................... 0.8062

Hancock, MS

Harrison, MS

Binghamton, NY............................................... 0.9260

Broome, NY

Tioga, NY

Birmingham, AL............................................... 0.8769

Blount, AL

Jefferson, AL

Saint Clair, AL

Shelby, AL

Walker, AL

Bismarck, ND................................................. 0.8812

Burleigh, ND

Morton, ND

Bloomington, IN.............................................. 0.8639

Monroe, IN

Bloomington-Normal, IL....................................... 0.8658

McLean, IL

Boise City, ID............................................... 0.9757

Ada, ID

Boston-Lawrence-Salem-Lowell-Brockton, MA.................... 1.1809

Essex, MA

Middlesex, MA

Norfolk, MA

Plymouth, MA

Suffolk, MA

Boulder-Longmont, CO......................................... 1.0149

Boulder, CO

Bradenton, FL................................................ 0.9262

Manatee, FL

Brazoria, TX................................................. 0.9314

Brazoria, TX

Bremerton, WA................................................ 0.9535

Kitsap, WA

Bridgeport-Stamford-Norwalk-Danbury.......................... 1.2032

Fairfield, CT

Brownsville-Harlingen, TX.................................... 0.8601

Cameron, TX

Bryan-College Station, TX.................................... 0.9489

Brazos, TX

Buffalo, NY.................................................. 0.8908

Erie, NY

Burlington, NC............................................... 0.7986

Alamance, NC

Burlington, VT............................................... 0.9358

[[Page 46472]]

Chittenden, VT

Grand Isle, VT

Caguas, PR................................................... 0.4479

Caguas, PR

Gurabo, PR

San Lorenz, PR

Aguas Buenas, PR

Cayey, PR

Cidra, PR

Canton, OH................................................... 0.8811

Carroll, OH

Stark, OH

Casper, WY................................................... 0.8891

Natrona, WY

Cedar Rapids, IA............................................. 0.8907

Linn, IA

Champaign-Urbana-Rantoul, IL................................. 0.8745

Champaign, IL

Charleston, SC............................................... 0.8331

Berkeley, SC

Charleston, SC

Dorchester, SC

Charleston, WV............................................... 0.9692

Kanawha, WV

Putnam, WV

Charlotte-Gastonia-Rock Hill, NC-SC.......................... 0.9486

Cabarrus, NC

Gaston, NC

Lincoln, NC

Mecklenburg, NC

Rowan, NC

Union, NC

York, SC

Charlottesville, VA.......................................... 0.9615

Albermarle, VA

Charlottesville City, VA

Fluvanna, VA

Greene, VA

Chattanooga, TN-GA........................................... 0.9198

Catoosa, GA

Dade, GA

Walker, GA

Hamilton, TN

Marion, TN

Sequatchie, TN

Cheyenne, WY................................................. 0.7908

Laramie, WY

Chicago, IL.................................................. 1.0518

Cook, IL

Du Page, IL

McHenry, IL

Chico, CA.................................................... 1.0981

Butte, CA

Cincinnati, OH-KY-IN......................................... 0.9821

Dearborn, IN

Boone, KY

Campbell, KY

Kenton, KY

Clermont, OH

Hamilton, OH

Warren, OH

Clarksville-Hopkinsville, TN-KY.............................. 0.7319

Christian, KY

Montgomery, TN

Cleveland, OH................................................ 1.0739

Cuyahoga, OH

Geauga, OH

Lake, OH

Medina, OH

Colorado Springs, CO......................................... 0.9816

El Paso, CO

Columbia, MO................................................. 0.9506

Boone, MO

Columbia, SC................................................. 0.8940

Lexington, SC

Richland, SC

Columbus, GA-AL.............................................. 0.7482

Russell, AL

Chattanoochee, GA

Muscogee, GA

Columbus, OH................................................. 0.9673

Delaware, OH

Fairfield, OH

Franklin, OH

Licking, OH

Madison, OH

Pickaway, OH

Union, OH

Corpus Christi, TX........................................... 0.8594

Nueces, TX

San Patricio, TX

Cumberland, MD-WV............................................ 0.8188

Allegany, MD

Mineral, WV

Dallas, TX................................................... 0.9638

Collin, TX

Dallas, TX

Denton, TX

Ellis, TX

Kaufman, TX

Rockwall, TX

Danville, VA................................................. 0.7506

Danville City, VA

Pittsylvania, VA

Davenport-Rock Island-Moline, IA-IL.......................... 0.8471

Scott, IA

Henry, IL

Rock Island, IL

Dayton-Springfield, OH....................................... 0.9664

Clark, OH

Greene, OH

Miami, OH

Montgomery, OH

Daytona Beach, FL............................................ 0.8943

Volusia, FL

Decatur, AL.................................................. 0.7487

Lawrence, AL

Morgan, AL

Decatur, IL.................................................. 0.8286

Macon, IL

Denver, CO................................................... 1.0758

Adams, CO

Arapahoe, CO

Denver, CO

Douglas, CO

Jefferson, CO

Des Moines, IA............................................... 0.9171

Dallas, IA

Polk, IA

Warren, IA

Detroit, MI.................................................. 1.0824

Lapeer, MI

Livingston, MI

Macomb, MI

Monroe, MI

Oakland, MI

Saint Clair, MI

Wayne, MI

Dothan, AL................................................... 0.7555

Dale, AL

Houston, AL

Dubuque, IA.................................................. 0.8374

Dubuque, IA

Duluth, MN-WI................................................ 0.9517

St. Louis, MN

Douglas, WI

Eau Claire, WI............................................... 0.8478

Chippewa, WI

Eau Claire, WI

El Paso, TX.................................................. 0.8714

El Paso, TX

Elkhart-Goshen, IN........................................... 0.8949

Elkhart, IN

Elmira, NY................................................... 0.8810

Chemung, NY

Enid, OK..................................................... 0.8912

Garfield, OK

Erie, PA..................................................... 0.9155

Erie, PA

Eugene-Springfield, OR....................................... 1.0164

Lane, OR

Evansville, IN-KY............................................ 0.9276

Posey, IN

Vanderburgh, IN

Warrick, IN

Henderson, KY

Fargo-Moorhead, ND-MN........................................ 0.9707

Clay, MN

Cass, ND

Fayetteville, NC............................................. 0.8296

Cumberland, NC

Fayetteville-Springdale, AR.................................. 0.7990

Washington, AR

Flint, MI.................................................... 1.1544

Genesee, MI

Florence, AL................................................. 0.7679

Colbert, AL

Lauderdale, AL

Florence, SC................................................. 0.8429

Florence, SC

Fort Collins-Loveland, CO.................................... 1.0238

Larimor, CO

Ft Lauderdale-Hollywood-Pompano Beach, FL.................... 1.0356

Broward, FL

Fort Myers-Cape Coral, FL.................................... 0.9799

Lee, FL

Fort Pierce, FL.............................................. 1.1041

Martin, FL

St. Lucie, FL

Fort Smith, AR-OK............................................ 0.7931

Crawford, AR

Sebastian, AR

Sequoyah, OK

Fort Walton Beach, FL........................................ 0.8916

Okaloosa, FL

Fort Wayne, IN............................................... 0.8901

Allen, IN

De Kalb, IN

Whitley, IN

Forth Worth-Arlington, TX.................................... 0.9747

[[Page 46473]]

Johnson, TX

Parker, TX

Tarrant, TX

Fresno, CA................................................... 1.0737

Fresno, CA

Gadsden, AL.................................................. 0.8199

Etowah, AL

Gainesville, FL.............................................. 0.8798

Alachua, FL

Bradford, FL

Galveston-Texas City, TX..................................... 0.9431

Galveston, TX

Gary-Hammond, IN............................................. 0.9866

Lake, IN

Porter, IN

Glens Falls, NY.............................................. 0.9231

Warren, NY

Washington, NY

Grand Forks, ND.............................................. 0.9577

Grand Forks, ND

Grand Rapids, MI............................................. 0.9883

Kent, MI

Ottawa, MI

Great Falls, MT.............................................. 0.9992

Cascade, MT

Greeley, CO.................................................. 0.9358

Weld, CO

Green Bay, WI................................................ 0.9585

Brown, WI

Greensboro-Winston-Salem-High Point, NC...................... 0.9165

Davidson, NC

Davie, NC

Forsyth, NC

Guilford, NC

Randolph, NC

Stokes, NC

Yadkin, NC

Greenville-Spartanburg, SC................................... 0.8923

Greenville, SC

Pickens, SC

Spartanburg, SC

Hagerstown, MD............................................... 0.9157

Washington, MD

Hamilton-Middletown, OH...................................... 0.9384

Butler, OH

Harrisburg-Lebanon-Carlisle, PA.............................. 0.9919

Cumberland, PA

Dauphin, PA

Lebanon, PA

Perry, PA

Hartford-Middletown-New Britain-Bristol, CT.................. 1.1916

Hartford, CT

Litchfield, CT

Middlesex, CT

Tolland, CT

Hickory, NC.................................................. 0.8741

Alexander, NC

Burke, NC

Catawba, NC

Honolulu, HI................................................. 1.1580

Honolulu, HI

Houma-Thibodaux, LA.......................................... 0.7344

Lafourche, LA

Terrebonne, LA

Houston, TX.................................................. 0.9935

Fort Bend, TX

Harris, TX

Liberty, TX

Montgomery, TX

Waller, TX

Huntington-Ashland, WV-KY-OH................................. 0.9438

Boyd, KY

Carter, KY

Greenup, KY

Lawrence, OH

Cabell, WV

Wayne, WV

Huntsville, AL............................................... 0.8835

Madison, AL

Indianapolis, IN............................................. 0.9663

Boone, IN

Hamilton, IN

Hancock, IN

Hendricks, IN

Johnson, IN

Marion, IN

Morgan, IN

Shelby, IN

Iowa City, IA................................................ 0.9528

Johnson, IA

Jackson, MI.................................................. 0.9664

Jackson, MI

Jackson, MS.................................................. 0.7733

Hinds, MS

Madison, MS

Rankin, MS

Jackson, TN.................................................. 0.7910

Madison, TN

Jacksonville, FL............................................. 0.9051

Clay, FL

Duval, FL

Nassau, FL

St. Johns, FL

Jacksonville, NC............................................. 0.7154

Onslow, NC

Jamestown-Dunkirk, NY........................................ 0.7735

Chautaqua, NY

Janesville-Beloit, WI........................................ 0.8466

Rock, WI

Jersey City, NJ.............................................. 1.0526

Hudson, NJ

Johnson City-Kingsport-Bristol, TN-VA........................ 0.8668

Carter, TN

Hawkins, TN

Sullivan, TN

Unicoi, TN

Washington, TN

Bristol City, VA

Scott, VA

Washington, VA

Johnstown, PA................................................ 0.9067

Cambria, PA

Somerset, PA

Joliet, IL................................................... 1.0278

Grundy, IL

Will, IL

Joplin, MO................................................... 0.7957

Jasper, MO

Newton, MO

Kalamazoo, MI................................................ 1.1709

Kalamazoo, MI

Kankakee, IL................................................. 0.8489

Kankakee, IL

Kansas City, KS-MO........................................... 0.9588

Johnson, KS

Leavenworth, KS

Miami, KS

Wyandotte, KS

Cass, MO

Clay, MO

Jackson, MO

Lafayette, MO

Platte, MO

Ray, MO

Kenosha, WI.................................................. 0.8855

Kenosha, WI

Killeen-Temple, TX........................................... 1.1295

Bell, TX

Coryell, TX

Knoxville, TN................................................ 0.8693

Anderson, TN

Blount, TN

Grainger, TN

Jefferson, TN

Knox, TN

Sevier, TN

Union, TN

Kokomo, IN................................................... 0.9435

Howard, IN

Tipton, IN

LaCrosse, WI................................................. 0.8956

LaCrosse, WI

Lafayette, LA................................................ 0.8227

Lafayette, LA

St. Martin, LA

Lafayette, IN................................................ 0.8432

Tippecanoe, IN

Lake Charles, LA............................................. 0.8374

Calcasieu, LA

Lake County, IL.............................................. 0.9994

Lake, IL

Lakeland-Winter Haven, FL.................................... 0.8171

Polk, FL

Lancaster, PA................................................ 0.9258

Lancaster, PA

Lansing-East Lansing, MI..................................... 1.0222

Clinton, MI

Eaton, MI

Ingham, MI

Laredo, TX................................................... 0.7278

Webb, TX

Las Cruces, NM............................................... 0.7909

Dona Ana, NM

Las Vegas, NV................................................ 1.0631

Clark, NV

Lawrence, KS................................................. 0.8937

Douglas, KS

Lawton, OK................................................... 0.8388

Comanche, OK

Lewiston-Auburn, ME.......................................... 0.9057

Androscoggin, ME

Lexington-Fayette, KY........................................ 0.8446

Bourbon, KY

Clark, KY

Fayette, KY

Jessamine, KY

Scott, KY

Woodford, KY

Lima, OH..................................................... 0.8062

Allen, OH

Auglaize, OH

Lincoln, NE.................................................. 0.8956

Lancaster, NE

Little Rock-North Little Rock, AR............................ 0.8420

[[Page 46474]]

Faulkner, AR

Lonoke, AR

Pulaski, AR

Saline, AR

Longview-Marshall, TX........................................ 0.8691

Gregg, TX

Harrison, TX

Lorain-Elyria, OH............................................ 0.8969

Lorain, OH

Los Angeles-Long Beach, CA................................... 1.2354

Los Angeles, CA

Louisville, KY-IN............................................ 0.9092

Clark, IN

Floyd, IN

Harrison, IN

Bullitt, KY

Jefferson, KY

Oldham, KY

Shelby, KY

Lubbock, TX.................................................. 0.8790

Lubbock, TX

Lynchburg, VA................................................ 0.8544

Amherst, VA

Campbell, VA

Lynchburg City, VA

Macon-Warner Robins, GA...................................... 0.8804

Bibb, GA

Huston, GA

Jones, GA

Peach, GA

Madison, WI.................................................. 1.0311

Dane, WI

Manchester-Nashua, NH........................................ 1.0261

Hillsborough, NH

Merrimack, NH

Mansfield, OH................................................ 0.8392

Richland, OH

Mayaguez, PR................................................. 0.4771

Anasco, PR

Cabo Rojo, PR

Hormigueros, PR

Mayaguez, PR

San German, PR

McAllen-Edinburg-Mission, TX................................. 0.7715

Hidalgo, TX

Medford, OR.................................................. 1.0045

Jackson, OR

Melbourne-Titusville Fl...................................... 0.9199

Brevard, Fl

Memphis, TN-AR-MS............................................ 0.9060

Crittenden, AR

De Soto, MS

Shelby, TN

Tipton, TN

Merced, CA................................................... 1.0312

Merced, CA

Miami-Hialeah, FL............................................ 1.0188

Dade, FL

Middlesex-Somerset-Hunterdon, NJ............................. 1.0401

Hunterdon, NJ

Middlesex, NJ

Somerset, NJ

Midland, TX.................................................. 1.0377

Midland, TX

Milwaukee, WI................................................ 0.9719

Milwaukee, WI

Ozaukee, WI

Washington, WI

Waukesha, WI

Minneapolis-St Paul, MN-WI................................... 1.0818

Anoka, MN

Carver, MN

Chisago, MN

Dakota, MN

Hennepin, MN

Isanti, MN

Ramsey, MN

Scott, MN

Washington, MN

Wright, MN

St. Croix, WI

Mobile, AL................................................... 0.8319

Baldwin, AL

Mobile, AL

Modesto, CA.................................................. 1.1577

Stanislaus, CA

Monmouth-Ocean, NJ........................................... 0.9900

Monmouth, NJ

Ocean, NJ

Monroe, LA................................................... 0.7864

Ouachita, LA

Montgomery, AL............................................... 0.7738

Autauga, AL

Elmore, AL

Montgomery, AL

Muncie, IN................................................... 0.8068

Delaware, IN

Muskegon, MI................................................. 0.9568

Muskegon, MI

Naples, FL................................................... 1.0324

Collier, FL

Nashville, TN................................................ 0.9397

Cheatham, TN

Davidson, TN

Dickson, TN

Robertson, TN

Rutherford TN

Sumner, TN

Williamson, TN

Wilson, TN

Nassau-Suffolk, NY........................................... 1.2938

Nassau, NY

Suffolk, NY

New Bedford-Fall River-Attleboro, MA......................... 1.0002

Bristol, MA

New Haven Waterbury-Meriden, CT.............................. 1.2095

New Haven, CT

New London, London-Norwich................................... 1.1571

New London, CT

New Orleans, LA.............................................. 0.8908

Jefferson, LA

Orleans, LA

St. Bernard, LA

St. Charles, LA

St. John The Baptist, LA

St. Tammany, LA

New York, NY................................................. 1.3460

Bronx, NY

Kings, NY

New York City, NY

Putnam, NY

Queens, NY

Richmond, NY

Rockland, NY

Westchester, NY

Newark, NJ................................................... 1.1232

Essex, NJ

Morris, NJ

Sussex, NJ

Union, NJ

Niagara Falls, NY............................................ 0.8382

Niagara, NY

Norfolk-Virginia Beach-Newport News, VA...................... 0.8515

Chesapeake City, VA

Gloucester, VA

Hampton City, VA

James City Co., VA

Newport News City, VA

Norfolk City, VA

Poquoson, VA

Portsmouth City, VA

Suffolk City, VA

Virginia Beach City, VA

Williamsburg City, VA

York, VA

Oakland, CA.................................................. 1.4283

Alameda, CA

Contra Costa, CA

Ocala, FL.................................................... 0.8614

Marion, FL

Odessa, TX................................................... 1.0817

Ector, TX

Oklahoma City, OK............................................ 0.9145

Canadian, OK

Cleveland, OK

Logan, OK

McClain, OK

Oklahoma, OK

Pottawatomie, OK

Olympia, WA.................................................. 1.1002

Thurston, WA

Omaha, NE-IA................................................. 0.8989

Pottawattamie, IA

Douglas, NE

Sarpy, NE

Washington, NE

Orange, County, NY........................................... 0.9653

Orange, NY

Orlando, FL.................................................. 0.9621

Orange, FL

Osceola, FL

Seminole, FL

Owensboro, KY................................................ 0.8114

Daviess, KY

Oxnard-Ventura, CA........................................... 1.2309

Ventura, CA

Panama City, FL.............................................. 0.8632

Bay, FL

Parkersburg-Marietta, WV-OH.................................. 0.8540

Washington, OH

Wood, WV

Pascagoula, MS............................................... 0.8755

Jackson, MS

Pensacola, FL................................................ 0.8623

[[Page 46475]]

Escambia, FL

Santa Rosa, FL

Peoria, IL................................................... 0.8710

Peoria, IL

Tazewell, IL

Woodford, IL

Philadelphia, PA-NJ.......................................... 1.0952

Burlington, NJ

Camden, NJ

Gloucester, NJ

Bucks, PA

Chester, PA

Delaware, PA

Montgomery, PA

Philadelphia, PA

Phoenix, AZ.................................................. 1.0429

Maricopa, AZ

Pine Bluff, AR............................................... 0.7872

Jefferson, AR

Pittsburgh, PA............................................... 1.0127

Allegheny, PA

Fayette, PA

Washington, PA

Westmoreland, PA .........

Pittsfield, MA............................................... 1.0782

Berkshire, MA

Ponce, PR.................................................... 0.4601

Juana Diaz, PR

Ponce, PR

Portland, ME................................................. 0.9292

Cumberland, ME

Sagadahoc, ME

York, ME

Portland, OR................................................. 1.1576

Clackamas, OR

Multnomah, OR

Washington, OR

Yamhill, OR

Portsmouth-Dover-Rochester, NH............................... 1.0080

Rockingham, NH

Strafford, NH

Poughkeepsie, NY............................................. 1.0447

Dutchess, NY

Providence-Pawtucket-Woonsocket, RI.......................... 1.0630

Bristol, RI

Kent, RI

Newport, RI

Providence, RI

Washington, RI

Provo-Orem, UT............................................... 1.0230

Utah, UT

Pueblo, CO................................................... 0.8722

Pueblo, CO

Racine, WI................................................... 0.8849

Racine, WI

Raleigh-Durham, NC........................................... 0.9465

Durham, NC

Franklin, NC

Orange, NC

Wake, NC

Rapid City, SD............................................... 0.8400

Pennington, SD

Reading, PA.................................................. 0.8814

Berks, PA

Redding, CA.................................................. 1.0549

Shasta, CA

Reno, NV..................................................... 1.1618

Washoe, NV

Richland-Kennewick, WA....................................... 0.9402

Benton, WA

Franklin, WA

Richmond-Petersburg, VA...................................... 0.9417

Charles City Co., VA

Chesterfield, VA

Colonial Heights City, VA

Dinwiddie, VA

Goochland, VA

Hanover, VA

Henrico, VA

Hopewell City, VA

New Kent, VA

Petersburg City, VA

Powhatan, VA

Prince George, VA

Richmond City, VA

Riverside-San Bernardino, CA................................. 1.1160

Riverside, CA

San Bernardino, CA

Roanoke, VA.................................................. 0.8284

Botetourt, VA

Roanoke, VA

Roanoke City, VA

Salem City, VA

Rochester, MN................................................ 1.1030

Olmsted, MN

Rochester, NY................................................ 0.9710

Livingston, NY

Monroe, NY

Ontario, NY

Orleans, NY

Wayne, NY

Rockford, IL................................................. 0.9283

Boone, IL

Winnebago, IL

Sacramento, CA............................................... 1.2232

Eldorado, CA

Placer, CA

Sacramento, CA

Yolo, CA

Saginaw-Bay City-Midland, MI................................. 1.0451

Bay, MI

Midland, MI

Saginaw, MI

St. Cloud, MN................................................ 0.9420

Benton, MN

Sherburne, MN

Stearns, MN

St. Joseph, MO............................................... 0.9414

Buchanan, MO

St. Louis, MO-IL............................................. 0.9388

Clinton, IL

Jersey, IL

Madison, IL

Monroe, IL

St. Clair, IL

Franklin, MO

Jefferson, MO

St. Charles, MO

St. Louis, MO

St. Louis City, MO

Sullivan City, MO

Salem, OR.................................................... 1.0445

Marion, OR

Polk, OR

Salinas-Seaside-Monterey, CA................................. 1.3041

Monterey, CA

Salt Lake City-Ogden, UT..................................... 0.9932

Davis, UT

Salt Lake, UT

Weber, UT

San Angelo, TX............................................... 0.8139

Tom Green, TX

San Antonio, TX.............................................. 0.8452

Bexar, TX

Comal, TX

Guadalupe, TX

San Diego, CA................................................ 1.1934

San Diego, CA

San Francisco, CA............................................ 1.4539

Marin, CA

San Francisco, CA

San Mateo, CA

San Jose, CA................................................. 1.4900

Santa Clara, CA

San Juan, PR................................................. 0.4987

Barcelona, PR

Bayoman, PR

Canovanas, PR

Carolina, PR

Catano, PR

Corozal, PR

Dorado, PR

Fajardo, PR

Florida, PR

Guaynabo, PR

Humacao, PR

Juncos, PR

Los Piedras, PR

Loiza, PR

Luguillo, PR

Manati, PR

Naranjito, PR

Rio Grande, PR

San Juan, PR

Toa Alta, PR

Toa Baja, PR

Trojillo Alto, PR

Vega Alta, PR

Vega Baja, PR

Santa Barbara-Santa Maria-Lompoc, CA......................... 1.1768

Santa Barbara, CA

Santa Cruz, CA............................................... 1.2784

Santa Cruz, CA

Santa Fe, NM................................................. 0.9139

Los Alamos, NM

Santa Fe, NM

Santa Rosa-Petaluma, CA...................................... 1.2957

Sonoma, CA

Sarasota, FL................................................. 0.9781

Sarasota, FL

Savannah, GA................................................. 0.8327

Chatham, GA

Effingham, GA

Scranton, Wilkes Barre, PA................................... 0.8952

Columbia, PA

Lackawanna, PA

Luzerne, PA

Monroe, PA

Wyoming, PA

Seattle, WA.................................................. 1.0871

King, WA

Snohomish, WA

Sharon, PA................................................... 0.9061

Mercer, PA

Sheboygan, WI................................................ 0.8872

[[Page 46476]]

Sheboygan, WI

Sherman-Denison, TX.......................................... 0.9089

Grayson, TX

Shreveport, LA............................................... 0.9299

Bossier, LA

Caddo, LA

Sioux City, IA-NE............................................ 0.8504

Woodbury, IA

Dakota, NE

Sioux Falls, SD.............................................. 0.8833

Minnehaha, SD

South Bend-Mishawaka, IN..................................... 1.0067

St. Joseph, IN

Spokane, WA.................................................. 1.0691

Spokane, WA

Springfield, IL.............................................. 0.9295

Menard, IL

Sangamon, IL

Springfield, MO.............................................. 0.8082

Christian, MO

Greene, MO

Springfield, MA.............................................. 1.0316

Hampden, MA

Hampshire, MA

State College, PA............................................ 0.9901

Centre, PA

Steubenville-Weirton, OH-WV.................................. 0.8712

Jefferson, OH

Brooke, WV

Hancock, WV

Stockton, CA................................................. 1.1612

San Joaquin, CA

Syracuse, NY................................................. 0.9917

Madison, NY

Onondaga, NY

Oswego, NY

Tacoma, WA................................................... 1.0317

Pierce, WA

Tallahassee, FL.............................................. 0.9220

Gadsden, FL

Leon, FL

Tampa-St. Petersburg-Clearwater, FL.......................... 0.9188

Hernando, FL

Hillsborough, FL

Pasco, FL

Pinellas, FL

Terre Haute, IN.............................................. 0.8758

Clay, IN

Vigo, IN

Texarkana, TX-AR............................................. 0.7892

Miller, AR

Bowie, TX

Toledo, OH................................................... 1.0097

Fulton, OH

Lucas, OH

Wood, OH

Topeka, KS................................................... 0.9302

Shawnee, KS

Trenton, NJ.................................................. 1.0038

Mercer, NJ

Tucson, AZ................................................... 0.9591

Pima, AZ

Tulsa, OK.................................................... 0.8532

Creeks, OK

Osage, OK

Rogers, OK

Tulsa, OK

Wagoner, OK

Tuscaloosa, AL............................................... 0.8521

Tuscaloosa, AL

Tyler, TX.................................................... 0.9838

Smith, TX

Utica-Rome, NY............................................... 0.8512

Herkimer, NY

Oneida, NY

Vallejo-Fairfield-Napa, CA................................... 1.3203

Napa, CA

Solano, CA

Vancouver, WA................................................ 1.0798

Clark, WA

Victoria, TX................................................. 0.8994

Victoria, TX

Vineland-Millville-Bridgeton, NJ............................. 0.9760

Cumberland, NJ

Visalia-Tulare-Porterville, CA............................... 1.0392

Tulare, CA

Waco, TX..................................................... 0.7814

McLennan, TX

Washington, DC-MD-VA......................................... 1.0941

District of Columbia, DC

Calvert, MD

Charles, MD

Frederick, MD

Montgomery, MD

Prince Georges, MD

Alexandria City, VA

Arlington, VA

Fairfax, VA

Fairfax City, VA

Falls Church City, VA

Loudoun, VA

Manassas City, VA

Manassas Park City, VA

Prince William, VA

Stafford, VA

Waterloo-Cedar Falls, IA..................................... 0.8642

Black Hawk, IA

Bremer, IA

Wausau, WI................................................... 0.9748

Marathon, WI

West Palm Beach-Boca Raton-Delray Beach, FL.................. 1.0135

Palm Beach, FL

Wheeling, WV-OH.............................................. 0.8067

Belmont, OH

Marshall, WV

Ohio, WV

Wichita, KS.................................................. 0.9809

Butler, KS

Harvey, KS

Sedgwick, KS

Wichita Falls, TX............................................ 0.8172

Wichita, TX

Williamsport, PA............................................. 0.8864

Lycoming, PA

Wilmington, DE-NJ-MD......................................... 1.0869

New Castle, DE

Cecil, MD

Salem, NJ

Wilmington, NC............................................... 0.8712

New Hanover, NC

Worcester-Fitchburg-Leominster, MA........................... 1.0826

Worcester, MA

Yakima, WA................................................... 1.0111

Yakima, WA

York, PA..................................................... 0.9021

Adams, PA

York, PA

Youngstown-Warren, OH........................................ 0.9866

Mahoning, OH

Trumbull, OH

Yuba City, CA................................................ 1.0167

Sutter, CA

Yuba, CA

Yuma, AZ..................................................... 0.8885

Yuma, AZ

------------------------------------------------------------------------

Table VI.--Wage Index for Rural Areas

------------------------------------------------------------------------

Wage

Non-urban areas index

------------------------------------------------------------------------

ALABAMA...................................................... 0.7121

ALASKA....................................................... 1.3426

ARIZONA...................................................... 0.8747

ARKANSAS..................................................... 0.6966

CALIFORNIA................................................... 1.0142

COLORADO..................................................... 0.8415

CONNECTICUT.................................................. 1.1905

DELAWARE..................................................... 0.8572

FLORIDA...................................................... 0.8730

GEORGIA...................................................... 0.7767

HAWAII....................................................... 0.9618

IDAHO........................................................ 0.8953

ILLINOIS..................................................... 0.7700

INDIANA...................................................... 0.7806

IOWA......................................................... 0.7532

KANSAS....................................................... 0.7446

KENTUCKY..................................................... 0.7793

LOUISIANA.................................................... 0.7384

MAINE........................................................ 0.8328

MARYLAND..................................................... 0.8061

MASSACHUSETTS................................................ 1.1654

MICHIGAN..................................................... 0.8826

MINNESOTA.................................................... 0.8309

MISSISSIPPI.................................................. 0.6957

MISSOURI..................................................... 0.7249

MONTANA...................................................... 0.8255

NEBRASKA..................................................... 0.6995

NEVADA....................................................... 0.9702

NEW HAMPSHIRE................................................ 0.9547

NEW JERSEY................................................... (\1\)

NEW MEXICO................................................... 0.8318

NEW YORK..................................................... 0.8402

NORTH CAROLINA............................................... 0.7936

NORTH DAKOTA................................................. 0.7719

OHIO......................................................... 0.8453

OKLAHOMA..................................................... 0.7400

OREGON....................................................... 0.9607

PENNSYLVANIA................................................. 0.8613

PUERTO RICO.................................................. \2\ 0.433

3

RHODE ISLAND................................................. (\1\)

SOUTH CAROLINA............................................... 0.7650

SOUTH DAKOTA................................................. 0.7168

TENNESSEE.................................................... 0.7340

TEXAS........................................................ 0.7591

UTAH......................................................... 0.8983

VERMONT...................................................... 0.9035

VIRGINIA..................................................... 0.7815

VIRGIN ISLANDS............................................... \2\ 0.573

4

WASHINGTON................................................... 0.9635

WEST VIRGINIA................................................ 0.8488

WISCONSIN.................................................... 0.8447

[[Page 46477]]

WYOMING...................................................... 0.8457

------------------------------------------------------------------------

\1\ All counties within State are classified urban.

\2\ Approximate value for area.

V. Impact Statement

For notices such as this, we generally prepare a regulatory

flexibility analysis that is consistent with the Regulatory Flexibility

Act (RFA) (5 U.S.C. 601 through 612) unless we certify that a notice

will not have a significant economic impact on a substantial number of

small entities. For purposes of the RFA, all SNFs are considered to be

small entities. Individuals and States are not included in the

definition of a small entity.

The purpose of the July 21, 1995 final rule was to allow SNFs that

provide fewer than 1,500 days of care to Medicare beneficiaries in a

cost reporting period to have the option of receiving prospectively

determined payment rates in the following cost reporting period. In our

analysis of the impact of the July 21 final rule (60 FR 37593), we

noted that Medicare payments to SNFs constitute only about 5.3 percent

of total SNF revenues and indicated that the rule would have only a

small impact on those revenues. We estimate that the prospectively

determined payment rates contained in this notice will result in a cost

to the Medicare program of $10 to $20 million for FY 1997. These costs

represent the difference between estimated aggregate payments to SNFs

that elect to be paid under the prospectively determined payment rates

and estimated aggregate payments to the same SNFs if paid on a

reasonable cost basis under the routine SNF cost limits. Thus, we

continue to believe that this optional payment system will have a

positive impact on small entities, while easing their cost reporting

burden.

In addition, section 1102(b) of the Act requires us to prepare a

regulatory impact analysis if a final notice such as this may have a

significant impact on the operations of a substantial number of small

rural hospitals. Such an 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 50 beds.

We are not preparing analyses for either the RFA or section 1102(b)

of the Act because we have determined, and we certify, that this final

notice will not have a significant economic impact on a substantial

number of small entities or a significant impact on the operations of a

substantial number of small rural hospitals.

In accordance with the provisions of Executive Order 12866, this

final notice was reviewed by the Office of Management and Budget.

Under the provisions of Public Law 104-121, we have determined that

this notice is not a major rule.

VI. Other Required Information

A. Collection of Information Requirements

This final notice with comment period 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 (44 U.S.C. 3501 et seq.).

B. Waiver of Proposed Notice and 30-Day Delay in the Effective Date

In adopting notices such as this, we ordinarily publish a proposed

notice in the Federal Register with a 60-day period for public comment

as required under section 1871(b)(1) of the Act. We also normally

provide a delay of 30 days in the effective date for documents such as

this. However, we may waive these procedures if we find good cause that

prior notice and comment or a delay in the effective date are

impracticable, unnecessary, or contrary to the public interest.

As discussed in section II of this notice, we have used the same

basic methodology to develop this schedule of rates that was used in

setting the rates published in section 2828 of the Provider

Reimbursement Manual for cost reporting periods beginning in Federal

fiscal year 1993. As discussed above, section 13503(b) of OBRA 1993

delayed the update to the schedule of prospectively determined payment

rates until Federal fiscal year 1996. However, the delay in passing the

proposed Federal fiscal year 1996 budget legislation, which contained

provisions affecting the Federal fiscal year 1996 and Federal fiscal

year 1997 prospectively determined payment rates, resulted in a delay

in publishing updated Federal fiscal year 1996 rates. Regardless of

that delay and in conformance with the clear direction of section

1888(d) of the Act and Sec. 413.320, this notice announces the update

to the schedule of prospectively determined payment rates for SNF

inpatient service costs for cost reporting periods beginning in Federal

fiscal year 1997. However, given the publishing time constraints

mandated in Sec. 413.320, it would not have been possible to publish a

proposed notice and still implement the updated prospectively

determined payment rates set forth in this notice. To do so would have

been impractical, unnecessary, and contrary to the public interest.

Therefore, we find good cause to waive publication of a proposed notice

and the 30-day delay in the effective date of this notice with comment

period. However, we are providing a 60-day period for public comment,

as indicated at the beginning of this notice.

C. Response to Comments

Because of the large number of items of correspondence we normally

receive on Federal Register documents published for comment, we are not

able to acknowledge or respond to them individually. We will consider

all comments we receive by the date and time specified in the DATES

section of this notice, and, if we proceed with a subsequent document,

we will respond to the comments in that document.

Appendix.--Derivation of ``Market Basket'' Index for SNF Routine Service Costs

----------------------------------------------------------------------------------------------------------------

Relative

Category of costs \1\ Price variable used \2\

importance

---------------------------------------1993---------------------------------------------------------------------

Payroll Expense.................. 64.0 Percentage changes in average hourly earnings of employees in

nursing and personal care facility. (SIC 805) Source: U.S.

Dept. of Labor, Bureau of Labor Statistics, Employment and

Earnings (monthly). Table C-2.

[[Page 46478]]

Employee Benefits................ 7.8 Supplements to wages and salaries per worker in nonagricultural

establishments. For supplements to wages. Source: U.S. Dept. of

Commerce, Bureau of Economic Analysis, Survey of Current

Business. Table 1.11.

For total employment. Source: U.S. Dept. of Labor, Bureau of

Labor Statistics, Employment and Earnings (monthly). Table B-4.

Food............................. 7.6 Processed foods and feeds component of producer price index.

Source: U.S. Dept. of Labor, Bureau of Labor Statistics,

Monthly Labor Review, Table 23.

Food and beverage component of Consumer Price Index, all urban.

Source: U.S. Dept. of Labor, Bureau of Labor Statistics,

Monthly Labor Review, Table 22.

Other business services.......... 5.1 Services component of Consumer Price Index, all urban. Source:

U.S. Dept. of Labor, Bureau of Labor Statistics, Monthly Labor

Review, Table 23.

Fuel and other utilities......... 4.0 A. Implicit price deflator-consumption of fuel oil and coal

(derived from fuel oil component of Consumer Price Index).

Source: U.S. Dept. of Commerce, Bureau of Economic Analysis,

Survey of Current Business (monthly), Table 7.11.

B. Implicit price deflator-consumer of electricity (derived from

electricity component of Consumer Price Index). Source: U.S.

Dept. of Commerce, Bureau of Economic Analysis.

C. Implicit price deflator for natural gas (derived from utility

(piped) gas component of Consumer Price Index). Source: Same as

electricity above.

D. Water and sewage maintenance component of the Consumer Price

Index. Source: U.S. Dept. of Labor, Bureau of Labor Statistics,

Monthly Labor Review, Table 23.

Supplies......................... 3.1 All Item Consumer Price Index, all urban. Source: U.S. Dept. of

Labor, Bureau of Labor Statistics, Monthly Labor Review, Table

23.

Drugs............................ 2.2 Pharmaceutical preparations, ethical component of producer price

index. Source: U.S. Dept. of Labor, Bureau of Labor Statistics,

Producer Prices and Price Indexes (monthly), Table 6.

Health services.................. 1.6 Physician services component of Consumer Price Index for all

urban consumers. Source: U.S. Dept. of Labor, Bureau of Labor

Statistics, Monthly Labor Review, Table 23.

Miscellaneous.................... 4.6 All Item Consumer Price Index, all urban. Source: U.S. Dept. of

Labor, Bureau of Labor Statistics, Monthly Labor Review, Table

23.

----------------------------------------------------------------------------------------------------------------

\1\ The basic weights for all major categories of skilled nursing home costs were obtained from the DHEW-

National Center for Health Statistics (NCHS) National Nursing Home Surveys (NNHS) for 1972 and 1976 for home

certified for participation in the Medicare program. See Nursing Home Costs 1972, United States: National

Nursing Home Survey, August 1973-April 1974, DHEW, NCHS: National Nursing Home Survey: 1977 Summary for the

United States, Vital and Health Statistics, Series 13, Number 43.

A Laspeyres price index was constructed using 1977 weights and price variables indicated in this table. In

calendar year 1977 each ``price'' variable has an index of 100.0. The relative routine service cost weights

change each period in accordance with price changes for each price variable. Cost categories with relatively

higher ``price'' increases get relatively higher cost weights and vice versa.

\2\ Forecasted by DRI/McGraw Hill, Health Care Costs, First Quarter, 1992, 1750 K St., NW, Washington D.C.

20006.

Authority: Secs. 1102, 1814(b), 1861(v)(1), 1866(a), 1871, and

1888 of the Social Security Act (42 U.S.C. 1302, 1395f(b),

1395x(v)(1), 1395cc(a), 1395hh, and 1395yy); sec. 13503(b) and (c)

of Pub. L. 103-66 (42 U.S.C. 1395x(v)(1)(B) and 1395yy (note)) and

42 CFR 413.1, 413.24, and 413.300 through 413.321).

(Catalog of Federal Domestic Assistance Program No. 93.773,

Medicare--Hospital Insurance)

Dated: July 1, 1996.

Bruce C. Vladeck,

Administrator, Health Care Financing Administration.

Dated: August 2, 1996.

Donna E. Shalala,

Secretary.

[FR Doc. 96-22376 Filed 8-30-96; 8:45 am]

BILLING CODE 4120-01-P