Medicare Program; Schedules of Per-Visit and Per-Beneficiary Limitations on Home Health Agency Costs for Cost Reporting Periods Beginning on or After October 1, 1999 and Portions of Cost Reporting Periods Beginning Before October 1, 2000

SUMMARY: This notice with comment period sets forth revised schedules

of limitations on home health agency costs that may be paid under the

Medicare program for cost reporting periods beginning on or after

October 1, 1999 and portions of cost reporting periods beginning before

October 1, 2000. These limitations replace the limitations that were

set forth in our August 11, 1998 notice with comment period (63 FR

42912).

DATES: Effective Date: These schedules of limitations are effective for

cost reporting periods beginning on or after October 1, 1999 and

portions of cost reporting periods beginning before October 1, 2000.

Comment Date: Written comments will be considered if we receive

them at the appropriate address, as provided below, no later than 5 p.

m. on October 4, 1999.

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

following address:

Health Care Financing Administration, Department of Health and Human

Services, Attention: HCFA-1060-NC, P.O. Box 31850, Baltimore, Maryland

21207-8850

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

and three copies) to one of the following addresses:

Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,

Washington, D.C. 20201, or

Room C5-16-03, Central Building, 7500 Security Boulevard, Baltimore,

Maryland 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.

Because of staffing and resource limitations, we cannot accept

comments by facsimile (FAX) transmission. In commenting, please refer

to file code HCFA-1060-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 443/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).

FOR FURTHER INFORMATION CONTACT: Michael Bussacca, (410) 786-4602.

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I. Background

Section 1861(v)(1)(A) of the Social Security Act (the Act)

authorizes the Secretary to establish limitations on allowable costs

incurred by a provider of services that may be paid under the Medicare

program, based on estimates of the costs necessary for the efficient

delivery of needed health services. Under this authority, we have

maintained limitations on home health agency (HHA) costs since 1979.

Additional statutory provisions specifically governing the limitations

applicable to HHAs are contained at section 1861(v)(1)(L) of the Act.

On October 21, 1998, the Omnibus Consolidated and Emergency

Supplemental Appropriations Act (OCESAA), 1999 (Public Law 105-277) was

signed into law. Section 5101 of OCESAA amended section 1861(v)(1)(L)

of the Act by providing for adjustments to the per-beneficiary and per-

visit limitations for cost reporting periods beginning on or after

October 1, 1998. Program Memoranda (Transmittal) Nos. A-98-38 and A-99-

1 were issued in November 1998 and January 1999, respectively,

outlining the specific provisions affecting the Interim Payment System

(IPS). We had published a notice with comment period establishing the

cost limitations for cost reporting periods beginning on or after

October 1, 1998 in the Federal Register that was entitled ``Medicare

Program; Schedules of Per-Visit and Per-Beneficiary Limitations on Home

Health Agency Costs for Cost Reporting Periods Beginning On or After

October 1, 1998'' (HCFA-1035-NC) on August 11, 1998 (63 FR 42912).

OCESAA made the following adjustments to these limitations:

Providers with a 12-month cost reporting period ending during

Fiscal Year (FY) 1994, whose per-beneficiary limitations were less than

the national median, which is to be set at 100 percent for comparison

purposes, will get their current per-beneficiary limitation plus \1/3\

of the difference between their rate and the adjusted national median

per-beneficiary limitation. New providers or providers without a 12-

month cost reporting period ending in Federal Fiscal Year (Federal FY)

1994 whose first cost reporting period begins before October 1, 1998

will receive 100 percent of the national median per-beneficiary

limitation.

New providers whose first cost reporting periods begin during

Federal FY 1999 will receive 75 percent of the national median per-

beneficiary limitation as published in the August 11, 1998 notice. In

the case of a new provider or a provider that did not have a 12-month

cost reporting period ending during Federal FY 1994 that filed an

application for HHA provider status before September 15, 1998 or that

was approved as a branch of its parent agency before that date and

becomes a

[[Page 42767]]

subunit of the parent agency or a separate freestanding agency on or

after that date, the per-beneficiary limitation will be set at 100

percent of the national median. The per-visit limitation effective for

costreporting periods beginning on or after October 1, 1998 is set at

106 percent of the median instead of 105 percent of the median, as

previously required in the Balanced Budget Act of 1997 (BBA) (Public

Law 105-33), enacted on August 5, 1997.

There is contingency language for the home health prospective

payment system (PPS) provided in the BBA that was also amended by

section 5101 of OCESAA. If the Secretary for any reason does not

establish and implement the PPS for home health services, the Secretary

will provide for a reduction by 15 percent to the per-visit cost limits

and per-beneficiary limits, as those limits would otherwise be in

effect on September 30, 2000.

Section 1861(v)(1)(L)(i)(V) of the Act specifies that the per-visit

limits shall not exceed 106 percent of the median of the labor-related

and nonlabor per-visit costs for freestanding HHAs. The reasonable

costs used in the per-visit calculations will be updated by the home

health market basket reduced by 1.1 percentage points as required by

section 1861(v)(1)(L)(ix) of the Act and excluding any change in the

home health market basket with respect to cost reporting periods that

began on or after July 1, 1994 and before July 1, 1996 as required by

section 1861(v)(1)(L)(iv) of the Act.

Section 1861(v)(1)(L)(v)(I) of the Act requires the per-beneficiary

annual limitation be a blend of (1) an agency-specific per-beneficiary

limitation based on 75 percent of 98 percent of the reasonable costs

(including nonroutine medical supplies) for the agency's 12-month cost

reporting period ending during Federal FY 1994, and (2) a census region

division per-beneficiary limitation based on 25 percent of 98 percent

of the regional average of these costs for the agency's census division

for cost reporting periods ending during FY 1994, standardized by the

hospital wage index. However, section 1861(v)(1)(L)(viii)(I) of the Act

provides that if the per-beneficiary limitation imposed under this

section of the Act is less than the median described under section

1861(v)(1)(L)(vi)(I) of the Act (but determined as if any reference

under section 1861(v)(1)(L)(v) of the Act to ``98 percent'' were a

reference to ``100 percent''), the per-beneficiary limitation imposed

under section 1861(v)(1)(L)(v) will be increased by \1/3\ of this

difference. The reasonable costs used in the per-beneficiary limitation

calculations in (1) and (2) above will be updated by the home health

market basket reduced by 1.1 percentage points and excluding any

changes in the home health market basket with respect to cost reporting

periods that began on or after July 1, 1994 and before July 1, 1996 as

required by sections 1861(v)(1)(L)(ix) and (iv) of the Act

respectively. This per-beneficiary limitation based on the blend of the

agency-specific and census region division per-beneficiary limitations

will then be multiplied by the agency's unduplicated census count of

beneficiaries (entitled to benefits under Medicare) to calculate the

HHA's aggregate per-beneficiary limitation for the cost reporting

period or portion of cost reporting period subject to the limitation.

Section 1861(v)(1)(L)(viii)(II) provides that for new providers and

providers without a 12-month cost reporting period ending in Federal FY

1994 but for which the first cost reporting period begins before

Federal FY 1999, the per-beneficiary limitation will be a national per-

beneficiary limitation that will be determined as if any reference to

98 percent were a reference to 100 percent. The national per-

beneficiary limitation is defined in section 1861(v)(1)(L)(vi) of the

Act.

For new providers for which the first cost reporting period begins

during or after Federal FY 1999 as defined in section

1861(v)(1)(L)(viii)(III) of the Act, the per-beneficiary limitation

will be equal to 75 percent of the national per-beneficiary limitation.

In the case of a new provider or a provider without a 12-month cost

reporting period ending in FY 1994, section 1861(v)(1)(L)(viii)(II)

shall apply to an HHA that filed an application for HHA provider status

under Medicare before September 15, 1998 or that was approved as a

branch of its parent agency before that date and becomes a subunit of

the parent agency or a separate agency on or after that date.

Payments by Medicare under this system of payment limitations must

be the lower of an HHA's actual reasonable allowable costs, per-visit

limitations in the aggregate, or a per-beneficiary limitation in the

aggregate.

Section 1895(a) of the Act, as amended by OCESAA, requires the

Secretary to provide for payments for home health services in

accordance with a PPS for cost reporting periods and portions of cost

reporting periods beginning on or after October 1, 2000. This, in

effect, will result in a dual payment system for agencies with cost

reporting periods spanning both Federal FY 2000 and Federal FY 2001.

Section 5101(e) of OCESAA also amended the contingency clause in

section 4603(e) of the BBA, whereby, if the Secretary does not

establish and implement the home health PPS, the per-visit and per-

beneficiary limitations in effect on September 30, 2000 will be reduced

by 15 percent and applied to portions of cost reporting periods

beginning on or after October 1, 2000.

Whether there is a home health PPS or a continuation of the IPS on

or after October 1, 2000, agencies will need to separately aggregate

visits and the unduplicated census count for services furnished before

and after October 1, 2000. These statistics will be needed in order to

recalculate the appropriate Medicare liability on the Medicare cost

report. The visits and unduplicated census counts for home health

services furnished on or after October 1, 1999 and before October 1,

2000 will have the per-visit and per-beneficiary limitations updated to

the end of the agency's cost reporting period applied. For services

furnished after October 1, 2000, the agency will be paid either under

the home health PPS or the per-visit and per-beneficiary limitations

set forth in this notice less 15 percent. We will be modifying our

Provider Statistical and Reimbursement Report (PS & R), which is used

by our contractors for verifying statistical data used for the payment

of Medicare services, to accommodate the change from IPS to PPS or IPS

to a reduced IPS effective October 1, 2000.

This notice with comment period sets forth cost limitations for

cost reporting periods beginning on or after October 1, 1999 and

portions of cost reporting periods beginning before October 1, 2000. As

required by section 1861(v)(1)(L)(iii) of the Act, we are using the

area wage index applicable under section 1886(d)(3)(E) of the Act

determined using the survey of the most recent available wages and

wage-related costs of hospitals located in the geographic area in which

the home health service is furnished. For purposes of this notice, the

HHA wage index is based on the most recent available final hospital

wage index, that is, the preclassified hospital wage index effective

for hospital discharges on or after March 1, 1999, which uses data from

Medicare cost reports for cost reporting periods beginning in FY 1995.

As the statute also specifies, in applying the hospital wage index to

HHAs, no adjustments are to be made to account for hospital

reclassifications under section 1886(d)(8)(B) of the Act, decisions of

the Medicare Geographic Classification Board (MGCRB) under section

1886(d)(10) of the Act, or decisions by the Secretary.

[[Page 42768]]

II. Analysis of and Responses to Public Comments to the August 11,

1998 Per-Visit and Per-Beneficiary Limitations Notice

We received nine items of timely correspondence on the August 11,

1998 notice. The comments pertaining to the per-visit and per-

beneficiary limitations and our responses are discussed below.

Comment: Commenters recommended that we explain specifically and

provide an example of how we envision prorating the unduplicated census

count between agencies for a beneficiary that receives services from

multiple agencies with different fiscal year ends.

Response: In the final rule with comment period entitled ``Schedule

of Per-Beneficiary Limitations on Home Health Agency Costs for Cost

Reporting Periods Beginning on or After October 1, 1997'' published in

the Federal Register on March 31, 1998 (63 FR 15718), we specifically

stated, ``The per-beneficiary limitation will be prorated based on a

ratio of the number of visits furnished to the individual beneficiary

by the HHA during its cost reporting period to the total number of

visits furnished by all HHAs to that individual beneficiary during the

same period.'' (63 FR 15727) The number of agencies providing visits to

the beneficiary is irrelevant. It is the total number of visits the

beneficiary receives by all agencies during the specified agency's cost

reporting period that triggers whether proration is required. What

point the other agencies are in their cost reporting period does not

enter into the computation. However, the total number of visits could

be different for each agency because of their individual cost reporting

periods.

Comment: Commenters encouraged us to explain how the data needed

for proration will be gathered and made available to intermediaries and

providers.

Response: The requirement to prorate the per-beneficiary limitation

when a beneficiary receives home health services from multiple agencies

is statutory. Due to other systems priorities for compliance with Y2K,

we are unable to make the necessary changes in our systems to

accommodate the data needed to do proration at a national level. That

does not, however, preclude contractors from making the necessary

adjustments for proration within their current operating systems.

Comment: Commenters stated that it is unclear in the Federal

Register when and under what circumstances the intermediaries are to

apply the Offset Adjustment for the Implementation of the Home Health

Outcome Assessment Information (OASIS) adjustment factor. Commenters

questioned whether the intermediaries should apply the adjustment

factor immediately and across the board to all agencies that request

the adjustment factor, or upon instructions from HCFA.

Response: In the August 11, 1998 Federal Register (63 FR 42916), we

specifically state that the OASIS adjustment will only apply to the

labor component of the specified per-visit limitations in the first

year of implementation of a new assessment tool. See section III.F of

this notice with comment period regarding our overall application of

the OASIS adjustment.

Comment: Commenters recommended that we clarify whether the option

for being classified as an ``old'' or ``new'' provider applies to

merged providers whose per-beneficiary limitation is based on a weight-

average. Commenters also recommend that we clarify whether the option

will be extended to HHAs that undergo similar mergers or

consolidations, including changes in status and ownership, after the

October 1, 1998 notification deadline.

Response: Agencies that experienced certain changes in status were

given the option to apply the provisions in the March 31, 1998 Federal

Register or the provisions in the August 11, 1998 Federal Register up

to the October 1, 1998 notification deadline. The option mainly

impacted those agencies that may have been classified as new providers

subject to the national per-beneficiary limitation. However, old

providers that merged after the cost reporting period ending during

Federal FY 1994 will be treated the same under this August 11, 1998

provision. That is, the surviving provider number will dictate the per-

beneficiary limitation that will be applied to the merged agencies for

all mergers after October 1, 1998.

Comment: Commenters stated that some intermediaries for hospital-

based agencies have yet to notify providers of their per-beneficiary

amounts or unduplicated census counts. The per-beneficiary amount and

unduplicated census count are important factors that enable providers

to make informed decisions regarding the providers' requests to change

their provider status. Therefore, commenters recommended that we

consider extending the deadline for HCFA notifying providers of their

decision to its end of the comment period (October 13, 1998).

Response: We do not believe it is necessary to extend the

notification deadline. Considering the importance of the per-

beneficiary limitations on an agency's financial needs, the

notification deadline of October 1, 1998 provided agencies adequate

time to assess the impact of the earlier provisions relating to new

provider status and make the election if warranted.

Comment: Commenters disagreed with our position that providers may

not request exceptions to their per-beneficiary amounts. Commenters

believed that we acknowledge that there will be valid circumstances not

anticipated by the per-visit limitation methodology that will cause an

agency to incur cost in excess of that allowed by the per-visit

limitation. Commenters stated that we provide ``atypical'' home health

service exceptions for those unique situations through 42 CFR

413.30(f)(1). Therefore, it appears that, since the statute is silent

on the matter of exceptions, we have the discretion to extend

authorization for exceptions of the per-beneficiary limitations.

Response: We do not agree. Section 1861(v)(1)(L)(ii) of the Act

specifically provides for exemptions and exceptions to the per-visit

limitations so deemed by the Secretary. As we stated in the March 31,

1998 Federal Register, we do not believe that the Congress intended the

general rules at Sec. 413.30 to apply to the establishment of the per-

beneficiary limitations. The statute does not provide any such

exceptions or exemptions to the per-beneficiary limitations.

Comment: A commenter stated that the limits as published used the

wrong wage indices. Section 1861(v)(1)(L)(iii) of the Act requires the

use of the most recently published hospital wage index, which would be

the hospital wage indices published in the final rule entitled

``Changes to the Hospital Inpatient Prospective Payment Systems and

Fiscal Year 1999 Rates'' Federal Register on July 31, 1998 (63 FR

40954).

Response: The statute requires us to use the most recent available

area wage indices applicable under section 1886(d)(3)(E) of the Act to

establish the limitations, which will be those indices that have been

published and in effect for hospitals. The wage indices published in

the Federal Register on July 31, 1998 were not effective under section

1886(d)(3)(E) of the Act until October 1, 1998. Therefore, when the

home health limitations were published, the wage indices in effect for

hospitals were those published in August, 1997 and effective October 1,

1997. Therefore, we believe the wage indices published for HHAs are in

accordance with the statute.

Comment: Commenters recommended that the Medicare cost report and

the Payment Statistical and Reimbursement report should be changed to

[[Page 42769]]

accommodate the requirement to use the wage index that corresponds to

the location where the home health service is furnished.

Response: Both the Medicare cost report and the Payment Statistical

and Reimbursement report have been modified to accommodate the site-of-

service requirement for applying the wage index.

Comment: Commenters believed it is our intent to allow retroactive

application of the August 11, 1998 new and old agency provisions to

both Federal FY 1998 and 1999 cost reports.

Response: Before October 1, 1998, providers will have the option of

being paid as either an ``old'' or ``new'' agency when the surviving

provider number had a 12-month cost reporting period ending in Federal

FY 1994. After October 1, 1998, providers will be paid on the basis of

being an ``old'' provider only if the surviving provider number had a

12-month cost reporting period ending in Federal FY 1994. Providers

will no longer have the option of being ``old'' or ``new'' after

October 1, 1998.

Comment: Commenters stated that the failure to consider the effects

of proration on the calculation on the per-beneficiary limitations is

questionable. If proration of the per-beneficiary limitation is to be

applied to cost reporting periods covered by the interim payment

system, proration must be considered in the calculation of the per-

beneficiary limitation.

Response: During the period used for establishing the per-

beneficiary limitations, proration of the unduplicated census count was

not required. As we stated in the August 11, 1998 Federal Register, the

proration as specified in the statute applies to the application of the

per-beneficiary limitation and not the calculation of the per-

beneficiary limitation. The methodology for establishing the per-

beneficiary limitations in the statute could have specifically

incorporated a proration provision in the methodology, but it did not.

Comment: Commenters stated that an HHA that was required to file

two partial year cost reports during Federal FY 1994 solely due to the

fact that it was located in a State where it was forced to change

fiscal intermediaries should be considered an ``old clause v''

provider. For example, an HHA operating for several years as a

hospital-based HHA has the hospital cease operations during Federal FY

1994. The HHA continues operations under the same ownership as a

freestanding entity and later experiences a change in ownership. Due to

the State where the HHA is located, the HHA was required to change to a

new fiscal intermediary and the partial year cost reports were required

to be filed. If the HHA were located in a different State, a change in

fiscal intermediary would not have occurred.

Response: Section 1861(v)(1)(L)(vi)(I) of the Act requires that for

new providers and those providers without a 12-month cost reporting

period ending in FY 1994, the per-beneficiary shall equal the median of

those limitations applied to old providers. The situation described in

the comment is a provider with less than a 12-month cost reporting

period. The provider does not meet the statutory requirements for

treatment as an ``old clause v'' provider.

Comment: Commenters believed that the OASIS adjustment should not

be phased out after 1 year. They recommended that we should clarify the

start and end dates for the OASIS adjustment and consider extending the

adjustment until cost limits can adequately account for the costs

associated with complying with OASIS requirements.

Response: We recognize there are various costs associated with

complying with OASIS reporting requirements. There are one-time costs

as described in the August 11, 1998 Federal Register that include

training of data entry staff, telephone installation, and other costs

associated with setting up OASIS. There are also ongoing OASIS costs

that include audits to ensure data accuracy, data entry, editing and

auditing, supplies, and telephone costs. We have broken these costs

down to the various elements and have grouped the costs into various

categories. See section III. F of this notice on how these costs are

broken down and the various time frames associated with adjusting the

per-visit limitations for these costs.

Comment: The commenters believed that the OASIS adjustment should

encompass the full range of costs associated with OASIS implementation.

Response: We agree that any adjustment derived for OASIS should

encompass the full range of reasonable costs associated with each

necessary expenditure. Section III. F of this notice, fully explains

the adjustments to the per-visit limitations for the costs associated

with the OASIS requirement.

Comment: The commenters believed that the OASIS adjustment should

apply to both the per-visit and per-beneficiary limitations. This

adjustment could possibly be included in the market basket index used

to update the per-beneficiary limitations for new and old providers.

Response: As we stated in the Federal Register dated August 11,

1998 (63 FR 42920), the statute requires the per-beneficiary

limitations to be based upon the costs incurred during a particular

base year, the Federal FY 1994, and does not contemplate adjustments

due to costs incurred subsequent to the base year.

III. Update of Per-Visit Limitations

The methodology used to develop the schedule of per-visit

limitations in this notice is the same as that used in setting the

limitations effective October 1, 1998. We are using the latest settled

cost report data from freestanding HHAs to develop the per-visit cost

limitations. We have updated the per-visit cost limitations to reflect

the expected cost increases between the cost reporting periods in the

database and September 30, 2000 by the home health market basket

reduced by 1.1 percentage points as required by section

1861(v)(1)(L)(ix) of the Act, and excluding any changes in the home

health market basket with respect to cost reporting periods that began

on or after July 1, 1994 and before July 1, 1996 as required by section

1861(v)(1)(L)(iv) of the Act.

A. Data Used

To develop the schedule of per-visit limitations effective for cost

reporting periods beginning on or after October 1, 1999, we extracted

actual cost per-visit data from the most recent settled Medicare cost

reports for periods beginning on or after October 1, 1994 and settled

by March 1999. The majority of the cost reports were from Federal FY

1996. We then adjusted the data using the latest available market

basket indices to reflect expected cost increases occurring between the

cost reporting periods contained in our database and September 30,

2000, reduced by 1.1 percentage points as required by section

1861(v)(1)(L)(ix) of the Act and excluding any changes in the home

health market basket with respect to cost reporting periods that began

on or after July 1, 1994 and before July 1, 1996 as required by section

1861(v)(1)(L)(iv) of the Act.

B. Wage Index

A wage index is used to adjust the labor-related portion of the

per-visit limitation to reflect differing wage levels among areas. In

establishing the per-visit limitation, we used the FY 1999 hospital

wage index effective for hospital discharges on or after March 1, 1999,

which is based on 1995 hospital wage data.

Each HHA's labor market area is determined based on the definitions

of

[[Page 42770]]

Metropolitan Statistical Areas (MSAs) issued by the Office of

Management and Budget (OMB). Section 1861(v)(1)(L)(iii) of the Act

requires us to use the most recently published hospital wage index

(that is, the FY 1999 hospital wage index, which was published in the

Federal Register on February 25, 1999 (63 FR 9378)) without regard to

whether those hospitals have been reclassified to a new geographic

area, to establish the HHA cost limitations. Therefore, the schedule of

per-visit limitations reflects the MSA definitions that are currently

in effect under the hospital PPS.

We are continuing to incorporate exceptions to the MSA

classification system for certain New England counties that were

identified in the July 1, 1992 notice entitled ``Schedule of Limits on

Home Health Agency Costs Per Visit'' (57 FR 29410). These exceptions

have been recognized in setting hospital cost limitations for cost

reporting periods beginning on and after July 1, 1979 (45 FR 41218) and

were authorized under section 601(g) of the Social Security Amendments

of 1983 (Public Law 98-21). Section 601(g) of Public Law 98-21 requires

that any hospital in New England that was classified as being in an

urban area under the classification system in effect in 1979 will be

considered urban for purposes of the hospital PPS. This provision is

intended to ensure equitable treatment under the hospital PPS. Under

this authority, the following counties have been deemed to be urban

areas for purposes of payment under the inpatient hospital prospective

system:

Litchfield County, CT in the Hartford, CT MSA.

York County, ME and Sagadahoc County, ME in the Portland, ME

MSA.

Merrimack County, NH in the Boston-Brockton-Nashua, MA-NH MSA.

Newport County, RI in the Providence Fall-Warwick, RI MSA

We are continuing to grant these urban exceptions for the purpose

of applying the Medicare hospital wage index to the HHA per-visit

limitations. These exceptions result in the same New England County

Metropolitan Area (NECMA) definitions for hospitals, skilled nursing

facilities, and HHAs. In New England, MSAs are defined on town

boundaries rather than on county lines but exclude parts of the four

counties cited above that would be considered urban under the MSA

definition. Under this notice, these four counties are urban under

either definition, NECMA or MSA.

Section 1861(v)(1)(L)(iii) requires the use of the area wage index

applicable under section 1886(d)(3)(E) of the Act and determined using

the survey of the most recent available wages and wage-related costs of

hospitals located in the geographic area in which the home health

service is furnished without regard to whether these hospitals have

been reclassified to a new geographic area under section 1886(d)(8)(B)

of the Act. The wage-index, as applied to the labor portion of the per-

visit limitation, must be based on the geographic location in which the

home health service is actually furnished rather than the physical

location of the HHA itself.

C. Standardization for Wage Levels

After adjustment by the market basket index reduced by 1.1

percentage points, as required by section 1861(v)(1)(L)(ix) of the Act,

and excluding any changes in the home health market basket with respect

to cost reporting periods that began on or after July 1, 1994 and

before July 1, 1996, as required by section 1861(v)(1)(L)(iv) of the

Act, we divided each HHA's per-visit costs into labor and nonlabor

portions. The labor portion of cost (77.668 percent as determined by

the market basket) represents the employee wage and benefit factor plus

the contract services factor from the market basket. We then divided

the labor portion of per-visit cost by the wage index applicable to the

HHA's location to arrive at an adjusted labor cost.

D. Adjustment for ``Outliers''

We transformed all per-visit cost data into their natural

logarithms and grouped them by type of service and MSA, NECMA, or non-

MSA location, in order to determine the median cost and standard

deviation for each group. We then eliminated all ``outlier'' costs,

which were all per-visit costs less than $10 and per-visit costs more

than $800, retaining only those per-visit costs within two standard

deviations of the median in each service.

E. Basic Service Limitation

We calculate a basic service limitation to 106 percent of the

median labor and nonlabor portions of the per-visit costs of

freestanding HHAs for each type of service. (See Table 6a in section

VIII.)

F. Offset Adjustment for the Implementation of the Home Health Outcome

Assessment Information

In the August 11, 1998 per-visit and per-beneficiary limitations

notice (63 FR 42912), we discussed a proposed adjustment for HHAs for

the agency collection of OASIS data. Collecting and reporting OASIS is

a condition of participation for HHAs who bill Medicare. As we stated

in the August 11, 1998 notice, we believe there will be no permanent

ongoing incremental costs associated with OASIS collection. We do,

however, believe both one-time and ongoing costs are associated with

reporting OASIS data. Our proposed OASIS adjustment is based on

information from the Medicare Quality and Improvement Demonstration as

well as OASIS demonstration data. We assume, for purposes of deriving

the OASIS proposed adjustment, that the typical HHA has 486 admissions

and 30,000 visits per year and an 18-person staff. OASIS reporting

adjustments are unlike the one-time OASIS collection adjustments

published in the August 11, 1998 Federal Register, which were based

only on the number of skilled visits. These reporting adjustments are

based on total Medicare visits. This adjustment factor was calculated

by including the estimated OASIS costs in the baseline costs used to

determine the median of the per-visit costs. The per-beneficiary

limitation cannot be adjusted for OASIS.

The three tables below reflect our estimates of the costs to an HHA

for OASIS reporting for a typical agency and form the basis for the

per-visit OASIS reporting adjustment. Those agencies that exceed the

per-visit limit may use the tables in this notice and in our August 11,

1998 notice to calculate an additional adjustment, over the limit, to

account for their recurring and nonrecurring costs for OASIS collection

and reporting. No adjustment is available for the per-beneficiary

limit, which is set explicitly in the statute. Once the OASIS reporting

system is fully implemented and we have gathered sufficient data, we

plan to review the ongoing cost and time components that constitute the

tables below.

[[Page 42771]]

Table 1.--Continuous OASIS Adjustment: Base

[For data reporting]

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

Cost per

Type of adjustment Source Formula visit

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

Audits to ensure data accuracy.......... University of Colorado (((((10 records per month * $.02542

(CHPR), BLS Occupational 12 months)) * .25 hrs) *

Employment Survey (1996), $25.42)/30,000 avg

1994 & 1995 HCFA Cost visits)...professional

Report Data. staff.

Data entry, editing, & auditing......... University of ((((8.5 hrs per month * 12) .06

Colorado(CHPR), Estimated + (5 hrs per month * 12) +

average salary for (1 hr per month * 12) + (5

clerical staff 1994 & 1995 hrs per year)) * $10 per

HCFA Cost Report Data. hour) / 30,000 avg visits).

Supplies................................ HCFA-3006-IFC OASIS $250 avg cost/30,000 avg .008333

Reporting (64 FR 3748), visits.

1994 & 1995 HCFA Cost

Report Data.

Ongoing telephone costs................. Bell Atlantic 1994 & 1995 (((($13.14 per month, per .007808

HCFA Cost Report Data (for line) + ($ 6.38 per month

average size HHA). subscriber fee)) * 12

months)/30,000 avg visits).

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

Total............................... ........................... ........................... $.101561

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

Table 2.--Continuous OASIS Adjustment: 5-Year Depreciation Averaging

[For data reporting]

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

Cost per

Type of adjustment Source Formula visit

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

Computer Hardware........................ American Hospital

Association's Health Data

& Coding Standards Group's

``Estimated Useful Lives

of Depreciable Hospital

Assets {revised 1998}

--Computer........................... Average cost for PC with $2050 computer depreciated $.022777

minimal acceptable over 3 years (($2050/3)/

standards 1994 & 1995 HCFA 30,000 avg visits

Cost Report Data

--Printer............................ Average cost for printer $600 printer cost .004

with minimal acceptable depreciated over 5 years

standards 1994 & 1995 HCFA (($600/5)/30,000 avg

Cost Report Data visits

First 3 Year's Adjustment.. * Note: computer & printer .026777

depreciation.

Next 2 Year's Adjustment... * Note: printer ONLY .004

depreciation.

5-Year Average Adjustment.. (((.026777 * 3) + (.004 * .01766

2))/5).

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

Personal Computer Minimal Specifications

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

Description Minimal specifications

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

Warranty..................... Minimum 3 year.

Processor.................... Pentium II Processor running at 400Mhz w/

512 Cache.

Operating System............. 32-bit operating system with Graphical

User Interface.

Hard Drive................... 3 Gb Hard drive minimum.

Memory....................... 32Mb minimum.

CD ROM....................... 14-32X, IDE, integrated sound.

Floppy Drive................. 3.5'' 1.44Mb diskette drive.

Fax Modem.................... 56K v.90 Data/Fax.

Monitor...................... 17'' Color Monitor.

Graphics..................... 8Mb AGP.

Mouse........................ Wheel mouse.

Keyboard..................... 104 key ergonomic keyboard.

Anti Virus................... Anti Virus Software.

Management Software.......... System management client software/

license.

Printer...................... 600 dpi Laser printer with cable.

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

Table 3.--OASIS Adjustment: ``One-Time''

[For data reporting]

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

Cost per

Type of adjustment Source Formula visit

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

Training of Data Entry Staff............ BLS Employer Provided (24 hrs * $10)/30,000 avg $.008

Training (Hrs of Training visits.

[1995] & an estimated

average salary for

clerical personnel 1994 &

1995 HCFA Cost Report Data.

[[Page 42772]]

Telephone installation.................. 1994 & 1995 HCFA Cost ($28 processing fee) + ($40 .002266

Report Data. per line connect fee)/

30,000 avg visits.

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

Total One Time Adjustment............. ........................... ........................... $.010266

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

Discussion of OASIS Adjustment Tables

These tables reflect our estimates of the costs to an HHA for

complying with the requirement to report data using the OASIS data set.

We are using three tables based on time parameters. Table 1 shows the

continuous OASIS costs for an HHA that include labor costs for the

audits that are conducted to ensure data accuracy, labor costs for data

entry and the editing and auditing costs associated with it, costs of

supplies, and telephone costs. We estimate these continuous OASIS costs

to total $.101561 per visit. Table 2 shows the OASIS personal computer

costs for those HHAs that are unable to run OASIS because they lack the

requisite hardware needed to support automation of it. We estimate this

percentage to be 50 percent as explained in the OASIS reporting

regulation (HCFA-3006-IFC 64 FR 3748). These costs consist of a

personal computer and printer as described in Table 2. For years 1

through 3, HHAs are able to depreciate both their personal computer and

printer. We estimate this OASIS cost to be $.0267 per visit. For years

4 and 5, HHAs can only depreciate their printer. We estimate this OASIS

cost to be $.004 per visit.

In order for HHAs to keep pace with ever evolving computing

standards, to include enhancements to computer hardware and software,

as well as future versions of HAVEN's OASIS software, this process of

the depreciation of computer hardware is one that would repeat itself

every 5 years. In that vein, a yearly average computer hardware

depreciation adjustment was computed so as to yield a continuous OASIS

adjustment for each year. This was accomplished by multiplying the

first 3 years' computer hardware depreciation adjustment of $.026777 by

3, multiplying the following 2 years' computer hardware depreciation

adjustment of $.004 by 2, summing those two factors, and dividing that

sum by the total number of depreciable years (5) to get a yearly

average for the computer hardware depreciation adjustment of $.01766.

This yearly average computer hardware depreciation adjustments

($.01766), when added to the base continuous OASIS adjustment

($.10156), results in a total continuous OASIS adjustment of $.11916.

Table 3 shows one-time OASIS costs (year 1) for an HHA that include

training of data entry staff and telephone installation. We estimate

these one-time OASIS costs to total $.0103 per visit. Any OASIS costs

recognized under the revised per-visit limits established by this

notice will be reflected in the budget neutral baseline for computing

HHA prospective rates when we convert to that payment system.

IV. Updating the Wage Index on a Budget-Neutral Basis

Section 4207(d)(2) of the Omnibus Budget Reconciliation Act of 1990

(OBRA '90) (Public Law 101-508) requires that, in updating the wage

index, aggregate payments to HHAs will remain the same as they would

have been if the wage index had not been updated. Therefore, overall

payments to HHAs are not affected by changes in the wage index values.

To comply with the requirements of section 4207(d)(2) of OBRA '90

that updating the wage indices be budget neutral, we determined that it

is necessary to apply a budget neutrality adjustment factor of 1.039 to

the labor-related portions of the per-visit and per-beneficiary

limitations for cost reporting periods beginning on or after October 1,

1999. This is the first year for which the per-beneficiary limitations

have been in place long enough to be affected by an update in the wage

indices. Because aggregate payments to HHAs encompass both the per-

visit and the per-beneficiary limitations, the budget neutrality

adjustment factor had to be determined using both per-visit and per-

beneficiary limitations in order to comply with the OBRA '90 budget

neutrality requirement. Therefore, overall payments to HHAs are not

affected by changes in the wage index values as applied to the labor-

related portions of both limitations.

To determine the budget neutrality adjustment factor, we used the

data obtained from the 574 providers in the audited cost report data

set developed for home health prospective payment. This sample was

extrapolated to reflect a national total of HHAs. We believe this is

the most current and accurate data we can obtain to reflect the effects

of both the per-visit limits and the per-beneficiary limits. This data

set includes a count of the number of beneficiaries served by each

agency. This information is not available on the data set used to

calculate the per-visit limitations. For each agency in the per-visit

limitation database, we replaced its current wage index with the one

corresponding to the 1982 hospital wage index. For each agency in the

per-beneficiary limitation database, we replaced their current wage

index with one corresponding to the 1994 hospital wage index. Some MSAs

that currently exist did not exist at the time this index was created

and therefore have no matching 1982 or 1994 wage index. Since the

unmatchable MSAs represented a small percentage of the total visits in

the databases, we deleted these agencies from the analysis. We then

determined what Medicare program payments would be using the 1982 and

1994 wage indices. We determined payments using the new wage index and

adjusted the labor portion of the payment by the factor necessary to

match program payments if the 1982 and 1994 wage indices were used with

respect to both limitations. (See the examples in section VIII. of this

notice regarding the adjustment of the per-visit and per-beneficiary

limitations by the wage index and the budget neutrality adjustment

factor.)

V. Update of the Per-Beneficiary Limitations

The methodologies and data used to develop the schedule of per-

beneficiary limitations set forth in this notice are the same as those

used in setting the per-beneficiary limitations that were effective for

cost reporting periods beginning on or after October 1, 1998. We have

updated the per-beneficiary limitations to reflect the expected cost

increases occurring between the cost reporting periods ended during FY

1994 and September 30, 2000, reduced by 1.1 percentage points and

excluding any changes in the home health market

[[Page 42773]]

basket with respect to cost reporting periods that began on or after

July 1, 1994 and before July 1, 1996.

A. Data Used

The cost report data used to develop the schedule of per-

beneficiary limitations set forth in this notice are for cost reporting

periods ending in Federal FY 1994, as required by section 1861(v)(1)(L)

of the Act. We have updated the per-beneficiary limitations to reflect

the expected cost increases occurring between the cost reporting

periods for the data contained in the database and September 30, 2000

reduced by 1.1 percentage points and excluding any changes in the home

health market basket for cost reporting periods beginning on or after

July 1, 1994 and before July 1, 1996.

The interim payment system sets limitations according to two

different methodologies. For agencies with cost reporting periods

ending during FY 1994, the limitation is based on 75 percent of 98

percent of the agencies' own reasonable costs and 25 percent of 98

percent of the average census region division costs. At the end of the

agency's cost reporting period subject to the per-beneficiary

limitations, the labor component of the census region division per-

beneficiary limitation is adjusted by a wage index based on where the

home health services are furnished.

For new providers and providers without a cost reporting period

ending during FY 1994, the per-beneficiary limitation is based on the

standardized national median of the blended agency-specific and census

region division per-beneficiary limitations described above. See

section C. below, which further defines how these limitations are

effectuated for new providers and providers without a 12-month cost

reporting period ending during FY 1994. This is done by arraying the

agencies' per-beneficiary limitations and selecting the median case.

The national per-beneficiary limitation is then standardized for the

effect of the wage index. The wage index is applied to the labor

component of the national per-beneficiary limitation at the end of the

cost reporting period beginning on or after October 1, 1999 and is

based on where the home health services are furnished.

B. Wage Index

A wage index is used to adjust the labor-related portion of the

standardized regional average per-beneficiary limitation and the

national per-beneficiary limitation to reflect differing wage levels

among areas. In establishing the regional average per-beneficiary

limitation and national per-beneficiary limitation, we used the FY 1999

hospital wage index effective with discharges on or after March 1,

1999, which is based on 1995 hospital wage data.

Each HHA's labor market area is determined based on the definitions

of MSAs issued by OMB. Section 1861(v)(1)(L)(iii) of the Act requires

us to use the current hospital wage index (that is, the FY 1999

hospital wage index, which was published in the Federal Register on

February 25, 1999 (63 FR 9378)), without regard to whether these

hospitals have been reclassified to a new geographic area, to establish

the HHA cost limitations. Therefore, the schedules of standardized

regional average per-beneficiary limitations and the national per-

beneficiary limitation reflect the MSA definitions that are currently

in effect under the hospital PPS.

As we did for the per-visit limitations, we are continuing to

incorporate exceptions to the MSA classification system for certain New

England counties that were identified in the July 1, 1992 notice (57 FR

29410). These exceptions have been recognized in setting hospital cost

limitations for cost reporting periods beginning on and after July 1,

1979 (45 FR 41218), and were authorized under section 601(g) of the

Social Security Amendments of 1983 (Public Law 98-21). Section 601(g)

of Public Law 98-21 requires that any hospital in New England that was

classified as being in an urban area under the classification system in

effect in 1979 will be considered urban for purposes of the hospital

PPS. This provision is intended to ensure equitable treatment under the

hospital PPS. Under this authority, the following counties have been

deemed to be urban areas for purposes of payment under the inpatient

hospital prospective system:

Litchfield County, CT in the Hartford, CT MSA.

York County, ME and Sagadahoc County, ME in the Portland,

ME MSA.

Merrimack County, NH in the Boston-Brockton-Nashua, MA-NH

MSA.

Newport County, RI in the Providence Fall-Warwick, RI MSA.

We are continuing to grant these urban exceptions for the purpose

of applying the Medicare hospital wage index to the HHA standardized

regional average per-beneficiary limitations and the national per-

beneficiary limitation. These exceptions result in the same NECMA

definitions for hospitals, skilled nursing facilities, and HHAs. In New

England, MSAs are defined on town boundaries rather than on county

lines but exclude parts of the four counties cited above that would be

considered urban under the MSA definition. Under this notice, these

four counties are urban under either definition, NECMA or MSA.

Section 1861(v)(1)(L)(iii) of the Act requires the use of the area

wage index applicable under section 1886(d)(3)(E) of the Act and

determined using the survey of the most recent available wages and

wage-related costs of hospitals located in the geographic area in which

the home health service is furnished without regard to whether these

hospitals have been reclassified to a new geographic area under section

1886(d)(8)(B) of the Act. The wage index, as applied to the labor

portion of the regional per-beneficiary limitation and the labor

portion of the national per-beneficiary limitation, must be based on

the geographic location in which the home health service is actually

furnished.

C. New Providers and Providers Without a 12-Month Cost Reporting Period

Ending During Federal Fiscal Year 1994

For a new provider or a provider without a 12-month cost reporting

period ending in FY 1994 but for which the first cost reporting period

began before October 1, 1998, the per-beneficiary limitation will be a

national per-beneficiary limitation, that will be equal to the median

of these limitations applied to other HHAs without the 2 percent

reduction.

For a new provider whose first cost reporting period begins on or

after October 1, 1998, the per-beneficiary limitation will be 75

percent of the national per-beneficiary limitation including the 2

percent reduction.

A new provider or a provider without a 12-month cost reporting

period ending in FY 1994, which filed an application for HHA provider

status before September 15, 1998, or which was approved as a branch of

its parent agency before that date and becomes a subunit of the parent

agency or a separate agency on or after that date, will be subject to

the national per-beneficiary limitation (without the 2 percent

reduction).

VI. Market Basket

The 1993-based cost categories and weights are listed in Table 4

below.

[[Page 42774]]

Table 4.--1993-Based Cost Categories, Basket Weights, and Price Proxies

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

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

Compensation including allocated 77.668

Contract Services' Labor.

Wages and Salaries including 64.226 HHA Occupational Wage

allocated Contract Services' Index.

Labor.

Employee benefits, including 13.442 HHA Occupational

allocated Contract Services' Benefits Index.

Labor.

Operations & Maintenance......... 0.832 CPI-U Fuel & Other

Utilities.

Administrative & General, 9.569

including allocated Contract

Services' Non-labor.

Telephone.................... 0.725 CPI-U Telephone.

Paper & Printing............. 0.529 CPI-U Household Paper,

Paper Products &

Stationery Supplies.

Postage...................... 0.724 CPI-U Postage.

Other Administrative & 7.591 CPI-Services.

General, including allocated

Contract Services Non-Labor.

Transportation................... 3.405 CPI-U Private

Transportation.

Capital-Related.................. 3.204

Insurance.................... 0.560 CPI-U Household

Insurance.

Fixed Capital................ 1.764 CPI-U Owner's

Equivalent.

Movable Capital.............. 0.880 PPI Machinery &

Equipment.

Other Expenses, including 5.322 CPI-U All Items Less

allocated Contract Services\1\ Food & Energy.

Non-Labor.

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

Total...................... 100.000

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

VII. Update of Database

The data used to develop the cost per-visit limitations, the census

region per-beneficiary limitations, and the national per-beneficiary

limitation were adjusted using the latest available market basket

factors to reflect expected cost increases occurring between the cost

reporting periods contained in our database and September 30, 2000,

reduced by 1.1 percentage points as required by section

1861(v)(1)(L)(ix) of the Act and excluding any changes in the home

health market basket with respect to cost reporting periods that began

on or after July 1, 1994 and before July 1, 1996 as required by section

1861(v)(1)(L)(iv) of the Act. The following inflation factors were used

in calculating the per-visit limitations, the census region per-

beneficiary limitations, and national per-beneficiary limitations:

Table 5.--Factors for Inflating Database Dollars to September 30, 1999

[Inflation adjustment factors \1\]

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

FY end 1993 1994 1995 1996 1997 1998

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

October 31.................................... 1.13775 1.10901 1.10487 1.10291 1.07843 1.04734

November 30................................... 1.13492 1.10771 1.10487 1.10193 1.07571 1.04500

December 31................................... 1.13210 1.10652 1.10487 1.10076 1.07305 1.04272

January 31.................................... ......... 1.12929 1.10568 1.10487 1.09935 1.07042

February 28................................... ......... 1.12650 1.10519 1.10487 1.09771 1.06782

March 31...................................... ......... 1.12374 1.10503 1.10487 1.09585 1.06524

April 30...................................... ......... 1.12107 1.10492 1.10487 1.09381 1.06263

May 31........................................ ......... 1.11850 1.10487 1.10487 1.09162 1.05999

June 30....................................... ......... 1.11604 1.10487 1.10487 1.08926 1.05732

July 31....................................... ......... 1.11388 1.10487 1.10468 1.08674 1.05472

August 31..................................... ......... 1.11202 1.10487 1.10428 1.08405 1.05219

September 30.................................. ......... 1.11045 1.10487 1.10369 1.08121 1.04974

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

\1\ Source: The HHA Price Index, produced by HCFA. The forecasts are from Standard and Poor's DRI HCC 1st QTR

1999;@USSIM/[email protected]/Control 1991 forecast exercise which has historical data through 1999:1.

Multiplying nominal dollars for a given FY end by their respective

inflation adjustment factor will express those dollars in the dollar

levels for the FY ending September 30, 1999.

The procedure followed to develop these tables, based on

requirements from BBA, was to hold the June 1994 level for input price

index constant through June 1996. From July 1996 forward, we trended

the revised index forward using the percentage gain each month from the

HCFA Home Health Agency Input Price Index reduced by 1.1 percentage

points for cost reporting periods beginning in Federal FY 2000.

A. Short Period Adjustment Factors for Cost Reporting Periods

Consisting of Less Than 12 Months

HHAs with cost reporting periods beginning on or after October 1,

1999 may have cost reporting periods that are less than 12 months in

length. This may happen, for example, when a new provider enters the

Medicare program after its selected FY has already begun or when a

provider experiences a change of ownership before the end of the cost

reporting period. The data used in calculating the limitations were

updated to September 30, 2000. Therefore, the cost limitations

published in this notice are for a 12-month cost reporting period

beginning October 1, 1999 and ending September 30, 2000. For 12-month

cost reporting periods beginning after October 1, 1999 and before

October 1, 2000, cost reporting period adjustment factors are provided

in Addendum 2. However, when a cost reporting period consists of

[[Page 42775]]

fewer than 12 months, adjustments must be made to the data that have

been developed for use with 12-month cost reporting periods. To promote

the efficient dissemination of cost limitations to agencies with cost

reporting periods of fewer than 12 months, we are publishing an example

and tables to enable intermediaries to calculate the applicable

adjustment factors.

Cost reporting periods of fewer than 12 months may not necessarily

begin on the first of the month or end on the last day of the month. In

order to simplify the process in calculating ``short period''

adjustment factors, if the short cost reporting period begins before

the 16th of the month, we will consider the period to have begun on the

1st of that month. If the start of the cost reporting period begins on

or after the 16th of the month, it will be considered to have begun at

the beginning of the next month. Also, if the short period ends before

the 16th of the month, we will consider the period to have ended at the

end of the preceding month; if the short period ends on or after the

16th of the month, it will be considered to have ended at the end of

that month.

Example: 1. After approval by its intermediary, an HHA that had a

1994 base year changed its FY end from June 30 to December 31. Due to

this change, the HHA had a short cost reporting period beginning on

July 1, 2000 and ending on December 31, 2000. The cost reporting period

ending during FY 1994 was the cost reporting period ending on June 30,

1994. The limitations that apply to this short period must be adjusted

as follows:

Step 1--From Addendum 3, sum the index levels for the months of

July 2000 through December 2000: 6.89916

Step 2--Divide the results from Step 1 by the number of months in

short period: 6.899166=1.14986

Step 3--From Addendum 3, sum the index levels for the months in the

common period of October 1999 through September 2000: 13.6905

Step 4--Divide the results in Step 3 by the number of months in the

common period: 13.6905 x 12 = 1.140875

Step 5--Divide the results from Step 2 by the results from Step 4.

This is the adjustment factor to be applied to the published per-visit

and per-beneficiary limitations: 1.14986 x 1.140875 = 1.00788

Step 6--Apply the results from Step 5 to the published limitations.

For example:

a. Urban skilled nursing per-visit labor portion

$78.07 x 1.00788 = $78.69

b. Urban skilled nursing per-visit nonlabor portion

$22.45 x 1.00788 = $22.63

c. West South Central Census region division labor portion per-

beneficiary limitation

$4,667.91 x 1.00788 = $4,704.69

d. West South Central Census region division nonlabor portion per-

beneficiary limitation

$1,342.17 x 1.0788 = $1,447.93

Step 7--Also apply the results from Step 5 to the calculated

agency-specific per-beneficiary amount that has been updated to

September 30, 2000 using Table 2.

B. Adjustment Factor for Reporting Year Beginning After October 1, 1999

and Before October 1, 2000

If an HHA has a 12-month cost reporting period beginning on or

after November 1, 1999, the per-visit limitation and the adjusted

census region division per-beneficiary limitation and the agency-

specific per-beneficiary limitation or the adjusted national per-

beneficiary limitations are again revised by an adjustment factor from

Addendum 2 that corresponds to the month and year in which the cost

reporting period begins. Each factor represents the compounded rate of

monthly increase derived from the projected annual increase in the

market basket index reduced by 1.1 percentage points as required by

section 1861(v)(1)(L)(ix) of the Act and excluding any changes in the

home health market basket with respect to cost reporting periods that

began on or after July 1, 1994 and before July 1, 1996 as required by

section 1861(v)(1)(L)(iv) of the Act and is used to account for

inflation in costs that will occur after the date on which the per-

beneficiary limitations become effective.

In adjusting the agency-specific per-beneficiary limitation for the

market basket increases since the end of the cost reporting period

ending during Federal FY 1994, the intermediary will increase the

agency-specific per-beneficiary limitation to September 30, 2000. That

way when the limitations need to be further adjusted for the cost

reporting period, all elements of the limitation calculations can be

adjusted by the same factor. For example, if an HHA is providing

services in the Dallas MSA only and has a cost reporting period

beginning January 1, 2000, its occupational therapy per-visit

limitation and its per-beneficiary limitation would be further adjusted

as follows:

Computation of Revised Per-Visit Limitations for Occupational Therapy

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

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

Adjusted per-visit limitation.............................. $113.24

Adjustment factor from Addendum 2.......................... 1.00394

Revised per-visit limitation............................... $113.69

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

\1\ Adjusted by appropriate wage index applicable to the Dallas MSA and

the budget neutrality adjustment factor of 1.039.

Computation of Revised Per-Beneficiary Limitations for an HHA With a

1994 Base Period

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

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

Agency-specific component inflated through December 31, $4,086.60

2000: $5,560.00 x .98 x .75...........................

West south central division component: $5,886.10 \1\ x \1\ $1,442.

.98 x .25............................................... 091

Blended per-beneficiary limitation for Dallas-MSA.......... $5,528.69

Adjustment factor from Addendum 2.......................... 1.00394

Adjusted blended per-beneficiary limitation for Dallas MSA. $5,550.47

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

\1\ Adjusted by the appropriate wage index applicable to the Dallas MSA

and the budget neutrality factor of 1.039.

Computation of Revised Per-Beneficiary Limitation for a New Provider

Whose First Cost Reporting Period Began Before October 1, 1997 in the

Dallas MSA

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

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

National per-beneficiary limitation for Dallas MSA \1\..... \1\ $3,513.

73

Adjustment factor from Addendum 2.......................... 1.00394

Adjusted national per-beneficiary limitation............... $3,527.57

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

\1\ From Table 6C Adjusted by the appropriate wage index applicable to

the Dallas MSA and the budget neutrality factor of 1.039.

VIII. Schedules of Per-Visit and Per-Beneficiary Limitations

The schedules of limitations set forth below apply to cost

reporting periods beginning on or after October 1, 1999. The

intermediaries will compute the adjusted limitations using the wage

indicies published in Addenda 1a and 1b for each MSA and non-MSA for

which the HHA provides services to Medicare beneficiaries. The

intermediary will notify each HHA it services of its applicable

limitations for the area(s) where the HHA furnishes HHA services to

Medicare beneficiaries. Each HHA's aggregate limitations cannot be

determined prospectively but depend on each HHA's Medicare utilization

(visits and unduplicated

[[Page 42776]]

census count) by location of the HHA services furnished for the cost

reporting periods subject to this document.

Section 1861(v)(1)(L)(vi)(II) of the Act requires the per-

beneficiary limitations to be prorated among HHAs for Medicare

beneficiaries who use services furnished by more than one HHA. The per-

beneficiary limitation will be prorated based on a ratio of the number

of visits furnished to the individual beneficiary by the HHA during its

cost reporting period to the total number of visits furnished by all

HHAs to that individual beneficiary during the same period.

The proration of the per-beneficiary limitation will be done based

on the fraction of services the beneficiary received from the HHA. For

example, if an HHA furnished 100 visits to an individual beneficiary

during its cost reporting period ending September 30, 2000, and that

same individual received a total of 400 visits during that same period

from that and other agencies, the HHA would count the beneficiary as a

.25 unduplicated census count of Medicare patients for the cost

reporting period ending September 30, 2000.

The HHA costs that are subject to the per-visit limitations include

the cost of medical supplies routinely furnished in conjunction with

patient care. Durable medical equipment, orthotic, prosthetic, and

other medical supplies directly identifiable as services to an

individual patient are excluded from the per-visit costs and are paid

without regard to the per-visit schedule of limitations. (See Chapter

IV of the Home Health Agency Manual (HCFA Pub. II).)

The HHA costs that are subject to the per-beneficiary limitations

include the costs of medical supplies routinely furnished and

nonroutine medical supplies furnished in conjunction with patient care.

Durable medical equipment directly identifiable as services to an

individual patient is excluded from the per-beneficiary limitations and

is paid without regard to this schedule of per-beneficiary limitations.

The intermediary will determine the aggregate limitations for each

HHA according to the location where the services are furnished by the

HHA. Medicare payment is based on the lower of the HHA's total

allowable Medicare costs plus the allowable Medicare costs of

nonroutine medical supplies, the aggregate per-visit limitation plus

the allowable Medicare costs of nonroutine medical supplies, or the

aggregate per-beneficiary limitation. An example of how the aggregate

limitations are computed for an HHA providing HHA service to Medicare

beneficiaries in both Dallas, Texas, and rural Texas is as follows:

Example: HHA X, an HHA located in Dallas, TX, has 11,550 skilled

nursing visits, 4,300 physical therapy visits, 8,900 home health aide

visits and an unduplicated census count of 400 Medicare beneficiaries

in the Dallas MSA and 5,000 skilled nursing visits, 2,300 physical

therapy visits, 4,300 home health aide visits, and an unduplicated

census count of 200 Medicare beneficiaries in rural Texas during its

12-month cost reporting period ending September 30, 2000. The

unadjusted agency-specific per-beneficiary amount for the base period

(cost reporting period ending September 30, 1994) is $4,825.00. The

aggregate limitations are calculated as follows:

Determining the Aggregate Per-Beneficiary Limitation

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

Unduplicated

census count Total per-

MSA/Non-MSA area Per-beneficiary limitation of Medicare beneficiary

beneficiaries limitation

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

Dallas, TX...................................... ($4,825.00 x 1.11045 x .98 x 400 $2,152,064

.75) plus (($4,667.91 x .9369

x 1.039) plus $1,342.17)) x

.98 x .25.

Rural, TX....................................... ($4,825.00 x 1.11045 .98 x 200 1,033,162

.75) plus (($4,667.91 x .7565

x 1.039) plus 1,342.17)) x .98

x .25.

Aggregate Limitation............................ .................................. ............. 3,185,226

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

Determining the Aggregate Per-Visit Limitation

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

Number of Per-visit

Area/Type of visit visits limit \1\ Total limit

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

Dallas-MSA:

Skilled nursing.............. 11,550 $ 98.45 $1,137,098

Physical therapy............. 4,300 112.84 485,212

Home health aide............. 8,900 45.36 403,704

Rural Texas:

Skilled nursing.............. 5,000 92.33 461,650

Physical therapy............. 2,300 105.71 243,133

Home health aide............. 4,300 38.80 166,840

Aggregate limitation............. ........... ........... $2,897,637

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

\1\ The per-visit has been adjusted by the appropriate wage index and

the budget neutrality adjustment factor of 1.039.

For the cost reporting period ending September 30, 2000, the HHA

incurred $2,935,500 in Medicare costs for the discipline services and

$335,000 for the costs of Medicare nonroutine medical supplies.

Medicare reimbursement for this HHA would be $3,185,226, which is the

lesser of the actual costs of $2,935,500 plus the costs of nonroutine

medical supplies of $335,000 or the aggregate per-visit limitation of

$2,897,637 plus the costs of nonroutine medical supplies of $335,000 or

the aggregate per-beneficiary limitation of $3,185,226.

Before the limitations are applied during settlement of the cost

report, the HHA's actual costs are reduced by the amount of individual

items of costs (for example, administrative compensation and contract

services) that are found to be excessive under the Medicare principles

of provider payment. That is,

[[Page 42777]]

the intermediary reviews the various reported costs, taking into

account all the Medicare payment principles, for example, the cost

guidelines for physical therapy furnished under arrangements (see

Sec. 413.106) and the limitation on costs that are substantially out of

line with those of comparable HHAs (see Sec. 413.9).

Table 6a.--Per-Visit Limitations

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

Per-Visit Labor Nonlabor

Type of visit limitation portion Portion \1\

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

MSA (NECMA) location:

Skilled nursing care......... $100.52 $78.07 $22.45

Physical therapy............. 115.22 89.49 25.73

Speech therapy............... 116.71 90.65 26.06

Occupational therapy......... 115.63 89.81 25.82

Medical social services...... 140.99 109.51 31.49

Home health aide............. 46.32 35.98 10.34

NonMSA location:

Skilled nursing care......... 110.74 86.01 24.73

Physical therapy............. 126.78 98.47 28.31

Speech therapy............... 132.64 103.02 29.62

Occupational therapy......... 132.12 102.61 29.50

Medical social services...... 173.67 134.89 38.78

Home health aides............ 46.53 36.14 10.39

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

\1\ Nonlabor portion of per-visit limitations for HHAs located in

Alaska, Hawaii, Puerto Rico, and the Virgin Islands is increased by

multiplying it by the following cost-of-living adjustment factors.

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

Adjustment

Location factor

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

Alaska..................................................... 1.250

Hawaii:

County of Honolulu..................................... 1.250

County of Hawaii....................................... 1.150

County of Kauai........................................ 1.225

County of Maui......................................... 1.225

County of Kalawao...................................... 1.225

Puerto Rico................................................ 1.100

Virgin Islands............................................. 1.200

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

Table 6b.--Standardized Per-Beneficiary Limitation by Census Region

Division, Labor/Nonlabor

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

Labor Nonlabor

Census region division component component

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

New England (CT, ME, MA, NH, RI, VT).......... $2,797.47 $804.37

Middle Atlantic (NJ, NY, PA).................. 2,073.06 596.06

South Atlantic (DE, DC, FL, GA, MD, NC, SC, 3,127.39 899.23

VA, WV)......................................

East North Central (IL, IN, MI, OH, WI)....... 2,535.84 729.14

East South Central (AL, KY, MS, TN)........... 4,808.31 1,382.55

West North Central (IA, KS, MN, MO, NE, ND, 2,435.65 700.32

SD)..........................................

West South Central (AR, LA, OK, TX)........... 4,667.91 1,342.17

Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..... 3,076.15 884.49

Pacific (AK, CA, HI, OR, WA).................. 2,383.02 685.20

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

Table 6c.\1\--Standardized Per-Beneficiary Limitation for New Agencies

and Agencies Without a 12-month Cost Report Ending During FY 1994 for

Which the First Cost Reporting Began Before October 1, 1998

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

Labor Nonlabor

component component

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

National...................................... $2,786.53 $801.21

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

\1\ This is the national rate set at 100 percent.

Table 6d.\2\--Standardized Per-Beneficiary Limitations for New Providers

for Which the First Cost Reporting Period Begins on or After October 1,

1998

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

Labor Nonlabor

component component

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

National...................................... $2,048.10 $588.89

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

\2\ This is the national rate set at 75 percent of 98 percent of Table

6c.

Table 6e.--Standardized Per-Beneficiary Limitations for Puerto Rico and

Guam

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

Labor Nonlabor

component component

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

Puerto Rico................................... $2,030.66 $583.88

Guam.......................................... 1,962.40 564.25

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

IX. Regulatory Impact Statement

A. Introduction

We have examined the impacts of this notice with comment as

required by Executive Order 12866, the Regulatory Flexibility Act (RFA)

(Pub. L. 96-354), and the Unfunded Mandates Reform Act

[[Page 42778]]

of 1995 (Pub. L. 104-4). Executive Order 12866 directs agencies to

assess all costs and benefits of available regulatory alternatives and,

when regulation is necessary, to select regulatory approaches that

maximize net benefits (including potential economic, environmental,

public health and safety effects; distributive impacts; and equity).

For purposes of the RFA, small entities include small business as

defined under the Small Business Administration, nonprofit

organizations, and small governmental jurisdictions. Most HHAs are

considered small entities either by nonprofit status or by meeting the

Small Business Administration's standard for a small business (annual

revenues of $5 million or less) .

Table 7 illustrates the Distribution of HHAs by type participating

in Medicare as of April 13, 1999.

Table 7.--Number of HHAs by Provider Type

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

HHA provider type Number

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

Visiting Nurse Association................................. 484

Combination Gov't and Voluntary............................ 34

Official Health Agency..................................... 1067

Rehab Facility-Based....................................... 2

Hospital-Based............................................. 2486

Skilled Nursing Facility-Based............................. 174

Other...................................................... 4612

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

Total.................................................. 8859

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

Source: HCFA--On Line Survey Certification and Reporting System

Standard Report 10--4/13/99

The following RFA analysis, together with the rest of this

preamble, explains the rationale for and purposes of this notice,

analyzes alternatives, and presents the measures we propose to minimize

the burden on small entities.

We anticipate this notice, in total, will not have a significant

impact on a substantial number of small entities. The policies set

forth in this notice are consistent with those set forth in the

``Schedules of Per-Visit and Per-Beneficiary Limitations on Home Health

Agency Costs for Cost Reporting Periods Beginning On or After October

1, 1998'' (63 FR 42912) as subsequently amended by section 5101 of

OCESAA '99, and the financial effect os this notice on HHAs is confined

to our rebasing of the per-visit limitations. We estimate that the

financial effect of this notice will be a cost to the Medicare program

of approximately $40 million in Federal FY 2000, which amount does not

meet the $100 million RFA threshold for an economically significant

rule.

In addition, we have examined the options for lessening the burden

on small entities; however, the statute does not allow for any

exceptions to these limitations based on size of entity. Therefore,

there are no options to lessen the regulatory burden that are

consistent with the statute. Although this notice does not meet the

$100 million threshold for an RFA analysis, we are preparing a

voluntary one because this notice with comment is an integral part of

the HHA IPS.

Section 202 of the Unfunded Mandates Reform Act requires agencies

to prepare an assessment of anticipated costs and benefits before

proposing any rule that may result in an annual expenditure by State,

local, or tribal governments, in the aggregate, or by private sector,

of $100 million (adjusted annually for inflation). We believe that

there are no costs associated with this notice with comment that apply

to these governmental and private sectors. Therefore, the law does not

apply.

This notice with comment is not a major rule as defined in title 5,

United States Code, section 804(2) and is not an economically

significant rule under Executive Order 12866. However, we are preparing

a regulatory impact statement because this notice with comment is an

integral part of the HHA IPS.

1. Background

This notice with comment period sets forth revised schedules of

limitations on HHA costs that may be paid under the Medicare program

for cost reporting periods beginning on or after October 1, 1999 and

portions of cost reporting periods beginning before October 1, 2000.

These limitations replace the limitations that were set forth in our

August 11, 1998 notice with comment period (63 FR 42912).

The methodology used to develop the schedule of per-visit

limitations in this notice is the same as that used in setting the

limitations effective October 1, 1998. We are using the latest settled

cost report data from freestanding HHAs to develop the per-visit cost

limitations. We have updated the per-visit cost limitations to reflect

the expected cost increases between the cost reporting periods in the

database and September 30, 2000 reduced by 1.1 percentage points as

required by section 1861(v)(1)(L)(ix) of the Act and excluding any

changes in the home health market basket with respect to cost reporting

periods that began on or after July 1, 1994 and before July 1, 1996 as

required by section 1861(v)(1)(l)(iv) of the Act.

To develop the schedule of per-visit limitations effective for cost

reporting periods beginning on or after October 1, 1999, we extracted

actual cost per-visit data from the most recent settled Medicare cost

reports for periods beginning on or after October 1, 1994 and settled

by March 1999. The majority of the cost reports were from Federal FY

1996. We then adjusted the data using the latest available market

basket indices to reflect expected cost increases occurring between the

cost reporting periods contained in our database and September 30,

2000, reduced by 1.1 percentage points as required by section

1861(v)(1)(L)(ix) of the Act and excluding any changes in the home

health market basket with respect to cost reporting periods that began

on or after July 1, 1994 and before July 1, 1996 as required by section

1861(v)(1)(L)(iv) of the Act.

A wage index is used to adjust the labor-related portion of the

per-visit limitation to reflect differing wage levels among areas. In

establishing the per-visit limitation, we used the FY 1999 hospital

wage index, which is based on 1995 hospital wage data.

The methodologies and data used to develop the schedule of per-

beneficiary limitations set forth in this notice are the same as those

used in setting the per-beneficiary limitations that were effective for

cost reporting periods beginning on or after October 1, 1998. We have

updated the per-beneficiary limitations to reflect the expected cost

increases occurring between the cost reporting periods ended during

Federal FY 1994 and September 30, 2000, excluding any changes in the

home health market basket with respect to cost reporting periods that

began on or after July 1, 1994 and before July 1, 1996 as required by

law.

The cost report data used to develop the schedule of per-

beneficiary limitations set forth in this notice are for cost reporting

periods ending in Federal FY 1994, as required by section 1861(v)(1)(L)

of the Act. We have updated the per-beneficiary limitations to reflect

the expected cost increases occurring between the cost reporting

periods for the data contained in the database and September 30, 2000

(excluding, as required by statute, any changes in the home health

market basket for cost reporting periods beginning on or after July 1,

1994 and before July 1, 1996).

A wage index is used to adjust the labor-related portion of the

standardized regional average per-beneficiary limitation and the

national per-

[[Page 42779]]

beneficiary limitation to reflect differing wage levels among areas. In

establishing the regional average per-beneficiary limitation and

national per-beneficiary limitation, we used the FY 1999 hospital wage

index effective with discharges on or after March 1, 1999, which is

based on 1995 hospital wage data.

For new providers and providers without a 12-month cost reporting

period ending in Federal FY 1994 but for which the first cost reporting

period began before October 1, 1998, the per-beneficiary limitation

will be a national per-beneficiary limitation that will be equal to the

median of these limitations applied to other HHAs without the two

percent reduction required in the original BBA legislation.

For new providers for which the first cost reporting period begins

on or after October 1, 1998, the per-beneficiary limitation will be the

75 percent of the national per-beneficiary limitations with the 2

percent reduction.

A new provider or a provider without a 12-month cost reporting

period in Federal FY 1994 that filed an application for home HHA

provider status before September 15, 1998, or that was approved as a

branch of its parent agency before that date and becomes a subunit of

the parent agency or a separate agency on or after that date will be

subject to the national per-beneficiary limitation without the 2

percent reduction.

The requirements for the per-visit and per-beneficiary limitations

are set forth in Section 1861(v)(1)(L) of the Act. (See Section I of

this notice for an expanded discussion.) These requirements are

numerically explicit and allow us no administrative latitude. Thus, it

is not possible to consider other alternatives for these limitations.

2. Effects of This Notice With Comment on HHAs

This notice updates the HHA IPS for Federal FY 2000. As we

mentioned earlier in this regulatory impact analysis, we estimate that

there will be a cost to the Medicare program of approximately $40

million in Federal FY 2000. Payments by Medicare under this system of

payment limitations must be the lower of an HHA's actual reasonable

allowable costs, per-visit limitations in the aggregate, or a per-

beneficiary limitation in the aggregate. The settled cost report data

that we are using have been adjusted by the most recent market basket

factors, reduced by 1.1 percentage points as required by section

1861(v)(1)((l)(ix) of the Act, and excluding market basket increases

for cost reporting periods beginning on or after July 1, 1994 and

before July 1, 1996, as required by section 1861(v)(1)(L)(iv) of the

Act to reflect the expected cost increases occurring between the cost

reporting periods for the data contained in the database and September

30, 2000.

The following quantitative analysis presents the projected effects

of the statutory changes effective for Federal FY 2000. We are unable

to identify the effects of the changes to the cost limits on individual

HHAs. However, Table 8 below illustrates the proportion of HHAs that

are likely to be affected by the limits. This table is a model of our

estimate of the revision in the schedule of the per-visit and per-

beneficiary limitations.

Table 8 represents the projected effects of the HHA IPS and is

based on the 574 providers in the audited cost report sample developed

for HHA PPS extrapolated into a national weighted total of 7,161 HHAs.

This sample has been adjusted by the most recent market basket factors

to reflect the expected cost increases occurring between the cost

reporting periods for the data contained in the database and September

30, 2001. Table 8 reflects cost reporting periods beginning Federal FY

2000 and those portions of cost reporting periods after October 1, 2000

that have a cost reporting period beginning in Federal FY 2000. These

portions will be subject to the limits in this notice minus 15 percent.

Column one of this table divides HHAs by a number of

characteristics including provider type, region, and urban versus rural

location. For purposes of this impact table four regions have been

defined: Northeast, South, Midwest, and West. The Northeast Region

consists of Connecticut, Massachusetts, Maine, New Hampshire, New

Jersey, New York, Pennsylvania, Puerto Rico, Rhode Island, Vermont, and

the Virgin Islands. The South Region consists of Alabama, Arkansas, the

District of Columbia, Delaware, Florida, Georgia, Kentucky, Louisiana,

Maryland, Mississippi, North Carolina, Oklahoma, South Carolina,

Tennessee, Texas, Virginia, and West Virginia. The Midwest Region

consists of Iowa, Illinois, Indiana, Kansas, Michigan, Minnesota,

Missouri, North Dakota, Nebraska, Ohio, South Dakota, and Wisconsin.

The West Region consists of Alaska, Arizona, California, Colorado,

Hawaii, Idaho, Montana, New Mexico, Nevada, Oregon, Utah, Washington,

and Wyoming.

This table takes into account the behaviors that we believe HHAs

will engage in to reduce the adverse effects of section 4602 of the BBA

on their allowable costs. We believe these behavioral offsets might

include an increase in the number of low-cost beneficiaries served, a

general decrease in the number of visits provided, and earlier

discharge of patients who are not eligible for Medicare home health

benefits because they no longer need skilled services but have only

chronic, custodial care needs. We believe that, on average, these

behavioral offsets will result in a 65 percent reduction in the effects

these limits might otherwise have on an individual HHA for the per-

beneficiary limitations and a 50 percent reduction for the per-visit

limitations.

Column one of this table divides HHAs by a number of

characteristics including their ownership, whether they are old or new

agencies, whether they are located in an urban or rural area, and the

region in which they are located. Column two shows the number of

agencies that fall within each characteristic or group of

characteristics. For example, there are 2,549 rural freestanding HHAs

in our database. Column three shows the percent of HHAs within a group

that are projected to exceed the per-visit limitation (and therefore

will not be affected by the per-beneficiary limitation) before the

behavioral offsets are taken into account. Column four shows the

average percent of costs over the per-visit limitation for an agency in

that cell, including behavioral offsets. Column five shows the percent

of HHAs within a group that are projected to exceed the per-beneficiary

limitation (and therefore will not be affected by the per-visit

limitation) before the behavioral offsets are taken into account.

Column six shows the average percent of costs over the per-beneficiary

limitation for an agency in that category, including behavioral

offsets. It is important to note that in determining the expected

percentage of an agency's costs exceeding the cost limitations, column

four (percent of costs exceeding visit limits) and column six (percent

of costs exceeding beneficiary limits) are not to be added together.

Either the per-visit limitation or the per-beneficiary limitation is

exceeded, but not both.

[[Page 42780]]

Impact of Table 8.--The IPS HHA Limits, Effective 10/1/99

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

Percent of Percent of Percent of Percent of

agencies costs agencies costs

Number of exceeding exceeding exceeding exceeding

agencies visit visit beneficiary beneficiary

limits limits limits limits

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

GEOGRAPHIC AREA

ALL AGENCIES................................... 7161 14.9 1.3 78.6 12.1

FREESTANDING................................... 4703 6.8 0.3 86.0 14.1

HOSPITAL-BASED................................. 2458 30.4 2.8 64.3 9.1

OLD AGENCIES............................... 4467 17.2 1.6 78.2 10.3

FREESTANDING........................... 2467 7.9 0.4 87.6 11.5

HOSPITAL-BASED......................... 2000 28.8 2.7 66.7 9.1

NEW AGENCIES*.............................. 2693 10.9 0.7 79.2 17.2

FREESTANDING........................... 2235 5.5 0.3 84.3 18.4

HOSPITAL-BASED......................... 458 37.2 4.1 54.3 9.4

ALL URBAN...................................... 4612 15.2 1.5 79.1 12.0

FREESTANDING............................... 3397 7.1 0.4 85.7 14.0

HOSPITAL BASED............................. 1215 38.0 3.0 60.4 9.1

OLD AGENCIES............................... 2574 16.0 1.7 82.0 10.2

FREESTANDING........................... 1611 8.9 0.5 88.3 11.4

HOSPITAL-BASED......................... 963 37.6 2.9 62.4 9.1

NEW AGENCIES............................... 2038 12.2 0.9 74.8 16.9

FREESTANDING........................... 1786 5.5 0.3 83.4 18.0

HOSPITAL-BASED......................... 252 39.3 4.0 52.9 8.8

ALL RURAL...................................... 2549 14.2 0.8 77.7 12.4

FREESTANDING............................... 1306 5.9 0.1 86.7 14.3

HOSPITAL-BASED............................. 1243 23.0 2.1 68.2 9.3

OLD AGENCIES............................... 1894 10.1 1.0 80.2 10.5

FREESTANDING........................... 857 6.0 0.1 86.1 11.6

HOSPITAL-BASED......................... 1037 20.6 2.1 70.6 9.1

NEW AGENCIES............................... 655 10.9 0.2 80.4 18.9

FREESTANDING........................... 449 5.7 0.0 88.0 20.3

HOSPITAL-BASED................................. 206 34.7 1.4 55.9 11.6

BY: REGION

OLD AGENCIES............................... 4467 17.2 1.6 78.2 10.3

MIDWEST................................ 1298 16.9 2.6 78.6 6.8

NORTHEAST.............................. 649 7.4 0.3 89.2 10.3

SOUTH.................................. 1857 17.0 1.2 80.1 12.0

WEST................................... 662 28.4 4.1 61.4 8.4

NEW AGENCIES............................... 2693 10.9 0.7 79.2 17.2

MIDWEST................................ 607 15.2 1.0 73.1 10.9

NORTHEAST.............................. 247 19.6 2.4 60.2 9.9

SOUTH.................................. 1316 7.2 0.4 83.5 21.4

WEST................................... 524 11.3 0.3 84.4 16.2

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

* New Agencies Are Those Without a 12-Month Cost Reporting Period Beginning in Federal FY 1994.

B. Percent of Costs Exceeding Per-Visit Limitations (Column Four)

Results from this column indicate that, for an HHA that reaches the

per-visit limitation first, the average percent of the agency's costs

exceeding the per-visit limitation for an HHA in the ``all agencies''

category is 1.3 percent after the behavioral offset. This relatively

low number should not be surprising since the intent of section 4602 of

the BBA is to control the soaring expenditures of the Medicare home

health benefit that have been driven largely by increased utilization

rather than the price per visit. For the all agencies category sorted

by provider type, the average percent of freestanding HHAs exceeding

the per-visit limitation is 0.3 percent; for hospital-based HHAs, it is

2.8 percent. This also should not be surprising as hospital-based HHAs

have historically had higher overhead costs. All discussion of the

analysis of the per-visit limitation is based on the fact that HHAs in

these categories reached the per-visit limitation and therefore are not

affected by the per-beneficiary limitation. For the overall old

agencies category (HHAs that filed a 12-month cost report that ended

during Federal FY 1994), the average percent of the agency's costs

exceeding the per-visit limitation is 1.6 percent; for freestanding

HHAs, it is 0.4 percent; and for hospital-based HHAs, it is 2.7

percent. For the overall new agencies category (such as HHAs that did

not have a 12-month cost reporting period ended in Federal FY 1994 or

that entered the Medicare program after Federal FY 1994), the average

percent of the agency's costs exceeding the per-visit limitation is 0.7

percent, for freestanding HHAs, it is 0.3 percent; and for hospital-

based HHAs, it is 4.1 percent.

For the urban areas HHA category, the average percent of the

agency's costs exceeding the per-visit limitation is 1.5 percent. For

freestanding HHAs, it is 0.4 percent; and for hospital-based HHAs, it

is 3.0 percent. For the rural areas HHA category, the average percent

of such agency's cost exceeding the per-visit limitation is 0.8

percent; for freestanding HHAs, it is 0.1 percent; and for hospital-

based HHAs, it is 2.1 percent.

For the old agencies urban provider type category, the average

percent of the agency's costs exceeding the per-visit limitation for

freestanding HHAs is 0.5 percent; and for hospital-based HHAs, it is

2.9 percent. For the old agencies rural provider type, the average

percent of the agency's costs exceeding the per-visit limitation for

freestanding HHAs is 0.1

[[Page 42781]]

percent; and for hospital-based HHAs, is 2.1 percent. For the old

agencies region category, the average percent of the agency's costs

exceeding the per-visit limitation ranges from a low of 0.3 percent in

the Northeast region to a high of 4.1 percent in the West region. The

other regions range between 1.2 and 2.6 percent.

For the new agencies urban provider type category, the average

percent of the agency's costs exceeding the per-visit limitation for

freestanding HHAs is 0.3 percent while for hospital-based HHAs it is

4.0 percent. For the new agencies rural provider type category the

average percent; of the agency's costs exceeding the per-visit

limitation for freestanding HHAs is 0.0 percent and for hospital based

HHAs is 1.4 percent. For the new agencies region category, the average

percent of the agency's costs exceeding the per-visit limitation ranges

from a low of 0.3 percent in the West region to a high of 2.4 percent

in the Northeast region. The other regions range between 0.4 percent

and 1.0 percent.

C. Percent of Costs Exceeding Per-Beneficiary Limitation (Column Six)

Results from this column indicate that, for an HHA that reaches the

per-beneficiary limitation first, the average percent of the agency's

costs exceeding the per-beneficiary limitation for an HHA in the ``all

agencies'' category is 12.1 percent after the behavioral offset; for

freestanding HHAs, it is 14.1 percent; and for hospital-based HHAs, it

is 9.1 percent. All discussion of the analysis of the per-beneficiary

limitation is based on the fact that HHAs in these categories reached

the per-beneficiary limitation and therefore are not affected by the

per-visit limitation.

For the overall old agencies category (HHAs that filed a 12-month

cost report that ended during Federal FY 1994), the average percent of

the agency's costs exceeding the per-beneficiary limitation is 10.3

percent; for freestanding HHAs, it is 11.5 percent; and for hospital-

based HHAs it is 9.1 percent. For the overall new agencies category

(including HHAs that did not have a 12-month cost reporting period

ended in Federal FY 1994 or that entered the Medicare program after

Federal FY 1994), the average percent of the agency's costs exceeding

the per-beneficiary limitation is 17.2 percent; for freestanding HHAs,

it is 18.4 percent; and for hospital-based HHAs, it is 9.4 percent. Old

agencies will not be affected as much by the per-beneficiary

limitations as the new agencies, on average, because the new agencies

have, in general, reported higher costs per patient related to higher

levels of utilization. Moreover, the statutory provision for old

providers that bases 75 percent of the limitation on their own cost

experience would implicitly result in less of an impact than

experienced by the new providers whose limitations are based on a

national median that may be higher or lower than their previous costs.

Also, we believe the differing impacts of these limits is an inherent

result of beginning to draw unexplained variation among providers

utilization and cost closer to national norms that existed before the

rapid increase in home health expenditures of the post '93 to '94

period.

For the urban areas HHA category, the average percent of the

agency's costs exceeding the per-beneficiary limitation is 12.0

percent; for freestanding HHAs, it is 14.0 percent; and for hospital-

based HHAs, it is 9.1 percent. For the rural areas HHA category, the

average percent of the agency's costs exceeding the per-beneficiary

limitation is 12.4 percent; for freestanding HHAs, it is 14.3 percent;

and for hospital-based HHAs, it is 9.3 percent. For the old agencies

urban provider type category, the average percent of the agency's costs

exceeding the per-beneficiary limitation for freestanding HHAs is 11.4

percent; and for hospital-based HHAs is 9.1 percent. For the old

agencies rural provider type category, the average percent of the

agency's costs exceeding the per-beneficiary limitation for

freestanding HHAs is 11.6 percent; and for hospital-based HHAs is 9.1

percent. For the old agencies region category, the average percent of

the agency's costs exceeding the per-beneficiary limitation ranges from

a low of 6.8 percent in the Midwest region to a high of 12.0 percent in

the South region. The other regions range between 8.4 percent and 10.3

percent. The differences between regions reflect the pattern of highly

disparate costs that have been reported historically between geographic

areas that cannot be explained by differences in patient

characteristics but appear more related to patterns of HHA business

practices. The impact tracks the pre-HH IPS pattern of regions with

highest costs.

For the new agencies urban provider type category, the average

percent of the agency's costs exceeding the per-beneficiary limitation

for freestanding HHAs is 18.0 percent; and for hospital based HHAs, it

is 8.8 percent. For the new agencies rural provider type category the

average percent of the agency's costs exceeding the per-beneficiary

limitation for freestanding HHAs is 20.3 percent; and for hospital-

based HHAs is 11.6 percent. For the new agencies region category, the

average percent of the agency's costs exceeding the per-beneficiary

limitation ranges from a low of 9.9 percent in the Northeast region to

a high of 21.4 percent in the South region. The other regions range

from 10.9 percent to 16.2 percent. In general, newer agencies in

regions that have exceptionally high cost histories experience a bigger

impact due to their being limited to the national median.

Although there is considerable variation in these limitations, we

believe this is a reflection of the wide variation in payments that

have been recognized under the present cost reimbursement system.

Moreover, we believe the differing impacts of these limitations is an

inherent result of beginning to draw unexplained variation among

providers closer to which existed before the rapid increase in home

health expenditures of the post '93 to '94 period. Because this rule

limits payments to HHAs to the lesser of actual cost, the per-visit

limitations, or the per-beneficiary limitation, we have estimated the

combined impact of these limitations in terms of the number of agencies

affected to a greater or lesser extent by both limits.

We estimate that in Federal FY 2000, 15 percent of the HHAs will be

limited by the per-visit limitation while 79 percent will be limited to

the per-beneficiary limitation. It is important to note again that an

HHA is affected either by the per-visit limitation or the per-

beneficiary. They will not be affected by both.

Medicare payments to managed care plans are based on fee-for-

service Medicare benefits. Although we do not know what home health

services are supplied for these payments, we know how much we pay the

plans as a result of fee-for-service home health payments. Thus,

managed care payments are figured in as part of our cost/savings

estimates. Managed care plans are not expected to reduce home health

services as a result of this notice. For Federal FY 2000, we estimate

that 20 percent of the Medicare cost will be for payments to managed

care plans, our estimate for Federal FY 2003 is 26 percent.

We believe that the effect of this notice on State Medicaid

programs overall will be small. However, because of the flexibility and

variation in State Medicaid policies and service delivery systems as

well as differences in provider behavior in reaction to these limits,

it is impossible to predict which States will be affected or the

magnitude of the impact.

We have reviewed this notice under the threshold criteria of

Executive Order 12612. We have determined that it does

[[Page 42782]]

not significantly affect the rights, roles, and responsibilities of

States.

X. Collection of Information Requirements

Under the Paperwork Reduction Act of 1995, agencies are required to

provide a 60-day notice in the Federal Register and solicit public

comments before a collection of information requirement is submitted to

the Office of Management and Budget for review and approval. This

document does not impose information collection and record keeping

requirements. Consequently, it need not be reviewed by the Office of

Management and Budget under the authority of the Paperwork Reduction

Act of 1995.

XI. Other Required Information

A. Waiver of Proposed Notice

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

notice in the Federal Register to provide a period for public comment

before the provisions of the notice take effect. However, we may waive

this procedure if for good cause we find that prior notice and comment

are impracticable, unnecessary, or contrary to public interest. (5 USC

section 553(b)(B)).

Section 1861(v)(1)(L) of the Act requires that the Secretary

establish revised HHA cost limits for cost reporting periods beginning

on or after July 1, 1991 and annually thereafter (except for cost

reporting periods beginning on or after July 1, 1994 and before July 1,

1996). In accordance with the statute, we have used the same

methodology to develop the schedules of limits that were used in

setting the limits effective for cost reporting periods beginning on or

after October 1, 1997. These cost limits have been updated by the

appropriate market basket adjustment factor to reflect the cost

increases occurring between the cost reporting periods for the data

contained in the database and September 30, 2000 as required by section

1861(v)(1)(L)(ix) of the Act excluding market basket increases, reduced

by 1.1 percentage points with respect to cost reporting periods that

began on or after July 1, 1994 and before July 1, 1996 as required by

section 1861(v)(1)(L)(iv) of the Act. In addition, as required under

section 1861(v)(1)(L) of the Act, we have used the most recently

published hospital wage index.

Therefore, for good cause we find that it was unnecessary to

undertake notice and comment procedures. Generally, the methodology

used to develop these schedules of limits is dictated by statute and

does not require the exercise of discretion. These methodologies have

also been previously published for public comment. It was also

necessary to inform HHAs of their new cost limitations in a timely

manner so that HHAs could benefit from the most recently published wage

index and updated market basket adjustment factor.

Accordingly, for good cause, we waive prior notice and comment

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

public comment, as indicated at the beginning of this notice.

B. Public Comments

Because of the large number of items of correspondence we normally

receive on a notice with comment period, we are not able to acknowledge

or respond to them individually. However, we will consider all comments

concerning the provisions of this notice that we receive by the date

and time specified in the ``Dates'' section of this notice, and we will

respond to those comments in a subsequent document.

Authority: Section 1861(v)(1)(L) of the Social Security Act (42

U.S.C. 1395x(v)(1)(L)); section 4207(d) of Pub. L. 101-508 (42

U.S.C. 1395x (note)).

(Catalog of Federal Domestic Assistance Program No. 93.773

Medicare--Hospital Insurance)

Dated: June 16, 1999.

Nancy-Ann Min DeParle,

Administrator, Health Care Financing Administration.

Dated: June 29, 1999.

Donna E. Shalala,

Secretary.

Addendum 1a.--Wage Index for Urban Areas

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

Wage

Urban area (Constituent counties) index

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

0040 Abilene, TX............................................. 0.7981

Taylor, TX

0060 Aguadilla, PR........................................... 0.4727

Aguada, PR

Aguadilla, PR

Moca, PR

0080 Akron, OH............................................... 0.9900

Portage, OH

Summit, OH

0120 Albany, GA.............................................. 0.7975

Dougherty, GA

Lee, GA

0160 Albany-Schenectady-Troy, NY............................. 0.8610

Albany, NY

Montgomery, NY

Rensselaer, NY

Saratoga, NY

Schenectady, NY

Schoharie, NY

0200 Albuquerque, NM......................................... 0.8613

Bernalillo, NM

Sandoval, NM

Valencia, NM

0220 Alexandria, LA.......................................... 0.8526

Rapides, LA

0240 Allentown-Bethlehem-Easton, PA.......................... 1.0204

Carbon, PA

Lehigh, PA

Northampton, PA

0280 Altoona, PA............................................. 0.9335

Blair, PA

0320 Amarillo, TX............................................

Potter, TX 0.8474

Randall, TX

0380 Anchorage, AK........................................... 1.2818

Anchorage, AK

0440 Ann Arbor, MI........................................... 1.1033

Lenawee, MI

Livingston, MI

Washtenaw, MI

0450 Anniston, AL............................................ 0.8658

Calhoun, AL

0460 Appleton-Oshkosh-Neenah, WI............................. 0.8825

Calumet, WI

Outagamie, WI

Winnebago, WI

0470 Arecibo, PR............................................. 0.4867

Arecibo, PR

Camuy, PR

Hatillo, PR

0480 Asheville, NC........................................... 0.8940

Buncombe, NC

Madison, NC

0500Athens, GA................................................ 0.8673

Clarke, GA

Madison, GA

Oconee, GA

0520 Atlanta, GA............................................. 0.9915

Barrow, GA

Bartow, GA

Carroll, GA

Cherokee, GA

Clayton, GA

Cobb, GA

Coweta, GA

DeKalb, GA

Douglas, GA

Fayette, GA

Forsyth, GA

Fulton, GA

Gwinnett, GA

Henry, GA

Newton, GA

Paulding, GA

Pickens, GA

Rockdale, GA

Spalding, GA

Walton, GA

0560 Atlantic-Cape May, NJ................................... 1.1536

Atlantic, NJ

Cape May, NJ

0600 Augusta-Aiken, GA-SC.................................... 0.9233

Columbia, GA

McDuffie, GA

Richmond, GA

Aiken, SC

Edgefield, SC

0640 Austin-San Marcos, TX................................... 0.8782

Bastrop, TX

[[Page 42783]]

Caldwell, TX

Hays, TX

Travis, TX

Williamson, TX

0680 Bakersfield, CA......................................... 0.9531

Kern, CA

0720 Baltimore, MD........................................... 0.9642

Anne Arundel, MD

Baltimore, MD

Baltimore City, MD

Carroll, MD

Harford, MD

Howard, MD

Queen Anne's, MD

0733 Bangor, ME.............................................. 0.9474

Penobscot, ME

0743Barnstable-Yarmouth, MA................................... 1.5382

Barnstable, MA

0760 Baton Rouge, LA......................................... 0.8872

Ascension, LA

East Baton Rouge, LA

Livingston, LA

West Baton Rouge, LA

0840 Beaumont-Port Arthur, TX................................ 0.8659

Hardin, TX

Jefferson, TX

Orange, TX

0860 Bellingham, WA.......................................... 1.1434

Whatcom, WA

0870 Benton Harbor, MI....................................... 0.8531

Berrien, MI

0875 Bergen-Passaic, NJ...................................... 1.2186

Bergen, NJ

Passaic, NJ

0880 Billings, MT............................................ 0.9143

Yellowstone, MT

0920 Biloxi-Gulfport-Pascagoula, MS.......................... 0.8276

Hancock, MS

Harrison, MS

Jackson, MS

0960 Binghamton, NY.......................................... 0.9059

Broome, NY

Tioga, NY

1000 Birmingham, AL.......................................... 0.9073

Blount, AL

Jefferson, AL

St. Clair, AL

Shelby, AL

1010 Bismarck, ND............................................ 0.8025

Burleigh, ND

Morton, ND

1020 Bloomington, IN......................................... 0.8965

Monroe, IN

1040 Bloomington-Normal, IL.................................. 0.8851

McLean, IL

1080 Boise City, ID.......................................... 0.9160

Ada, ID

Canyon, ID

1123 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH........ 1.1269

Bristol, MA

Essex, MA

Middlesex, MA

Norfolk, MA

Plymouth, MA

Suffolk, MA

Worcester, MA

Hillsborough, NH

Merrimack, NH

Rockingham, NH

Strafford, NH

1125 Boulder-Longmont, CO.................................... 1.0038

Boulder, CO

1145 Brazoria, TX............................................ 0.8906

Brazoria, TX

1150 Bremerton, WA........................................... 1.1055

Kitsap, WA

1240 Brownsville-Harlingen-San Benito, TX.................... 0.8237

Cameron, TX

1260 Bryan-College Station, TX............................... 0.7820

Brazos, TX

1280 Buffalo-Niagara Falls, NY............................... 0.9587

Erie, NY

Niagara, NY

1303 Burlington, VT.......................................... 0.9577

Chittenden, VT

Franklin, VT

Grand Isle, VT

1310 Caguas, PR.............................................. 0.4400

Caguas, PR

Cayey, PR

Cidra, PR

Gurabo, PR

San Lorenzo, PR

1320 Canton-Massillon, OH.................................... 0.8813

Carroll, OH

Stark, OH

1350 Casper, WY.............................................. 0.8701

Natrona, WY

1360 Cedar Rapids, IA........................................ 0.8814

Linn, IA

1400 Champaign-Urbana, IL.................................... 0.8723

Champaign, IL

1440 Charleston-North Charleston, SC......................... 0.9114

Berkeley, SC

Charleston, SC

Dorchester, SC

1480 Charleston, WV.......................................... 0.8990

Kanawha, WV

Putnam, WV

1520 Charlotte-Gastonia-Rock Hill, NC-SC..................... 0.9686

Cabarrus, NC

Gaston, NC

Lincoln, NC

Mecklenburg, NC

Rowan, NC

Stanly, NC

Union, NC

York, SC

1540 Charlottesville, VA..................................... 1.0272

Albemarle, VA

Charlottesville City, VA

Fluvanna, VA

Greene, VA

1560 Chattanooga, TN-GA...................................... 0.9074

Catoosa, GA

Dade, GA

Walker, GA

Hamilton, TN

Marion, TN

1580 Cheyenne, WY............................................ 0.8149

Laramie, WY

1600 Chicago, IL............................................. 1.0461

Cook, IL

DeKalb, IL

DuPage, IL

Grundy, IL

Kane, IL

Kendall, IL

Lake, IL

McHenry, IL

Will, IL

1620 Chico-Paradise, CA...................................... 1.0145

Butte, CA

1640 Cincinnati, OH-KY-IN.................................... 0.9595

Dearborn, IN

Ohio, IN

Boone, KY

Campbell, KY

Gallatin, KY

Grant, KY

Kenton, KY

Pendleton, KY

Brown, OH

Clermont, OH

Hamilton, OH

Warren, OH

1660 Clarksville-Hopkinsville, TN-KY......................... 0.8040

Christian, KY

Montgomery, TN

1680 Cleveland-Lorain-Elyria, OH............................. 0.9886

Ashtabula, OH

Cuyahoga, OH

Geauga, OH

Lake, OH

Lorain, OH

Medina, OH

1720 Colorado Springs, CO.................................... 0.9390

El Paso, CO

1740 Columbia, MO............................................ 0.8942

Boone, MO

1760 Columbia, SC............................................ 0.9290

Lexington, SC

Richland, SC

1800 Columbus, GA-AL.........................................

Russell, AL 0.8511

Chattahoochee, GA

Harris, GA

Muscogee, GA

1840 Columbus, OH............................................ 0.9781

Delaware, OH

Fairfield, OH

Franklin, OH

Licking, OH

Madison, OH

Pickaway, OH

1880 Corpus Christi, TX...................................... 0.8513

Nueces, TX

San Patricio, TX

1900 Cumberland, MD-WV....................................... 0.8242

Allegany, MD

Mineral, WV

1920 Dallas, TX.............................................. 0.9369

Collin, TX

Dallas, TX

Denton, TX

Ellis, TX

Henderson, TX

Hunt, TX

Kaufman, TX

Rockwall, TX

1950 Danville, VA............................................ 0.9045

Danville City, VA

Pittsylvania, VA

[[Page 42784]]

1960 Davenport-Moline-Rock...................................

Island, IA-IL 0.8413

Scott, IA

Henry, IL

Rock Island, IL

2000 Dayton-Springfield, OH.................................. 0.9605

Clark, OH

Greene, OH

Miami, OH

Montgomery, OH

2020 Daytona Beach, FL..................................... 0.9134

Flagler, FL

Volusia, FL

2030 Decatur, AL............................................. 0.8233

Lawrence, AL

Morgan, AL

2040 Decatur, IL............................................. 0.8035

Macon, IL

2080 Denver, CO.............................................. 1.0331

Adams, CO

Arapahoe, CO

Denver, CO

Douglas, CO

Jefferson, CO

2120 Des Moines, IA.......................................... 0.8448

Dallas, IA

Polk, IA

Warren, IA

2160 Detroit, MI............................................. 1.0544

Lapeer, MI

Macomb, MI

Monroe, MI

Oakland, MI

St. Clair, MI

Wayne, MI

2180 Dothan, AL.............................................. 0.7892

Dale, AL

Houston, AL

2190 Dover, DE............................................... 0.9363

Kent, DE

2200 Dubuque, IA............................................. 0.8222

Dubuque, IA

2240 Duluth-Superior, MN-WI.................................. 0.9962

St. Louis, MN

Douglas, WI

2281 Dutchess County, NY..................................... 1.0530

Dutchess, NY

2290 Eau Claire, WI.......................................... 0.8573

Chippewa, WI

Eau Claire, WI

2320 El Paso, TX............................................. 0.9215

El Paso, TX

2330 Elkhart-Goshen, IN...................................... 0.9305

Elkhart, IN

2335 Elmira, NY.............................................. 0.8440

Chemung, NY

2340Enid, OK.................................................. 0.7983

Garfield, OK

2360 Erie, PA................................................ 0.9271

Erie, PA

2400 Eugene-Springfield, OR.................................. 1.1193

Lane, OR

2440 Evansville-Henderson, IN-KY............................. 0.8528

Posey, IN

Vanderburgh, IN

Warrick, IN

Henderson, KY

2520 Fargo-Moorhead, ND-MN................................... 0.9520

Clay, MN

Cass, ND

2560 Fayetteville, NC........................................ 0.8389

Cumberland, NC

2580 Fayetteville-Springdale-Rogers, AR...................... 0.8614

Benton, AR

Washington, AR

2620 Flagstaff, AZ-UT........................................ 0.9483

Coconino, AZ

Kane, UT

2640 Flint, MI............................................... 1.1031

Genesee, MI

2650 Florence, AL............................................ 0.7676

Colbert, AL

Lauderdale, AL

2655 Florence, SC............................................ 0.8501

Florence, SC

2670 Fort Collins-Loveland, CO............................... 1.0770

Larimer, CO

2680 Ft. Lauderdale, FL...................................... 0.9807

Broward, FL

2700 Fort Myers-Cape Coral, FL............................... 0.8942

Lee, FL

2710 Fort Pierce-Port St. Lucie, FL.......................... 1.0241

Martin, FL

St. Lucie, FL

2720 Fort Smith, AR-OK....................................... 0.7623

Crawford, AR

Sebastian, AR

Sequoyah, OK

2750 Fort Walton Beach, FL................................... 0.8615

Okaloosa, FL

2760 Fort Wayne, IN.......................................... 0.9047

Adams, IN

Allen, IN

De Kalb, IN

Huntington, IN

Wells, IN

Whitley, IN

2800 Forth Worth-Arlington, TX............................... 0.9719

Hood, TX

Johnson, TX

Parker, TX

Tarrant, TX

2840 Fresno, CA.............................................. 1.0700

Fresno, CA

Madera, CA

2880 Gadsden, AL............................................. 0.8779

Etowah, AL

2900 Gainesville, FL......................................... 0.9453

Alachua, FL

2920 Galveston-Texas City, TX................................ 1.0894

Galveston, TX

2960 Gary, IN................................................ 0.9435

Lake, IN

Porter, IN

2975 Glens Falls, NY......................................... 0.8490

Warren, NY

Washington, NY

2980 Goldsboro, NC........................................... 0.8530

Wayne, NC

2985 Grand Forks, ND-MN...................................... 0.8836

Polk, MN

Grand Forks, ND

2995 Grand Junction, CO...................................... 0.8279

Mesa, CO

3000 Grand Rapids-Muskegon-Holland, MI....................... 0.9971

Allegan, MI

Kent, MI

Muskegon, MI

Ottawa, MI

3040 Great Falls, MT......................................... 0.8872

Cascade, MT

3060 Greeley, CO............................................. 0.9457

Weld, CO

3080 Green Bay, WI........................................... 0.9156

Brown, WI

3120 Greensboro-Winston-Salem-High Point, NC................. 0.9547

Alamance, NC

Davidson, NC

Davie, NC

Forsyth, NCGuilford, NC

Randolph, NC

Stokes, NC

Yadkin, NC

3150 Greenville, NC.......................................... 0.9434

Pitt, NC

3160 Greenville-Spartanburg-Anderson, SC..................... 0.9222

Anderson, SC

Cherokee, SC

Greenville, SC

Pickens, SC

Spartanburg, SC

3180 Hagerstown, MD.......................................... 1.0183

Washington, MD

3200 Hamilton-Middletown, OH................................. 0.9233

Butler, OH

3240 Harrisburg-Lebanon-Carlisle, PA......................... 1.0060

Cumberland, PA

Dauphin, PA

Lebanon, PA

Perry, PA

3283 Hartford, CT 1 2........................................ 1.1831

Hartford, CT

Litchfield, CT

Middlesex, CT

Tolland, CT

3285 Hattiesburg, MS......................................... 0.7261

Forrest, MS

Lamar, MS

3290 Hickory-Morganton-Lenoir, NC............................ 0.8904

Alexander, NC

Burke, NC

Caldwell, NC

Catawba, NC

3320 Honolulu, HI............................................ 1.1510

Honolulu, HI

3350 Houma, LA............................................... 0.8197

Lafourche, LA

Terrebonne, LA

3360 Houston, TX............................................. 0.9889

Chambers, TX

Fort Bend, TX

Harris, TX

Liberty, TX

Montgomery, TX

Waller, TX

3400 Huntington-Ashland, WV-KY-OH............................ 0.9647

Boyd, KY

Carter, KY

Greenup, KY

Lawrence, OH

Cabell, WV

[[Page 42785]]

Wayne, WV

3440 Huntsville, AL.......................................... 0.8385

Limestone, AL

Madison, AL

3480 Indianapolis, IN........................................ 0.9831

Boone, IN

Hamilton, IN

Hancock, IN

Hendricks, IN

Johnson, IN

Madison, IN

Marion, IN

Morgan, IN

Shelby, IN

3500 Iowa City, IA........................................... 0.9481

Johnson, IA

3520 Jackson, MI............................................. 0.9224

Jackson, MI

3560 Jackson, MS............................................. 0.8292

Hinds, MS

Madison, MS

Rankin, MS

3580 Jackson, TN............................................. 0.8560

Madison, TN

Chester, TN

3600 Jacksonville, FL........................................ 0.8900

Clay, FL

Duval, FL

Nassau, FL

St. Johns, FL

3605 Jacksonville, NC........................................ 0.7556

Onslow, NC

3610 Jamestown, NY........................................... 0.7660

Chautauqua, NY

3620 Janesville-Beloit, WI................................... 0.9051

Rock, WI

3640 Jersey City, NJ......................................... 1.1598

Hudson, NJ

3660 Johnson City-Kingsport-Bristol, TN-VA................... 0.8773

Carter, TN

Hawkins, TN

Sullivan, TN

Unicoi, TN

Washington, TN

Bristol City, VA

Scott, VA

Washington, VA

3680 Johnstown, PA........................................... 0.8619

Cambria, PA

Somerset, PA

3700 Jonesboro, AR........................................... 0.7407

Craighead, AR

3710 Joplin, MO.............................................. 0.7873

Jasper, MO

Newton, MO

3720 Kalamazoo-Battlecreek, MI............................... 1.1331

Calhoun, MI

Kalamazoo, MI

Van Buren, MI

3740 Kankakee, IL............................................ 0.9418

Kankakee, IL

3760 Kansas City, KS-MO...................................... 0.9645

Johnson, KS

Leavenworth, KS

Miami, KS

Wyandotte, KS

Cass, MO

Clay, MO

Clinton, MO

Jackson, MO

Lafayette, MO

Platte, MO

Ray, MO

3800 Kenosha, WI............................................. 0.9129

Kenosha, WI

3810 Killeen-Temple, TX...................................... 1.0109

Bell, TX

Coryell, TX

3840 Knoxville, TN........................................... 0.8918

Anderson, TN

Blount, TN

Knox, TN

Loudon, TN

Sevier, TN

Union, TN

3850 Kokomo, IN.............................................. 0.9275

Howard, IN

Tipton, IN

3870 La Crosse, WI-MN........................................ 0.8913

Houston, MN

La Crosse, WI

3880 Lafayette, LA........................................... 0.8255

Acadia, LA

Lafayette, LA

St. Landry, LA

St. Martin, LA

3920 Lafayette, IN........................................... 0.8841

Clinton, IN

Tippecanoe, IN

3960 Lake Charles, LA........................................ 0.7674

Calcasieu, LA

3980 Lakeland-Winter Haven, FL............................... 0.8939

Polk, FL

4000 Lancaster, PA........................................... 0.9561

Lancaster, PA

4040 Lansing-East Lansing, MI................................ 1.0090

Clinton, MI

Eaton, MI

Ingham, MI

4080 Laredo, TX.............................................. 0.7343

Webb, TX

4100 Las Cruces, NM.......................................... 0.8870

Dona Ana, NM

4120 Las Vegas, NV-AZ........................................ 1.1413

Mohave, AZ

Clark, NV

Nye, NV

4150 Lawrence, KS............................................ 0.8655

Douglas, KS

4200 Lawton, OK.............................................. 0.8697

Comanche, OK

4243 Lewiston-Auburn, ME..................................... 0.9149

Androscoggin, ME

4280 Lexington, KY........................................... 0.8506

Bourbon, KY

Clark, KY

Fayette, KY

Jessamine, KY

Madison, KY

Scott, KY

Woodford, KY

4320 Lima, OH................................................ 0.8949

Allen, OH

Auglaize, OH

4360 Lincoln, NE............................................. 0.9303

Lancaster, NE

4400 Little Rock-North Little Rock, AR....................... 0.8503

Faulkner, AR

Lonoke, AR

Pulaski, AR

Saline, AR

4420 Longview-Marshall, TX................................... 0.8698

Gregg, TX

Harrison, TX

Upshur, TX

4480 Los Angeles-Long Beach, CA.............................. 1.2085

Los Angeles, CA

4520 Louisville, KY-IN....................................... 0.9093

Clark, IN

Floyd, IN

Harrison, IN

Scott, IN

Bullitt, KY

Jefferson, KY

Oldham, KY

4600 Lubbock, TX............................................. 0.8496

Lubbock, TX

4640 Lynchburg, VA........................................... 0.8900

Amherst, VA

Bedford, VA

Bedford City, VA

Campbell, VA

Lynchburg City, VA

4680 Macon, GA............................................... 0.8980

Bibb, GA

Houston, GA

Jones, GA

Peach, GA

Twiggs, GA

4720 Madison, WI............................................. 1.0018

Dane, WI

4800 Mansfield, OH........................................... 0.8534

Crawford, OH

Richland, OH

4840 Mayaguez, PR............................................ 0.4401

Anasco, PR

Cabo Rojo, PR

Hormigueros, PR

Mayaguez, PR

Sabana Grande, PR

San German, PR

4880 McAllen-Edinburg-Mission, TX............................ 0.8893

Hidalgo, TX

4890 Medford-Ashland, OR..................................... 1.0020

Jackson, OR

4900 Melbourne-Titusville-Palm Bay, FL....................... 0.9216

Brevard, FL

4920 Memphis, TN-AR-MS....................................... 0.8361

Crittenden, AR

DeSoto, MS

Fayette, TN

Shelby, TN

Tipton, TN

4940 Merced, CA.............................................. 1.0033

Merced, CA

5000 Miami, FL............................................... 1.0017

Dade, FL

5015 Middlesex-Somerset-Hunterdon, NJ........................ 1.1152

Hunterdon, NJ

Middlesex, NJ

Somerset, NJ

5080 Milwaukee-Waukesha, WI.................................. 0.9356

Milwaukee, WI

Ozaukee, WI

[[Page 42786]]

Washington, WI

Waukesha, WI

5120 Minneapolis-St. Paul, MN-WI............................. 1.0854

Anoka, MN

Carver, MN

Chisago, MN

Dakota, MN

Hennepin, MN

Isanti, MN

Ramsey, MN

Scott, MN

Sherburne, MN

Washington, MN

Wright, MN

Pierce, WI

St. Croix, WI

5140 Missoula, MT............................................ 0.9189

Missoula, MT

5160 Mobile, AL.............................................. 0.8377

Baldwin, AL

Mobile, AL

5170 Modesto, CA............................................. 1.0346

Stanislaus, CA

5190 Monmouth-Ocean, NJ...................................... 1.1317

Monmouth, NJ

Ocean, NJ

5200 Monroe, LA.............................................. 0.8219

Ouachita, LA

5240 Montgomery, AL.......................................... 0.7821

Autauga, AL

Elmore, AL

Montgomery, AL

5280 Muncie, IN.............................................. 0.9414

Delaware, IN

5330 Myrtle Beach, SC........................................ 0.8179

Horry, SC

5345 Naples, FL.............................................. 1.0177

Collier, FL

5360 Nashville, TN........................................... 0.9480

Cheatham, TN

Davidson, TN

Dickson, TN

Robertson, TN

Rutherford, TN

Sumner, TN

Williamson, TN

Wilson, TN

5380 Nassau-Suffolk, NY...................................... 1.3593

Nassau, NY

Suffolk, NY

5483 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT..... 1.2328

Fairfield, CT

New Haven, CT

5523 New London-Norwich, CT.................................. 1.1616

New London, CT

5560 New Orleans, LA......................................... 0.9310

Jefferson, LA

Orleans, LA

Plaquemines, LA

St. Bernard, LA

St. Charles, LA

St. James, LA

St. John The Baptist, LA

St. Tammany, LA

5600 New York, NY............................................ 1.4461

Bronx, NY

Kings, NY

New York, NY

Putnam, NY

Queens, NY

Richmond, NY

Rockland, NY

Westchester, NY

5640 Newark, NJ.............................................. 1.1866

Essex, NJ

Morris, NJ

Sussex, NJ

Union, NJ

Warren, NJ

5660 Newburgh, NY-PA......................................... 1.1155

Orange, NY

Pike, PA

5720 Norfolk-Virginia Beach-Newport News, VA-NC.............. 0.8275

Currituck, NC

Chesapeake City, VA

Gloucester, VA

Hampton City, VA

Isle of Wight, VA

James City, VA

Mathews, VA

Newport News City, VA

Norfolk City, VA

Poquoson City, VA

Portsmouth City, VA

Suffolk City, VA

Virginia Beach City, VA

Williamsburg City, VA

York, VA

5775 Oakland, CA............................................. 1.4993

Alameda, CA

Contra Costa, CA

5790 Ocala, FL............................................... 0.9152

Marion, FL

5800 Odessa-Midland, TX...................................... 0.8656

Ector, TX

Midland, TX

5880 Oklahoma City, OK....................................... 0.8708

Canadian, OK

Cleveland, OK

Logan, OK

McClain, OK

Oklahoma, OK

Pottawatomie, OK

5910 Olympia, WA ........................................... 1.1522

Thurston, WA

5920 Omaha, NE-IA............................................ 0.9972

Pottawattamie, IA

Cass, NE

Douglas, NE

Sarpy, NE

Washington, NE

5945 Orange County, CA....................................... 1.1522

Orange, CA

5960 Orlando, FL............................................. 0.9813

Lake, FL

Orange, FL

Osceola, FL

Seminole, FL

5990 Owensboro, KY........................................... 0.7771

Daviess, KY

6015 Panama City, FL......................................... 0.8507

Bay, FL

6020 Parkersburg-Marietta, WV-OH............................. 0.8016

Washington, OH

Wood, WV

6080 Pensacola, FL........................................... 0.8246

Escambia, FL

Santa Rosa, FL

6120 Peoria-Pekin, IL........................................ 0.8058

Peoria, IL

Tazewell, IL

Woodford, IL

6160 Philadelphia, PA-NJ..................................... 1.1370

Burlington, NJ

Camden, NJ

Gloucester, NJ

Salem, NJ

Bucks, PA

Chester, PA

Delaware, PA

Montgomery, PA

Philadelphia, PA

6200 Phoenix-Mesa, AZ........................................ 0.9591

Maricopa, AZ

Pinal, AZ

6240 Pine Bluff, AR.......................................... 0.7912

Jefferson, AR

6280 Pittsburgh, PA.......................................... 0.9789

Allegheny, PA

Beaver, PA

Butler, PA

Fayette, PA

Washington, PA

Westmoreland, PA

6323 Pittsfield, MA.......................................... 1.0819

Berkshire, MA

6340 Pocatello, ID........................................... 0.8792

Bannock, ID

6360 Ponce, PR............................................... 0.4788

Guayanilla, PR

Juana Diaz, PR

Penuelas, PR

Ponce, PR

Villalba, PR

Yauco, PR

6403 Portland, ME............................................ 0.9561

Cumberland, ME

Sagadahoc, ME

York, ME

6440 Portland-Vancouver, OR-WA............................... 1.1178

Clackamas, OR

Columbia, OR

Multnomah, OR

Washington, OR

Yamhill, OR

Clark, WA

6483 Providence-Warwick-Pawtucket, RI........................ 1.0801

Bristol, RI

Kent, RI

Newport, RI

Providence, RI

Washington, RI

6520 Provo-Orem, UT.......................................... 0.9885

Utah, UT

6560 Pueblo, CO.............................................. 0.8712

Pueblo, CO

6580 Punta Gorda, FL......................................... 0.9031

Charlotte, FL

6600 Racine, WI.............................................. 0.9130

Racine, WI

6640 Raleigh-Durham-Chapel Hill, NC.......................... 0.9812

Chatham, NC

[[Page 42787]]

Durham, NC

Franklin, NC

Johnston, NC

Orange, NC

Wake, NC

6660 Rapid City, SD.......................................... 0.8208

Pennington, SD

6680 Reading, PA............................................. 0.9234

Berks, PA

6690 Redding, CA............................................. 1.1858

Shasta, CA

6720 Reno, NV................................................ 1.1095

Washoe, NV

6740 Richland-Kennewick-Pasco, WA............................ 1.0287

Benton, WA

Franklin, WA

6760 Richmond-Petersburg, VA................................. 0.9211

Charles City County, 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

6780 Riverside-San Bernardino, CA............................ 1.0757

Riverside, CA

San Bernardino, CA

6800 Roanoke, VA............................................. 0.8509

Botetourt, VA

Roanoke, VA

Roanoke City, VA

Salem City, VA

6820 Rochester, MN........................................... 1.1698

Olmsted, MN

6840 Rochester, NY........................................... 0.9657

Genesee, NY

Livingston, NY

Monroe, NY

Ontario, NY

Orleans, NY

Wayne, NY

6880 Rockford, IL............................................ 0.8615

Boone, IL

Ogle, IL

Winnebago, IL

6895 Rocky Mount, NC......................................... 0.9012

Edgecombe, NC

Nash, NC

6920 Sacramento, CA.......................................... 1.1962

El Dorado, CA

Placer, CA

Sacramento, CA

6960 Saginaw-Bay City-Midland, MI............................ 0.9487

Bay, MI

Midland, MI

Saginaw, MI

6980 St. Cloud, MN........................................... 0.9586

Benton, MN

Stearns, MN

7000 St. Joseph, MO.......................................... 0.9889

Andrew, MO

Buchanan, MO

7040 St. Louis, MO-IL........................................ 0.9151

Clinton, IL

Jersey, IL

Madison, IL

Monroe, IL

St. Clair, IL

Franklin, MO

Jefferson, MO

Lincoln, MO

St. Charles, MO

St. Louis, MO

St. Louis City, MO

Warren, MO

7080 Salem, OR............................................... 0.9904

Marion, OR

Polk, OR

7120 Salinas, CA............................................. 1.5142

Monterey, CA

7160 Salt Lake City-Ogden, UT................................ 0.9398

Davis, UT

Salt Lake, UT

Weber, UT

7200 San Angelo, TX.......................................... 0.7646

Tom Green, TX

7240 San Antonio, TX......................................... 0.8100

Bexar, TX

Comal, TX

Guadalupe, TX

Wilson, TX

7320 San Diego, CA........................................... 1.2265

San Diego, CA

7360 San Francisco, CA....................................... 1.3957

Marin, CA

San Francisco, CA

San Mateo, CA

7400 San Jose, CA............................................ 1.3827

Santa Clara, CA

7440 San Juan-Bayamon, PR.................................... 0.4623

Aguas Buenas, PR

Barceloneta, PR

Bayamon, PR

Canovanas, PR

Carolina, PR

Catano, PR

Ceiba, PR

Comerio, PR

Corozal, PR

Dorado, PR

Fajardo, PR

Florida, PR

Guaynabo, PR

Humacao, PR

Juncos, PR

Los Piedras, PR

Loiza, PR

Luguillo, PR

Manati, PR

Morovis, PR

Naguabo, PR

Naranjito, PR

Rio Grande, PR

San Juan, PR

Toa Alta, PR

Toa Baja, PR

Trujillo Alto, PR

Vega Alta, PR

Vega Baja, PR

Yabucoa, PR

7460 San Luis Obispo-Atascadero-Paso Robles, CA.............. 1.1264

San Luis Obispo, CA

7480 Santa Barbara-Santa Maria-Lompoc, CA.................... 1.1194

Santa Barbara, CA

7485 Santa Cruz-Watsonville, CA.............................. 1.3981

Santa Cruz, CA

7490 Santa Fe, NM............................................ 0.9652

Los Alamos, NM

Santa Fe, NM

7500 Santa Rosa, CA.......................................... 1.3597

Sonoma, CA

7510 Sarasota-Bradenton, FL.................................. 0.9532

Manatee, FL

Sarasota, FL

7520 Savannah, GA............................................ 1.0060

Bryan, GA

Chatham, GA

Effingham, GA

7560 Scranton--Wilkes-Barre--Hazleton, PA.................... 0.8299

Columbia, PA

Lackawanna, PA

Luzerne, PA

Wyoming, PA

7600 Seattle-Bellevue-Everett, WA............................ 1.1526

Island, WA

King, WA

Snohomish, WA

7610 Sharon, PA.............................................. 0.8847

Mercer, PA

7620 Sheboygan, WI........................................... 0.8225

Sheboygan, WI

7640 Sherman-Denison, TX..................................... 0.8570

Grayson, TX

7680 Shreveport-Bossier City, LA............................. 0.9386

Bossier, LA

Caddo, LA

Webster, LA

7720 Sioux City, IA-NE....................................... 0.8481

Woodbury, IA

Dakota, NE

7760 Sioux Falls, SD......................................... 0.8912

Lincoln, SD

Minnehaha, SD

7800 South Bend, IN.......................................... 0.9859

St. Joseph, IN

7840 Spokane, WA............................................. 1.0928

Spokane, WA

7880 Springfield, IL......................................... 0.8720

Menard, IL

Sangamon, IL

7920 Springfield, MO......................................... 0.8071

Christian, MO

Greene, MO

Webster, MO

8003 Springfield, MA......................................... 1.0990

Hampden, MA

Hampshire, MA

8050 State College, PA....................................... 0.9449

Centre, PA

8080 Steubenville-Weirton, OH-WV............................. 0.8428

Jefferson, OH

Brooke, WV

Hancock, WV

8120 Stockton-Lodi, CA....................................... 1.1075

San Joaquin, CA

[[Page 42788]]

8140 Sumter, SC.............................................. 0.8127

Sumter, SC

8160 Syracuse, NY............................................ 0.9400

Cayuga, NY

Madison, NY

Onondaga, NY

Oswego, NY

8200 Tacoma, WA.............................................. 1.0380

Pierce, WA

8240 Tallahassee, FL......................................... 0.8449

Gadsden, FL

Leon, FL

8280 Tampa-St. Petersburg-Clearwater, FL..................... 0.9113

Hernando, FL

Hillsborough, FL

Pasco, FL

Pinellas, FL

8320 Terre Haute, IN......................................... 0.8991

Clay, IN

Vermillion, IN

Vigo, IN

8360 Texarkana, AR-Texarkana, TX............................. 0.8506

Miller, AR

Bowie, TX

8400 Toledo, OH.............................................. 0.9991

Fulton, OH

Lucas, OH

Wood, OH

8440 Topeka, KS.............................................. 0.9812

Shawnee, KS

8480 Trenton, NJ............................................. 1.0509

Mercer, NJ

8520 Tucson, AZ.............................................. 0.9028

Pima, AZ

8560 Tulsa, OK............................................... 0.8463

Creek, OK

Osage, OK

Rogers, OK

Tulsa, OK

Wagoner, OK

8600 Tuscaloosa, AL.......................................... 0.7641

Tuscaloosa, AL

8640 Tyler, TX............................................... 0.8818

Smith, TX

8680 Utica-Rome, NY.......................................... 0.8418

Herkimer, NY

Oneida, NY

8720 Vallejo-Fairfield-Napa, CA.............................. 1.3413

Napa, CA

Solano, CA

8735 Ventura, CA............................................. 1.1014

Ventura, CA

8750 Victoria, TX............................................ 0.8381

Victoria, TX

8760 Vineland-Millville-Bridgeton, NJ........................ 1.0440

Cumberland, NJ

8780 Visalia-Tulare-Porterville, CA.......................... 1.0083

Tulare, CA

8800 Waco, TX................................................ 0.8371

McLennan, TX

8840 Washington, DC-MD-VA-WV................................. 1.0807

District of Columbia, DC

Calvert, MD

Charles, MD

Frederick, MD

Montgomery, MD

Prince Georges, MD

Alexandria City, VA

Arlington, VA

Clarke, VA

Culpeper, VA

Fairfax, VA

Fairfax City, VA

Falls Church City, VA

Fauquier, VA

Fredericksburg City, VA

King George, VA

Loudoun, VA

Manassas City, VA

Manassas Park City, VA

Prince William, VA

Spotsylvania, VA

Stafford, VA

Warren, VA

Berkeley, WV

Jefferson, WV

8920 Waterloo-Cedar Falls, IA 0.7958

Black Hawk, IA

8940 Wausau, WI.............................................. 0.9733

Marathon, WI

8960 West Palm Beach-Boca Raton, FL.......................... 1.0219

Palm Beach, FL

9000 Wheeling, WV-OH......................................... 0.7627

Belmont, OH

Marshall, WV

Ohio, WV

9040 Wichita, KS............................................. 0.8898

Butler, KS

Harvey, KS

Sedgwick, KS

9080 Wichita Falls, TX....................................... 0.7830

Archer, TX

Wichita, TX

9140 Williamsport, PA........................................ 0.8556

Lycoming, PA

9160 Wilmington-Newark, DE-MD................................ 1.1868

New Castle, DE

Cecil, MD

9200 Wilmington, NC.......................................... 0.9343

New Hanover, NC

Brunswick, NC

9260 Yakima, WA.............................................. 1.0318

Yakima, WA

9270 Yolo, CA................................................ 1.1233

Yolo, CA

9280 York, PA................................................ 0.9410

York, PA

9320 Youngstown-Warren, OH 0.9815

Columbiana, OH

Mahoning, OH

Trumbull, OH

9340 Yuba City, CA........................................... 1.0865

Sutter, CA

Yuba, CA

9360 Yuma, AZ................................................ 1.0058

Yuma, AZ

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

Addendum 1b.--Wage Index for Rural Areas

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

Wage

Nonurban area index

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

Alabama....................................................... 0.7294

Alaska........................................................ 1.2430

Arizona....................................................... 0.7989

Arkansas...................................................... 0.7250

California.................................................... 0.9979

Colorado...................................................... 0.8436

Connecticut................................................... 1.2074

Delaware...................................................... 0.8807

Florida....................................................... 0.8877

Georgia....................................................... 0.7888

Guam.......................................................... 0.6516

Hawaii........................................................ 1.0910

Idaho......................................................... 0.8477

Illinois...................................................... 0.7916

Indiana....................................................... 0.8380

Iowa.......................................................... 0.7777

Kansas........................................................ 0.7319

Kentucky...................................................... 0.7844

Louisiana..................................................... 0.7454

Maine......................................................... 0.8467

Maryland...................................................... 0.8555

Massachusetts................................................. 1.0834

Michigan...................................................... 0.8875

Minnesota..................................................... 0.8595

Mississippi................................................... 0.7312

Missouri...................................................... 0.7452

Montana.....................................................

This text is long and has been trimmed here. Open the source document for the complete record.