[Federal Register: August 4, 2005 (Volume 70, Number 149)]
[Rules and Regulations]
[Page 45025-45127]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr04au05-8]
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Part III
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 409, 411, 424, and 489
Medicare Program; Prospective Payment System and Consolidated Billing
for Skilled Nursing Facilities for FY 2006; Final Rule
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 409, 411, 424, and 489
[CMS-1282-F]
RIN 0938-AN65
Medicare Program; Prospective Payment System and Consolidated
Billing for Skilled Nursing Facilities for FY 2006
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
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SUMMARY: In this final rule we update the payment rates used under the
prospective payment system (PPS) for skilled nursing facilities (SNFs),
for fiscal year (FY) 2006. Annual updates to the PPS rates are required
by section 1888(e) of the Social Security Act (the Act), as amended by
the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of
1999 (BBRA), the Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000 (BIPA), and the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (MMA), relating to Medicare
payments and consolidated billing for SNFs. This final rule also
responds to public comments submitted on the proposed rule published on
May 19, 2005 (70 FR 29070), and promulgates provisions set forth in
that proposed rule, along with several additional technical revisions
to the regulations.
DATES: Effective Date: This final rule becomes effective on October 1,
2005.
FOR FURTHER INFORMATION CONTACT: Ellen Gay, (410) 786-4528 (for
information related to the case-mix classification methodology, and for
information related to swing-bed providers).
Jeanette Kranacs, (410) 786-9385 (for information related to the
development of the payment rates, and for information related to the
wage index).
Bill Ullman, (410) 786-5667 (for information related to coverage
requirements, level of care determinations, consolidated billing, and
general information).
SUPPLEMENTARY INFORMATION: To assist readers in referencing sections
contained in this document, we are providing the following Table of
Contents.
Table of Contents
I. Background
A. Current System for Payment of SNF Services Under Part A of
the Medicare Program
B. Requirements of the Balanced Budget Act of 1997 (BBA) for
Updating the SNF PPS
C. The Medicare, Medicaid, and SCHIP Balanced Budget Refinement
Act of 1999 (BBRA)
D. The Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000 (BIPA)
E. The Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA)
F. General Overview of the SNF PPS
1. Payment Provisions--Federal Rates
2. Payment Provisions--Initial Transition Period
G. Use of the SNF Market Basket Index
II. Summary of the Provisions of the FY 2006 Proposed Rule
III. Analysis of and Response to Public Comments on the FY 2006
Proposed Rule
A. General Comments on the FY 2006 Proposed Rule
1. Public Comment Schedule for the FY 2006 Proposed Rule
B. Update of Federal Payment Rates Under the SNF PPS
1. Costs and Services Covered by the Federal Rates
2. Methodology Used for the Calculation of the Federal Rates
C. Case-Mix Adjustment and Other Clinical Issues
1. Proposed Refinements to the RUG-III Case-Mix Classification
System
2. Proposed Increases to the RUG-III Case-Mix Weight Values
3. Implementation Issues
4. Additional Clinical and Related Issues
a. Proposed Changes to the MDS Coding Requirements (``Look-
Back'' Period, 5-day Grace Periods for PPS MDS Assessments, and
Projection of Anticipated Therapy Services during the 5-day PPS
Assessment (Section T))
b. Long-Term Payment and Quality Incentive Proposals
c. Proposal to Clarify ``Direct'' and ``Indirect'' Employment
Relationships for Nurse Practitioners and Clinical Nurse Specialists
d. Completion of Other Medicare Required Assessments (OMRAs)
e. Concurrent Therapy
5. Case-Mix Adjusted Federal Rates and Associated Indexes
D. Wage Index Adjustment to Federal Rates
1. Proposal to Incorporate the Revised OMB Definitions for
Metropolitan Statistical Areas and Combined Statistical Areas
2. Determining the Labor-Related Portion of the SNF PPS Rate
3. Calculating the Budget Neutrality Factor
E. Updates to the Federal Rates
F. Relationship of Case-Mix Classification System to Existing
SNF Level-of-Care Criteria
1. Proposals on the 9 New Rehabilitation Plus Extensive Services
Groups
G. Example of Computation of Adjusted PPS Rates and SNF Payment
H. SNF Market Basket Index
1. Background
2. Use of the SNF Market Basket Percentage
3. Market Basket Forecast Error Adjustment
4. Federal Rate Update Factor
I. Consolidated Billing
J. Application of the SNF PPS to SNF Services Furnished by
Swing-Bed Hospitals
K. Qualifying Three-Day Inpatient Hospital Stay Requirement
IV. Provisions of the Final Rule
V. Waiver of Proposed Rulemaking
VI. Collection of Information Requirements
VII. Regulatory Impact Analysis
A. Overall Impact
B. Anticipated Effects
C. Accounting Statement
D. Alternatives Considered Regulation Text
VIII. Addendum
In addition, because of the many terms to which we refer by
abbreviation in this final rule, we are listing these abbreviations and
their corresponding terms in alphabetical order below:
ADL Activity of Daily Living
ARD Assessment Reference Date
BBA Balanced Budget Act of 1997, Pub. L. 105-33
BBRA Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of
1999, Pub. L. 106-113
BEA (U.S. Department of Commerce) Bureau of Economic Analysis
BIPA Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000, Pub. L. 106-554
CAH Critical Access Hospital
CBSA Core-Based Statistical Area
CFR Code of Federal Regulations
CMS Centers for Medicare & Medicaid Services
CMSA Consolidated Metropolitan Statistical Area
CPT (Physicians') Current Procedural Terminology
DRG Diagnosis Related Group
FI Fiscal Intermediary
FR Federal Register
FY Fiscal Year
GAO Government Accountability Office
HCPCS Healthcare Common Procedure Coding System
ICD-9-CM International Classification of Diseases, Ninth Edition,
Clinical Modification
IFC Interim Final Rule With Comment Period
MDS Minimum Data Set
MEDPAR Medicare Provider Analysis and Review File
MMA Medicare Prescription Drug, Improvement, and Modernization Act
of 2003, Pub. L. 108-173
MSA Metropolitan Statistical Area
NECMA New England County Metropolitan Area
OIG Office of Inspector General
OMRA Other Medicare Required Assessment
PMSA Primary Metropolitan Statistical Area
PPI Producer Price Index
PPS Prospective Payment System
PRM Provider Reimbursement Manual
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RAI Resident Assessment Instrument
RAP Resident Assessment Protocol
RAVEN Resident Assessment Validation Entry
RFA Regulatory Flexibility Act, Pub. L. 96-354
RIA Regulatory Impact Analysis
RUG Resource Utilization Group
SCHIP State Children's Health Insurance Program
SNF Skilled Nursing Facility
STM Staff Time Measurement
UMRA Unfunded Mandates Reform Act, Pub. L. 104-4
I. Background
On May 19, 2005, we published a proposed rule in the Federal
Register (70 FR 29070, hereafter referred to as the FY 2006 SNF PPS
proposed rule), setting forth the proposed updates to the payment rates
used under the prospective payment system (PPS) for skilled nursing
facilities (SNFs), for FY 2006. Annual updates to the PPS rates are
required by section 1888(e) of the Social Security Act (the Act), as
amended by the Medicare, Medicaid, and SCHIP Balanced Budget Refinement
Act of 1999 (BBRA, Pub. L. 106-113), the Medicare, Medicaid, and SCHIP
Benefits Improvement and rotection Act of 2000 (BIPA, Pub. L. 106-554),
and the Medicare Prescription Drug, Improvement, and Modernization Act
of 2003 (MMA, Pub. L. 100-173), relating to Medicare payments and
consolidated billing for SNFs. In the FY 2006 SNF PPS proposed rule, we
invited public comments on a number of proposed revisions and technical
corrections to the regulations.
A. Current System for Payment of SNF Services Under Part A of the
Medicare Program
Section 4432 of the Balanced Budget Act of 1997 (BBA, Pub. L. 105-
33) amended section 1888 of the Act to provide for the implementation
of a per diem PPS for SNFs, covering all costs (routine, ancillary, and
capital-related) of covered SNF services furnished to beneficiaries
under Part A of the Medicare program, effective for cost reporting
periods beginning on or after July 1, 1998. We are updating the per
diem payment rates for SNFs for FY 2006. Major elements of the SNF PPS
include:
Rates. Per diem Federal rates were established for urban
and rural areas using allowable costs from FY 1995 cost reports. These
rates also included an estimate of the cost of services that, before
July 1, 1998, were paid under Part B but furnished to Medicare
beneficiaries in a SNF during a Part A covered stay. The rates were
adjusted annually using a SNF market basket index. Rates were case-mix
adjusted using a classification system (Resource Utilization Groups,
version III (RUG-III)) based on beneficiary assessments (using the
Minimum Data Set (MDS) version 2.0) (In section III.C of this final
rule, we discuss refinements to the case-mix classification system).
The rates were also adjusted by the hospital wage index to account for
geographic variation in wages. (In section III.D of this final rule, we
discuss the wage index adjustment in detail.) Correction notices were
published in the Federal Register on October 7, 2004 (69 FR 60158) and
on December 30, 2004 (69 FR 78445) that announced corrections to
several of the wage factors. Additionally, as noted in the July 30,
2004 update notice (69 FR 45775), section 101 of BBRA and certain
sections of BIPA also affect the payment rate.
Transition. The SNF PPS included an initial 3-year, phased
transition that blended a facility-specific payment rate with the
Federal case-mix adjusted rate. For each cost reporting period after a
facility migrated to the new system, the facility-specific portion of
the blend decreased and the Federal portion increased in 25 percentage
point increments. For most facilities, the facility-specific rate was
based on allowable costs from FY 1995; however, since the last year of
the transition was FY 2001, all facilities were paid at the full
Federal rate by the following fiscal year (FY 2002). Therefore, as
discussed in section I.F.2 of this final rule, we are no longer
including adjustment factors related to facility-specific rates for the
coming fiscal year.
Coverage. The establishment of the SNF PPS did not change
Medicare's fundamental requirements for SNF coverage. However, because
the RUG-III classification is based, in part, on the beneficiary's need
for skilled nursing care and therapy, we have attempted, where
possible, to coordinate claims review procedures involving level of
care determinations with the outputs of beneficiary assessment and RUG-
III classifying activities. We discuss this coordination in greater
detail in section III.F of this final rule. Moreover, the Part A SNF
benefit has not only level of care requirements, but also a set of
technical, or ``posthospital'' requirements as well. In section III.K
of this final rule, we discuss one aspect of the technical requirement
for a qualifying prior inpatient hospital stay of at least 3
consecutive days, on which we invited public comment in the FY 2006 SNF
PPS proposed rule.
Consolidated Billing. The SNF PPS includes a consolidated
billing provision that requires a SNF to submit consolidated Medicare
claims for almost all of the services that the resident receives during
the course of a covered Part A stay. (In addition, this provision
places with the SNF the Medicare billing responsibility for physical
and occupational therapy, and speech-language pathology services that
the resident receives during a noncovered stay.) The statute excludes
from the consolidated billing provision a few services--primarily those
of physicians and certain other types of practitioners--which remain
separately billable to Part B by the outside entity that furnishes
them. We discuss this provision in greater detail in section III.I of
this final rule.
Application of the SNF PPS to SNF services furnished by
swing-bed hospitals. Section 1883 of the Act permits certain small,
rural hospitals to enter into a Medicare swing-bed agreement, under
which the hospital can use its beds to provide either acute or SNF
care, as needed. For critical access hospitals (CAHs), Part A pays on a
reasonable cost basis for SNF services furnished under a swing-bed
agreement. However, in accordance with section 1888(e)(7) of the Act,
these services furnished by non-CAH rural hospitals are paid under the
SNF PPS, effective with cost reporting periods beginning on or after
July 1, 2002. A more detailed discussion of this provision appears in
section III.J of this final rule.
Technical corrections. We are also taking this opportunity
to make certain technical corrections in the text of the regulations,
as discussed in greater detail in section IV. of this final rule.
B. Requirements of the Balanced Budget Act of 1997 (BBA) for Updating
the SNF PPS
Section 1888(e)(4)(H) of the Act requires that we publish in the
Federal Register:
1. The unadjusted Federal per diem rates to be applied to days of
covered SNF services furnished during the FY.
2. The case-mix classification system to be applied with respect to
these services during the FY.
3. The factors to be applied in making the area wage adjustment
with respect to these services.
In the July 30, 1999 final rule (64 FR 41670), we indicated that we
would announce any changes to the guidelines for Medicare level of care
determinations related to modifications in the RUG-III classification
structure (see section III.F of this final rule).
Along with a number of other revisions discussed later in this
preamble, this final rule provides the
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annual updates to the Federal rates as mandated by the Act.
C. The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of
1999 (BBRA)
There were several provisions in the BBRA that resulted in
adjustments to the SNF PPS. These provisions were described in detail
in the final rule that we published in the Federal Register on July 31,
2000 (65 FR 46770). In particular, sections 101(a) and (b) of the BBRA
provided for a temporary 20 percent increase in the per diem adjusted
payment rates for 15 specified RUG-III groups (SE3, SE2, SE1, SSC, SSB,
SSA, CC2, CC1, CB2, CB1, CA2, CA1, RHC, RMC, and RMB). Under section
101(c) of the BBRA, this temporary increase remains in effect until the
later of October 1, 2000, or the implementation of case-mix refinements
in the PPS. (We discuss refinements to the case-mix classification
system in section III.C of this final rule.) In addition, section
101(d) of the BBRA included a 4 percent across-the-board increase in
the adjusted Federal per diem payment rates each year for FYs 2001 and
2002, exclusive of the 20 percent increase.
We included further information on all of the provisions of the
BBRA that affect the SNF PPS in Program Memoranda A-99-53 and A-99-61
(December 1999), and Program Memorandus AB-00-18 (March 2000). In
addition, for swing-bed hospitals with more than 49 (but less than 100)
beds, section 408 of the BBRA provided for the repeal of certain
statutory restrictions on length of stay and aggregate payment for
patient days, effective with the end of the SNF PPS transition period
described in section 1888(e)(2)(E) of the Act. In the July 31, 2001
final rule (66 FR 39562), we made conforming changes to the regulations
in Sec. 413.114(d), effective for services furnished in cost reporting
periods beginning on or after July 1, 2002, to reflect section 408 of
the BBRA.
D. The Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000 (BIPA)
The BIPA included several provisions that resulted in adjustments
to the PPS for SNFs. These provisions were described in detail in the
final rule that we published in the Federal Register on July 31, 2001
(66 FR 39562), as follows:
Section 203 of the BIPA exempted critical access hospital
(CAH) swing-beds from the SNF PPS; we included further information on
this provision in Program Memorandum A-01-09 (January 16, 2001).
Section 311 of the BIPA eliminated the 1 percent reduction
in the SNF market basket that the statutory update formula had
previously specified for FY 2001, and changed the 1 percent reduction
specified for FYs 2002 and 2003 to a 0.5 percent reduction. This
section also required us to conduct a study of alternative case-mix
classification systems for the SNF PPS, and to submit a report to the
Congress on the results of the study.
Section 312 of the BIPA provided for a temporary 16.66
percent increase in the nursing component of the case-mix adjusted
Federal rate for services furnished on or after April 1, 2001, and
before October 1, 2002. This section also required the Government
Accountability Office (GAO) to conduct an audit of SNF nursing staff
ratios and submit a report to the Congress on whether the temporary
increase in the nursing component should be continued. GAO issued this
report (GAO-03-176) in November 2002.
Section 313 of the BIPA repealed the consolidated billing
requirement for services (other than physical and occupational therapy,
and speech-language pathology services) furnished to SNF residents
during noncovered stays, effective January 1, 2001.
Section 314 of the BIPA adjusted the payment rates for all
of the 14 rehabilitation RUGs (RUC, RUB, RUA, RVC, RVB, RVA, RHC, RHB,
RHA, RMC, RMB, RMA, RLB, and RLA), in order to correct an anomaly under
which the existing payment rates for three particular rehabilitation
RUGs--RHC, RMC, and RMB--were higher than the rates for some other,
more intensive rehabilitation RUGs. Under the BIPA adjustment, the
temporary increase that sections 101(a) and (b) of the BBRA had applied
to the RHC, RMC, and RMB rehabilitation RUGs was revised from 20
percent to 6.7 percent, and the BIPA adjustment also applied this
temporary 6.7 percent increase to each of the other 11 rehabilitation
RUGs. Under this provision, the temporary increase remained at 20
percent for each of the 12 non-rehabilitation RUGs specified in section
101(b) of the BBRA (SE3, SE2, SE1, SSC, SSB, SSA, CC2, CC1, CB2, CB1,
CA2, and CA1).
Section 315 of the BIPA authorized us to establish a
geographic reclassification procedure that is specific to SNFs, but
only after collecting the data necessary to establish a SNF wage index
that is based on wage data from nursing homes.
We included further information on several of these provisions in
Program Memorandum A-01-08 (January 16, 2001).
E. The Medicare Prescription Drug, Improvement, and Modernization Act
of 2003 (MMA)
A provision of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) resulted in a further adjustment to the
PPS for SNFs. Specifically, section 511 of the MMA amended paragraph
(12) of section 1888(e) of the Act to provide for a temporary 128
percent increase in the PPS per diem payment for any SNF resident with
Acquired Immune Deficiency Syndrome (AIDS), effective with services
furnished on or after October 1, 2004. As discussed in Transmittal No.
160 (Change Request No. 3291, April 30, 2004, available online at
http://www.cms.hhs.gov/manuals/ transmittals/comm--date--dsc.asp), this
add-on applies to claims with diagnosis code 042. Like the temporary
add-on payments created by section 101(a) of the BBRA (as amended by
section 314 of the BIPA), this special AIDS add-on was not intended to
remain in effect indefinitely. As amended by section 511 of the MMA,
section 1888(e)(12)(B) of the Act specifies that this temporary
increase for patients with AIDS is to remain in effect only until ``* *
* such date as the Secretary certifies that there is an appropriate
adjustment in the case mix * * * to compensate for the increased costs
associated with [such] residents * * *.'' As discussed in the FY 2006
SNF PPS proposed rule (70 FR 29080), we are not addressing the issue of
such certification at this time and, accordingly, the temporary add-on
payments created by section 511 of the MMA will remain in effect during
FY 2006.
The law further provided that the 128 percent increase in payment
under the AIDS add-on is to be ``* * * determined without regard to any
increase'' under section 101 of the BBRA (as amended by section 314 of
the BIPA). As explained in the MMA Conference report, this means that
if a resident qualifies for the temporary 128 percent increase in
payment under the special AIDS add-on, ``the BBRA temporary RUG add-on
does not apply in this case * * *.'' (H.R. Conf. Rep. No. 108-391 at
662).
In addition, section 410 of the MMA contained a provision that
affects the SNF consolidated billing requirement's treatment of certain
services furnished as of January 1, 2005, by rural health clinics
(RHCs) and Federally qualified health centers (FQHCs). This provision
was discussed in Transmittal No. 390 (Change Request No. 3575), issued
on December 10, 2004, which is available online at http://www.cms.hhs.gov/
[[Page 45029]]
manuals/ transmittals/comm--date--dsc.asp.
F. General Overview of the SNF PPS
We implemented the Medicare SNF PPS for cost reporting periods
beginning on or after July 1, 1998. Under the PPS, we pay SNFs through
prospective, case-mix adjusted per diem payment rates applicable to all
covered SNF services. These payment rates cover all the costs of
furnishing covered skilled nursing services (routine, ancillary, and
capital-related costs) other than costs associated with approved
educational activities. Covered SNF services include post-hospital
services for which benefits are provided under Part A and all items and
services that, before July 1, 1998, had been paid under Part B (other
than physician and certain other services specifically excluded under
the BBA) but furnished to Medicare beneficiaries in a SNF during a
covered Part A stay. A complete discussion of these provisions appears
in the May 12, 1998 interim final rule (63 FR 26252).
1. Payment Provisions--Federal Rate
The PPS uses per diem Federal payment rates based on mean SNF costs
in a base year updated for inflation to the first effective period of
the PPS. We developed the Federal payment rates using allowable costs
from hospital-based and freestanding SNF cost reports for reporting
periods beginning in FY 1995. The data used in developing the Federal
rates also incorporated an estimate of the amounts that would be
payable under Part B for covered SNF services furnished to individuals
during the course of a covered Part A stay in a SNF.
In developing the rates for the initial period, we updated costs to
the first effective year of PPS (the 15-month period beginning July 1,
1998) using a SNF market basket, and then standardized for the costs of
facility differences in case-mix and for geographic variations in
wages. The database used to compute the Federal payment rates excluded
providers that received new provider exemptions from the routine cost
limits, as well as costs related to payments for exceptions to the
routine cost limits. In accordance with the formula prescribed in the
BBA, we set the Federal rates at a level equal to the weighted mean of
freestanding costs plus 50 percent of the difference between the
freestanding mean and weighted mean of all SNF costs (hospital-based
and freestanding) combined. We computed and applied separately the
payment rates for facilities located in urban and rural areas. In
addition, we adjusted the portion of the Federal rate attributable to
wage-related costs by a wage index.
The Federal rate also incorporates adjustments to account for
facility case-mix, using a classification system that accounts for the
relative resource utilization of different patient types. This
classification system, Resource Utilization Groups, version III (RUG-
III), uses beneficiary assessment data from the Minimum Data Set (MDS)
completed by SNFs to assign beneficiaries to one of 44 RUG-III groups.
The May 12, 1998 interim final rule (63 FR 26252) included a complete
and detailed description of the RUG-III classification system. A
further discussion of the case-mix classification system, including the
issue of case-mix refinements, appears in section III.C of this final
rule.
The Federal rates in this final rule reflect an update to the rates
that we published for FY 2005 equal to the full change in the SNF
market basket index. According to section 1888(e)(4)(E)(ii)(IV) of the
Act, for FY 2006, we have adjusted the current rates by the full SNF
market basket index.
2. Payment Provisions--Initial Transition Period
The SNF PPS included an initial, phased transition from a facility-
specific rate (which reflected the individual facility's historical
cost experience) to the Federal case-mix adjusted rate. The transition
extended through the facility's first three cost reporting periods
under the PPS, up to, and potentially including, the one that began in
FY 2001. (Further, once section 102 of the BBRA took effect, a facility
could elect to bypass the remainder of its transition period and go
directly to being paid entirely under the Federal rates.) Accordingly,
starting with cost reporting periods beginning in FY 2002, we base
payments entirely on the Federal rates and, as mentioned previously in
this final rule, we no longer include adjustment factors related to
facility-specific rates for the coming fiscal year.
G. Use of the SNF Market Basket Index
Section 1888(e)(5) of the Act requires us to establish a SNF market
basket index that reflects changes over time in the prices of an
appropriate mix of goods and services included in the covered SNF
services. The SNF market basket index is used to update the Federal
rates on an annual basis. The final rule published on July 31, 2001 (66
FR 39562) revised and rebased the market basket to reflect 1997 total
cost data. The SNF market basket index is discussed in greater detail
in section III.H of this final rule.
In addition, as explained in the FY 2004 final rule (68 FR 46058,
August 4, 2003) and in section III.H of this final rule, the annual
update of the payment rates includes, as appropriate, an adjustment to
account for market basket forecast error. This adjustment takes into
account the forecast error from the most recently available fiscal year
for which there are final data, and is applied whenever the difference
between the forecasted and actual change in the market basket exceeds a
0.25 percentage point threshold. For FY 2004 (the most recently
available fiscal year for which there are final data), the estimated
increase in the market basket index was 3.0 percentage points, while
the actual increase also was 3.0 percentage points. Therefore, the
payment rates for FY 2006 do not include a forecast error adjustment,
as there is no difference between the estimated and actual amounts of
change. Table 1 below shows the forecasted and actual market basket
amounts for FY 2004.
Table 1.--FY 2004 Forecast Error Correction for CMS SNF Market Basket
------------------------------------------------------------------------
FY 2004
Forecasted Actual FY forecast
Index FY 2004 2004 error
increase* increase** correction***
------------------------------------------------------------------------
SNF.......................... 3.0 3.0 0.0
------------------------------------------------------------------------
* Published in August 4, 2003 Federal Register; based on second quarter
2003 Global Insight/DRI-WEFA forecast.
** Based on the second quarter 2005 Global Insight/DRI-WEFA forecast.
*** The FY 2004 forecast error correction will be applied to the FY 2006
PPS update. Any forecast error less than 0.25 percentage points is not
reflected in the update.
[[Page 45030]]
II. Summary of the Provisions of the FY 2006 Proposed Rule
The FY 2006 SNF PPS proposed rule included proposed updates to the
FY 2006 Federal payment rates used under the SNF PPS. In accordance
with section 1888(e)(4)(E)(ii)(IV) of the Act, the updates reflect the
full SNF market basket percentage change for the fiscal year. We also
proposed to introduce, as of January 1, 2006, a refined case-mix
classification system that would add nine new Rehabilitation plus
Extensive Services groups at the top of the existing RUG hierarchy. The
FY 2006 SNF PPS proposed rule discussed and invited public comment on a
number of other clinical issues as well, involving alternative ways to
improve quality and efficiency and ensure accurate payments under the
SNF PPS.
We also proposed to incorporate OMB's revised definitions for
Metropolitan Statistical Areas and its new definitions of Micropolitan
Statistical Areas and Combined Statistical Areas, and we invited
comments on the appropriateness of implementing this change through a
transition period similar to that adopted under the inpatient hospital
PPS (IPPS). Further, we invited public comments on additional HCPCS
codes that could represent the type of ``high-cost, low probability''
services within certain designated service categories (that is,
chemotherapy and its administration, radioisotope services, and
customized prosthetic devices) that section 103 of the BBRA has
authorized us to exclude from the SNF consolidated billing provision.
We also invited comments on the apparent hospital practice of having
patients spend time in observation status prior to a formal inpatient
admission, and on the potential implications of this practice for the
SNF benefit's qualifying 3-day hospital stay requirement.
In addition to discussing these general issues in the FY 2006 SNF
PPS proposed rule, we also proposed making the following specific
revisions to the existing text of the regulations:
In Sec. 424.3, we would make a technical correction to
the definition of ``HCPCS''.
In Sec. 424.20, we would revise paragraph (e)(2) to
clarify the distinction between ``direct'' and ``indirect'' employment
relationships in terms of the ability of nurse practitioners and
clinical nurse specialists to perform SNF certifications and
recertifications.
More detailed information on each of these issues, to the extent
that we received public comments on them, appears in the discussion
contained in the following sections of this preamble.
III. Analysis of and Responses to Public Comments on the FY 2006
Proposed Rule
In response to the publication of the FY 2006 SNF PPS proposed
rule, we received 149 timely items of correspondence from the public.
We received numerous comments from various trade associations and major
organizations. Comments also originated from nursing homes, hospitals,
and other providers, suppliers, and practitioners, nursing home
resident advocacy groups, health care consulting firms, and private
citizens. The following discussion, arranged by subject area, includes
a summary of the public comments that we received, and our responses to
the comments appear under the appropriate heading.
A. General Comments on the FY 2006 SNF PPS Proposed Rule
1. Public Comment Schedule for the FY 2006 SNF PPS Proposed Rule
Comment: A few commenters noted that the July 12, 2005, closing
date for the public comment period fell less than 60 days after the
proposed rule's May 19, 2005, publication date in the Federal Register,
and expressed concern about abbreviating the comment period available
for the proposed rule. They asserted that a timeframe of less than 60
days was burdensome, and affected their ability to furnish
comprehensive responses. They asked us to provide the full 60-day
comment period in the future.
Response: We note that in accordance with the requirements of
section 1871(b)(1) of the Act, ``notice of the proposed regulation in
the Federal Register'' was provided as of May 13, 2005. At that same
time, the document was also posted on the CMS website. Accordingly, the
contents of the proposed rule were, in fact, available to the public
for the full 60-day comment period.
B. Update of Federal Payment Rates Under the SNF PPS
This final rule sets forth a schedule of Federal prospective
payment rates applicable to Medicare Part A SNF services beginning
October 1, 2005. The schedule incorporates per diem Federal rates that
provide Part A payment for all costs of services furnished to a
beneficiary in a SNF during a Medicare-covered stay. In the proposed
rule, we proposed case-mix refinements, including the introduction of 9
new RUGs. As part of this process, we proposed to update and
recalibrate the therapy and nursing case-mix indexes associated with
all RUGs. We also proposed to increase both the nursing and therapy
case-mix indexes and provide additional funding to the system in order
to account for the variation in non-therapy ancillary costs.
Comment: Several commenters expressed concern regarding the overall
fiscal impact of the proposed changes and recommended that the
aggregate expenditure levels be increased, either by further increasing
the case-mix weights or by increasing the baseline expenditure levels.
Other commenters stated that they had been unable to reconcile their
independent analyses with the information contained in the proposed
rule, and were concerned that the impact of the proposed rate structure
would exceed the CMS projections. In other cases, commenters submitted
technical questions on the accuracy of the methodology used in
developing our proposals, and urged that these methodological issues be
addressed for the final rule.
Response: Throughout the comment period, we examined the data
presented in the proposed rule, updated the analyses to reflect the
most recent available data, and corrected minor technical errors. We
received information from industry representatives and others, which
helped us to verify the accuracy of the data used in the rate
calculations, and then to ensure that the resulting rates correctly
reflected the policies specified in the proposed rule. To accomplish
these objectives, we made several adjustments to our models to better
reflect the methodologies described in the proposed rule.
For example, for our modeling in the proposed rule, we used a
therapy case-mix index that originally had been created for use in our
FY 2001 refinements proposal, and utilized the same therapy case-mix
weights for the new groups as for the original rehabilitation groups;
that is, the therapy case-mix weight for the ultra high rehabilitation
and combined ultra high rehabilitation/extensive care RUG groups were
the same. As part of our ongoing review, we also tested several
adjustments to our model, including recalibration of the therapy case-
mix weights, using different sets of decision rules, to create separate
therapy weights for the nine new groups. The purpose of this exercise
was to test whether the adjusted model(s) better reflected the policy
outlined in the proposed rule.
Using the adjusted therapy case-mix weights, we repeated the
payment simulation described in the proposed
[[Page 45031]]
rule. We then recalculated the payment adjustment needed to ensure
parity when comparing the aggregate expenditure levels of the 44-group
and 53-group RUG models. We found that, in recalibrating both the
nursing and therapy case-mix weights, applying the payment adjustment
solely to the nursing case-mix weights was no longer appropriate. Thus,
we tested a second adjustment to the model that modified the payment
simulation provision to apply the payment adjustment to both the
nursing and therapy case-mix weights. We posted the analyses on our CMS
web site.
Industry representatives and others used these data to replicate
these analyses, to suggest alternative methodologies, and to develop
their formal comments on the proposed rule. Thus, the information
exchange through the CMS website was productive, and was beneficial in
terms of finalizing our analysis.
Comment: A commenter questioned the methodology used to recalibrate
the therapy case-mix weights, and also expressed concerns about the
small staff time measurement (STM) sample size used to create separate
therapy weights for each of the RUG-III groups.
Response: As part of the ongoing analysis described above, we
reviewed the methodology used to create the case-mix weights for the
initial introduction of the SNF PPS in 1998, and the ABT recalibration
that was published in our FY 2001 proposed rule. We found that, as
mentioned by a commenter, we were relying on extremely small sample
sizes for several of the combined rehabilitation and extensive care
groups. In addition, we found several variations in the decision rules
used in the two sets of analyses. We were able to adjust for these
methodological differences by recreating the therapy case-mix indexes
using the original decision rules.
Once these methodological changes were made, we examined the model
to determine the potential impact of using small sample sizes to
establish therapy case-mix weights for all 23 rehabilitation groups;
that is, 14 existing rehabilitation groups and 9 combined
rehabilitation and extensive care groups. We concluded that we could
not fully adjust for these small sample sizes when recalibrating the
therapy case-mix weights, either as proposed or as noted on our
website. Therefore, we have determined that retaining the same therapy
case-mix weights that are being used in the 44-group RUG model would
best reflect our policy objectives as stated in the proposed rule.
These weights will be applied to the RUG groups based on the
rehabilitation level. For example, a therapy case-mix weight of 2.25
will be used for the RUC, RUB, RUA, RUX, and RUL groups.
Once the case-mix weight structure was determined, we developed the
final rates in accordance with the procedures outlined in the proposed
rule. As we updated the nursing case-mix index only, we then applied
the payment simulation to the nursing case-mix weights by adding 8.65
percent to maintain parity between the 44-group and 53-group models.
Then, a final adjustment of 8.51 percent was made to the nursing
weights to reflect the variability in non-therapy ancillary
utilization.
In conducting these analyses, it was clear that relying on data
collected before the introduction of the SNF PPS is not a permanent
solution. We intend to revisit the structural development of the case-
mix weights as part of our upcoming STM study, in which we will survey
SNFs and collect data to better reflect current practice patterns and
resource use in the SNF PPS. In addition, we intend to investigate
alternative methods of updating the payment system as part of our
ongoing program monitoring and evaluation activities.
1. Costs and Services Covered by the Federal Rates
The Federal rates apply to all costs (routine, ancillary, and
capital-related costs) of covered SNF services other than costs
associated with approved educational activities as defined in Sec.
413.85. Under section 1888(e)(2) of the Act, covered SNF services
include post-hospital SNF services for which benefits are provided
under Part A (the hospital insurance program), as well as all items and
services (other than those services excluded by statute) that, before
July 1, 1998, were paid under Part B (the supplementary medical
insurance program) but furnished to Medicare beneficiaries in a SNF
during a Part A covered stay. (These excluded service categories are
discussed in greater detail in section V.B.2 of the May 12, 1998
interim final rule (63 FR 26295 through 26297)).
2. Methodology Used for the Calculation of the Federal Rates
The FY 2006 rates reflect an update using the full amount of the
latest market basket index. The FY 2006 market basket increase factor
is 3.1 percent. A complete description of the multi-step process was
initially delineated in the May 12, 1998 interim final rule (63 FR
26252), and was further revised in subsequent rules. We note that in
accordance with section 101(a) of the BBRA and section 314 of the BIPA,
the existing, temporary increase in the per diem adjusted payment rates
of 20 percent for certain specified clinically complex RUGs (and 6.7
percent for rehabilitation RUGs) remains in effect until January 1,
2006, when the refined RUG-53 classification system is implemented.
We used the SNF market basket to adjust each per diem component of
the Federal rates forward to reflect price increases occurring between
the midpoint of the Federal fiscal year beginning October 1, 2004, and
ending September 30, 2005, and the midpoint of the Federal fiscal year
beginning October 1, 2005, and ending September 30, 2006, to which the
payment rates apply. In accordance with section 1888(e)(4)(E)(ii)(IV)
of the Act, the payment rates for FY 2005 are updated by a factor equal
to the full market basket index percentage increase to determine the
payment rates for FY 2006. The rates are further adjusted by a wage
index budget neutrality factor, described later in this section. The
unadjusted rates are the same under both the 44-group RUG-III
classification system and the refined RUG-53 classification system.
Tables 2 and 3 below reflect the updated components of the unadjusted
Federal rates for FY 2006.
Table 2.--FY 2006 Unadjusted Federal Rate Per Diem--Urban
----------------------------------------------------------------------------------------------------------------
Nursing--case- Therapy--case- Therapy--non-
Rate component mix mix case-mix Non-case-mix
----------------------------------------------------------------------------------------------------------------
Per Diem Amount.................................... $137.59 $103.64 $13.65 $70.22
----------------------------------------------------------------------------------------------------------------
[[Page 45032]]
Table 3.--FY 2006 Unadjusted Federal Rate Per Diem--Rural
----------------------------------------------------------------------------------------------------------------
Nursing--case- Therapy--case- Therapy--non-
Rate component mix mix case-mix Non-case-mix
----------------------------------------------------------------------------------------------------------------
Per Diem Amount.................................... $131.45 $119.51 $14.58 $71.52
----------------------------------------------------------------------------------------------------------------
C. Case-Mix Adjustment and Other Clinical Issues
1. Proposed Refinements to the RUG-III Case-Mix Classification System
Under the BBA, we must publish the SNF PPS case-mix classification
methodology applicable for the next Federal fiscal year before August 1
of each year. In the FY 2006 SNF PPS proposed rule, we proposed to
implement refinements in the existing 44-group RUG-III case-mix
classification system that would add 9 new Rehabilitation plus
Extensive Services groups at the top of the existing hierarchy. A full
discussion of our proposal can be found in this year's proposed rule
for FY 2006 (70 FR 29075-81). The following is a discussion of the
comments that we received on this issue.
Comment: A number of commenters viewed the introduction of the
proposed refinements in a positive light, both as a means to address
the needs of a specific heavy-care population and as a way to remove
the uncertainty over the past several years surrounding the pending
expiration of the BBRA's temporary add-on payments, which had made it
difficult for SNFs to predict with any certainty what their payments
would be from one year to the next. Other commenters questioned why we
introduced RUG refinements through the regulatory process before
finalizing a long term research project and submitting a report to the
Congress on the results of that research. Several commenters suggested
that it would be more appropriate to wait until the upcoming STM study
is completed, so that we could take advantage of more recent data on
practice patterns and resource use. Still others were concerned that
the proposed refinements do not go far enough to reimburse SNFs
adequately for non-therapy ancillaries, and questioned why we proposed
a series of incremental changes to the existing RUG-III system rather
than developing a comprehensive replacement to the current SNF PPS.
Response: The RUG refinements and the SNF PPS report to the
Congress on alternative systems have often been viewed as two
components of a single project. However, while there is a definite
relationship, the RUG refinements and the SNF PPS report to the
Congress are, and should be viewed as, end products of two separate
Congressional mandates.
The BBRA legislation authorized temporary payment adjustments that
were intended to serve as short term, interim adjustments to the
payment rates and RUG-III case-mix classification system as published
in our July 30, 1999 final rule (64 FR 41644). In fact, while the
legislation included a contingency plan to maintain the temporary
payments until refinements to better account for ``medically complex''
patients were introduced, the Congress clearly envisioned that these
temporary payments would expire on October 1, 2000. Given this short
time frame, it seems clear that the ``refinements'' could be expected
to be modest in scope. We believe the rulemaking process was the most
appropriate vehicle for introducing any refinement policy changes, as
it affords all stakeholders the opportunity to comment before any
policy recommendations are finalized.
In contrast, section 311(e) of the BIPA directed us to conduct a
study of the different systems for categorizing patients in Medicare
SNFs, and to issue a report with any appropriate recommendations to the
Congress. Based upon the broad language describing the purpose of this
study, and the multi-year timeframe provided for conducting it, we
believe that the Congress clearly intended for this study to address
more comprehensive changes, by evaluating a number of different
classification systems and considering the full range of patient types.
The results of this broader research will be discussed in a report that
will be released to the Congress once it has been completed.
However, we believe the need for ongoing evaluation and change
should not preclude the more immediate introduction of incremental
adjustments and improvements to the SNF PPS. We intend to use the
report to Congress to outline a series of next steps, including the
need for a new STM study, that support our ongoing efforts to enhance
the accuracy and efficiency of the SNF PPS.
We note that many of the concerns advanced by the commenters are
similar to the ones that some commenters expressed in response to the
SNF PPS proposed rule for FY 2004 (68 FR 26758, May 16, 2003), when we
last invited public comments on the issue of case-mix refinements.
However, as we subsequently observed in the final rule for FY 2004,
other commenters were at that same time urging us ``* * * to move
quickly to identify and implement short-term incremental improvements
to provide more appropriate reimbursement for patients with heavy non-
therapy ancillary needs'' (68 FR 46041, August 4, 2003). As discussed
in this year's FY 2006 proposed rule, we believe the refinements that
we have developed offer an effective means of enabling the SNF PPS to
make more accurate payments for non-therapy ancillary services (thus
ensuring continued access to quality care for the very vulnerable
heavy-care population), while at the same time avoiding the drawbacks
in terms of added complexity that were inherent in previous proposals
to address this issue (70 FR 29079). Accordingly, we are implementing
the case-mix refinements as set forth in the proposed rule.
Comment: Commenters suggested we expand the proposed RUG-53
classification system by, for instance, creating an additional
Rehabilitation RUG between Medium and High and the expansion of the
Extensive Services category to include criteria such as cardiac
respiratory conditions that require monitoring and the administration
of aerosol medications.
Response: During future analysis, most notably our upcoming STM
study, we will evaluate whether the RUG categories should be further
modified.
In addition, we have discovered that in the FY 2006 SNF PPS
proposed rule, we inadvertently misidentified some RUG classification
categories corresponding to Rehab High, Rehab Medium, and Rehab Low in
Table 3a (``Crosswalk Between Existing RUG-III Rehabilitation Groups
and the Proposed Extensive Plus Rehabilitation Groups''). Accordingly,
in this final rule, we are reprinting the retitled and corrected Table
3a, as set forth below.
[[Page 45033]]
Table 3a.--Crosswalk Between Existing RUG-III Rehabilitation Groups and the New Rehabilitation Plus Extensive
Services Groups
----------------------------------------------------------------------------------------------------------------
New rehabilitation plus extensive
Current rehabilitation groups services groups
----------------------------------------------------------------------------------------------------------------
Rehab Ultra......................... RUC--ADL 16-18............. RUX--ADL 16-18.
RUB--ADL 9-15.............. RUL--ADL 7-15.
RUA--ADL 4-8...............
Rehab Very High..................... RVC--ADL 16-18............. RVX--ADL 16-18.
RVB--ADL 9-15.............. RVL--ADL 7-15.
RVA--ADL 4-8...............
Rehab High.......................... RHC--ADL 13-18............. RHX--ADL 13-18.
RHB--ADL 8-12.............. RHL--ADL 7-12.
RHA--ADL 4-7...............
Rehab Medium........................ RMC--ADL 15-18............. RMX--ADL 15-18.
RMB--ADL 8-14.............. RML--ADL 7-14.
RMA--ADL 4-7...............
Rehab Low........................... RLB--ADL 14-18............. RLX--ADL 7-18.
RLA--ADL 4-13..............
----------------------------------------------------------------------------------------------------------------
2. Proposed Increases to the RUG-III Case-Mix Weight Values
To help address the high degree of variability in the use of non-
therapy ancillary services that we have identified both within and
across groups, in the FY 2006 SNF PPS proposed rule, we proposed to
increase the case-mix weights for all 53 RUGs (that is, the 44 existing
RUG-III groups, as well as the proposed 9 new Rehabilitation plus
Extensive Services groups). Specifically, we proposed to apply an
increase of 8.4 percent to the component of the case-mix weights that
includes both nursing and non-therapy ancillary costs (producing a 3
percent increase in aggregate spending), and to do so in a manner that
would integrate the increase into base line spending levels and
continue it in future years (70 FR 29079). (As noted previously in
section III.B, the proposed 8.4 percent increase to the nursing
component of the case-mix weights is now 8.51 percent in this final
rule.) The following is a discussion of the comments that we received
on this issue.
Comment: A number of commenters were concerned about the adequacy
of payment for non-therapy ancillary services, and questioned whether
the proposed increase in the nursing case-mix weights fully addresses
the issue. Several commenters recommended that the case-mix weights
should be adjusted by more than the 8.4 percent presented in the
proposed rule. Others suggested that, rather than adjusting the case-
mix weights by a factor comparable to outlier pools (that is, 3 percent
of aggregate spending) established for other prospective payment
systems, we implement a SNF outlier pool that could more specifically
target high-cost cases. A few commenters also recommended that we adopt
a payment adjustment for hospital-based SNFs, either as part of an
outlier policy or as an adjustment to the base rates that would address
not only the different levels of non-therapy ancillary utilization
between hospital-based and freestanding facilities, but the overall
cost structure differences related to differences in patient
characteristics and care needs. In addition, several commenters
recommended creating a variable per diem payment mechanism similar to
the mechanism used for inpatient psychiatric hospitals, where higher
payments could be made for the early (and presumably more costly) days
of a SNF stay. Finally, a few commenters expressed concern that the
effect of the refinements would be to redirect dollars away from
beneficiaries needing complex medical services.
Response: As discussed here and in our proposed rule, the
variability in non-therapy ancillary utilization increased the
difficulty of any refinement to the RUG-III system without increasing
the system complexity to such a degree that it would become both
burdensome and confusing to the facility staff responsible for
administering the system. In evaluating potential options, we
recognized that this across-the-board increase in the nursing component
is only an incremental improvement, but it is a change that did not
give rise to the concerns about undue complexity noted above.
Moreover, while the introduction of these refinements fulfills our
obligations under section 101 of the BBRA, we note it is just the first
of an ongoing series of analyses aimed at enhancing the SNF PPS payment
structure. For example, we are already examining the potential for an
outlier program to further enhance program accuracy and beneficiary
access to care.
The introduction of this incremental change is part of this ongoing
process that will also include update activities such as the upcoming
STM study and investigation of potential alternatives to the RUG system
itself. However, the commitment to long term analysis and refinement
should not preclude the introduction of more immediate methodological
and policy updates.
While most commenters viewed the adoption of the nine new groups as
beneficial, a few commenters were concerned that money was being
redirected away from the complex medical RUGs. We are confident that
the introduction of these refinements benefits heavy-care
beneficiaries. However, as shown in Table 12 of this final rule,
changes in the FY 2006 rate structure reflect an interrelationship
between many factors, including the elimination of the BBRA add-ons,
changes in the wage index, and the introduction of the refinements.
Comment: Some commenters suggested that the underfunding in the
Medicaid system should be addressed at the same time as the Medicare
RUGs refinement, and expressed concern about the impact that Medicare
payment rate reductions would have in combination with changes in State
Medicaid payments.
Response: While Medicare and Medicaid are independent programs that
are subject to different ratesetting and budgetary mechanisms, we
recognize their interrelationship, particularly for those States that
utilize variations of Medicare's RUG case-mix classification system. We
further recognize that Medicaid needs to establish rates that
accurately reflect the cost of Medicaid services. In order to
[[Page 45034]]
assist in realizing that objective, we plan to use our upcoming STM
study to look at the entire RUG payment system, including facilities
that are predominately Medicaid-based. Additionally, the Pay for
Performance quality initiatives discussed in the FY 2006 proposed rule
could apply to both covered Part A and noncovered (Part B) stays of
dual-eligibles.
3. Implementation Issues
In order to enable nursing homes and Medicare contractors to have
sufficient lead time to prepare for the changes associated with
implementing the RUG-III case-mix refinements, in the FY 2006 SNF PPS
proposed rule we proposed an effective date for the refinements of
January 1, 2006, rather than the start of the fiscal year on October 1,
2005. (Under the terms of section 101(c) of the BBRA, the temporary
add-on payments enacted by sections 101(a) and (b) of the BBRA for
certain designated RUG-III groups would expire on the date that these
refinements take effect.) The following is a discussion of the comments
that we received on this issue.
Comment: Generally, commenters were supportive of the delay in
implementing the case-mix refinements. However, some commenters were
concerned that the January 2006 date does not provide adequate
preparation time, especially for the software vendors and facilities
that will need to update their MDS data systems. They pointed out the
need for adequate lead time to ensure a smooth transition. In addition,
a few commenters wanted to know which date would determine when the new
RUG classification would need to be reported on the claim (for example
the Assessment Reference Date (ARD, item A3a), the Minimum Data Set
(MDS) completion date (item R2b), the service date, or the admission
date), as well as whether the MDS edits will provide a 44-group RUG for
corrected MDSs. Finally, a few commenters noted that the RAVEN software
would need to be updated prior to any changes to the existing RUG-III
classification system.
Response: We agree that software vendors and SNFs must have enough
time to design, test, and implement the system changes needed to
support these refinements. For this reason, we have scheduled a
software vendor conference call on August 4, 2005 to review the data
specifications, and respond to questions on the changes. Further
information on this vendor teleconference is posted on our Quality
Improvement Evaluation System (QIES) website at the following address:
http://www.qtso.com/vendor.html We will also make available the new software specifications at http://www.cms.hhs.gov/medicaid/mds20/mdssoftw.asp.
and vendors should implement the appropriate software by
November 22, 2005. This timeline provides the vendors over 3 months to
update their programs for SNFs. We also plan to release training
materials and billing instructions in sufficient time so that SNFs will
be able to transition to the refined RUG model.
As stated in the proposed rule, we will begin to apply the RUG
case-mix refinement on January 1, 2006. Even though payments are
determined by the MDS, the CMS claims processing systems operate on a
date of service basis. Thus, the new rates need to go into effect as of
January 1, 2006, rather than by the ARD date. This procedure is
consistent with the billing procedures used at the start of each rate
year. Providers are always instructed to prepare separate bills for
services prior to and on or after October 1. This ensures that the
claim is paid using the correct rate.
We believe that by scheduling implementation for January 1, 2006,
rather than October 1, 2005 (the beginning of FY 2006), we are allowing
ample time for providers to adjust to the refined RUG case-mix
classification system and to train and educate their staff. This date
also allows vendors sufficient time to update their programs to meet
our requirements. Finally, by providing a date certain, all systems
(State, CMS, FI, providers) can be configured uniformly, thus limiting
potential billing errors.
The provider shall bill the appropriate RUG category based on the
calendar date of service. For days of service before January 1, 2006,
the provider shall record the 44-group RUG on the claim. For days of
service beginning on January 1, 2006, the provider shall record the 53-
group RUG on the claim.
If for some unforeseen reason, a software vendor is not able to
update its program by mid-November, the State system ``Final Validation
Report'' to the provider will list both the 44-group RUG and the 53-
group RUG for SNF PPS assessments with ARDs of 11/22/2005 through 1/13/
2006. These are the potential transition assessments that could be used
for days of service both before January 1, 2006 and for days of service
in 2006. For example, a 60-day SNF PPS MDS can be completed as early as
day 50 of the beneficiary's SNF Part A stay. If the resident's 50th day
of the stay is November 22, 2005 and the provider chooses this date as
the ARD for the 60-day PPS MDS, the 44-group RUG would be billed from
day 61 (December 3, 2005) to day 89 (December 31, 2005) and the 53-
group RUG would be billed for day 90 (January 1, 2006).
For assessments with ARDs before November 22, 2005, only the 44-
group RUG is appropriate for billing and the ``Final Validation
Report'' will only report the 44-group RUG when the facility submits an
incorrect 44-group RUG on the assessment. For assessments with ARDs
after January 13, 2006, only the 53-group RUG is appropriate for
billing and the ``Final Validation Report'' will only report the 53-
group RUG when the facility submits an incorrect 53-group RUG on the
assessment. For assessments with ARDs from November 22, 2005 through
January 13, 2006, the MDS may be submitted with either the 44-group RUG
or the 53-group RUG.
Correction assessments (Modifications or Significant Correction
Assessments) will be processed in the same manner as other assessments.
The RUG grouper (44-group vs. 53-group RUG) that will be calculated and
accepted will be determined by the ARD of the Modification or
Significant Correction Assessment.
We believe that these steps provide adequate support, and will
proceed with the implementation of the refinements effective January 1,
2006.
4. Additional Clinical and Related Issues
In addition to the proposed case-mix refinements, the FY 2006 SNF
PPS proposed rule discussed and invited public comment on a number of
other clinical and related issues involving alternative ways to improve
quality and efficiency and continue to ensure accurate payments under
the SNF PPS.
a. Proposed Changes to the MDS Coding Requirements (``Look Back''
Period, 5-Day Grace Periods for PPS MDS Assessments, and Projection of
Anticipated Therapy Services During the 5-Day PPS Assessment (Section
T))
In the FY 2006 SNF PPS proposed rule, we invited public comment on
possible changes in MDS coding requirements, such as decreasing the
length of the ``look-back'' period (to restrict coding of certain high
intensity services to those actually received in the SNF), decreasing
or eliminating the grace periods associated with PPS MDS assessments
(specifically with reference to the 5-day PPS MDS assessment), and
possibly eliminating the projection of anticipated therapy services
during the 5-day PPS assessment (70 FR 29080).
Comment: We received numerous comments on several potential changes
to the MDS and the case-mix
[[Page 45035]]
classification system that we proposed. The overwhelming majority of
commenters opposed the elimination of two current policies: The
availability of grace days when completing the MDS, and the method of
estimating therapy services during the first 15 days of a SNF
admission. However, a few commenters supported eliminating the method
of estimating therapy services, mentioning findings by the GAO and the
Data Assessment and Verification Project (DAVE) that demonstrated a
mismatch between the estimated and actual amount of therapy provided,
and expressing concern that there may be some abuse of this policy. In
addition, a few commenters suggested limiting the use of grace days to
the 5-day and 14-day assessments. We also received numerous comments on
the change in the MDS assessment ``look back'' period to restrict MDS
reporting to services furnished in the SNF rather than during the
preceding hospital stay. While some commenters supported the change in
terms of SNF reimbursement policy, most commenters believed there were
strong care planning reasons for retaining the current policy.
Specifically, the commenters were concerned that facility staff would
be unable to perform an accurate assessment of the resident, and that
the elimination of the data would result in an underestimate of
resource needs and negatively affect the development of an
individualized care plan. A number of commenters also recommended that
the type of changes discussed in the proposed rule needed to be
coordinated with other CMS initiatives, including the development of
MDS 3.0 and the upcoming STM study.
Response: After reviewing the comments, we agree that the changes
discussed above should be addressed as part of a comprehensive
examination of both the MDS 3.0 design initiative and the case-mix
classification system. Therefore, we will not implement changes at this
time, but will continue to study these and other issues during the
upcoming STM study and MDS 3.0 design initiative.
b. Long-Term Payment and Quality Incentive Proposals
In the FY 2006 SNF PPS proposed rule, we discussed and invited
comment on various long-term payment and quality incentives (70 FR
29080-29081). The following is a discussion of the comments that we
received on these issues.
Comment: Commenters generally responded positively to our
discussion of these issues. Regarding Pay for Performance initiatives,
the overwhelming majority of commenters believed that its design should
be a collaborative process between CMS, industry representatives, and
other stakeholders to ensure development of a fair and equitable
program. In some cases, the comments we received contained detailed
suggestions on the design, validation, and use of quality measures in
such a program. A few commenters also suggested specific funding
structures. Other commenters suggested that additional work is needed
to evaluate the interaction between performance measures used for
payment and the design structure of an MDS 3.0 assessment tool.
Commenters also expressed interest in the integrated post acute payment
system, and were supportive of the idea that reimbursement under such a
system could be more closely linked to actual patient need. Similarly,
the majority of commenters believed that the development of electronic
health records has a real potential for improving the accuracy and
efficiency of the system. Commenters were also very supportive of
enhanced discharge planning, and saw it as a way of achieving improved
outcomes in terms of quality of care as well as quality of life for
facility residents.
Response: We agree with the commenters that the most effective way
of designing any of these initiatives would be through a collaborative
process. To that end, we have begun work on a SNF Pay for Performance
model, and have already had informal discussions with stakeholders,
where we asked them for their input and comments on specific design
issues. These issues included the type of measures that would be most
appropriate, and the importance of ensuring that they reflect the needs
of the entire population, from post acute patients to chronic, long-
term care patients. We also informed the stakeholders that we have
contracted with Abt Associates to design a demonstration model, and we
asked for their feedback on the type of model that would be most
effective in fostering quality of care. We plan to follow up with a
general meeting early this fall, where we will discuss design issues
and potential quality measures in greater detail. We expect to follow
similar procedures as we undertake development of the various other
initiatives discussed here and in the proposed rule.
c. Proposal To Clarify ``Direct'' and ``Indirect'' Employment
Relationships for Nurse Practitioners and Clinical Nurse Specialists
The Medicare statute specifies that a nurse practitioner (NP) or a
clinical nurse specialist (CNS) can perform the required level of care
certifications and recertifications in a SNF only if the NP or CNS `` *
* * does not have a direct or indirect employment relationship with the
facility * * *'' (section 1814(a)(2) of the Act). In the FY 2006 SNF
PPS proposed rule, we proposed revising our policies at Sec.
424.20(e)(2) of the regulations to distinguish more clearly between
``direct'' and ``indirect'' employment relationships in terms of the
ability of NPs and CNSs to perform SNF certifications and
recertifications. We noted that NPs and CNSs who are employed by SNFs
not only perform the types of delegated physician tasks that are
permitted under the long-term care facility requirements for
participation at 42 CFR 483.40(e), but typically perform general
nursing services as well. In those situations where no direct
employment relationship exists between an NP or CNS and the SNF, we
proposed that an indirect employment relationship exists for any NP or
CNS who performs these general nursing services for the SNF under the
regulations at 42 CFR 409.21 (70 FR 29082).
Comment: Many commenters expressed concern that our proposal to
define ``indirect'' employment in terms of the provision of general
nursing services was overly restrictive. They argued that adopting this
approach would inhibit NPs and CNSs from engaging in their full scope
of practice, and would limit SNF residents' access to their services.
It was also asserted that our proposed definition actually goes well
beyond the intent of the Congressional restriction on indirect
employment relationships, as it could encompass even those NPs and CNSs
who operate in independent practice and have no employment relationship
whatsoever with the SNF, either directly or through another entity. In
addition, some commenters suggested that our proposed approach
represents a double standard, in that it would not subject physicians
to similar restrictions.
Response: Regarding the concerns about unduly impeding the scope of
practice for NPs and CNSs and limiting resident access to their
services, we note that under section 1814(a)(2) of the Act, the
statutory prohibition against an NP or CNS having a direct or indirect
employment relationship with the SNF applies solely in terms of
performing the
[[Page 45036]]
required certification and recertifications of the beneficiary's need
for Part A SNF services, and does not carry over to any other context.
This means that while the presence of such an employment relationship
would serve to preclude an NP or CNS from performing the required SNF
certification and recertifications, it would not additionally prevent
the NP or CNS from furnishing the full range of direct patient care to
the SNF's residents. Further, regarding the issue of the differential
treatment of physicians (who are not subject to this restriction), we
note that the statute itself specifically applies the restriction to
NPs and CNSs, but not to physicians.
In essence, we believe that a direct employment relationship is one
in which the SNF itself exercises the right of direction and control
over the NP or CNS that characterizes an employment relationship under
the common law test (see the regulations at 20 CFR 404.1005, 404.1007,
and 404.1009), while an indirect employment relationship is one in
which another entity exercises this right on the SNF's behalf. However,
we agree that an indirect employment relationship should not be defined
so broadly as to encompass an NP or CNS who is operating in independent
practice and, thus, has no employer-employee relationship whatsoever,
either with the SNF or with any other entity. Moreover, we believe this
term should not encompass situations where an entity other than the
SNF, although employing the NP or CNS, does not do so on the SNF's
behalf. For example, it is common for an NP or CNS who is employed by a
group practice to see SNF residents on behalf of one of the group
practice's physicians. There may be instances where the group practice
enters into an agreement with the SNF that includes having the group
practice's NP or CNS employee furnish general nursing services to the
SNF's residents. As these general nursing services would fall within
the package of bundled services for which the SNF is financially and
professionally responsible, the group practice under such an agreement
essentially would be exercising its authority as the NP's or CNS's
employer on the SNF's behalf, so that an indirect employment
relationship would exist between the SNF and the NP or CNS.
By contrast, if the group practice's agreement with the SNF does
not involve the provision of bundled nursing services (for example, it
is solely for the purpose of gaining admitting privileges for the group
practice's physicians, or for providing excluded NP or CNS services to
the SNF's residents), then the group practice's exercise of its
authority as the NP's or CNS's employer would not be done on the SNF's
behalf. Consequently, an indirect employment relationship would not
arise under such an agreement, and the NP or CNS would not be precluded
from either furnishing the separately billable NP or CNS services to
the SNF's residents, or from completing the required certifications and
recertifications. Similarly, an indirect employment relationship would
not arise in those instances where the only services that the NP or CNS
furnishes to the SNF's residents under the agreement are delegated
physician tasks under 42 CFR 483.40(e).
Accordingly, in response to comments, we are modifying this aspect
of the proposed rule in the regulations at Sec. 424.20 to specify that
in contrast to a direct employment relationship with a SNF (in which
the SNF itself exercises the right of direction and control over the NP
or CNS that characterizes an employment relationship under the common
law test), an indirect employment relationship exists in situations
where an NP or CNS meets both of the following conditions: (1) The NP
or CNS has a direct employment relationship with an entity other than
the SNF itself; and (2) The NP's or CNS's employer enters into an
agreement with the SNF for the provision of bundled general nursing
services to the SNF's residents. Under this definition, an NP or CNS
who is employed by an entity other than the SNF can still perform SNF
certifications and recertifications, as long as his or her employer has
not entered into such an agreement with the SNF.
d. Completion of Other Medicare Required Assessments (OMRAs)
In the FY 2006 SNF PPS proposed rule, we noted that one of the
requirements governing the completion of Other Medicare Required
Assessments (OMRAs) specifies that an OMRA ``is due'' 8 to 10 days
after the cessation of all therapy (occupational and physical therapies
and speech-language pathology services) in all situations where the
beneficiary was assigned a rehabilitation RUG on the previous
assessment. We then went on to clarify how the last day of therapy is
determined in this context.
Comment: Most commenters supported introduction of the
clarification, while a small number of commenters expressed concern
about the wording. Others expressed concerns on issues that are not
directly related to the OMRA language, including comments expressing
concern about the limited ability to capture the ``short-stay patients
discharged before the five-day assessment,'' and suggesting that we
introduce either an at-admission or an at-discharge assessment, or that
we eliminate the 5-day assessment.
Response: After reviewing the comments, we agree that we can
further clarify our discussion of OMRA assessments in the proposed
rule. Therefore, we wish to clarify that in our previous statements
that the OMRA ``is due'' 8 to 10 days after the cessation of all
therapy, and that therapeutic leave days are counted in determining the
OMRA ``due date,'' the due date to which we refer is, in fact, the
Assessment Reference Date (ARD). Thus, it is the ARD of the OMRA that
must be set 8 to 10 days after the cessation of all therapy, and
therapeutic leave days are counted when setting the OMRA ARD. Further,
we note that we will keep the commenters' additional suggestions in
this area in mind as we pursue our ongoing efforts to improve the
accuracy and efficiency of the SNF PPS and the MDS processing system.
e. Concurrent Therapy
In the FY 2006 SNF PPS proposed rule, we solicited public comment
on whether additional guidance might be warranted to help prevent the
inappropriate provision of concurrent therapy in situations where it is
not clinically justified (70 FR 29082-29083). The following is a
discussion of the comments that we received on this issue.
Comment: A majority of commenters support the continuation of
concurrent therapy as a delivery mode for rehabilitation services when
properly furnished by the therapist. Many commenters suggested that CMS
establish guidelines or develop examples that would provide guidance on
the appropriate use of concurrent therapy, while a few commenters
pointed out that CMS already has authority to conduct medical reviews
and opposed further regulation. We also received some comments that
suggested ways to decrease confusion among therapists, including
educational outreach with the assistance of the professional
associations, and establishing a single set of guidelines for Medicare
Part A and Medicare Part B. Several commenters reported abuse and some
reported that staff are being coerced to maximize minutes and
reimbursement. One commenter expressed concern that, in the absence of
concurrent therapy, some patients might not receive any services.
However, another commenter suggested that the overuse of concurrent
therapy
[[Page 45037]]
could mean that a beneficiary might never receive necessary
individualized care.
Response: We addressed the practice of concurrent therapy in the FY
2006 SNF PPS proposed rule in order to reiterate Medicare policy and to
solicit public comment. Our concern was two-fold: That therapists'
professional judgment was being overridden by pressures to be more
productive by treating multiple beneficiaries concurrently; and that
the Medicare policy that allows for the treatment of multiple
beneficiaries was being used inappropriately and could lead to
diminished quality of care. We wished to convey that the therapist's
professional judgment should not be compromised and concurrent therapy
should be performed only when it is clinically appropriate to render
care to more than one individual (other than group therapy) at the same
time. We agree that, at times, such care can be provided concurrently
with another therapy patient, as long as the decision to do so is
driven by valid clinical considerations. As requested by several
commenters and based on the reports of overuse and/or abuse of
concurrent therapy, we will continue to monitor these issues. We intend
to work with professional organizations to determine the type of
guidelines and educational materials that would be most helpful to
therapists and other stakeholders. In addition, we also intend to
address concurrent and group therapy utilization patterns during our
STM study scheduled to start later this calendar year.
5. Case-Mix Adjusted Federal Rates and Associated Indexes
We have established January 1, 2006, as the beginning date for the
use of the case-mix refinements. Accordingly, from October 1, 2005,
through December 31, 2005, we will make payment based entirely on the
existing 44-group RUG-III classification system. Tables 4, 5, 6, and 7
reflect the corresponding rate information for the existing 44-group
RUG-III classification system to be used during this time.
Beginning on January 1, 2006, we will make payment based entirely
on the refined RUG-53 classification system (and, thus, would not
include the add-on payments). Tables 4a, 5a, 6a, and 7a reflect the
corresponding rate information for the RUG-53 classification system.
As part of our ongoing analysis of the 53-group model, we updated
the nursing case-mix weights presented in the proposed rule using 2001
data, the most current data available. In addition, based on comments,
we adjusted the 53-group model to retain the existing therapy case-mix
weights for the 23 Rehabilitation and combined Rehabilitation/Extensive
Care groups. We then used the updated case-mix data to repeat the
payment simulation described in the proposed rule. The payment
simulation showed that adjustments were needed to maintain parity
between the 44-group and 53-group models. Thus, we modified the payment
simulation model to apply the payment adjustment to both the nursing
and therapy case-mix weights proportionally by the aggregate number of
days in therapy RUGs versus non-therapy RUGs. This parity was achieved
by increasing the nursing case-mix weight by 8.65 percent. Finally,
using the methodology described in the proposed rule, we calculated an
8.51 percent nursing case-mix weight adjustment factor to use to
address variability in non-therapy ancillary costs. The steps taken to
calculate the 53-group model nursing case-mix weights are shown on the
SNF PPS website, at http://www.cms.hhs.gov/providers/snfpps.
Tables 4 and 5 reflect the updated SNF Federal rates for FY 2006
for the existing 44-group RUG-III classification system. Tables 4a and
5a reflect the updated SNF Federal rates for FY 2006 for the RUG-53
classification system. The first nine groups listed in Tables 4a and 5a
are for the new Rehabilitation plus Extensive Services groups.
Table 4.--RUG-44 Case-Mix Adjusted Federal Rates and Associated Indexes--Urban
--------------------------------------------------------------------------------------------------------------------------------------------------------
Non-case Non-case
RUG III category Nursing Therapy Nursing Therapy mix therapy mix Total rate
index index component component component component
--------------------------------------------------------------------------------------------------------------------------------------------------------
RUC.......................................................... 1.30 2.25 178.87 233.19 ........... 70.22 482.28
RUB.......................................................... 0.95 2.25 130.71 233.19 ........... 70.22 434.12
RUA.......................................................... 0.78 2.25 107.32 233.19 ........... 70.22 410.73
RVC.......................................................... 1.13 1.41 155.48 146.13 ........... 70.22 371.83
RVB.......................................................... 1.04 1.41 143.09 146.13 ........... 70.22 359.44
RVA.......................................................... 0.81 1.41 111.45 146.13 ........... 70.22 327.80
RHC.......................................................... 1.26 0.94 173.36 97.42 ........... 70.22 341.00
RHB.......................................................... 1.06 0.94 145.85 97.42 ........... 70.22 313.49
RHA.......................................................... 0.87 0.94 119.70 97.42 ........... 70.22 287.34
RMC.......................................................... 1.35 0.77 185.75 79.80 ........... 70.22 335.77
RMB.......................................................... 1.09 0.77 149.97 79.80 ........... 70.22 299.99
RMA.......................................................... 0.96 0.77 132.09 79.80 ........... 70.22 282.11
RLB.......................................................... 1.11 0.43 152.72 44.57 ........... 70.22 267.51
RLA.......................................................... 0.80 0.43 110.07 44.57 ........... 70.22 224.86
SE3.......................................................... 1.70 ........... 233.90 ........... 13.65 70.22 317.77
SE2.......................................................... 1.39 ........... 191.25 ........... 13.65 70.22 275.12
SE1.......................................................... 1.17 ........... 160.98 ........... 13.65 70.22 244.85
SSC.......................................................... 1.13 ........... 155.48 ........... 13.65 70.22 239.35
SSB.......................................................... 1.05 ........... 144.47 ........... 13.65 70.22 228.34
SSA.......................................................... 1.01 ........... 138.97 ........... 13.65 70.22 222.84
CC2.......................................................... 1.12 ........... 154.10 ........... 13.65 70.22 237.97
CC1.......................................................... 0.99 ........... 136.21 ........... 13.65 70.22 220.08
CB2.......................................................... 0.91 ........... 125.21 ........... 13.65 70.22 209.08
CB1.......................................................... 0.84 ........... 115.58 ........... 13.65 70.22 199.45
CA2.......................................................... 0.83 ........... 114.20 ........... 13.65 70.22 198.07
CA1.......................................................... 0.75 ........... 103.19 ........... 13.65 70.22 187.06
IB2.......................................................... 0.69 ........... 94.94 ........... 13.65 70.22 178.81
IB1.......................................................... 0.67 ........... 92.19 ........... 13.65 70.22 176.06
IA2.......................................................... 0.57 ........... 78.43 ........... 13.65 70.22 162.30
[[Page 45038]]
IA1.......................................................... 0.53 ........... 72.92 ........... 13.65 70.22 156.79
BB2.......................................................... 0.68 ........... 93.56 ........... 13.65 70.22 177.43
BB1.......................................................... 0.65 ........... 89.43 ........... 13.65 70.22 173.30
BA2.......................................................... 0.56 ........... 77.05 ........... 13.65 70.22 160.92
BA1.......................................................... 0.48 ........... 66.04 ........... 13.65 70.22 149.91
PE2.......................................................... 0.79 ........... 108.70 ........... 13.65 70.22 192.57
PE1.......................................................... 0.77 ........... 105.94 ........... 13.65 70.22 189.81
PD2.......................................................... 0.72 ........... 99.06 ........... 13.65 70.22 182.93
PD1.......................................................... 0.70 ........... 96.31 ........... 13.65 70.22 180.18
PC2.......................................................... 0.65 ........... 89.43 ........... 13.65 70.22 173.30
PC1.......................................................... 0.64 ........... 88.06 ........... 13.65 70.22 171.93
PB2.......................................................... 0.51 ........... 70.17 ........... 13.65 70.22 154.04
PB1.......................................................... 0.50 ........... 68.80 ........... 13.65 70.22 152.67
PA2.......................................................... 0.49 ........... 67.42 ........... 13.65 70.22 151.29
PA1.......................................................... 0.46 ........... 63.29 ........... 13.65 70.22 147.16
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 4a.--RUG-53 Case-Mix Adjusted Federal Rates and Associated Indexes--Urban
--------------------------------------------------------------------------------------------------------------------------------------------------------
Non-case Non-case
RUG-53 category Nursing Therapy Nursing Therapy mix therapy mix Total rate
index index component component component component
--------------------------------------------------------------------------------------------------------------------------------------------------------
RUX.......................................................... 1.90 2.25 261.42 233.19 ........... 70.22 564.83
RUL.......................................................... 1.40 2.25 192.63 233.19 ........... 70.22 496.04
RVX.......................................................... 1.54 1.41 211.89 146.13 ........... 70.22 428.24
RVL.......................................................... 1.33 1.41 182.99 146.13 ........... 70.22 399.34
RHX.......................................................... 1.42 0.94 195.38 97.42 ........... 70.22 363.02
RHL.......................................................... 1.37 0.94 188.50 97.42 ........... 70.22 356.14
RMX.......................................................... 1.93 0.77 265.55 79.80 ........... 70.22 415.57
RML.......................................................... 1.68 0.77 231.15 79.80 ........... 70.22 381.17
RLX.......................................................... 1.31 0.43 180.24 44.57 ........... 70.22 295.03
RUC.......................................................... 1.28 2.25 176.12 233.19 ........... 70.22 479.53
RUB.......................................................... 0.99 2.25 136.21 233.19 ........... 70.22 439.62
RUA.......................................................... 0.84 2.25 115.58 233.19 ........... 70.22 418.99
RVC.......................................................... 1.23 1.41 169.24 146.13 ........... 70.22 385.59
RVB.......................................................... 1.09 1.41 149.97 146.13 ........... 70.22 366.32
RVA.......................................................... 0.82 1.41 112.82 146.13 ........... 70.22 329.17
RHC.......................................................... 1.22 0.94 167.86 97.42 ........... 70.22 335.50
RHB.......................................................... 1.11 0.94 152.72 97.42 ........... 70.22 320.36
RHA.......................................................... 0.94 0.94 129.33 97.42 ........... 70.22 296.97
RMC.......................................................... 1.15 0.77 158.23 79.80 ........... 70.22 308.25
RMB.......................................................... 1.09 0.77 149.97 79.80 ........... 70.22 299.99
RMA.......................................................... 1.04 0.77 143.09 79.80 ........... 70.22 293.11
RLB.......................................................... 1.14 0.43 156.85 44.57 ........... 70.22 271.64
RLA.......................................................... 0.85 0.43 116.95 44.57 ........... 70.22 231.74
SE3.......................................................... 1.86 ........... 255.92 ........... 13.65 70.22 339.79
SE2.......................................................... 1.49 ........... 205.01 ........... 13.65 70.22 288.88
SE1.......................................................... 1.26 ........... 173.36 ........... 13.65 70.22 257.23
SSC.......................................................... 1.23 ........... 169.24 ........... 13.65 70.22 253.11
SSB.......................................................... 1.13 ........... 155.48 ........... 13.65 70.22 239.35
SSA.......................................................... 1.10 ........... 151.35 ........... 13.65 70.22 235.22
CC2.......................................................... 1.22 ........... 167.86 ........... 13.65 70.22 251.73
CC1.......................................................... 1.06 ........... 145.85 ........... 13.65 70.22 229.72
CB2.......................................................... 0.98 ........... 134.84 ........... 13.65 70.22 218.71
CB1.......................................................... 0.91 ........... 125.21 ........... 13.65 70.22 209.08
CA2.......................................................... 0.90 ........... 123.83 ........... 13.65 70.22 207.70
CA1.......................................................... 0.80 ........... 110.07 ........... 13.65 70.22 193.94
IB2.......................................................... 0.74 ........... 101.82 ........... 13.65 70.22 185.69
IB1.......................................................... 0.72 ........... 99.06 ........... 13.65 70.22 182.93
IA2.......................................................... 0.61 ........... 83.93 ........... 13.65 70.22 167.80
IA1.......................................................... 0.56 ........... 77.05 ........... 13.65 70.22 160.92
BB2.......................................................... 0.73 ........... 100.44 ........... 13.65 70.22 184.31
BB1.......................................................... 0.69 ........... 94.94 ........... 13.65 70.22 178.81
BA2.......................................................... 0.60 ........... 82.55 ........... 13.65 70.22 166.42
BA1.......................................................... 0.52 ........... 71.55 ........... 13.65 70.22 155.42
PE2.......................................................... 0.85 ........... 116.95 ........... 13.65 70.22 200.82
PE1.......................................................... 0.82 ........... 112.82 ........... 13.65 70.22 196.69
PD2.......................................................... 0.78 ........... 107.32 ........... 13.65 70.22 191.19
PD1.......................................................... 0.76 ........... 104.57 ........... 13.65 70.22 188.44
PC2.......................................................... 0.71 ........... 97.69 ........... 13.65 70.22 181.56
[[Page 45039]]
PC1.......................................................... 0.69 ........... 94.94 ........... 13.65 70.22 178.81
PB2.......................................................... 0.55 ........... 75.67 ........... 13.65 70.22 159.54
PB1.......................................................... 0.54 ........... 74.30 ........... 13.65 70.22 158.17
PA2.......................................................... 0.53 ........... 72.92 ........... 13.65 70.22 156.79
PA1.......................................................... 0.50 ........... 68.80 ........... 13.65 70.22 152.67
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 5.--RUG-44 Case-Mix Adjusted Federal Rates and Associated Indexes--Rural
--------------------------------------------------------------------------------------------------------------------------------------------------------
Non-case Non-case
RUG III category Nursing Therapy Nursing Therapy mix therapy mix Total rate
index index component component component component
--------------------------------------------------------------------------------------------------------------------------------------------------------
RUC.......................................................... 1.30 2.25 170.89 268.90 ........... 71.52 511.31
RUB.......................................................... 0.95 2.25 124.88 268.90 ........... 71.52 465.30
RUA.......................................................... 0.78 2.25 102.53 268.90 ........... 71.52 442.95
RVC.......................................................... 1.13 1.41 148.54 168.51 ........... 71.52 388.57
RVB.......................................................... 1.04 1.41 136.71 168.51 ........... 71.52 376.74
RVA.......................................................... 0.81 1.41 106.47 168.51 ........... 71.52 346.50
RHC.......................................................... 1.26 0.94 165.63 112.34 ........... 71.52 349.49
RHB.......................................................... 1.06 0.94 139.34 112.34 ........... 71.52 323.20
RHA.......................................................... 0.87 0.94 114.36 112.34 ........... 71.52 298.22
RMC.......................................................... 1.35 0.77 177.46 92.02 ........... 71.52 341.00
RMB.......................................................... 1.09 0.77 143.28 92.02 ........... 71.52 306.82
RMA.......................................................... 0.96 0.77 126.19 92.02 ........... 71.52 289.73
RLB.......................................................... 1.11 0.43 145.91 51.39 ........... 71.52 268.82
RLA.......................................................... 0.80 0.43 105.16 51.39 ........... 71.52 228.07
SE3.......................................................... 1.70 ........... 223.47 ........... 14.58 71.52 309.57
SE2.......................................................... 1.39 ........... 182.72 ........... 14.58 71.52 268.82
SE1.......................................................... 1.17 ........... 153.80 ........... 14.58 71.52 239.90
SSC.......................................................... 1.13 ........... 148.54 ........... 14.58 71.52 234.64
SSB.......................................................... 1.05 ........... 138.02 ........... 14.58 71.52 224.12
SSA.......................................................... 1.01 ........... 132.76 ........... 14.58 71.52 218.86
CC2.......................................................... 1.12 ........... 147.22 ........... 14.58 71.52 233.32
CC1.......................................................... 0.99 ........... 130.14 ........... 14.58 71.52 216.24
CB2.......................................................... 0.91 ........... 119.62 ........... 14.58 71.52 205.72
CB1.......................................................... 0.84 ........... 110.42 ........... 14.58 71.52 196.52
CA2.......................................................... 0.83 ........... 109.10 ........... 14.58 71.52 195.20
CA1.......................................................... 0.75 ........... 98.59 ........... 14.58 71.52 184.69
IB2.......................................................... 0.69 ........... 90.70 ........... 14.58 71.52 176.80
IB1.......................................................... 0.67 ........... 88.07 ........... 14.58 71.52 174.17
IA2.......................................................... 0.57 ........... 74.93 ........... 14.58 71.52 161.03
IA1.......................................................... 0.53 ........... 69.67 ........... 14.58 71.52 155.77
BB2.......................................................... 0.68 ........... 89.39 ........... 14.58 71.52 175.49
BB1.......................................................... 0.65 ........... 85.44 ........... 14.58 71.52 171.54
BA2.......................................................... 0.56 ........... 73.61 ........... 14.58 71.52 159.71
BA1.......................................................... 0.48 ........... 63.10 ........... 14.58 71.52 149.20
PE2.......................................................... 0.79 ........... 103.85 ........... 14.58 71.52 189.95
PE1.......................................................... 0.77 ........... 101.22 ........... 14.58 71.52 187.32
PD2.......................................................... 0.72 ........... 94.64 ........... 14.58 71.52 180.74
PD1.......................................................... 0.70 ........... 92.02 ........... 14.58 71.52 178.12
PC2.......................................................... 0.65 ........... 85.44 ........... 14.58 71.52 171.54
PC1.......................................................... 0.64 ........... 84.13 ........... 14.58 71.52 170.23
PB2.......................................................... 0.51 ........... 67.04 ........... 14.58 71.52 153.14
PB1.......................................................... 0.50 ........... 65.73 ........... 14.58 71.52 151.83
PA2.......................................................... 0.49 ........... 64.41 ........... 14.58 71.52 150.51
PA1.......................................................... 0.46 ........... 60.47 ........... 14.58 71.52 146.57
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 5a.--RUG-53 Case-Mix Adjusted Federal Rates and Associated Indexes--Rural
--------------------------------------------------------------------------------------------------------------------------------------------------------
Non-case Non-case
RUG-53 category Nursing Therapy Nursing Therapy mix therapy mix Total rate
index index component component comp component
--------------------------------------------------------------------------------------------------------------------------------------------------------
RUX.......................................................... 1.90 2.25 249.76 268.90 ........... 71.52 590.18
RUL.......................................................... 1.40 2.25 184.03 268.90 ........... 71.52 524.45
RVX.......................................................... 1.54 1.41 202.43 168.51 ........... 71.52 442.46
RVL.......................................................... 1.33 1.41 174.83 168.51 ........... 71.52 414.86
RHX.......................................................... 1.42 0.94 186.66 112.34 ........... 71.52 370.52
RHL.......................................................... 1.37 0.94 180.09 112.34 ........... 71.52 363.95
[[Page 45040]]
RMX.......................................................... 1.93 0.77 253.70 92.02 ........... 71.52 417.24
RML.......................................................... 1.68 0.77 220.84 92.02 ........... 71.52 384.38
RLX.......................................................... 1.31 0.43 172.20 51.39 ........... 71.52 295.11
RUC.......................................................... 1.28 2.25 168.26 268.90 ........... 71.52 508.68
RUB.......................................................... 0.99 2.25 130.14 268.90 ........... 71.52 470.56
RUA.......................................................... 0.84 2.25 110.42 268.90 ........... 71.52 450.84
RVC.......................................................... 1.23 1.41 161.68 168.51 ........... 71.52 401.71
RVB.......................................................... 1.09 1.41 143.28 168.51 ........... 71.52 383.31
RVA.......................................................... 0.82 1.41 107.79 168.51 ........... 71.52 347.82
RHC.......................................................... 1.22 0.94 160.37 112.34 ........... 71.52 344.23
RHB.......................................................... 1.11 0.94 145.91 112.34 ........... 71.52 329.77
RHA.......................................................... 0.94 0.94 123.56 112.34 ........... 71.52 307.42
RMC.......................................................... 1.15 0.77 151.17 92.02 ........... 71.52 314.71
RMB.......................................................... 1.09 0.77 143.28 92.02 ........... 71.52 306.82
RMA.......................................................... 1.04 0.77 136.71 92.02 ........... 71.52 300.25
RLB.......................................................... 1.14 0.43 149.85 51.39 ........... 71.52 272.76
RLA.......................................................... 0.85 0.43 111.73 51.39 ........... 71.52 234.64
SE3.......................................................... 1.86 ........... 244.50 ........... 14.58 71.52 330.60
SE2.......................................................... 1.49 ........... 195.86 ........... 14.58 71.52 281.96
SE1.......................................................... 1.26 ........... 165.63 ........... 14.58 71.52 251.73
SSC.......................................................... 1.23 ........... 161.68 ........... 14.58 71.52 247.78
SSB.......................................................... 1.13 ........... 148.54 ........... 14.58 71.52 234.64
SSA.......................................................... 1.10 ........... 144.60 ........... 14.58 71.52 230.70
CC2.......................................................... 1.22 ........... 160.37 ........... 14.58 71.52 246.47
CC1.......................................................... 1.06 ........... 139.34 ........... 14.58 71.52 225.44
CB2.......................................................... 0.98 ........... 128.82 ........... 14.58 71.52 214.92
CB1.......................................................... 0.91 ........... 119.62 ........... 14.58 71.52 205.72
CA2.......................................................... 0.90 ........... 118.31 ........... 14.58 71.52 204.41
CA1.......................................................... 0.80 ........... 105.16 ........... 14.58 71.52 191.26
IB2.......................................................... 0.74 ........... 97.27 ........... 14.58 71.52 183.37
IB1.......................................................... 0.72 ........... 94.64 ........... 14.58 71.52 180.74
IA2.......................................................... 0.61 ........... 80.18 ........... 14.58 71.52 166.28
IA1.......................................................... 0.56 ........... 73.61 ........... 14.58 71.52 159.71
BB2.......................................................... 0.73 ........... 95.96 ........... 14.58 71.52 182.06
BB1.......................................................... 0.69 ........... 90.70 ........... 14.58 71.52 176.80
BA2.......................................................... 0.60 ........... 78.87 ........... 14.58 71.52 164.97
BA1.......................................................... 0.52 ........... 68.35 ........... 14.58 71.52 154.45
PE2.......................................................... 0.85 ........... 111.73 ........... 14.58 71.52 197.83
PE1.......................................................... 0.82 ........... 107.79 ........... 14.58 71.52 193.89
PD2.......................................................... 0.78 ........... 102.53 ........... 14.58 71.52 188.63
PD1.......................................................... 0.76 ........... 99.90 ........... 14.58 71.52 186.00
PC2.......................................................... 0.71 ........... 93.33 ........... 14.58 71.52 179.43
PC1.......................................................... 0.69 ........... 90.70 ........... 14.58 71.52 176.80
PB2.......................................................... 0.55 ........... 72.30 ........... 14.58 71.52 158.40
PB1.......................................................... 0.54 ........... 70.98 ........... 14.58 71.52 157.08
PA2.......................................................... 0.53 ........... 69.67 ........... 14.58 71.52 155.77
PA1.......................................................... 0.50 ........... 65.73 ........... 14.58 71.52 151.83
--------------------------------------------------------------------------------------------------------------------------------------------------------
D. Wage Index Adjustment to Federal Rates
Section 1888(e)(4)(G)(ii) of the Act requires that we adjust the
Federal rates to account for differences in area wage levels, using a
wage index that we find appropriate. Since the inception of a PPS for
SNFs, we have used hospital wage data in developing a wage index to be
applied to SNFs. We are continuing that practice for FY 2006.
1. Proposal To Incorporate the Revised OMB Definitions for Metropolitan
Statistical Areas and Combined Statistical Areas
In the FY 2006 SNF PPS proposed rule, we proposed to incorporate
into the SNF PPS the revised OMB definitions for Metropolitan
Statistical Areas, as well as the new definitions of Micropolitan
Statistical Areas and Combined Statistical Areas. For a full discussion
of this proposal, see our FY 2006 proposed rule (70 FR 29090-94). We
also invited comments on the appropriateness of implementing this
change through a transition period similar to that adopted under the
inpatient hospital PPS (IPPS)(70 FR 29095). The following is a
discussion of the comments that we received on this issue.
Comment: A number of commenters questioned the continued use of the
hospital wage index, and suggested that, rather than using the hospital
wage index to implement the OMB designations, CMS postpone action until
a SNF-specific wage index can be created. Commenters also recommended
adopting policies included in the IPPS, such as the creation of a
geographic reclassification policy for SNFs and the introduction of a
``rural floor'' (ensuring that no urban wage index value is lower than
the State-wide rural wage index.
Response: As part of our ongoing program analysis, we periodically
reevaluate the suitability of establishing a SNF-specific wage index
and a provider reclassification methodology. However, as we noted in
the FY 2004 SNF PPS final rule when this issue was
[[Page 45041]]
raised previously (68 FR 46046, August 4, 2003), in view of the
volatility of existing SNF wage data and the significant amount of
resources that would be required to improve the quality of that data,
we do not expect to propose a SNF-specific wage index until we can
demonstrate that it would significantly improve our ability to
determine payment for facilities and justify the resources required to
collect the data, as well as the increased burden on providers.
In addition, we note that the development of the hospital wage data
can also be scrutinized and evaluated by the SNF industry when
commenting on the hospital proposed rule that is published each spring.
Therefore, because of the problems associated with the current SNF-
specific data, and our inability to demonstrate that a SNF-specific
wage index would be more reflective of the wages and salaries paid in a
specific area, we continue to believe that hospital wage data are the
most appropriate data for adjusting payments made to SNFs.
We also noted in the FY 2004 final rule that while section 315 of
the BIPA does authorize the SNF PPS to use a reclassification
methodology that would allow providers to seek geographic
reclassification, it specifically provides that such reclassification
cannot be implemented until we have collected the data necessary to
establish a SNF-specific wage index. At that time, we also invited
input from the industry that could demonstrate that the adoption of a
``rural floor'' would provide a more accurate wage index. To date,
however, we have not received evidence that such an approach would, in
fact, accomplish this result. Accordingly, we are not adopting these
suggested changes at this time.
Comment: Several commenters recommended that we withdraw or
postpone implementation of this provision because the fiscal impact of
the wage index changes have a disproportionate effect on different
facilities or in different localities. One commenter also questioned
whether CMS has the legislative authority to implement the OMB
designations, as the SNF PPS structure distinguishes between urban and
rural providers, but doesn't include a category for micropolitan areas.
Response: The statute provides the Secretary with broad authority
to select an appropriate wage index, and we believe that the adoption
of these OMB designations is consistent with and in compliance with the
statutory authority. We further understand that impact on providers
based on the wage index adjustments (which, by statute, must be
accomplished in a budget neutral manner) will always vary as an
inherent aspect of such adjustments, and would occur regardless of
whether we continue to use the current MSA designations or use the more
accurate CBSA designations established by OMB in June 2003. Therefore,
we continue to believe that an appropriate wage index includes the CBSA
designations described in the proposed rule.
Comment: A large number of commenters urged CMS to develop a
transition policy to minimize the fiscal impact of the transition to
the OMB designations. Many commenters urged CMS to adopt broad
protections for facilities against changes in the wage index due to the
adoption of the new OMB designations. Commenters offered various
recommendations about how to provide such protection. Some advocated
transition mechanisms such as blending wage index factors specifically
for those facilities that would experience a wage index decrease
(similar to the approach adopted under the IPPS), with a one to four
year phase-in period to allow SNFs to make appropriate adjustments in
their operations. In addition, many commenters recommended caps on
gains and losses or a hold harmless provision for SNFs facing
significant wage index reductions under the proposal.
Response: In the FY 2006 SNF PPS proposed rule, while we did not
view it as appropriate or necessary to propose a transition period, we
provided various transition options and specifically invited comments
on our proposed approaches. We continue to recognize that some SNFs
will experience decreases in their applicable wage index as a result of
the conversion from the MSA to the CBSA structure. We also agree that
it is appropriate to assist providers in adapting to these changes in a
manner that provides the most benefit to the largest number of
providers. Therefore, based in part upon the comments, we now agree
that a transition period for SNFs would be appropriate and beneficial.
In evaluating transition options, we looked for approaches that
would provide relief to the largest percentage of adversely affected
SNFs with the least impact to the rest of the facilities, who either
received small increases or remained the same. One possible approach
that we considered would involve creating a floor (for example, at a 2
percent decrease), to be funded by also imposing a ceiling (for
example, at a 5 percent gain). Instead, we have decided to use a 1-year
transition with a blended wage index for all providers. The wage index
for each provider will consist of a blend of 50 percent of the FY 2006
MSA-based wage index and 50 percent of the FY 2006 CBSA-based wage
index (both using FY 2002 hospital wage data). We refer to this blended
wage index as the FY 2006 SNF PPS transition wage index and these
values can be found in the Addendum in Table A. This option achieves
our objective of creating a transition policy that provides relief to
the largest percentage of adversely affected SNFs with the least impact
to the rest of the facilities. In addition, the 50/50 blend option
allows us to achieve a high degree of stability in the unadjusted base
rates. The adoption of this option results in only minimal change to
the budget neutrality factor, from 1.0011 to 1.0012. In fact, the
unadjusted base rates applicable to all SNFs actually show a slight
increase.
Accordingly, as noted above, after consideration of these comments,
we have modified the wage index proposal to include the transition
policy discussed above. This transition policy is for a one-year
period. It goes into effect October 1, 2005, and remains in effect
through September 30, 2006. Thus, the transition will end at the start
of FY 2007.
In addition, we solicited comments on approaches to calculating the
wage index values for areas without hospitals for FY 2006 and
subsequent years. We received no comments on our approach and we will
implement the methodology described in the FY 2006 SNF PPS proposed
rule (70 FR 29096).
2. Determining the Labor-Related Portion of the SNF PPS Rate
The wage index adjustment is applied to the labor-related portion
of the Federal rate, which is 75.922 percent of the total rate, as
explained in section III.H.1 of this final rule. This percentage
reflects the labor-related relative importance for FY 2006. The labor-
related relative importance is calculated from the SNF market basket,
and approximates the labor-related portion of the total costs after
taking into account historical and projected price changes between the
base year and FY 2006. The price proxies that move the different cost
categories in the market basket do not necessarily change at the same
rate, and the relative importance captures these changes. Accordingly,
the relative importance figure more closely reflects the cost share
weights for FY 2006 than the base year weights from the SNF market
basket.
We calculate the labor-related relative importance for FY 2006 in
four steps.
[[Page 45042]]
First, we compute the FY 2006 price index level for the total market
basket and each cost category of the market basket. Second, we
calculate a ratio for each cost category by dividing the FY 2006 price
index level for that cost category by the total market basket price
index level. Third, we determine the FY 2006 relative importance for
each cost category by multiplying this ratio by the base year (FY 1997)
weight. Finally, we sum the FY 2006 relative importance for each of the
labor-related cost categories (wages and salaries, employee benefits,
nonmedical professional fees, labor-intensive services, and capital-
related expenses) to produce the FY 2006 labor-related relative
importance. Tables 6 and 7 show the Federal rates by labor-related and
non-labor-related components for the existing 44-group RUG-III
classification system. Tables 6a and 7a show the Federal rates by
labor-related and non-labor-related components for the refined 53-group
RUG classification system.
Table 6.--RUG-44 Case-Mix Adjusted Federal Rates for Urban SNFs by Labor
and Non-Labor Component
------------------------------------------------------------------------
Labor Non-labor
RUG III category Total rate portion portion
------------------------------------------------------------------------
RUC.............................. 482.28 366.16 116.12
RUB.............................. 434.12 329.59 104.53
RUA.............................. 410.73 311.83 98.90
RVC.............................. 371.83 282.30 89.53
RVB.............................. 359.44 272.89 86.55
RVA.............................. 327.80 248.87 78.93
RHC.............................. 341.00 258.89 82.11
RHB.............................. 313.49 238.01 75.48
RHA.............................. 287.34 218.15 69.19
RMC.............................. 335.77 254.92 80.85
RMB.............................. 299.99 227.76 72.23
RMA.............................. 282.11 214.18 67.93
RLB.............................. 267.51 203.10 64.41
RLA.............................. 224.86 170.72 54.14
SE3.............................. 317.77 241.26 76.51
SE2.............................. 275.12 208.88 66.24
SE1.............................. 244.85 185.90 58.95
SSC.............................. 239.35 181.72 57.63
SSB.............................. 228.34 173.36 54.98
SSA.............................. 222.84 169.18 53.66
CC2.............................. 237.97 180.67 57.30
CC1.............................. 220.08 167.09 52.99
CB2.............................. 209.08 158.74 50.34
CB1.............................. 199.45 151.43 48.02
CA2.............................. 198.07 150.38 47.69
CA1.............................. 187.06 142.02 45.04
IB2.............................. 178.81 135.76 43.05
IB1.............................. 176.06 133.67 42.39
IA2.............................. 162.30 123.22 39.08
IA1.............................. 156.79 119.04 37.75
BB2.............................. 177.43 134.71 42.72
BB1.............................. 173.30 131.57 41.73
BA2.............................. 160.92 122.17 38.75
BA1.............................. 149.91 113.81 36.10
PE2.............................. 192.57 146.20 46.37
PE1.............................. 189.81 144.11 45.70
PD2.............................. 182.93 138.88 44.05
PD1.............................. 180.18 136.80 43.38
PC2.............................. 173.30 131.57 41.73
PC1.............................. 171.93 130.53 41.40
PB2.............................. 154.04 116.95 37.09
PB1.............................. 152.67 115.91 36.76
PA2.............................. 151.29 114.86 36.43
PA1.............................. 147.16 111.73 35.43
------------------------------------------------------------------------
Table 6a.--RUG-53 Case-Mix Adjusted Federal Rates for Urban SNFs by
Labor and Non-Labor Component
------------------------------------------------------------------------
Labor Non-labor
RUG-53 category Total rate portion portion
------------------------------------------------------------------------
RUX.............................. 564.83 428.83 136.00
RUL.............................. 496.04 376.60 119.44
RVX.............................. 428.24 325.13 103.11
RVL.............................. 399.34 303.19 96.15
RHX.............................. 363.02 275.61 87.41
RHL.............................. 356.14 270.39 85.75
RMX.............................. 415.57 315.51 100.06
RML.............................. 381.17 289.39 91.78
RLX.............................. 295.03 223.99 71.04
RUC.............................. 479.53 364.07 115.46
[[Page 45043]]
RUB.............................. 439.62 333.77 105.85
RUA.............................. 418.99 318.11 100.88
RVC.............................. 385.59 292.75 92.84
RVB.............................. 366.32 278.12 88.20
RVA.............................. 329.17 249.91 79.26
RHC.............................. 335.50 254.72 80.78
RHB.............................. 320.36 243.22 77.14
RHA.............................. 296.97 225.47 71.50
RMC.............................. 308.25 234.03 74.22
RMB.............................. 299.99 227.76 72.23
RMA.............................. 293.11 222.53 70.58
RLB.............................. 271.64 206.23 65.41
RLA.............................. 231.74 175.94 55.80
SE3.............................. 339.79 257.98 81.81
SE2.............................. 288.88 219.32 69.56
SE1.............................. 257.23 195.29 61.94
SSC.............................. 253.11 192.17 60.94
SSB.............................. 239.35 181.72 57.63
SSA.............................. 235.22 178.58 56.64
CC2.............................. 251.73 191.12 60.61
CC1.............................. 229.72 174.41 55.31
CB2.............................. 218.71 166.05 52.66
CB1.............................. 209.08 158.74 50.34
CA2.............................. 207.70 157.69 50.01
CA1.............................. 193.94 147.24 46.70
IB2.............................. 185.69 140.98 44.71
IB1.............................. 182.93 138.88 44.05
IA2.............................. 167.80 127.40 40.40
IA1.............................. 160.92 122.17 38.75
BB2.............................. 184.31 139.93 44.38
BB1.............................. 178.81 135.76 43.05
BA2.............................. 166.42 126.35 40.07
BA1.............................. 155.42 118.00 37.42
PE2.............................. 200.82 152.47 48.35
PE1.............................. 196.69 149.33 47.36
PD2.............................. 191.19 145.16 46.03
PD1.............................. 188.44 143.07 45.37
PC2.............................. 181.56 137.84 43.72
PC1.............................. 178.81 135.76 43.05
PB2.............................. 159.54 121.13 38.41
PB1.............................. 158.17 120.09 38.08
PA2.............................. 156.79 119.04 37.75
PA1.............................. 152.67 115.91 36.76
------------------------------------------------------------------------
Table 7.--RUG-44 Case-Mix Adjusted Federal Rates for Rural SNFs by Labor
and Non-Labor Component
------------------------------------------------------------------------
Labor Non-labor
RUG III category Total rate portion portion
------------------------------------------------------------------------
RUC.............................. 511.31 388.20 123.11
RUB.............................. 465.30 353.27 112.03
RUA.............................. 442.95 336.30 106.65
RVC.............................. 388.57 295.01 93.56
RVB.............................. 376.74 286.03 90.71
RVA.............................. 346.50 263.07 83.43
RHC.............................. 349.49 265.34 84.15
RHB.............................. 323.20 245.38 77.82
RHA.............................. 298.22 226.41 71.81
RMC.............................. 341.00 258.89 82.11
RMB.............................. 306.82 232.94 73.88
RMA.............................. 289.73 219.97 69.76
RLB.............................. 268.82 204.09 64.73
RLA.............................. 228.07 173.16 54.91
SE3.............................. 309.57 235.03 74.54
SE2.............................. 268.82 204.09 64.73
SE1.............................. 239.90 182.14 57.76
SSC.............................. 234.64 178.14 56.50
SSB.............................. 224.12 170.16 53.96
SSA.............................. 218.86 166.16 52.70
[[Page 45044]]
CC2.............................. 233.32 177.14 56.18
CC1.............................. 216.24 164.17 52.07
CB2.............................. 205.72 156.19 49.53
CB1.............................. 196.52 149.20 47.32
CA2.............................. 195.20 148.20 47.00
CA1.............................. 184.69 140.22 44.47
IB2.............................. 176.80 134.23 42.57
IB1.............................. 174.17 132.23 41.94
IA2.............................. 161.03 122.26 38.77
IA1.............................. 155.77 118.26 37.51
BB2.............................. 175.49 133.24 42.25
BB1.............................. 171.54 130.24 41.30
BA2.............................. 159.71 121.26 38.45
BA1.............................. 149.20 113.28 35.92
PE2.............................. 189.95 144.21 45.74
PE1.............................. 187.32 142.22 45.10
PD2.............................. 180.74 137.22 43.52
PD1.............................. 178.12 135.23 42.89
PC2.............................. 171.54 130.24 41.30
PC1.............................. 170.23 129.24 40.99
PB2.............................. 153.14 116.27 36.87
PB1.............................. 151.83 115.27 36.56
PA2.............................. 150.51 114.27 36.24
PA1.............................. 146.57 111.28 35.29
------------------------------------------------------------------------
Table 7a.--RUG-53 Case-Mix Adjusted Federal Rates for Rural SNFs by
Labor and Non-Labor Component
------------------------------------------------------------------------
Labor Non-labor
RUG-53 category Total rate portion portion
------------------------------------------------------------------------
RUX.............................. 590.18 448.08 142.10
RUL.............................. 524.45 398.17 126.28
RVX.............................. 442.46 335.92 106.54
RVL.............................. 414.86 314.97 99.89
RHX.............................. 370.52 281.31 89.21
RHL.............................. 363.95 276.32 87.63
RMX.............................. 417.24 316.78 100.46
RML.............................. 384.38 291.83 92.55
RLX.............................. 295.11 224.05 71.06
RUC.............................. 508.68 386.20 122.48
RUB.............................. 470.56 357.26 113.30
RUA.............................. 450.84 342.29 108.55
RVC.............................. 401.71 304.99 96.72
RVB.............................. 383.31 291.02 92.29
RVA.............................. 347.82 264.07 83.75
RHC.............................. 344.23 261.35 82.88
RHB.............................. 329.77 250.37 79.40
RHA.............................. 307.42 233.40 74.02
RMC.............................. 314.71 238.93 75.78
RMB.............................. 306.82 232.94 73.88
RMA.............................. 300.25 227.96 72.29
RLB.............................. 272.76 207.08 65.68
RLA.............................. 234.64 178.14 56.50
SE3.............................. 330.60 251.00 79.60
SE2.............................. 281.96 214.07 67.89
SE1.............................. 251.73 191.12 60.61
SSC.............................. 247.78 188.12 59.66
SSB.............................. 234.64 178.14 56.50
SSA.............................. 230.70 175.15 55.55
CC2.............................. 246.47 187.12 59.35
CC1.............................. 225.44 171.16 54.28
CB2.............................. 214.92 163.17 51.75
CB1.............................. 205.72 156.19 49.53
CA2.............................. 204.41 155.19 49.22
CA1.............................. 191.26 145.21 46.05
IB2.............................. 183.37 139.22 44.15
IB1.............................. 180.74 137.22 43.52
IA2.............................. 166.28 126.24 40.04
IA1.............................. 159.71 121.26 38.45
[[Page 45045]]
BB2.............................. 182.06 138.22 43.84
BB1.............................. 176.80 134.23 42.57
BA2.............................. 164.97 125.25 39.72
BA1.............................. 154.45 117.26 37.19
PE2.............................. 197.83 150.20 47.63
PE1.............................. 193.89 147.21 46.68
PD2.............................. 188.63 143.21 45.42
PD1.............................. 186.00 141.21 44.79
PC2.............................. 179.43 136.23 43.20
PC1.............................. 176.80 134.23 42.57
PB2.............................. 158.40 120.26 38.14
PB1.............................. 157.08 119.26 37.82
PA2.............................. 155.77 118.26 37.51
PA1.............................. 151.83 115.27 36.56
------------------------------------------------------------------------
3. Calculating the Budget Neutrality Factor
Section 1888(e)(4)(G)(ii) of the Act also requires that we apply
this wage index in a manner that does not result in aggregate payments
that are greater or lesser than would otherwise be made in the absence
of the wage adjustment. For FY 2006 (Federal rates effective October 1,
2005), we are applying the wage index applicable to SNF payments using
the most recent hospital wage data applicable to FY 2006 payments (as
discussed previously in section III.D.1 of this final rule), and
applying an adjustment to fulfill the budget neutrality requirement.
This requirement is met by multiplying each of the components of the
unadjusted Federal rates by a factor equal to the ratio of the volume
weighted mean wage adjustment factor (using the wage index from the
previous year) to the volume weighted mean wage adjustment factor,
using the wage index for the fiscal year beginning October 1, 2005. The
same volume weights are used in both the numerator and denominator and
were derived from 1997 Medicare Provider Analysis and Review File
(MEDPAR) data. The wage adjustment factor used in this calculation is
defined as the labor share of the rate component multiplied by the wage
index plus the non-labor share. The budget neutrality factor has been
recalculated to reflect the addition of a transition policy. Effective
October 1, 2005, we will adopt a budget neutrality factor of 1.0012. In
order to give the public a sense of the magnitude of this adjustment,
last year's factor was 1.0011.
E. Updates to the Federal Rates
In accordance with section 1888(e)(4)(E) of the Act, the final
payment rates listed here reflect an update equal to the full SNF
market basket, which equals 3.1 percent.
We will continue to disseminate the rates, wage index, and case-mix
classification methodology in the Federal Register before August 1
preceding the start of each succeeding fiscal year. Along with a number
of other revisions discussed elsewhere in this preamble, this final
rule provides the annual updates to the Federal rates as required by
statute.
F. Relationship of Case-Mix Classification System to Existing SNF
Level-of-Care Criteria
As discussed in Sec. 413.345, we include in each update of the
Federal payment rates in the Federal Register the designation of those
specific RUGs under the classification system that represent the
required SNF level of care, as provided in Sec. 409.30. This
designation reflects an administrative presumption that we initially
adopted under the original 44-group RUG-III classification system.
Under the presumption, any beneficiary correctly assigned to one of the
upper 26 of the 44 RUG-III groups in the initial 5-day, Medicare-
required assessment is automatically classified as meeting the SNF
level of care definition up to the assessment reference date (ARD) for
that assessment.
A beneficiary assigned to any of the lower 18 of the 44 RUG-III
groups is not automatically classified as either meeting or not meeting
the definition, but instead receives an individual level of care
determination using the existing administrative criteria. This
presumption recognizes the strong likelihood that beneficiaries
assigned to one of the upper 26 groups during the immediate post-
hospital period require a covered level of care, which would be
significantly less likely for those beneficiaries assigned to one of
the lower 18 groups.
1. Proposals on the 9 New Rehabilitation Plus Extensive Services Groups
In the FY 2006 SNF PPS proposed rule, we noted that the 9 new
Rehabilitation plus Extensive Services groups that we proposed to add
at the top of the existing RUG-III hierarchy would effectively
encompass care ``* * * that is at least as intensive as that identified
by any of the upper 26 RUG-III groups under the original, 44-group RUG-
III classification system.'' Accordingly, with the adoption of those 9
new groups as discussed elsewhere in this final rule (and as proposed),
we hereby designate as representing a covered level of care under the
administrative presumption the upper 35 groups of the refined case-mix
classification system (including the upper 26 groups that were
previously so designated under the original 44-group system, plus the
additional 9 Rehabilitation plus Extensive Services groups that we are
now adopting), consisting of the following RUG classifications:
All groups within the new Rehabilitation plus Extensive
Services category;
All groups within the Ultra High Rehabilitation category;
All groups within the Very High Rehabilitation category;
All groups within the High Rehabilitation category;
All groups within the Medium Rehabilitation category;
All groups within the Low Rehabilitation category;
All groups within the Extensive Services category;
All groups within the Special Care category; and
[[Page 45046]]
All groups within the Clinically Complex category.
Comment: Commenters consistently supported the extension of the
administrative presumption to the nine new RUG groups.
Response: We appreciate the commenters' support, and will implement
this provision as proposed without modification.
G. Example of Computation of Adjusted PPS Rates and SNF Payment
As explained in section II., from October 1, 2005, through December
31, 2005, we will make payment based entirely on the existing 44-group
RUG-III classification system (including any associated add-on
payments). Using the model SNF (XYZ) described in Table 10, the
following shows the adjustments made to the Federal per diem rate to
compute the provider's actual per diem PPS for the time period
mentioned above using the existing 44-group RUG-III classification
system.
Beginning January 1, 2006, we will make payment based on the
refined RUG-53 classification system (and, thus, would not include the
add-on payments). Table 10a shows an example of the actual per diem PPS
payments under the RUG-53 classification system.
The Labor and Non-labor columns are derived from Tables 6 or 6a. In
addition, the adjustment for residents with AIDS enacted in section 511
of the MMA is reflected in Tables 10 and 10a.
Table 10.--RUG-44, SNF XYZ: Located in Benton County, IA (Urban CBSA Designation), Wage Index: 0.8710 (See Transition Wage Index in Table A)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Adjusted Adjusted Percent Medicare
RUG group Labor Wage index labor Non-labor rate adjustment days Payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
RVC............................................. $282.30 0.8710 $245.88 $89.53 $335.41 *$357.88 14 $5,010
RHA............................................. 218.15 0.8710 190.01 69.19 259.20 *276.57 16 4,425
CC2............................................. 180.67 0.8710 157.36 57.30 214.66 **489.42 10 4,894
SSC............................................. 181.72 0.8710 158.28 57.63 215.91 ***259.09 30 7,773
IA2............................................. 123.22 0.8710 107.32 39.08 146.40 146.40 30 4,392
--------------
Total....................................... ........... ........... ........... ........... ........... ........... 100 26,494
--------------------------------------------------------------------------------------------------------------------------------------------------------
*Reflects a 6.7 percent adjustment from section 314 of the BIPA.
**Reflects a 128 percent adjustment from section 511 of the MMA. Section 101(a) of the BBRA no longer applies because of the MMA section 511
adjustment.
***Reflects a 20 percent adjustment from section 101(a) of the BBRA.
Table 10a.--RUG-53, SNF XYZ: Located in Benton County, IA (Urban CBSA Designation) Wage Index: 0.8710 (See Transition Wage Index in Table A)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Adjusted Adjusted Percent Medicare
RUG group Labor Wage index labor Non-labor rate adjustment days Payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
RVX............................................. $325.13 0.871 $283.19 $103.11 $386.30 $386.30 14 $5,408
RHA............................................. 225.47 0.871 196.38 71.50 267.88 267.88 16 4,286
CC2............................................. 191.12 0.871 166.47 60.61 227.08 517.73 10 5,177
RLX............................................. 223.99 0.871 195.10 71.04 266.14 266.14 30 7,984
IA2............................................. 127.40 0.871 110.97 40.40 151.37 151.37 30 4,541
--------------
Total....................................... ........... ........... ........... ........... ........... ........... 100 27,396
--------------------------------------------------------------------------------------------------------------------------------------------------------
* Reflects a 128 percent adjustment from section 511 of the MMA.
H. SNF Market Basket Index
1. Background
Section 1888(e)(5)(A) of the Act requires us to establish a SNF
market basket index (input price index) that reflects changes over time
in the prices of an appropriate mix of goods and services included in
the SNF PPS. This final rule incorporates the latest available
projections of the SNF market basket index. Accordingly, we have
developed a SNF market basket index that encompasses the most commonly
used cost categories for SNF routine services, ancillary services, and
capital-related expenses. In the July 31, 2001 Federal Register (66 FR
39562), we included a complete discussion on the rebasing of the SNF
market basket to FY 1997. There are 21 separate cost categories and
respective price proxies. These cost categories were illustrated in
Table 10.A, Table 10.B, and Appendix A, along with other relevant
information, in the July 31, 2001 Federal Register.
Each year, we calculate a revised labor-related share based on the
relative importance of labor-related cost categories in the input price
index. Table 11 summarizes the updated labor-related share for FY 2006.
Table 11.--Labor-related Relative Importance, FY2005 and FY2006
------------------------------------------------------------------------
Relative Relative
importance, importance,
labor-related, labor-related,
FY 2005 (97 FY 2006 (97
index) index)
------------------------------------------------------------------------
Wages and salaries.................. 54.356 54.391
Employee benefits................... 11.506 11.648
Nonmedical professional fees........ 2.708 2.739
[[Page 45047]]
Labor-intensive services............ 4.114 4.128
Capital-related..................... 3.092 3.016
-------------------
Total........................... 75.776 75.922
------------------------------------------------------------------------
Source: Global Insights, Inc., formerly DRI-WEFA, 2nd Quarter, 2005.
2. Use of the SNF Market Basket Percentage
Section 1888(e)(5)(B) of the Act defines the SNF market basket
percentage as the percentage change in the SNF market basket index, as
described in the previous section, from the average index level of the
prior fiscal year to the average index level of the current fiscal
year. For the Federal rates established in this final rule, this
percentage increase in the SNF market basket index is used to compute
the update factor occurring between FY 2005 and FY 2006. We used the
Global Insights, Inc. (formerly DRI-WEFA), 2nd quarter 2005 forecasted
percentage increase in the FY 1997-based SNF market basket index for
routine, ancillary, and capital-related expenses, described in the
previous section, to compute the update factor.
Comment: The current SNF market basket is based on FY 1997 Medicare
cost report data. Several commenters requested that CMS utilize more
up-to-date cost reports in the SNF market basket in order to produce
more accurate and representative weights for the various cost
categories, such as compensation and pharmaceuticals. They also
requested that CMS review the price proxies used in the market basket,
specifically the Employment Cost Index (ECI) for wages and salaries for
Private Nursing Homes. This price proxy includes wage price data for
SNFs as well as for other nursing and long-term care facilities. One
commenter claimed the staffing mix in a SNF is much different than in
these other types of facilities. Finally, a few commenters suggested
that CMS collect SNF-specific labor data provided by the SNF industry.
Response: CMS is considering revising and rebasing the SNF market
basket in the near future. We would expect to use the most recent and
complete SNF Medicare cost reports available. Moreover, we would use
the SNF Medicare cost reports to develop as many viable cost category
weights (such as wages and salaries, benefits, contract labor, and
pharmaceuticals) as possible. We also plan to review alternative price
proxies based on our criteria of relevance, reliability, timeliness,
and public availability. We will include a detailed discussion of our
analysis when we propose a revised and rebased SNF market basket, and
will also provide an opportunity for public comment.
Comment: Several commenters requested that the SNF rebasing follow
the same frequency planned for IPPS hospital rebasing, currently set at
every four years.
Response: As noted above, we intend to revise and rebase the SNF
market basket in the near future, and we would use the most recent and
complete SNF Medicare cost reports available to do this. We will keep
the commenters' suggestions in mind in considering whether to establish
a schedule for rebasing the SNF market basket.
Comment: Several commenters requested that the SNF market basket be
revised to reflect industry data and CMS's own data, which show that
prescription drugs represent more than 10 percent of SNF costs. They
cite the CMS Health Care Financing Review, which shows that Medicare
SNF facility charges for pharmaceuticals from 1997 to 2001 represent
over 10 percent of total Medicare SNF facility charges. Also, one
commenter stated the pharmaceutical cost weight was derived using a
combination of nursing facility and hospital cost reports.
Response: The market basket is intended to reflect the average
change in the price of a basket of goods and services that SNFs
purchase in order to furnish patient care. The current market basket is
based on the purchasing behavior of SNFs in 1997. Preliminary analysis
shows that both the FY 2002 and FY 2003 pharmaceutical cost weights
(the cost of pharmaceuticals as a percent of total costs), based on
freestanding SNF Medicare cost reports, are slightly below 3 percent,
compared to 3 percent in the 1997-based SNF market basket. It would be
inappropriate for the market basket weight to reflect trends in
charges, which have little relationship to the actual costs incurred.
The pharmaceutical cost weight in the 1997-based SNF market basket
is based on Medicare cost reports of freestanding SNF facilities. As
discussed in the SNF PPS proposed rule for FY 2002, hospital cost
report data were not used to derive this cost weight (66 FR 24013, May
10, 2001).
Comment: In view of the concern regarding the adequacy of the
pharmaceutical cost weight included in the SNF market basket, we
received a comment recommending that we identify discrepancies between
the forecasted and actual cost of pharmaceuticals, and develop an
adjustment mechanism similar to the forecast error correction policy
described previously in section I.G of this final rule.
Response: As part of the forecast error correction, the difference
between the projected and actual pharmaceutical price increases is
incorporated. Therefore, it would be inappropriate to develop a
separate mechanism.
Comment: One commenter suggested that CMS should study the effect
of adding a separate weight for professional liability insurance (PLI),
and should work with the SNF industry to determine how the weight
should be calculated and how to develop an appropriate price index.
Response: We intend to review both SNF cost reports and other
industry data to determine the feasibility of developing a weight and
price proxy for PLI for SNFs. We look forward to working with the SNF
industry on this effort, and have already received feedback about the
nature of PLI for SNFs.
3. Market Basket Forecast Error Adjustment
As discussed in the June 10, 2003, supplemental proposed rule (68
FR 34768) and finalized in the August 4, 2003, final rule (68 FR
46067), the regulations at 42 CFR 413.337(d)(2) provide for an
adjustment to account for market basket forecast error. The initial
[[Page 45048]]
adjustment applied to the update of the FY 2003 rate that occurred in
FY 2004, and took into account the cumulative forecast error for the
period from FY 2000 through FY 2002. Subsequent adjustments in
succeeding FYs take into account the forecast error from the most
recently available fiscal year for which there is final data, and are
applied whenever the difference between the forecasted and actual
change in the market basket exceeds a 0.25 percentage point threshold.
As discussed previously in section I.G of this final rule, as the
difference between the estimated and actual amounts of increase in the
market basket index for FY 2004 (the most recently available fiscal
year for which there is final data) did not exceed the 0.25 percentage
point threshold, the payment rates for FY 2006 do not include a
forecast error adjustment.
4. Federal Rate Update Factor
Section 1888(e)(4)(E)(ii)(IV) of the Act requires that the update
factor used to establish the FY 2006 Federal rates be at a level equal
to the full market basket percentage change. Accordingly, to establish
the update factor, we determined the total growth from the average
market basket level for the period of October 1, 2004 through September
30, 2005 to the average market basket level for the period of October
1, 2005 through September 30, 2006. Using this process, the market
basket update factor for FY 2006 SNF Federal rates is 3.1 percent. We
used this revised update factor to compute the Federal portion of the
SNF PPS rate shown in Tables 2 and 3.
I. Consolidated Billing
As established by section 4432(b) of the BBA, the consolidated
billing requirement places with the SNF the Medicare billing
responsibility for virtually all of the services that the SNF's
residents receive, except for a small number of services that the
statute specifically identifies as being excluded from this provision.
Section 103 of the BBRA amended this provision by further excluding a
number of high-cost, low probability services (identified by Healthcare
Common Procedure Coding System (HCPCS) codes) within several broader
categories that otherwise remained subject to the provision. Section
313 of the BIPA further amended this provision by repealing its Part B
aspect, that is, its applicability to services furnished to a resident
during a SNF stay that Medicare does not cover. (However, physical and
occupational therapy, and speech-language pathology services remain
subject to consolidated billing, regardless of whether the resident who
receives these services is in a covered Part A stay.) In addition,
section 313 of the BIPA specified that consolidated billing applies
only to services furnished to those individuals residing in an
institution (or portion of an institution) that is actually certified
by Medicare as a SNF. Further, as noted in section I.E. of this final
rule, section 410 of the MMA revised the SNF consolidated billing
requirement as to certain services furnished on or after January 1,
2005, by rural health clinics (RHCs) and Federally qualified health
centers (FQHCs).
To date, the Congress has enacted no further legislation affecting
the consolidated billing provision. However, as we noted in the April
10, 2000 proposed rule (65 FR 19232), section 1888(e)(2)(A)(iii) of the
Act, as added by section 103 of the BBRA, not only identified for
exclusion from this provision a number of particular service codes
within four specified categories (that is, chemotherapy items,
chemotherapy administration services, radioisotope services, and
customized prosthetic devices), but `` * * * also gives the Secretary
the authority to designate additional, individual services for
exclusion within each of the specified service categories.'' In the FY
2001 proposed rule, we also noted that the BBRA Conference Report (H.R.
Conf. Rep. No. 106-479 at 854) characterizes the individual services
that this legislation targets for exclusion as ``* * * high-cost, low
probability events that could have devastating financial impacts
because their costs far exceed the payment [SNFs] receive under the
prospective payment system * * *.'' According to the conferees, section
103(a) ``is an attempt to exclude from the PPS certain services and
costly items that are provided infrequently in SNFs * * *.'' By
contrast, we noted that the Congress declined to designate for
exclusion any of the remaining services within those four categories
(thus leaving all of those services subject to SNF consolidated
billing), because they are relatively inexpensive and are furnished
routinely in SNFs.
As we further explained in the July 31, 2000 final rule (65 FR
46790), any additional service codes that we might designate for
exclusion under our discretionary authority must meet the same criteria
that the Congress used in identifying the original codes excluded from
consolidated billing under section 103(a) of the BBRA: They must fall
within one of the four service categories specified in the BBRA, and
they also must meet the same standards of high cost and low probability
in the SNF setting. Accordingly, we characterized this statutory
authority to identify additional service codes for exclusion ``* * * as
essentially affording the flexibility to revise the list of excluded
codes in response to changes of major significance that may occur over
time (for example, the development of new medical technologies or other
advances in the state of medical practice)'' (65 FR 46791). In view of
the amount of time that has elapsed since we last invited comments on
this issue, we invited public comments in the FY 2006 SNF PPS proposed
rule on codes in any of these four service categories which represent
recent medical advances that might meet the BBRA criteria for exclusion
from SNF consolidated billing (70 FR 29098).
Comment: Commenters proposed for exclusion particular services that
fell within the four specified categories specified by section 103 of
the BBRA (chemotherapy items, chemotherapy administration services,
radioisotope services, and customized prosthetic devices).
Response: We will further examine whether these particular services
should be excluded as we complete work on the 2006 annual updated list
of the specific HCPCS codes that are excluded from consolidated
billing, which we plan to issue this fall.
Comment: Noting that some chemotherapy drugs have two HCPCS codes
assigned--both a C code and a J code--two commenters pointed out that a
number of the chemotherapy medications that we exclude by J code also
have C codes assigned to them. They asserted that hospital outpatient
departments are mandated to use C codes when billing Medicare for some
chemotherapy medications under the hospital outpatient prospective
payment system and asked that we add the corresponding C codes for the
following codes: J9040, J9060, J9065, J9070, J9093, J9100, J9130,
J9150, J9181, J9200, J9208, J9211, J9265, and J9280.
Response: It is our understanding that hospital outpatient
departments can, in fact, use J codes when billing Medicare for
chemotherapy medications. Accordingly, at this time we see no need to
add the corresponding C codes when the J code chemotherapy medications
are already excluded.
Comment: Although the FY 2006 SNF PPS proposed rule specifically
invited comments on possible exclusions within the specific service
categories identified in the BBRA legislation, a number of commenters
took this opportunity to reiterate concerns about other aspects of
consolidated billing.
[[Page 45049]]
For example, we received a number of comments concerning the possible
exclusion of additional categories of services from SNF consolidated
billing, beyond those specified in the BBRA. The commenters identified
services such as barium swallows, video fluoroscopies, hyperbaric
oxygen therapy, sterile larvae therapy, ultrasonic procedures and
duplex scans, PET scans, and nuclear medicine as appropriate candidates
for exclusion. In addition, a number of commenters recommended a
further set of services for exclusion. These additional services are
durable medical equipment (including, but not limited to, wound care
devices and diabetic shoes), total parenteral nutrition (TPN), and
specialized bariatric equipment.
Response: As we noted previously in the final rule of August 4,
2003 (68 FR 46060), the original set of consolidated billing exclusions
at section 1888(e)(2)(A)(ii) of the Act (as enacted by section 4432(b)
of the BBA) broadly excluded entire categories of services from
consolidated billing (primarily, those of physicians and certain other
types of medical practitioners). By contrast, the set of statutory
exclusions at section 1888(e)(2)(A)(iii) of the Act, as subsequently
enacted by section 103 of the BBRA, was more specifically targeted
within a number of broader service categories. In the FY 2006 SNF PPS
proposed rule, we noted that the original BBRA legislation (as well as
the implementing regulations) provides the Secretary the authority to
designate additional, individual services for exclusion within each of
the BBRA-specified service categories. However, the statute does not
provide the Secretary the authority to create additional categories of
excluded services beyond those specified in the law. Therefore, based
on the statute, we cannot exclude services and items from consolidated
billing unless they fall into the categories of services provided in
the statute.
Comment: Some commenters cited the existing list of exclusions (in
Sec. 411.15(p)(3)(iii)) for certain high-intensity outpatient hospital
services, and expressed the view that these exclusions should not be
limited to only those services that actually require the intensity of a
hospital setting, but rather, should also encompass services furnished
in other, nonhospital settings as well. As examples, they cited
services such as magnetic resonance imaging (MRIs) and computerized
axial tomography (CT) scans furnished in freestanding imaging centers,
and radiation therapy furnished in physician's clinics or ambulatory
care centers, all of which may be cheaper and more accessible in
certain particular localities (such as rural settings) than those
furnished by hospitals.
Response: As we noted in the May 12, 1998 interim final rule (63 FR
26298), in the July 31, 2000 final rule (65 FR 46790 through 46791),
and again in the August 4, 2003 final rule (68 FR 46061), the exclusion
of certain outpatient hospital services (in Sec. 411.15(p)(3)(iii)) is
targeted specifically at those services ``* * * that, under commonly
accepted standards of medical practice, lie exclusively within the
purview of hospitals * * *'' (emphasis added); that is, services which
generally require the intensity of the hospital setting in order to be
furnished safely and effectively. We have determined that this high
level of outpatient hospital care is beyond the scope of SNF
comprehensive care plans and should be excluded from consolidated
billing. However, this exclusion does not encompass services furnished
in any other health care setting. Thus, to the extent that advances in
medical practice over time may make it feasible to perform such a
service more widely in a less intensive, nonhospital setting, this
would not argue in favor of excluding the nonhospital performance of
the service from consolidated billing under these regulations, but
rather, would call into question whether the service should continue to
be excluded from consolidated billing at all, even when performed in
the hospital setting. In addition, we note that unlike the outpatient
hospital exclusions in Sec. 411.15(p)(3)(iii), the statutory
exclusions enacted by the BBRA for certain chemotherapy and other
services apply regardless of the setting (hospital versus freestanding)
in which the services are furnished. However, we do not have the
authority to add services such as MRIs, CT scans, or radiation therapy
to the existing statutory list administratively.
Comment: Several commenters also proposed expanding the list of
excluded services by redefining categories of service that are
currently excluded from consolidated billing. For example, while the
BBRA excludes specific chemotherapy services by HCPCS codes, these
commenters recommended not only adding to the list of excluded
chemotherapy pharmaceuticals, but expanding the exclusion to encompass
all related services associated with a chemotherapy treatment, such as
supplies and other pharmaceuticals used to treat side effects. In
addition, several commenters recommended exclusion of oral chemotherapy
agents that are not separately billable to Medicare Part B for any
beneficiary, and are currently covered only as part of the overall
package of services furnished under the Part A inpatient hospital or
SNF benefits.
Response: In the FY 2006 SNF PPS proposed rule, we noted that the
BBRA's list of services excluded by HCPCS code is a targeted list,
narrowly carving out only certain individual ``high-cost, low
probability'' services within a number of broader service categories--
such as chemotherapy services--that otherwise remained subject to
consolidated billing. As we noted in the FY 2006 SNF PPS proposed rule,
the BBRA provides the Secretary the authority to designate additional,
individual services for exclusion within each of the service categories
that it specifies. However, the statute does not provide authority to
exclude other services that, while related, fall outside of the
specified service categories themselves. For example, although anti-
nausea drugs are commonly used in conjunction with chemotherapy, they
are not in themselves chemotherapeutic agents and, consequently, do not
fall within one of the excluded categories designated in the BBRA.
Further, we believe that the Congress was clear in its intent regarding
the particular items and services to be excluded from consolidated
billing, by use of the HCPCS codes specified in the Act. Regarding the
suggestion to exclude from consolidated billing those oral chemotherapy
agents that are not separately billable to Part B (and are currently
covered only under the Part A inpatient hospital and SNF benefits), we
note that expanding the existing statutory drug coverage available
under Part B to include those drugs is not within our authority.
We note that some chemotherapy pharmaceuticals that commenters
proposed for exclusion have already been added to the list of HCPCS
codes excluded from the consolidated billing provisions. The most
recent annual update regarding HCPCS exclusions from consolidated
billing can be found in Transmittal No. 360 (Change Request (CR) No.
3542), issued on November 5, 2004, which is available online at http://www.cms.hhs.gov
/manuals/transmittals /comm--date--dsc.asp.
Comment: A few commenters requested an expansion of the existing
Part B dialysis exclusion to encompass dialysis services furnished
directly by the SNF. In addition, several commenters noted that
erythropoietin (EPO or Aranesp) currently is excluded from consolidated
billing only when furnished in conjunction with the Part B dialysis
benefit, and they
[[Page 45050]]
recommended expanding this exclusion to encompass its use in connection
with other, non-dialysis forms of treatment (such as chemotherapy).
Response: As we noted previously in the final rule published on
August 4, 2003 (68 FR 46062), under section 1888(e)(2)(A)(ii) of the
Act, the exclusion of dialysis services from consolidated billing
applies only to those services that meet the requirements for coverage
under the separate Part B dialysis benefit at section 1861(s)(2)(F) of
the Act. The Part B benefit allows for home dialysis and dialysis
performed on the premises of a certified dialysis facility. By
contrast, if the SNF itself elects to furnish dialysis services to a
resident during a covered Part A stay (either directly with its own
resources, or under an ``arrangement'' with a certified dialysis
facility in which the SNF itself does the billing), the services are no
longer considered Part B dialysis services, but instead are Part A SNF
services. Accordingly, they would no longer be subject to the statutory
exclusion of Part B dialysis services from consolidated billing, and
would instead be bundled into the comprehensive PPS per diem payment
that the SNF receives for the package of services that it furnishes
during the resident's covered Part A stay.
Similarly, under section 1888(e)(2)(A)(ii) of the Act, the
exclusion of EPO from consolidated billing applies only to those
services that meet the requirements for coverage under the separate
Part B EPO benefit at section 1861(s)(2)(O) of the Act. Section
1861(s)(2)(O) of the Act permits coverage of EPO and items related to
its administration for those dialysis patients who can self-administer
the drug, subject to methods and standards established by the Secretary
for its safe and effective use (as described in Sec. 405.2163(g) and
(h)). Since EPO that is used for non-dialysis patients does not fall
within the scope of section 1861(s)(2)(O) of the Act, that usage does
not fall within the scope of the EPO exclusion from consolidated
billing.
Comment: One commenter requested that we amend 42 CFR Sec.
409.20(a)(3) and 409.23 to add recreational therapy to the current list
of rehabilitation services (i.e., physical and occupational therapy and
speech-language pathology services).
Response: The purpose of the two above-cited sections of the
regulations is to implement section 1861(h)(3) of the Act, which
currently specifies that ``* * * `extended care services' means the
following items and services furnished to an inpatient of a skilled
nursing facility * * * (3) physical or occupational therapy or speech-
language pathology services furnished by the skilled nursing facility
or by others under arrangements with them made by the facility * * *.''
Notably, recreational therapy is not included in this statutory
definition and we cannot adopt the commenter's request to revise the
regulations.
J. Application of the SNF PPS to SNF Services Furnished by Swing-Bed
Hospitals
In accordance with section 1888(e)(7) of the Act (as amended by
section 203 of the BIPA), Part A pays critical access hospitals (CAHs)
on a reasonable cost basis for SNF services furnished under a swing-bed
agreement. However, as noted previously in section I.A. of this final
rule, the services furnished by non-CAH rural hospitals are paid under
the SNF PPS. In the July 31, 2001 final rule (66 FR 39562), we
announced the conversion of swing-bed rural hospitals to the SNF PPS,
effective with the start of the provider's first cost reporting period
beginning on or after July 1, 2002. We selected this date consistent
with the statutory provision to integrate swing-bed rural hospitals
into the SNF PPS by the end of the SNF transition period, June 30,
2002.
As of June 30, 2003, all swing-bed rural hospitals have come under
the SNF PPS. Therefore, the SNF PPS rates and wage indexes outlined in
earlier sections of this final rule for SNFs also apply to all swing-
bed rural hospitals. A complete discussion of assessment schedules, the
MDS and the transmission software, Raven-SB for Swing Beds can be found
in the July 31, 2001 final rule (66 FR 39562). The latest changes in
the MDS for swing-bed rural hospitals are listed on our SNF PPS web
site, http://www.cms.hhs.gov/providers/snfpps/default.asp.
K. Qualifying Three-Day Inpatient Hospital Stay Requirement
In the FY 2006 SNF PPS proposed rule, we noted that one of the
prerequisites for Part A coverage under the Medicare SNF benefit is a
qualifying hospital stay of at least 3 consecutive days, and that under
current policy, only time following the formal inpatient admission to
the hospital counts toward meeting this requirement. We invited
comments on having patients spend time in observation status prior to a
formal inpatient admission, and on the potential implications of this
practice for the SNF benefit's qualifying 3-day hospital stay
requirement.
Comment: Of the comments that we received on this issue, most
expressed support for the idea that hospital time spent in observation
status immediately preceding a formal inpatient admission should count
toward satisfying the SNF benefit's statutory qualifying three-day
hospital stay requirement, while some advocated eliminating the
statutory requirement altogether. Still others recommended counting all
time spent in the hospital (not only in observation status, but also in
the emergency room as well), while some others supported counting the
observation time but were opposed to counting time spent in the
emergency room. Other commenters raised related issues regarding the
availability of information in this area, such as the inability of
existing CMS operating systems (including the claims and cost reporting
systems) to accommodate the counting of observation time for this
purpose without further modification, and the inability of SNFs to
distinguish between observation and emergency room time spent in the
hospital. Some of these commenters also suggested taking certain
additional measures, such as requiring the hospital to certify that a
beneficiary has met the SNF benefit's qualifying 3-day stay requirement
(and to assume the financial liability for any related coverage
denials), and examining ways in which SNFs can obtain better
information from hospitals about the specific nature and duration of a
patient's hospital stay.
Response: Regarding the comments that expressed support for
repealing the statutory 3-day qualifying hospital stay requirement
altogether, we note that such an action would require legislation by
the Congress to amend the law itself and, thus, is beyond the scope of
this final rule. Further, we do not share the belief expressed by some
commenters that time spent in the emergency room is essentially
comparable to observation time in this context. As we noted in the FY
2006 SNF PPS proposed rule, except for scheduled admissions, the
emergency room generally serves as the overall point of entry into the
hospital for most patients; thus, the mere presence of time spent in
the emergency room prior to formal admission would not, in itself,
serve to identify the degree of severity of a particular patient's
condition during that time.
With regard to the comments that suggested other possible
modifications to the 3-day inpatient hospital stay requirement, we note
that we are continuing to review this issue, but are not yet ready to
make a final determination at this time. As we observed in the FY 2006
SNF PPS proposed rule, the SNF benefit was never intended to cover
long-term, relatively low-level ``custodial'' care;
[[Page 45051]]
rather, the Congress envisioned this benefit more narrowly, in terms of
serving as a less expensive alternative to what would otherwise be the
final, convalescent portion of an acute care stay of several days as an
inpatient at a hospital. Thus, any potential changes in the SNF
benefit's qualifying hospital stay requirement would need to be
carefully evaluated, in order to ensure that they accurately reflect
Congressional intent in establishing the qualifying hospital stay
requirement, and would not result in altering the unique nature of the
SNF benefit in a manner that is inconsistent with that intent.
IV. Provisions of the Final Rule
In section III. above, ``Analysis of and Responses to Public
Comments on the FY 2006 SNF PPS Proposed Rule,'' we have added a
statement at the end of each issue indicating our final decision either
to adopt the provisions as set forth in the FY 2006 SNF PPS proposed
rule or to make modifications based on public comments. However, all
other changes, including clarifying and technical changes that are not
issue-specific will be addressed in this section below.
Specifically, we are making the following technical correction in
the regulations text, as discussed in the FY 2006 SNF PPS proposed
rule: we are correcting the definition of ``HCPCS'' that appears in
Sec. 424.3, by removing the acronym ``CMS'' and adding the word
``Healthcare'' in its place.
Further, we note that we are taking this opportunity to make two
additional technical corrections in Part 409 of the regulations. The
first involves updating an obsolete citation that appears in several
places in Sec. 409.60(c). This section of the regulations sets forth
several administrative presumptions that serve to help determine the
end of a benefit period in a SNF, and it makes repeated references to
an obsolete citation (Sec. 405.330) for the provision dealing with
limitation of liability for care that is custodial or not reasonable
and necessary. Accordingly, we are hereby updating that obsolete
citation by replacing it with the current citation, Sec. 411.400.
The other correction to Part 409 involves the regulations at 42 CFR
409.31(b)(2), which describe one aspect of the SNF level of care
requirements. In a final rule published on August 22, 2003 (68 FR
50855), we added Sec. 409.31(b)(2)(iii) regarding Medicare+Choice
(M+C) enrollees. However, in republishing Sec. 409.31(b)(2)(ii), we
inadvertently omitted several words that previously had appeared in the
text. Accordingly, we are now taking this opportunity to restore the
missing language, so that Sec. 409.31(b)(2)(ii) is revised to reflect
its original complete and accurate language.
Finally, we note that in the FY 2004 final rule (68 FR 46060,
46070, August 4, 2003), we added two radiopharmaceuticals, Zevalin and
Bexxar, to the list of chemotherapy drugs that are excluded from
consolidated billing (and, thus, are separately billable to Part B when
furnished to a SNF resident during a covered Part A stay). The final
rule specified that regulation text at 42 CFR 411.15(p)(2)(xii) and 42
CFR 489.20(s)(12) list the Healthcare Common Procedure Coding System
(HCPCS) codes for Zevalin (A9522 and A9523) ``as of January 1, 2004.''
At the time the FY 2004 final rule was published, the codes for Bexxar
were not yet available (see 68 FR 46060) but were about to be issued.
Accordingly, we are now adding the initial Bexxar HCPCS codes to 42 CFR
411.15(p)(2)(xii) and 42 CFR 489.20(s)(12) effective ``as of January 1,
2004.'' These codes for Bexxar are A9533 and A9534. As we clarified in
the September 29, 2003 Federal Register (68 FR 55883), the HCPCS codes
to be utilized in connection with Bexxar and Zevalin include any
successor codes that may replace (or supplement) the codes currently
listed in the regulation. Such successor codes are disseminated through
program instructions.
V. Waiver of Proposed Rulemaking
Regarding the technical corrections to Parts 409, 411, and 489 of
the regulations that we discuss in the preceding section, we note that
we would ordinarily publish a notice of proposed rulemaking in the
Federal Register to provide a period for public comment before
revisions in the regulations text would take effect; however, we can
waive this procedure if we find good cause that a notice and comment
procedure is impracticable, unnecessary, or contrary to the public
interest and incorporate a statement of the finding and its reasons in
the notice issued. We find it unnecessary to undertake notice and
comment rulemaking in connection with these particular revisions, as
they merely provide technical corrections to the regulations, without
making any substantive changes. Therefore, for good cause, we waive
notice and comment procedures for the revisions that we are making to
the regulations text in Parts 409, 411, and 489.
VI. Collection of Information Requirements
This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.).
VII. Regulatory Impact Analysis
A. Overall Impact
We have examined the impacts of this final rule as required by
Executive Order 12866 (September 1993, Regulatory Planning and Review),
the Regulatory Flexibility Act (RFA, September 16, 1980, Pub. L. 96-
354), section 1102(b) of the Social Security Act, the Unfunded Mandates
Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.
Executive Order 12866 (as amended by Executive Order 13258, which
merely reassigns responsibility of duties) directs agencies to assess
all costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). A
regulatory impact analysis (RIA) must be prepared for major rules with
economically significant effects ($100 million or more in any 1 year).
This final rule is a major rule, as defined in Title 5, United States
Code, section 804(2), because we estimate the impact to the Medicare
program, and the annual effects to the overall economy, would be more
than $100 million.
The RFA requires agencies to analyze options for regulatory relief
of small businesses. For purposes of the RFA, small entities include
small businesses, nonprofit organizations, and government agencies.
Most SNFs and most other providers and suppliers are small entities,
either by their nonprofit status or by having revenues of $11.5 million
or less in any 1 year. For purposes of the RFA, approximately 53
percent of SNFs are considered small businesses according to the Small
Business Administration's latest size standards, with total revenues of
$11.5 million or less in any 1 year (for further information, see 65 FR
69432, November 17, 2000). Individuals and States are not included in
the definition of a small entity. In addition, approximately 29 percent
of SNFs are nonprofit organizations.
This final rule updates the SNF PPS rates published in the FY 2005
update
[[Page 45052]]
notice on July 30, 2004 (69 FR 45775) and the associated correction
notices published on October 7, 2004 (69 FR 60158), and December 30,
2004 (69 FR 78445).
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 603 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 100 beds. We anticipate that the
impact on swing-bed facilities will be similar to the impact on rural
hospital-based facilities, which benefit from the case-mix refinement
(see Table 12 below).
Section 202 of the Unfunded Mandates Reform Act of 1995 also
requires that agencies assess anticipated costs and benefits before
issuing any rule that may result in expenditure in any 1 year by State,
local, or tribal governments, in the aggregate, or by the private
sector, of $110 million or more. This final rule will not have a
substantial effect on the governments mentioned, or on private sector
costs.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. As stated above, this final rule will not have a
substantial effect on State and local governments.
B. Anticipated Effects
This final rule sets forth updates of the SNF PPS rates contained
in the FY 2005 update notice (69 FR 45775) and the associated
correction notices (69 FR 60158 and 69 FR 78445), and implements a
refinement to the RUG-III case-mix classification system to be
incorporated into the Medicare SNF PPS effective January 1, 2006.
As described in Section III., providers will continue to be paid
under the current 44-group RUG-III system from October 1, 2005 through
December 31, 2005. Beginning January 1, 2006, providers will be paid
under the refined RUG-53 system.
Based on the above, we estimate the FY 2006 impact will be a net
increase of $20 million in payments to SNF providers (this reflects a
$1.02 billion reduction from the expiration of temporary payment
increases, offset by a $510 million increase from the refined case-mix
classification system and a $530 million increase from the update to
the payment rates, as explained in greater detail later in this
section). The impact analysis in Table 12 of this final rule represents
the projected effects of the policy changes in the SNF PPS from FY 2005
to FY 2006. We estimate the effects by estimating payments while
holding all other payment variables constant. We use the best data
available, but we do not attempt to predict behavioral responses to
these changes, and we do not make adjustments for future changes in
such variables as days or case-mix.
We note that certain events may combine to limit the scope or
accuracy of our impact analysis, because such an analysis is future-
oriented and, thus, susceptible to forecasting errors due to other
changes in the forecasted impact time period. Some examples are newly-
legislated general Medicare program funding changes by the Congress, or
changes specifically related to SNFs. In addition, changes to the
Medicare program may continue to be made as a result of the BBA, the
BBRA, the BIPA, the MMA, or new statutory provisions. Although these
changes may not be specific to the SNF PPS, the nature of the Medicare
program is such that the changes may interact, and the complexity of
the interaction of these changes could make it difficult to predict
accurately the full scope of the impact upon SNFs.
In accordance with section 1888(e)(4)(E) of the Act, we are
updating the payment rates for FY 2006. The BBRA, BIPA, and MMA
provided for several temporary adjustments to the SNF PPS payment rates
that together, using the most recent data available, accounted for an
estimated impact of $1.4 billion per year.
We note that in accordance with section 101(a) of the BBRA and
section 314 of the BIPA, the existing, temporary increase in the per
diem adjusted payment rates of 20 percent for certain specified
clinically complex RUGs (and 6.7 percent for other, rehabilitation
RUGs) would expire with the implementation of the case-mix refinements
in the SNF PPS. As explained in section II. of this final rule, section
511 of the MMA, which provides for a 128 percent increase in the PPS
per diem payment for any SNF resident with Acquired Immune Deficiency
Syndrome (AIDS), remains in effect. However, we have not provided a
separate impact analysis for the MMA provision. Our latest estimates
indicate that there are less than 2,000 beneficiaries who qualify for
the AIDS add-on payment. The impact to Medicare is included in the
``total'' column of Table 12.
In updating the rates for FY 2006, we made a number of standard
annual revisions and clarifications mentioned elsewhere in this final
rule (for example, the update to the wage and market basket indexes
used for adjusting the Federal rates). These revisions would increase
payments to SNFs by approximately $530 million.
The aggregate change in payments associated with this final rule is
estimated to be an increase in payments to SNFs of $20 million for FY
2006. The decrease of $1.02 billion due to the elimination of the
temporary add-ons, together with the additional payment due to the
refined case-mix classification system of $510 million and the market
basket increase of $530 million, results in a net change in payments of
$20 million. There are two areas of change that produce this impact on
SNFs:
1. The implementation of a refined case-mix classification system
under section 1888(e)(4)(G)(i) of the Act and, consequently, the
expiration of the temporary 20 percent/6.7 percent add-ons to the
Federal rates for the specified RUG groups.
2. The total change in payments from FY 2005 levels to FY 2006
levels. This includes all of the previously noted changes in addition
to the effect of the update to the rates.
The impacts are shown in Table 12. The breakdown of the various
categories of data in the table follows.
The first column shows the breakdown of all SNFs by urban or rural
status, hospital-based or freestanding status, and census region.
The first row of figures in the first column describes the
estimated effects of the various changes on all facilities. The next 6
rows show the effects on facilities split by hospital-based,
freestanding, urban, and rural categories. The urban and rural
designations are based on the location of the facility under the CBSA
designations. The next 20 rows show the effects on urban versus rural
status by census region.
The second column in the table shows the number of facilities in
the impact database.
The third column of the table shows the effect of the annual update
to the wage index. This represents the effect of using the most recent
wage data available. The total impact of this change is zero percent;
however, there are distributional effects of the change.
The fourth column of the table shows the effect of using the new
OMB geographic designations based on
[[Page 45053]]
CBSAs. During the FY 2006 transition to CBSAs, SNFs will receive a
transition-based wage index value consisting of a blend of 50 percent
of the FY 2006 MSA-based wage index and 50 percent of the FY 2006 CBSA-
based wage index (see Table A in the Addendum), as described in Section
III.D.1 of this final rule.
The fifth column of the table shows the effect of the elimination
of the add-on for specified RUG groups. As expected, this results in a
decrease in payments for all providers.
The sixth column of the table shows the effect of the refinements
to the case-mix classification system. Table 12 shows that there is a
positive 3 percent overall impact from the case-mix refinements.
Distributional effects are noted for specific providers. For example,
hospital-based facilities are expected to receive greater than an 7.7
percent increase in payment, compared with freestanding facilities that
show an increase in payments of between 2.2 percent and 2.6 percent.
Additionally, rural Census regions show increases in payments of 3.4
percent.
The seventh column of the table shows the effect of all of the
changes on the FY 2006 payments. As the market basket increase of 3.1
percentage points is constant for all providers, it is not shown
individually; however, we note that the ``Total FY 2006 change'' column
does incorporate this increase. It is projected that aggregate payments
will increase by $20 million, assuming facilities do not change their
care delivery and billing practices in response.
As can be seen from this table, the combined effects of all of the
changes would vary by specific types of providers and by location. For
example, though facilities in the urban New England and rural South
Atlantic regions experience payment decreases of 0.4 percent and 0.4
percent, respectively, some providers (such as those in the rural
Pacific and rural New England regions) show increases of 4.1 percent
and 2.4 percent, respectively. Payment increases for facilities in the
Rural Pacific area of the country are the highest for any provider
category.
Table 12.--Projected Impact to the SNF PPS for FY 2006
--------------------------------------------------------------------------------------------------------------------------------------------------------
Eliminate add-
Number of Update wage MSA to CBSA on to certain Case-mix Total FY 2006
facilities data (percent) RUGs refinements change
(percent) (percent) (percent) (percent)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total................................................... 15,675 0.0 0.0 -6.0 3.0 0.1
Urban................................................... 10,599 0.0 0.0 -6.0 2.9 0.0
Rural................................................... 5,076 0.1 0.1 -6.0 3.4 0.7
Hospital based urban.................................... 1,097 0.0 0.0 -6.3 7.8 4.6
Freestanding urban...................................... 8,693 0.0 0.0 -5.9 2.2 -0.6
Hospital based rural.................................... 1,160 0.0 0.1 -6.8 7.7 4.1
Freestanding rural...................................... 3,372 0.1 0.1 -5.9 2.6 0.1
---------------------------------------------------------
Urban by Region
--------------------------------------------------------------------------------------------------------------------------------------------------------
New England............................................. 917 -0.2 -0.1 -6.4 3.2 -0.4
Middle Atlantic......................................... 1,499 0.2 0.0 -6.1 3.0 0.2
South Atlantic.......................................... 1,739 -0.3 0.0 -5.9 2.9 -0.3
East North Central...................................... 2,009 -0.4 0.0 -5.7 2.9 -0.2
East South Central...................................... 531 0.3 0.0 -6.0 2.6 0.0
West North Central...................................... 836 -0.6 0.0 -5.9 3.6 0.3
West South Central...................................... 1,093 -0.1 0.1 -5.8 2.6 0.0
Mountain................................................ 467 -0.3 0.1 -5.6 2.9 0.2
Pacific................................................. 1,501 1.2 0.0 -6.2 2.9 1.0
---------------------------------------------------------
Rural by Region
--------------------------------------------------------------------------------------------------------------------------------------------------------
New England............................................. 139 2.0 0.0 -5.7 3.0 2.4
Middle Atlantic......................................... 283 -0.1 0.1 -6.0 3.6 0.7
South Atlantic.......................................... 612 -0.3 0.0 -6.2 3.0 -0.4
East North Central...................................... 947 0.3 0.0 -5.9 3.8 1.4
East South Central...................................... 571 0.1 0.1 -6.3 2.6 -0.4
West North Central...................................... 1,219 -0.5 0.1 -6.2 4.1 0.7
West South Central...................................... 823 0.2 0.0 -6.2 2.7 -0.2
Mountain................................................ 298 0.6 -0.2 -5.9 3.8 1.4
Pacific................................................. 182 1.6 0.0 -4.2 3.6 4.1
---------------------------------------------------------
Ownership
--------------------------------------------------------------------------------------------------------------------------------------------------------
Government.............................................. 693 0.0 0.2 -6.5 4.8 1.6
Proprietary............................................. 9,317 0.0 0.0 -5.9 2.3 -0.6
Voluntary............................................... 3,493 -0.1 0.0 -6.0 4.9 1.9
--------------------------------------------------------------------------------------------------------------------------------------------------------
Comment: Several commenters asked that we provide additional data
and files to help them model the impact on providers.
Response: CMS worked to make additional data and updated analyses
readily available throughout the comment period, and posted these
additional data and analyses to the CMS website as soon as they became
available.
Comment: A few commenters expressed concern that the proposed FY
2006 market basket update was included in our impact analysis. They
contended that the market basket update reflects changes in price
levels that have already taken place and, in their view, reimburses
them for expenses they have already incurred. By including the market
basket update in the impact
[[Page 45054]]
analysis, these commenters argue that we have understated the actual
impact of the FY 2006 changes.
Response: The impact analyses presented here and in the proposed
rule utilize the same methodology that has been in effect since the
introduction of the SNF PPS. Specifically, we determine the impact
analysis by estimating aggregate payments attributable to each major
component of the rate, including the market basket adjustment, while
holding all other payment variables constant. By including the FY 2006
market basket variable in the analysis, and then comparing the
expenditures to the FY 2005 levels (which also include a market basket
update factor), we obtain a more accurate picture of aggregate spending
changes.
Comment: Several commenters expressed concern regarding the overall
fiscal impact of the proposed changes and recommended that the
aggregate expenditure levels be increased. Other commenters stated that
they had been unable to reconcile their independent analyses with the
information contained in the proposed rule, and were concerned that the
impact of the proposed rate structure would exceed the CMS projections.
Response: As mentioned in Section III., throughout the comment
period, we reexamined the data presented in the proposed rule, updated
the analyses to reflect the most recent available data, and corrected
minor technical errors. We also received information from industry
representatives and others, which helped us to verify the accuracy of
the data used in the rate calculations, and then to ensure that the
resulting rates correctly reflected the policies specified in the
proposed rule. We then repeated the payment simulation described in the
proposed rule. Next we recalculated the payment adjustment needed to
ensure parity when comparing the aggregate expenditure levels of the
44-group and 53-group RUG models. As a final step, we applied an 8.51
percent increase to the nursing weights to reflect variation in non-
therapy ancillary costs.
The impact analyses presented here and in the proposed rule utilize
the same methodology that has been in effect since the introduction of
the SNF PPS. The numbers presented in the impact analysis section
represent the impact to the Federal Government which is calculated as
total payments net of coinsurance. However, when considering total
payments (not total impact), such as determining any adjustment to the
nursing weights to reflect the variation in non-therapy ancillary
costs, we use total payments including the coinsurance amounts.
We further note that, while the market basket increases are
mandated in the statute, the Congress established an oversight
mechanism to adjust or eliminate the updates based on MedPAC's annual
analysis and recommendations. For FY 2006, MedPAC recommended a zero
update. Had the Congress accepted that recommendation and enacted a
change, the market basket adjustment would have been zero, and we would
have included that factor in our impact analyses.
C. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf
), in Table 13 below, we
have prepared an accounting statement showing the classification of the
expenditures associated with the provisions of this final rule. This
table provides our best estimate of the change in Medicare payments
under the SNF PPS as a result of the policies in this final rule based
on the data for 15,675 SNFs in our database. All expenditures are
classified as transfers to Medicare providers (that is, SNFs).
Table 13.--Accounting Statement: Classification of Estimated
Expenditures, From the 2005 SNF PPS Rate Year to the 2006 SNF PPS Rate
Year (in Millions)
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers......... $20 million.
From Whom To Whom?..................... Federal Government to SNF
Medicare Providers.
------------------------------------------------------------------------
D. Alternatives Considered
Section 1888(e) of the Act establishes the SNF PPS for the payment
of Medicare SNF services for cost reporting periods beginning on or
after July 1, 1998. This section of the statute prescribes a detailed
formula for calculating payment rates under the SNF PPS, and does not
provide for the use of any alternative methodology. It specifies that
the base year cost data to be used for computing the payment rates must
be from FY 1995 (October 1, 1994, through September 30, 1995.) In
accordance with the statute, we also incorporated a number of elements
into the SNF PPS, such as a case-mix classification methodology, the
MDS assessment schedule, a market basket index, a wage index, and the
urban and rural distinction used in the development or adjustment of
the Federal rates. Further, section 1888(e)(4)(H) of the Act
specifically requires us to disseminate the payment rates for each new
fiscal year through the Federal Register, and to do so before the
August 1 that precedes the start of the new fiscal year.
Because we have determined that this final rule will have a
significant economic impact on SNFs, we will discuss the alternatives
we considered. We reviewed the options considered in the proposed rule
and took into consideration comments received during the public comment
period as discussed in the preamble.
As discussed previously in section II. of this final rule, we will
implement refinements to the RUG-III case-mix classification system
under section 1888(e)(4)(G)(i) of the Act. At the same time, we
continue to evaluate longer-range, more comprehensive changes in the
case-mix classification system. One alternative that we considered was
to defer refinements at this time until our evaluation of longer-range,
more comprehensive changes is complete. However, we believe that these
refinements will serve to improve the distribution of payments under
the PPS in a manner that more accurately accounts for the care needs of
the most medically complex patients. While our additional research may
identify more comprehensive modifications, it is not currently known
when the results of this research would become available. Therefore, we
have decided to implement the refinements discussed elsewhere in this
final rule.
As discussed in section III.D, we considered several budget neutral
options that would most effectively implement the adoption of the CBSA
designation. Among the alternatives that we considered were the options
discussed in the proposed rule and new options that took into
consideration comments received during the public comment period, as
discussed elsewhere in this final rule.
[[Page 45055]]
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
List of Subjects
42 CFR Part 409
Health facilities, Medicare.
42 CFR Part 411
Kidney diseases, Medicare, Reporting and recordkeeping
requirements.
42 CFR Part 424
Emergency medical services, Health facilities, Health professions,
Medicare.
42 CFR Part 489
Health facilities, Medicare, Reporting and recordkeeping
requirements.
0
For the reasons set forth in the preamble, the Centers for Medicare &
Medicaid Services amends 42 CFR chapter IV as follows:
PART 409--HOSPITAL INSURANCE BENEFITS
0
1. The authority citation for part 409 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
Subpart D--Requirements for Coverage of Posthospital SNF Care
0
2. Amend Sec. 409.31 by--
0
A. Republishing paragraph (b)(2) introductory text.
0
B. Revising paragraph (b)(2)(ii) to read as follows:
Sec. 409.31 Level of care requirement.
* * * * *
(b) * * *
(2) Those services must be furnished for a condition--
(i) * * *
(ii) Which arose while the beneficiary was receiving care in a SNF
or swing-bed hospital for a condition for which he or she received
inpatient hospital or inpatient CAH services; or
* * * * *
Subpart F--Scope of Hospital Insurance Benefits
0
3. Amend Sec. 409.60(c) by removing the references to ``Sec.
405.330'' and adding ``Sec. 411.400'' in its place.
PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE
PAYMENT
0
1. The authority citation for part 411 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
Subpart A--General Exclusions and Exclusion of Particular Services
0
2. Amend Sec. 411.15 by--
0
A. Republishing paragraph (p)(2) introductory text.
0
B. Revising paragraph (p)(2)(xii) to read as follows:
Sec. 411.15 Particular services excluded from coverage.
* * * * *
(p) * * *
(2) Exceptions. The following services are not excluded from
coverage, provided that the claim for payment includes the SNF's
Medicare provider number in accordance with Sec. 424.32(a)(5) of this
chapter:
* * * * *
(xii) Those chemotherapy items identified, as of July 1, 1999, by
HCPCS codes J9000-J9020; J9040-J9151; J9170-J9185; J9200-J9201; J9206-
J9208; J9211; J9230-J9245; and J9265-J9600; and, as of January 1, 2004,
by HCPCS codes A9522, A9523, A9533, and A9534.
* * * * *
PART 424--CONDITIONS FOR MEDICARE PAYMENT
0
1. The authority citation for part 424 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
Subpart B--Certification and Plan of Treatment Requirements
Sec. 424.3 Definitions.
0
2. In Sec. 424.3, in the definition of ``HCPCS'' remove the word
``CMS'' and add the word ``Healthcare'' in its place.
0
3. In Sec. 424.20, paragraph (e)(2) is revised to read as follows:
Sec. 424.20 Requirements for posthospital SNF care.
* * * * *
(e) * * *
(2) A nurse practitioner or clinical nurse specialist, neither of
whom has a direct or indirect employment relationship with the facility
but who is working in collaboration with a physician. For purposes of
this section--
(i) Collaboration means a process whereby a nurse practitioner or
clinical nurse specialist works with a doctor of medicine or osteopathy
to deliver health care services. The services are delivered within the
scope of the nurse's professional expertise, with medical direction and
appropriate supervision as provided for in guidelines jointly developed
by the nurse and the physician or other mechanisms defined by Federal
regulations and the law of the State in which the services are
performed.
(ii) A direct employment relationship with the facility is one in
which the nurse practitioner or clinical nurse specialist meets the
common law definition of the facility's ``employee,'' as specified in
Sec. 404.1005, Sec. 404.1007, and Sec. 404.1009 of title 20 of the
regulations. When a nurse practitioner or clinical nurse specialist
meets this definition with respect to an entity other than the facility
itself, and that entity has an agreement with the facility for the
provision of nursing services under Sec. 409.21 of this subchapter,
the facility is considered to have an indirect employment relationship
with the nurse practitioner or clinical nurse specialist. An indirect
employment relationship does not exist if the agreement between the
entity and the facility involves only the performance of delegated
physician tasks under Sec. 483.40(e) of this chapter.
* * * * *
PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL
0
1. The authority citation for part 489 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
Subpart B--Essentials of Provider Agreements
0
2. Section 489.20 is amended by:
0
A. Republishing the introductory text and the paragraph (s)
introductory text.
0
B. Revising paragraph (s)(12).
Sec. 489.20 Basic commitments.
The provider agrees to the following:
* * * * *
(s) In the case of an SNF, either to furnish directly or make
arrangements (as defined in Sec. 409.3 of this chapter) for all
Medicare-covered services furnished to a resident (as defined in Sec.
411.15(p)(3) of this chapter) of the SNF, except the following:
* * * * *
(12) Those chemotherapy items identified, as of July 1, 1999, by
HCPCS codes J9000-J9020; J9040-J9151; J9170-J9185; J9200-J9201; J9206-
J9208; J9211; J9230-J9245; and J9265-J9600; and, as of January 1, 2004,
by HCPCS codes A9522, A9523, A9533, and A9534.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital
[[Page 45056]]
Insurance Program; and No. 93.774, Medicare--Supplementary Medical
Insurance Program)
Dated: July 19, 2005.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
Approved: July 27, 2005.
Michael O. Leavitt,
Secretary.
[[Page 45057]]
Addendum--FY 2006 Transition Wage Index and CBSA Tables
In this addendum, we provide the tables referred to in the preamble
to this final rule. Tables 8 and 9 provide the CBSA-based wage index
values for urban and rural providers. Though we will use the
transition-based wage index values presented in Table A for FY 2006,
CBSA-based wage index values will be used for FY 2007 when the
transition will expire. Tables 8 and 9 serve the purpose of showing a
possible format of how the CBSA-based wage index values will be
presented for FY 2007.
Table A provides the following information: Social Security
Administration (SSA) State and County Code; State and County name;
existing MSA-based labor market area designation; MSA-based urban/rural
geographic designation; FY 2006 MSA-based wage index; FY 2006 CBSA-
based wage index; CBSA-based labor market area; CBSA-based urban/rural
geographic designation (which will be used for the FY 2006 transition);
and the FY 2006 transition wage index (based on 50 percent of the FY
2006 MSA-based wage index and 50 percent of the FY 2006 CBSA-based wage
index).
Table 8.--FY 2006 Wage Index For Urban Areas Based On CBSA Labor Market Areas
----------------------------------------------------------------------------------------------------------------
Wage
CBSA code Urban area (constituent counties) index
----------------------------------------------------------------------------------------------------------------
10180........................................ Abilene, TX............................................. 0.7896
Callahan County, TX
Jones County, TX
Taylor County, TX
10380........................................ Aguadilla-Isabela-San Sebastian, PR..................... 0.4738
Aguada Municipio, PR
Aguadilla Municipio, PR
Anasco Municipio, PR
Isabela Municipio, PR
Lares Municipio, PR
Moca Municipio, PR
Rincon Municipio, PR
San Sebastian Municipio, PR
10420........................................ Akron, OH............................................... 0.8982
Portage County, OH
Summit County, OH
10500........................................ Albany, GA.............................................. 0.8628
Baker County, GA
Dougherty County, GA
Lee County, GA
Terrell County, GA
Worth County, GA
10580........................................ Albany-Schenectady-Troy, NY............................. 0.8589
Albany County, NY
Rensselaer County, NY
Saratoga County, NY
Schenectady County, NY
Schoharie County, NY
10740........................................ Albuquerque, NM......................................... 0.9684
Bernalillo County, NM
Sandoval County, NM
Torrance County, NM
Valencia County, NM
10780........................................ Alexandria, LA.......................................... 0.8033
Grant Parish, LA
Rapides Parish, LA
10900........................................ Allentown-Bethlehem-Easton, PA-NJ....................... 0.9818
Warren County, NJ
Carbon County, PA
Lehigh County, PA
Northampton County, PA
11020........................................ Altoona, PA............................................. 0.8944
Blair County, PA
11100........................................ Amarillo, TX............................................ 0.9156
Armstrong County, TX
Carson County, TX
Potter County, TX
Randall County, TX
11180........................................ Ames, IA................................................ 0.9536
Story County, IA
11260........................................ Anchorage, AK........................................... 1.1895
Anchorage Municipality, AK
Matanuska-Susitna Borough, AK
11300........................................ Anderson, IN............................................ 0.8586
Madison County, IN
11340........................................ Anderson, SC............................................ 0.8997
Anderson County, SC
11460........................................ Ann Arbor, MI........................................... 1.0859
[[Page 45058]]
Washtenaw County, MI
11500........................................ Anniston-Oxford, AL..................................... 0.7682
Calhoun County, AL
11540........................................ Appleton, WI............................................ 0.9288
Calumet County, WI
Outagamie County, WI
11700........................................ Asheville, NC........................................... 0.9285
Buncombe County, NC
Haywood County, NC
Henderson County, NC
Madison County, NC
12020........................................ Athens-Clarke County, GA................................ 0.9855
Clarke County, GA
Madison County, GA
Oconee County, GA
Oglethorpe County, GA
12060........................................ Atlanta-Sandy Springs-Marietta, GA...................... 0.9793
Barrow County, GA
Bartow County, GA
Butts County, GA
Carroll County, GA
Cherokee County, GA
Clayton County, GA
Cobb County, GA
Coweta County, GA
Dawson County, GA
DeKalb County, GA
Douglas County, GA
Fayette County, GA
Forsyth County, GA
Fulton County, GA
Gwinnett County, GA
Haralson County, GA
Heard County, GA
Henry County, GA
Jasper County, GA
Lamar County, GA
Meriwether County, GA
Newton County, GA
Paulding County, GA
Pickens County, GA
Pike County, GA
Rockdale County, GA
Spalding County, GA
Walton County, GA
12100........................................ Atlantic City, NJ....................................... 1.1615
Atlantic County, NJ
12220........................................ Auburn-Opelika, AL...................................... 0.8100
Lee County, AL
12260........................................ Augusta-Richmond County, GA-SC.......................... 0.9748
Burke County, GA
Columbia County, GA
McDuffie County, GA
Richmond County, GA
Aiken County, SC
Edgefield County, SC
12420........................................ Austin-Round Rock, TX................................... 0.9437
Bastrop County, TX
Caldwell County, TX
Hays County, TX
Travis County, TX
Williamson County, TX
12540........................................ Bakersfield, CA......................................... 1.0470
Kern County, CA
12580........................................ Baltimore-Towson, MD.................................... 0.9897
Anne Arundel County, MD
Baltimore County, MD
Carroll County, MD
Harford County, MD
Howard County, MD
Queen Anne's County, MD
[[Page 45059]]
Baltimore City, MD
12620........................................ Bangor, ME.............................................. 0.9993
Penobscot County, ME
12700........................................ Barnstable Town, MA..................................... 1.2600
Barnstable County, MA
12940........................................ Baton Rouge, LA......................................... 0.8593
Ascension Parish, LA
East Baton Rouge Parish, LA
East Feliciana Parish, LA
Iberville Parish, LA
Livingston Parish, LA
Pointe Coupee Parish, LA
St. Helena Parish, LA
West Baton Rouge Parish, LA
West Feliciana Parish, LA
12980........................................ Battle Creek, MI........................................ 0.9508
Calhoun County, MI
13020........................................ Bay City, MI............................................ 0.9343
Bay County, MI
13140........................................ Beaumont-Port Arthur, TX................................ 0.8412
Hardin County, TX
Jefferson County, TX
Orange County, TX
13380........................................ Bellingham, WA.......................................... 1.1731
Whatcom County, WA
13460........................................ Bend, OR................................................ 1.0786
Deschutes County, OR
13644........................................ Bethesda-Frederick-Gaithersburg, MD..................... 1.1483
Frederick County, MD
Montgomery County, MD
13740........................................ Billings, MT............................................ 0.8834
Carbon County, MT
Yellowstone County, MT
13780........................................ Binghamton, NY.......................................... 0.8562
Broome County, NY
Tioga County, NY
13820........................................ Birmingham-Hoover, AL................................... 0.8959
Bibb County, AL
Blount County, AL
Chilton County, AL
Jefferson County, AL
St. Clair County, AL
Shelby County, AL
Walker County, AL
13900........................................ Bismarck, ND............................................ 0.7574
Burleigh County, ND
Morton County, ND
13980........................................ Blacksburg-Christiansburg-Radford, VA................... 0.7954
Giles County, VA
Montgomery County, VA
Pulaski County, VA
Radford City, VA
14020........................................ Bloomington, IN......................................... 0.8447
Greene County, IN
Monroe County, IN
Owen County, IN
14060........................................ Bloomington-Normal, IL.................................. 0.9075
McLean County, IL
14260........................................ Boise City-Nampa, ID.................................... 0.9052
Ada County, ID
Boise County, ID
Canyon County, ID
Gem County, ID
Owyhee County, ID
14484........................................ Boston-Quincy, MA....................................... 1.1558
Norfolk County, MA
Plymouth County, MA
Suffolk County, MA
14500........................................ Boulder, CO............................................. 0.9734
Boulder County, CO
[[Page 45060]]
14540........................................ Bowling Green, KY....................................... 0.8211
Edmonson County, KY
Warren County, KY
14740........................................ Bremerton-Silverdale, WA................................ 1.0675
Kitsap County, WA
14860........................................ Bridgeport-Stamford-Norwalk, CT......................... 1.2592
Fairfield County, CT
15180........................................ Brownsville-Harlingen, TX............................... 0.9804
Cameron County, TX
15260........................................ Brunswick, GA........................................... 0.9311
Brantley County, GA
Glynn County, GA
McIntosh County, GA
15380........................................ Buffalo-Niagara Falls, NY............................... 0.9511
Erie County, NY
Niagara County, NY
15500........................................ Burlington, NC.......................................... 0.8905
Alamance County, NC
15540........................................ Burlington-South Burlington, VT......................... 0.9410
Chittenden County, VT
Franklin County, VT
Grand Isle County, VT
15764........................................ Cambridge-Newton-Framingham, MA......................... 1.1172
Middlesex County, MA
15804........................................ Camden, NJ.............................................. 1.0517
Burlington County, NJ
Camden County, NJ
Gloucester County, NJ
15940........................................ Canton-Massillon, OH.................................... 0.8935
Carroll County, OH
Stark County, OH
15980........................................ Cape Coral-Fort Myers, FL............................... 0.9356
Lee County, FL
16180........................................ Carson City, NV......................................... 1.0234
Carson City, NV
16220........................................ Casper, WY.............................................. 0.9026
Natrona County, WY
16300........................................ Cedar Rapids, IA........................................ 0.8825
Benton County, IA
Jones County, IA
Linn County, IA
16580........................................ Champaign-Urbana, IL.................................... 0.9594
Champaign County, IL
Ford County, IL
Piatt County, IL
16620........................................ Charleston, WV.......................................... 0.8445
Boone County, WV
Clay County, WV
Kanawha County, WV
Lincoln County, WV
Putnam County, WV
16700........................................ Charleston-North Charleston, SC......................... 0.9245
Berkeley County, SC
Charleston County, SC
Dorchester County, SC
16740........................................ Charlotte-Gastonia-Concord, NC-SC....................... 0.9750
Anson County, NC
Cabarrus County, NC
Gaston County, NC
Mecklenburg County, NC
Union County, NC
York County, SC
16820........................................ Charlottesville, VA..................................... 1.0187
Albemarle County, VA
Fluvanna County, VA
Greene County, VA
Nelson County, VA
Charlottesville City, VA
16860........................................ Chattanooga, TN-GA...................................... 0.9088
Catoosa County, GA
Dade County, GA
[[Page 45061]]
Walker County, GA
Hamilton County, TN
Marion County, TN
Sequatchie County, TN
16940........................................ Cheyenne, WY............................................ 0.8775
Laramie County, WY
16974........................................ Chicago-Naperville-Joliet, IL........................... 1.0790
Cook County, IL
DeKalb County, IL
DuPage County, IL
Grundy County, IL
Kane County, IL
Kendall County, IL
McHenry County, IL
Will County, IL
17020........................................ Chico, CA............................................... 1.0511
Butte County, CA
17140........................................ Cincinnati-Middletown, OH-KY-IN......................... 0.9615
Dearborn County, IN
Franklin County, IN
Ohio County, IN
Boone County, KY
Bracken County, KY
Campbell County, KY
Gallatin County, KY
Grant County, KY
Kenton County, KY
Pendleton County, KY
Brown County, OH
Butler County, OH
Clermont County, OH
Hamilton County, OH
Warren County, OH
17300........................................ Clarksville, TN-KY...................................... 0.8284
Christian County, KY
Trigg County, KY
Montgomery County, TN
Stewart County, TN
17420........................................ Cleveland, TN........................................... 0.8139
Bradley County, TN
Polk County, TN
17460........................................ Cleveland-Elyria-Mentor, OH............................. 0.9213
Cuyahoga County, OH
Geauga County, OH
Lake County, OH
Lorain County, OH
Medina County, OH
17660........................................ Coeur d'Alene, ID....................................... 0.9647
Kootenai County, ID
17780........................................ College Station-Bryan, TX............................... 0.8900
Brazos County, TX
Burleson County, TX
Robertson County, TX
17820........................................ Colorado Springs, CO.................................... 0.9468
El Paso County, CO
Teller County, CO
17860........................................ Columbia, MO............................................ 0.8345
Boone County, MO
Howard County, MO
17900........................................ Columbia, SC............................................ 0.9057
Calhoun County, SC
Fairfield County, SC
Kershaw County, SC
Lexington County, SC
Richland County, SC
Saluda County, SC
17980........................................ Columbus, GA-AL......................................... 0.8560
Russell County, AL
Chattahoochee County, GA
Harris County, GA
Marion County, GA
[[Page 45062]]
Muscogee County, GA
18020........................................ Columbus, IN............................................ 0.9588
Bartholomew County, IN
18140........................................ Columbus, OH............................................ 0.9860
Delaware County, OH
Fairfield County, OH
Franklin County, OH
Licking County, OH
Madison County, OH
Morrow County, OH
Pickaway County, OH
Union County, OH
18580........................................ Corpus Christi, TX...................................... 0.8550
Aransas County, TX
Nueces County, TX
San Patricio County, TX
18700........................................ Corvallis, OR........................................... 1.0729
Benton County, OR
19060........................................ Cumberland, MD-WV....................................... 0.9317
Allegany County, MD
Mineral County, WV
19124........................................ Dallas-Plano-Irving, TX................................. 1.0228
Collin County, TX
Dallas County, TX
Delta County, TX
Denton County, TX
Ellis County, TX
Hunt County, TX
Kaufman County, TX
Rockwall County, TX
19140........................................ Dalton, GA.............................................. 0.9079
Murray County, GA
Whitfield County, GA
19180........................................ Danville, IL............................................ 0.9028
Vermilion County, IL
19260........................................ Danville, VA............................................ 0.8489
Pittsylvania County, VA
Danville City, VA
19340........................................ Davenport-Moline-Rock Island, IA-IL..................... 0.8724
Henry County, IL
Mercer County, IL
Rock Island County, IL
Scott County, IA
19380........................................ Dayton, OH.............................................. 0.9064
Greene County, OH
Miami County, OH
Montgomery County, OH
Preble County, OH
19460........................................ Decatur, AL............................................. 0.8469
Lawrence County, AL
Morgan County, AL
19500........................................ Decatur, IL............................................. 0.8067
Macon County, IL
19660........................................ Deltona-Daytona Beach-Ormond Beach, FL.................. 0.9299
Volusia County, FL
19740........................................ Denver-Aurora, CO....................................... 1.0723
Adams County, CO
Arapahoe County, CO
Broomfield County, CO
Clear Creek County, CO
Denver County, CO
Douglas County, CO
Elbert County, CO
Gilpin County, CO
Jefferson County, CO
Park County, CO
19780........................................ Des Moines, IA.......................................... 0.9669
Dallas County, IA
Guthrie County, IA
Madison County, IA
Polk County, IA
[[Page 45063]]
Warren County, IA
19804........................................ Detroit-Livonia-Dearborn, MI............................ 1.0424
Wayne County, MI
20020........................................ Dothan, AL.............................................. 0.7721
Geneva County, AL
Henry County, AL
Houston County, AL
20100........................................ Dover, DE............................................... 0.9776
Kent County, DE
20220........................................ Dubuque, IA............................................. 0.9024
Dubuque County, IA
20260........................................ Duluth, MN-WI........................................... 1.0213
Carlton County, MN
St. Louis County, MN
Douglas County, WI
20500........................................ Durham, NC.............................................. 1.0244
Chatham County, NC
Durham County, NC
Orange County, NC
Person County, NC
20740........................................ Eau Claire, WI.......................................... 0.9201
Chippewa County, WI
Eau Claire County, WI
20764........................................ Edison, NJ.............................................. 1.1249
Middlesex County, NJ
Monmouth County, NJ
Ocean County, NJ
Somerset County, NJ
20940........................................ El Centro, CA........................................... 0.8906
Imperial County, CA
21060........................................ Elizabethtown, KY....................................... 0.8802
Hardin County, KY
Larue County, KY
21140........................................ Elkhart-Goshen, IN...................................... 0.9627
Elkhart County, IN
21300........................................ Elmira, NY.............................................. 0.8250
Chemung County, NY
21340........................................ El Paso, TX............................................. 0.8977
El Paso County, TX
21500........................................ Erie, PA................................................ 0.8737
Erie County, PA
21604........................................ Essex County, MA........................................ 1.0538
Essex County, MA
21660........................................ Eugene-Springfield, OR.................................. 1.0818
Lane County, OR
21780........................................ Evansville, IN-KY....................................... 0.8713
Gibson County, IN
Posey County, IN
Vanderburgh County, IN
Warrick County, IN
Henderson County, KY
Webster County, KY
21820........................................ Fairbanks, AK........................................... 1.1408
Fairbanks North Star Borough, AK
21940........................................ Fajardo, PR............................................. 0.4153
Ceiba Municipio, PR
Fajardo Municipio, PR
Luquillo Municipio, PR
22020........................................ Fargo, ND-MN............................................ 0.8486
Cass County, ND
Clay County, MN
22140........................................ Farmington, NM.......................................... 0.8509
San Juan County, NM
22180........................................ Fayetteville, NC........................................ 0.9416
Cumberland County, NC
Hoke County, NC
22220........................................ Fayetteville-Springdale-Rogers, AR-MO................... 0.8661
Benton County, AR
Madison County, AR
Washington County, AR
McDonald County, MO
[[Page 45064]]
22380........................................ Flagstaff, AZ........................................... 1.2092
Coconino County, AZ
22420........................................ Flint, MI............................................... 1.0655
Genesee County, MI
22500........................................ Florence, SC............................................ 0.8947
Darlington County, SC
Florence County, SC
22520........................................ Florence-Muscle Shoals, AL.............................. 0.8272
Colbert County, AL
Lauderdale County, AL
22540........................................ Fond du Lac, WI......................................... 0.9640
Fond du Lac County, WI
22660........................................ Fort Collins-Loveland, CO............................... 1.0122
Larimer County, CO
22744........................................ Fort Lauderdale-Pompano Beach-Deerfield Beach, FL....... 1.0432
Broward County, FL
22900........................................ Fort Smith, AR-OK....................................... 0.8230
Crawford County, AR
Franklin County, AR
Sebastian County, AR
Le Flore County, OK
Sequoyah County, OK
23020........................................ Fort Walton Beach-Crestview-Destin, FL.................. 0.8872
Okaloosa County, FL
23060........................................ Fort Wayne, IN.......................................... 0.9793
Allen County, IN
Wells County, IN
Whitley County, IN
23104........................................ Fort Worth-Arlington, TX................................ 0.9486
Johnson County, TX
Parker County, TX
Tarrant County, TX
Wise County, TX
23420........................................ Fresno, CA.............................................. 1.0538
Fresno County, CA
23460........................................ Gadsden, AL............................................. 0.7938
Etowah County, AL
23540........................................ Gainesville, FL......................................... 0.9388
Alachua County, FL
Gilchrist County, FL
23580........................................ Gainesville, GA......................................... 0.8874
Hall County, GA
23844........................................ Gary, IN................................................ 0.9395
Jasper County, IN
Lake County, IN
Newton County, IN
Porter County, IN
24020........................................ Glens Falls, NY......................................... 0.8559
Warren County, NY
Washington County, NY
24140........................................ Goldsboro, NC........................................... 0.8775
Wayne County, NC
24220........................................ Grand Forks, ND-MN...................................... 0.7901
Polk County, MN
Grand Forks County, ND
24300........................................ Grand Junction, CO...................................... 0.9550
Mesa County, CO
24340........................................ Grand Rapids-Wyoming, MI................................ 0.9390
Barry County, MI
Ionia County, MI
Kent County, MI
Newaygo County, MI
24500........................................ Great Falls, MT......................................... 0.9052
Cascade County, MT
24540........................................ Greeley, CO............................................. 0.9570
Weld County, CO
24580........................................ Green Bay, WI........................................... 0.9483
Brown County, WI
Kewaunee County, WI
Oconto County, WI
24660........................................ Greensboro-High Point, NC............................... 0.9104
[[Page 45065]]
Guilford County, NC
Randolph County, NC
Rockingham County, NC
24780........................................ Greenville, NC.......................................... 0.9425
Greene County, NC
Pitt County, NC
24860........................................ Greenville, SC.......................................... 1.0027
Greenville County, SC
Laurens County, SC
Pickens County, SC
25020........................................ Guayama, PR............................................. 0.3181
Arroyo Municipio, PR
Guayama Municipio, PR
Patillas Municipio, PR
25060........................................ Gulfport-Biloxi, MS..................................... 0.8929
Hancock County, MS
Harrison County, MS
Stone County, MS
25180........................................ Hagerstown-Martinsburg, MD-WV........................... 0.9489
Washington County, MD
Berkeley County, WV
Morgan County, WV
25260........................................ Hanford-Corcoran, CA.................................... 1.0036
Kings County, CA
25420........................................ Harrisburg-Carlisle, PA................................. 0.9313
Cumberland County, PA
Dauphin County, PA
Perry County, PA
25500........................................ Harrisonburg, VA........................................ 0.9088
Rockingham County, VA
Harrisonburg City, VA
25540........................................ Hartford-West Hartford-East Hartford, CT................ 1.1073
Hartford County, CT
Litchfield County, CT
Middlesex County, CT
Tolland County, CT
25620........................................ Hattiesburg, MS......................................... 0.7601
Forrest County, MS
Lamar County, MS
Perry County, MS
25860........................................ Hickory-Lenoir-Morganton, NC............................ 0.8921
Alexander County, NC
Burke County, NC
Caldwell County, NC
Catawba County, NC
25980........................................ Hinesville-Fort Stewart, GA\1\.......................... .......
Liberty County, GA
Long County, GA
26100........................................ Holland-Grand Haven, MI................................. 0.9055
Ottawa County, MI
26180........................................ Honolulu, HI............................................ 1.1214
Honolulu County, HI
26300........................................ Hot Springs, AR......................................... 0.9005
Garland County, AR
26380........................................ Houma-Bayou Cane-Thibodaux, LA.......................... 0.7894
Lafourche Parish, LA
Terrebonne Parish, LA
26420........................................ Houston-Baytown-Sugar Land, TX.......................... 0.9992
Austin County, TX
Brazoria County, TX
Chambers County, TX
Fort Bend County, TX
Galveston County, TX
Harris County, TX
Liberty County, TX
Montgomery County, TX
San Jacinto County, TX
Waller County, TX
26580........................................ Huntington-Ashland, WV-KY-OH............................ 0.9477
Boyd County, KY
Greenup County, KY
[[Page 45066]]
Lawrence County, OH
Cabell County, WV
Wayne County, WV
26620........................................ Huntsville, AL.......................................... 0.9146
Limestone County, AL
Madison County, AL
26820........................................ Idaho Falls, ID......................................... 0.9420
Bonneville County, ID
Jefferson County, ID
26900........................................ Indianapolis, IN........................................ 0.9920
Boone County, IN
Brown County, IN
Hamilton County, IN
Hancock County, IN
Hendricks County, IN
Johnson County, IN
Marion County, IN
Morgan County, IN
Putnam County, IN
Shelby County, IN
26980........................................ Iowa City, IA........................................... 0.9747
Johnson County, IA
Washington County, IA
27060........................................ Ithaca, NY.............................................. 0.9793
Tompkins County, NY
27100........................................ Jackson, MI............................................. 0.9304
Jackson County, MI
27140........................................ Jackson, MS............................................. 0.8311
Copiah County, MS
Hinds County, MS
Madison County, MS
Rankin County, MS
Simpson County, MS
27180........................................ Jackson, TN............................................. 0.8964
Chester County, TN
Madison County, TN
27260........................................ Jacksonville, FL........................................ 0.9290
Baker County, FL
Clay County, FL
Duval County, FL
Nassau County, FL
St. Johns County, FL
27340........................................ Jacksonville, NC........................................ 0.8236
Onslow County, NC
27500........................................ Janesville, WI.......................................... 0.9538
Rock County, WI
27620........................................ Jefferson City, MO...................................... 0.8387
Callaway County, MO
Cole County, MO
Moniteau County, MO
Osage County, MO
27740........................................ Johnson City, TN........................................ 0.7937
Carter County, TN
Unicoi County, TN
Washington County, TN
27780........................................ Johnstown, PA........................................... 0.8354
Cambria County, PA
27860........................................ Jonesboro, AR........................................... 0.7911
Craighead County, AR
Poinsett County, AR
27900........................................ Joplin, MO.............................................. 0.8582
Jasper County, MO
Newton County, MO
28020........................................ Kalamazoo-Portage, MI................................... 1.0381
Kalamazoo County, MI
Van Buren County, MI
28100........................................ Kankakee-Bradley, IL.................................... 1.0721
Kankakee County, IL
28140........................................ Kansas City, MO-KS...................................... 0.9476
Franklin County, KS
Johnson County, KS
[[Page 45067]]
Leavenworth County, KS
Linn County, KS
Miami County, KS
Wyandotte County, KS
Bates County, MO
Caldwell County, MO
Cass County, MO
Clay County, MO
Clinton County, MO
Jackson County, MO
Lafayette County, MO
Platte County, MO
Ray County, MO
28420........................................ Kennewick-Richland-Pasco, WA............................ 1.0619
Benton County, WA
Franklin County, WA
28660........................................ Killeen-Temple-Fort Hood, TX............................ 0.8526
Bell County, TX
Coryell County, TX
Lampasas County, TX
28700........................................ Kingsport-Bristol-Bristol, TN-VA........................ 0.8054
Hawkins County, TN
Sullivan County, TN
Bristol City, VA
Scott County, VA
Washington County, VA
28740........................................ Kingston, NY............................................ 0.9255
Ulster County, NY
28940........................................ Knoxville, TN........................................... 0.8441
Anderson County, TN
Blount County, TN
Knox County, TN
Loudon County, TN
Union County, TN
29020........................................ Kokomo, IN.............................................. 0.9508
Howard County, IN
Tipton County, IN
29100........................................ La Crosse, WI-MN........................................ 0.9564
Houston County, MN
La Crosse County, WI
29140........................................ Lafayette, IN........................................... 0.8736
Benton County, IN
Carroll County, IN
Tippecanoe County, IN
29180........................................ Lafayette, LA........................................... 0.8428
Lafayette Parish, LA
St. Martin Parish, LA
29340........................................ Lake Charles, LA........................................ 0.7833
Calcasieu Parish, LA
Cameron Parish, LA
29404........................................ Lake County-Kenosha County, IL-WI....................... 1.0429
Lake County, IL
Kenosha County, WI
29460........................................ Lakeland, FL............................................ 0.8912
Polk County, FL
29540........................................ Lancaster, PA........................................... 0.9694
Lancaster County, PA
29620........................................ Lansing-East Lansing, MI................................ 0.9794
Clinton County, MI
Eaton County, MI
Ingham County, MI
29700........................................ Laredo, TX.............................................. 0.8068
Webb County, TX
29740........................................ Las Cruces, NM.......................................... 0.8467
Dona Ana County, NM
29820........................................ Las Vegas-Paradise, NV.................................. 1.1437
Clark County, NV
29940........................................ Lawrence, KS............................................ 0.8537
Douglas County, KS
30020........................................ Lawton, OK.............................................. 0.7872
Comanche County, OK
[[Page 45068]]
30140........................................ Lebanon, PA............................................. 0.8459
Lebanon County, PA
30300........................................ Lewiston, ID-WA......................................... 0.9886
Nez Perce County, ID
Asotin County, WA
30340........................................ Lewiston-Auburn, ME..................................... 0.9331
Androscoggin County, ME
30460........................................ Lexington-Fayette, KY................................... 0.9075
Bourbon County, KY
Clark County, KY
Fayette County, KY
Jessamine County, KY
Scott County, KY
Woodford County, KY
30620........................................ Lima, OH................................................ 0.9225
Allen County, OH
30700........................................ Lincoln, NE............................................. 1.0214
Lancaster County, NE
Seward County, NE
30780........................................ Little Rock-North Little Rock, AR....................... 0.8747
Faulkner County, AR
Grant County, AR
Lonoke County, AR
Perry County, AR
Pulaski County, AR
Saline County, AR
30860........................................ Logan, UT-ID............................................ 0.9164
Franklin County, ID
Cache County, UT
30980........................................ Longview, TX............................................ 0.8730
Gregg County, TX
Rusk County, TX
Upshur County, TX
31020........................................ Longview, WA............................................ 0.9579
Cowlitz County, WA
31084........................................ Los Angeles-Long Beach-Glendale, CA..................... 1.1783
Los Angeles County, CA
31140........................................ Louisville, KY-IN....................................... 0.9251
Clark County, IN
Floyd County, IN
Harrison County, IN
Washington County, IN
Bullitt County, KY
Henry County, KY
Jefferson County, KY
Meade County, KY
Nelson County, KY
Oldham County, KY
Shelby County, KY
Spencer County, KY
Trimble County, KY
31180........................................ Lubbock, TX............................................. 0.8783
Crosby County, TX
Lubbock County, TX
31340........................................ Lynchburg, VA........................................... 0.8691
Amherst County, VA
Appomattox County, VA
Bedford County, VA
Campbell County, VA
Bedford City, VA
Lynchburg City, VA
31420........................................ Macon, GA............................................... 0.9443
Bibb County, GA
Crawford County, GA
Jones County, GA
Monroe County, GA
Twiggs County, GA
31460........................................ Madera, CA.............................................. 0.8713
Madera County, CA
31540........................................ Madison, WI............................................. 1.0659
Columbia County, WI
[[Page 45069]]
Dane County, WI
Iowa County, WI
31700........................................ Manchester-Nashua, NH................................... 1.0354
Hillsborough County, NH
Merrimack County, NH
31900........................................ Mansfield, OH \1\....................................... .......
Richland County, OH
32420........................................ Mayaguez, PR............................................ 0.4020
Hormigueros Municipio, PR
Mayaguez Municipio, PR
32580........................................ McAllen-Edinburg-Pharr, TX.............................. 0.8934
Hidalgo County, TX
32780........................................ Medford, OR............................................. 1.0225
Jackson County, OR
32820........................................ Memphis, TN-MS-AR....................................... 0.9397
Crittenden County, AR
DeSoto County, MS
Marshall County, MS
Tate County, MS
Tunica County, MS
Fayette County, TN
Shelby County, TN
Tipton County, TN
32900........................................ Merced, CA.............................................. 1.1109
Merced County, CA
33124........................................ Miami-Miami Beach-Kendall, FL........................... 0.9750
Miami-Dade County, FL
33140........................................ Michigan City-La Porte, IN.............................. 0.9399
LaPorte County, IN
33260........................................ Midland, TX............................................. 0.9514
Midland County, TX
33340........................................ Milwaukee-Waukesha-West Allis, WI....................... 1.0146
Milwaukee County, WI
Ozaukee County, WI
Washington County, WI
Waukesha County, WI
33460........................................ Minneapolis-St. Paul-Bloomington, MN-WI................. 1.1075
Anoka County, MN
Carver County, MN
Chisago County, MN
Dakota County, MN
Hennepin County, MN
Isanti County, MN
Ramsey County, MN
Scott County, MN
Sherburne County, MN
Washington County, MN
Wright County, MN
Pierce County, WI
St. Croix County, WI
33540........................................ Missoula, MT............................................ 0.9473
Missoula County, MT
33660........................................ Mobile, AL.............................................. 0.7891
Mobile County, AL
33700........................................ Modesto, CA............................................. 1.1885
Stanislaus County, CA
33740........................................ Monroe, LA.............................................. 0.8031
Ouachita Parish, LA
Union Parish, LA
33780........................................ Monroe, MI.............................................. 0.9468
Monroe County, MI
33860........................................ Montgomery, AL.......................................... 0.8618
Autauga County, AL
Elmore County, AL
Lowndes County, AL
Montgomery County, AL
34060........................................ Morgantown, WV.......................................... 0.8420
Monongalia County, WV
Preston County, WV
34100........................................ Morristown, TN.......................................... 0.7961
Grainger County, TN
[[Page 45070]]
Hamblen County, TN
Jefferson County, TN
34580........................................ Mount Vernon-Anacortes, WA.............................. 1.0454
Skagit County, WA
34620........................................ Muncie, IN.............................................. 0.8930
Delaware County, IN
34740........................................ Muskegon-Norton Shores, MI.............................. 0.9664
Muskegon County, MI
34820........................................ Myrtle Beach-Conway-North Myrtle Beach, SC.............. 0.8934
Horry County, SC
34900........................................ Napa, CA................................................ 1.2643
Napa County, CA
34940........................................ Naples-Marco Island, FL................................. 1.0139
Collier County, FL
34980........................................ Nashville-Davidson--Murfreesboro, TN.................... 0.9741
Cannon County, TN
Cheatham County, TN
Davidson County, TN
Dickson County, TN
Hickman County, TN
Macon County, TN
Robertson County, TN
Rutherford County, TN
Smith County, TN
Sumner County, TN
Trousdale County, TN
Williamson County, TN
Wilson County, TN
35004........................................ Nassau-Suffolk, NY...................................... 1.2719
Nassau County, NY
Suffolk County, NY
35084........................................ Newark-Union, NJ-PA..................................... 1.1883
Essex County, NJ
Hunterdon County, NJ
Morris County, NJ
Sussex County, NJ
Union County, NJ
Pike County, PA
35300........................................ New Haven-Milford, CT................................... 1.1887
New Haven County, CT
35380........................................ New Orleans-Metairie-Kenner, LA......................... 0.8995
Jefferson Parish, LA
Orleans Parish, LA
Plaquemines Parish, LA
St. Bernard Parish, LA
St. Charles Parish, LA
St. John the Baptist Parish, LA
St. Tammany Parish, LA
35644........................................ New York-Wayne-White Plains, NY-NJ...................... 1.3188
Bergen County, NJ
Hudson County, NJ
Passaic County, NJ
Bronx County, NY
Kings County, NY
New York County, NY
Putnam County, NY
Queens County, NY
Richmond County, NY
Rockland County, NY
Westchester County, NY
35660........................................ Niles-Benton Harbor, MI................................. 0.8879
Berrien County, MI
35980........................................ Norwich-New London, CT.................................. 1.1345
New London County, CT
36084........................................ Oakland-Fremont-Hayward, CA............................. 1.5346
Alameda County, CA
Contra Costa County, CA
36100........................................ Ocala, FL............................................... 0.8925
Marion County, FL
36140........................................ Ocean City, NJ.......................................... 1.1011
Cape May County, NJ
[[Page 45071]]
36220........................................ Odessa, TX.............................................. 0.9884
Ector County, TX
36260........................................ Ogden-Clearfield, UT.................................... 0.9029
Davis County, UT
Morgan County, UT
Weber County, UT
36420........................................ Oklahoma City, OK....................................... 0.9031
Canadian County, OK
Cleveland County, OK
Grady County, OK
Lincoln County, OK
Logan County, OK
McClain County, OK
Oklahoma County, OK
36500........................................ Olympia, WA............................................. 1.0927
Thurston County, WA
36540........................................ Omaha-Council Bluffs, NE-IA............................. 0.9560
Harrison County, IA
Mills County, IA
Pottawattamie County, IA
Cass County, NE
Douglas County, NE
Sarpy County, NE
Saunders County, NE
Washington County, NE
36740........................................ Orlando, FL............................................. 0.9464
Lake County, FL
Orange County, FL
Osceola County, FL
Seminole County, FL
36780........................................ Oshkosh-Neenah, WI...................................... 0.9183
Winnebago County, WI
36980........................................ Owensboro, KY........................................... 0.8780
Daviess County, KY
Hancock County, KY
McLean County, KY
37100........................................ Oxnard-Thousand Oaks-Ventura, CA........................ 1.1622
Ventura County, CA
37340........................................ Palm Bay-Melbourne-Titusville, FL....................... 0.9839
Brevard County, FL
37460........................................ Panama City-Lynn Haven, FL.............................. 0.8005
Bay County, FL
37620........................................ Parkersburg-Marietta, WV-OH............................. 0.8270
Washington County, OH
Pleasants County, WV
Wirt County, WV
Wood County, WV
37700........................................ Pascagoula, MS.......................................... 0.8156
George County, MS
Jackson County, MS
37860........................................ Pensacola-Ferry Pass-Brent, FL.......................... 0.8096
Escambia County, FL
Santa Rosa County, FL
37900........................................ Peoria, IL.............................................. 0.8870
Marshall County, IL
Peoria County, IL
Stark County, IL
Tazewell County, IL
Woodford County, IL
37964........................................ Philadelphia, PA........................................ 1.1038
Bucks County, PA
Chester County, PA
Delaware County, PA
Montgomery County, PA
Philadelphia County, PA
38060........................................ Phoenix-Mesa-Scottsdale, AZ............................. 1.0127
Maricopa County, AZ
Pinal County, AZ
38220........................................ Pine Bluff, AR.......................................... 0.8680
Cleveland County, AR
Jefferson County, AR
[[Page 45072]]
Lincoln County, AR
38300........................................ Pittsburgh, PA.......................................... 0.8845
Allegheny County, PA
Armstrong County, PA
Beaver County, PA
Butler County, PA
Fayette County, PA
Washington County, PA
Westmoreland County, PA
38340........................................ Pittsfield, MA.......................................... 1.0181
Berkshire County, MA
38540........................................ Pocatello, ID........................................... 0.9351
Bannock County, ID
Power County, ID
38660........................................ Ponce, PR............................................... 0.4939
Juana Diaz Municipio, PR
Ponce Municipio, PR
Villalba Municipio, PR
38860........................................ Portland-South Portland-Biddeford, ME................... 1.0382
Cumberland County, ME
Sagadahoc County, ME
York County, ME
38900........................................ Portland-Vancouver-Beaverton, OR-WA..................... 1.1266
Clackamas County, OR
Columbia County, OR
Multnomah County, OR
Washington County, OR
Yamhill County, OR
Clark County, WA
Skamania County, WA
38940........................................ Port St. Lucie-Fort Pierce, FL.......................... 1.0123
Martin County, FL
St. Lucie County, FL
39100........................................ Poughkeepsie-Newburgh-Middletown, NY.................... 1.0891
Dutchess County, NY
Orange County, NY
39140........................................ Prescott, AZ............................................ 0.9869
Yavapai County, AZ
39300........................................ Providence-New Bedford-Fall River, RI-MA................ 1.0966
Bristol County, MA
Bristol County, RI
Kent County, RI
Newport County, RI
Providence County, RI
Washington County, RI
39340........................................ Provo-Orem, UT.......................................... 0.9500
Juab County, UT
Utah County, UT
39380........................................ Pueblo, CO.............................................. 0.8623
Pueblo County, CO
39460........................................ Punta Gorda, FL......................................... 0.9255
Charlotte County, FL
39540........................................ Racine, WI.............................................. 0.8997
Racine County, WI
39580........................................ Raleigh-Cary, NC........................................ 0.9691
Franklin County, NC
Johnston County, NC
Wake County, NC
39660........................................ Rapid City, SD.......................................... 0.8987
Meade County, SD
Pennington County, SD
39740........................................ Reading, PA............................................. 0.9686
Berks County, PA
39820........................................ Redding, CA............................................. 1.2203
Shasta County, CA
39900........................................ Reno-Sparks, NV......................................... 1.0982
Storey County, NV
Washoe County, NV
40060........................................ Richmond, VA............................................ 0.9328
Amelia County, VA
Caroline County, VA
[[Page 45073]]
Charles City County, VA
Chesterfield County, VA
Cumberland County, VA
Dinwiddie County, VA
Goochland County, VA
Hanover County, VA
Henrico County, VA
King and Queen County, VA
King William County, VA
Louisa County, VA
New Kent County, VA
Powhatan County, VA
Prince George County, VA
Sussex County, VA
Colonial Heights City, VA
Hopewell City, VA
Petersburg City, VA
Richmond City, VA
40140........................................ Riverside-San Bernardino-Ontario, CA.................... 1.1027
Riverside County, CA
San Bernardino County, CA
40220........................................ Roanoke, VA............................................. 0.8374
Botetourt County, VA
Craig County, VA
Franklin County, VA
Roanoke County, VA
Roanoke City, VA
Salem City, VA
40340........................................ Rochester, MN........................................... 1.1131
Dodge County, MN
Olmsted County, MN
Wabasha County, MN
40380........................................ Rochester, NY........................................... 0.9121
Livingston County, NY
Monroe County, NY
Ontario County, NY
Orleans County, NY
Wayne County, NY
40420........................................ Rockford, IL............................................ 0.9984
Boone County, IL
Winnebago County, IL
40484........................................ Rockingham County-Strafford County, NH.................. 1.0374
Rockingham County, NH
Strafford County, NH
40580........................................ Rocky Mount, NC......................................... 0.8915
Edgecombe County, NC
Nash County, NC
40660........................................ Rome, GA................................................ 0.9414
Floyd County, GA
40900........................................ Sacramento--Arden-Arcade--Roseville, CA................. 1.2969
El Dorado County, CA
Placer County, CA
Sacramento County, CA
Yolo County, CA
40980........................................ Saginaw-Saginaw Township North, MI...................... 0.9088
Saginaw County, MI
41060........................................ St. Cloud, MN........................................... 0.9965
Benton County, MN
Stearns County, MN
41100........................................ St. George, UT.......................................... 0.9392
Washington County, UT
41140........................................ St. Joseph, MO-KS....................................... 0.9519
Doniphan County, KS
Andrew County, MO
Buchanan County, MO
DeKalb County, MO
41180........................................ St. Louis, MO-IL........................................ 0.8954
Bond County, IL
Calhoun County, IL
Clinton County, IL
Jersey County, IL
[[Page 45074]]
Macoupin County, IL
Madison County, IL
Monroe County, IL
St. Clair County, IL
Crawford County, MO
Franklin County, MO
Jefferson County, MO
Lincoln County, MO
St. Charles County, MO
St. Louis County, MO
Warren County, MO
Washington County, MO
St. Louis City, MO
41420........................................ Salem, OR............................................... 1.0442
Marion County, OR
Polk County, OR
41500........................................ Salinas, CA............................................. 1.4128
Monterey County, CA
41540........................................ Salisbury, MD........................................... 0.9064
Somerset County, MD
Wicomico County, MD
41620........................................ Salt Lake City, UT...................................... 0.9421
Salt Lake County, UT
Summit County, UT
Tooele County, UT
41660........................................ San Angelo, TX.......................................... 0.8271
Irion County, TX
Tom Green County, TX
41700........................................ San Antonio, TX......................................... 0.8980
Atascosa County, TX
Bandera County, TX
Bexar County, TX
Comal County, TX
Guadalupe County, TX
Kendall County, TX
Medina County, TX
Wilson County, TX
41740........................................ San Diego-Carlsbad-San Marcos, CA....................... 1.1413
San Diego County, CA
41780........................................ Sandusky, OH............................................ 0.9019
Erie County, OH
41884........................................ San Francisco-San Mateo-Redwood City, CA................ 1.4994
Marin County, CA
San Francisco County, CA
San Mateo County, CA
41900........................................ San German-Cabo Rojo, PR................................ 0.4650
Cabo Rojo Municipio, PR
Lajas Municipio, PR
Sabana Grande Municipio, PR
San German Municipio, PR
41940........................................ San Jose-Sunnyvale-Santa Clara, CA...................... 1.5099
San Benito County, CA
Santa Clara County, CA
41980........................................ San Juan-Caguas-Guaynabo, PR............................ 0.4621
Aguas Buenas Municipio, PR
Aibonito Municipio, PR
Arecibo Municipio, PR
Barceloneta Municipio, PR
Barranquitas Municipio, PR
Bayamon Municipio, PR
Caguas Municipio, PR
Camuy Municipio, PR
Canovanas Municipio, PR
Carolina Municipio, PR
Catano Municipio, PR
Cayey Municipio, PR
Ciales Municipio, PR
Cidra Municipio, PR
Comerio Municipio, PR
Corozal Municipio, PR
Dorado Municipio, PR
[[Continued on page 45075]]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
]
[[pp. 45075-45124]] Medicare Program; Prospective Payment System and Consolidated
Billing for Skilled Nursing Facilities for FY 2006
[[Continued from page 45074]]
[[Page 45075]]
Florida Municipio, PR
Guaynabo Municipio, PR
Gurabo Municipio, PR
Hatillo Municipio, PR
Humacao Municipio, PR
Juncos Municipio, PR
Las Piedras Municipio, PR
Loiza Municipio, PR
Manati Municipio, PR
Maunabo Municipio, PR
Morovis Municipio, PR
Naguabo Municipio, PR
Naranjito Municipio, PR
Orocovis Municipio, PR
Quebradillas Municipio, PR
Rio Grande Municipio, PR
San Juan Municipio, PR
San Lorenzo Municipio, PR
Toa Alta Municipio, PR
Toa Baja Municipio, PR
Trujillo Alto Municipio, PR
Vega Alta Municipio, PR
Vega Baja Municipio, PR
Yabucoa Municipio, PR
42020........................................ San Luis Obispo-Paso Robles, CA......................... 1.1349
San Luis Obispo County, CA
42044........................................ Santa Ana-Anaheim-Irvine, CA............................ 1.1559
Orange County, CA
42060........................................ Santa Barbara-Santa Maria-Goleta, CA.................... 1.1694
Santa Barbara County, CA
42100........................................ Santa Cruz-Watsonville, CA.............................. 1.5166
Santa Cruz County, CA
42140........................................ Santa Fe, NM............................................ 1.0920
Santa Fe County, NM
42220........................................ Santa Rosa-Petaluma, CA................................. 1.3493
Sonoma County, CA
42260........................................ Sarasota-Bradenton-Venice, FL........................... 0.9639
Manatee County, FL
Sarasota County, FL
42340........................................ Savannah, GA............................................ 0.9461
Bryan County, GA
Chatham County, GA
Effingham County, GA
42540........................................ Scranton--Wilkes-Barre, PA.............................. 0.8540
Lackawanna County, PA
Luzerne County, PA
Wyoming County, PA
42644........................................ Seattle-Bellevue-Everett, WA............................ 1.1577
King County, WA
Snohomish County, WA
43100........................................ Sheboygan, WI........................................... 0.8911
Sheboygan County, WI
43300........................................ Sherman-Denison, TX..................................... 0.9507
Grayson County, TX
43340........................................ Shreveport-Bossier City, LA............................. 0.8760
Bossier Parish, LA
Caddo Parish, LA
De Soto Parish, LA
43580........................................ Sioux City, IA-NE-SD.................................... 0.9381
Woodbury County, IA
Dakota County, NE
Dixon County, NE
Union County, SD
43620........................................ Sioux Falls, SD......................................... 0.9635
Lincoln County, SD
McCook County, SD
Minnehaha County, SD
Turner County, SD
43780........................................ South Bend-Mishawaka, IN-MI............................. 0.9788
St. Joseph County, IN
Cass County, MI
[[Page 45076]]
43900........................................ Spartanburg, SC......................................... 0.9172
Spartanburg County, SC
44060........................................ Spokane, WA............................................. 1.0905
Spokane County, WA
44100........................................ Springfield, IL......................................... 0.8792
Menard County, IL
Sangamon County, IL
44140........................................ Springfield, MA......................................... 1.0248
Franklin County, MA
Hampden County, MA
Hampshire County, MA
44180........................................ Springfield, MO......................................... 0.8237
Christian County, MO
Dallas County, MO
Greene County, MO
Polk County, MO
Webster County, MO
44220........................................ Springfield, OH......................................... 0.8396
Clark County, OH
44300........................................ State College, PA....................................... 0.8356
Centre County, PA
44700........................................ Stockton, CA............................................ 1.1307
San Joaquin County, CA
44940........................................ Sumter, SC.............................................. 0.8377
Sumter County, SC
45060........................................ Syracuse, NY............................................ 0.9574
Madison County, NY
Onondaga County, NY
Oswego County, NY
45104........................................ Tacoma, WA.............................................. 1.0742
Pierce County, WA
45220........................................ Tallahassee, FL......................................... 0.8688
Gadsden County, FL
Jefferson County, FL
Leon County, FL
Wakulla County, FL
45300........................................ Tampa-St. Petersburg-Clearwater, FL..................... 0.9233
Hernando County, FL
Hillsborough County, FL
Pasco County, FL
Pinellas County, FL
45460........................................ Terre Haute, IN......................................... 0.8304
Clay County, IN
Sullivan County, IN
Vermillion County, IN
Vigo County, IN
45500........................................ Texarkana, TX-Texarkana, AR............................. 0.8283
Miller County, AR
Bowie County, TX
45780........................................ Toledo, OH.............................................. 0.9574
Fulton County, OH
Lucas County, OH
Ottawa County, OH
Wood County, OH
45820........................................ Topeka, KS.............................................. 0.8920
Jackson County, KS
Jefferson County, KS
Osage County, KS
Shawnee County, KS
Wabaunsee County, KS
45940........................................ Trenton-Ewing, NJ....................................... 1.0834
Mercer County, NJ
46060........................................ Tucson, AZ.............................................. 0.9007
Pima County, AZ
46140........................................ Tulsa, OK............................................... 0.8543
Creek County, OK
Okmulgee County, OK
Osage County, OK
Pawnee County, OK
Rogers County, OK
Tulsa County, OK
[[Page 45077]]
Wagoner County, OK
46220........................................ Tuscaloosa, AL.......................................... 0.8645
Greene County, AL
Hale County, AL
Tuscaloosa County, AL
46340........................................ Tyler, TX............................................... 0.9168
Smith County, TX
46540........................................ Utica-Rome, NY.......................................... 0.8358
Herkimer County, NY
Oneida County, NY
46660........................................ Valdosta, GA............................................ 0.8866
Brooks County, GA
Echols County, GA
Lanier County, GA
Lowndes County, GA
46700........................................ Vallejo-Fairfield, CA................................... 1.4936
Solano County, CA
46940........................................ Vero Beach, FL.......................................... 0.9434
Indian River County, FL
47020........................................ Victoria, TX............................................ 0.8160
Calhoun County, TX
Goliad County, TX
Victoria County, TX
47220........................................ Vineland-Millville-Bridgeton, NJ........................ 0.9827
Cumberland County, NJ
47260........................................ Virginia Beach-Norfolk-Newport News, VA-NC.............. 0.8799
Currituck County, NC
Gloucester County, VA
Isle of Wight County, VA
James City County, VA
Mathews County, VA
Surry County, VA
York County, VA
Chesapeake City, VA
Hampton City, VA
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City, VA
Williamsburg City, VA
47300........................................ Visalia-Porterville, CA................................. 1.0123
Tulare County, CA
47380........................................ Waco, TX................................................ 0.8518
McLennan County, TX
47580........................................ Warner Robins, GA....................................... 0.8645
Houston County, GA
47644........................................ Warren-Farmington Hills-Troy, MI........................ 0.9871
Lapeer County, MI
Livingston County, MI
Macomb County, MI
Oakland County, MI
St. Clair County, MI
47894........................................ Washington-Arlington-Alexandria, DC-VA-MD-WV............ 1.0926
District of Columbia, DC
Calvert County, MD
Charles County, MD
Prince George's County, MD
Arlington County, VA
Clarke County, VA
Fairfax County, VA
Fauquier County, VA
Loudoun County, VA
Prince William County, VA
Spotsylvania County, VA
Stafford County, VA
Warren County, VA
Alexandria City, VA
Fairfax City, VA
Falls Church City, VA
[[Page 45078]]
Fredericksburg City, VA
Manassas City, VA
Manassas Park City, VA
Jefferson County, WV
47940........................................ Waterloo-Cedar Falls, IA................................ 0.8557
Black Hawk County, IA
Bremer County, IA
Grundy County, IA
48140........................................ Wausau, WI.............................................. 0.9590
Marathon County, WI
48260........................................ Weirton-Steubenville, WV-OH............................. 0.7819
Jefferson County, OH
Brooke County, WV
Hancock County, WV
48300........................................ Wenatchee, WA........................................... 1.0070
Chelan County, WA
Douglas County, WA
48424........................................ West Palm Beach-Boca Raton-Boynton Beach, FL............ 1.0067
Palm Beach County, FL
48540........................................ Wheeling, WV-OH......................................... 0.7161
Belmont County, OH
Marshall County, WV
Ohio County, WV
48620........................................ Wichita, KS............................................. 0.9153
Butler County, KS
Harvey County, KS
Sedgwick County, KS
Sumner County, KS
48660........................................ Wichita Falls, TX....................................... 0.8285
Archer County, TX
Clay County, TX
Wichita County, TX
48700........................................ Williamsport, PA........................................ 0.8364
Lycoming County, PA
48864........................................ Wilmington, DE-MD-NJ.................................... 1.0471
New Castle County, DE
Cecil County, MD
Salem County, NJ
48900........................................ Wilmington, NC.......................................... 0.9582
Brunswick County, NC
New Hanover County, NC
Pender County, NC
49020........................................ Winchester, VA-WV....................................... 1.0214
Frederick County, VA
Winchester City, VA
Hampshire County, WV
49180........................................ Winston-Salem, NC....................................... 0.8944
Davie County, NC
Forsyth County, NC
Stokes County, NC
Yadkin County, NC
49340........................................ Worcester, MA........................................... 1.1028
Worcester County, MA
49420........................................ Yakima, WA.............................................. 1.0155
Yakima County, WA
49500........................................ Yauco, PR............................................... 0.4408
Guanica Municipio, PR
Guayanilla Municipio, PR
Penuelas Municipio, PR
Yauco Municipio, PR
49620........................................ York-Hanover, PA........................................ 0.9347
York County, PA
49660........................................ Youngstown-Warren-Boardman, OH-PA....................... 0.8603
Mahoning County, OH
Trumbull County, OH
Mercer County, PA
49700........................................ Yuba City, CA........................................... 1.0921
Sutter County, CA
Yuba County, CA
49740........................................ Yuma, AZ................................................ 0.9126
[[Page 45079]]
Yuma County, AZ
----------------------------------------------------------------------------------------------------------------
\1\At this time, there are no hospitals located in these urban areas on which to base a wage index.
Table 9.--FY 2006 Wage Index Based on CBSA Labor Market Areas for Rural
Areas
------------------------------------------------------------------------
Wage
CBSA code Nonurban area index
------------------------------------------------------------------------
1.......................... Alabama.......................... 0.7446
2.......................... Alaska........................... 1.1977
3.......................... Arizona.......................... 0.8768
4.......................... Arkansas......................... 0.7466
5.......................... California....................... 1.1054
6.......................... Colorado......................... 0.9380
7.......................... Connecticut...................... 1.1730
8.......................... Delaware......................... 0.9579
10......................... Florida.......................... 0.8568
11......................... Georgia.......................... 0.7662
12......................... Hawaii........................... 1.0551
13......................... Idaho............................ 0.8037
14......................... Illinois......................... 0.8271
15......................... Indiana.......................... 0.8624
16......................... Iowa............................. 0.8509
17......................... Kansas........................... 0.8035
18......................... Kentucky......................... 0.7766
19......................... Louisiana........................ 0.7411
20......................... Maine............................ 0.8843
21......................... Maryland......................... 0.9353
22......................... Massachusetts \1\................ 1.2016
23......................... Michigan......................... 0.8895
24......................... Minnesota........................ 0.9132
25......................... Mississippi...................... 0.7674
26......................... Missouri......................... 0.7900
27......................... Montana.......................... 0.8762
28......................... Nebraska......................... 0.8657
29......................... Nevada........................... 0.9065
30......................... New Hampshire.................... 1.0817
31......................... New Jersey \1\................... ........
32......................... New Mexico....................... 0.8635
33......................... New York......................... 0.8154
34......................... North Carolina................... 0.8540
35......................... North Dakota..................... 0.7261
36......................... Ohio............................. 0.8826
37......................... Oklahoma......................... 0.7581
38......................... Oregon........................... 0.9826
39......................... Pennsylvania..................... 0.8291
40......................... Puerto Rico1..................... 0.4047
41......................... Rhode Island \1\................. ........
42......................... South Carolina................... 0.8638
43......................... South Dakota..................... 0.8560
44......................... Tennessee........................ 0.7895
45......................... Texas............................ 0.8003
46......................... Utah............................. 0.8118
47......................... Vermont.......................... 0.9830
48......................... Virgin Islands................... 0.7615
49......................... Virginia......................... 0.8013
50......................... Washington....................... 1.0510
51......................... West Virginia.................... 0.7717
52......................... Wisconsin........................ 0.9509
53......................... Wyoming.......................... 0.9257
65......................... Guam............................. 0.9611
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban, with the
exception of Massachusetts and Puerto Rico. Massachusetts and Puerto
Rico have areas designated as rural; however, no short-term, acute
care hospitals are located in the area(s) for FY 2006. Because more
recent data is not available for those areas, we are using last year's
wage index value.
Table A.--FY 2006 SNF PPS Transition Wage Index Table
----------------------------------------------------------------------------------------------------------------
2006 2006
SSA state/county MSA urban/ MSA- CBSA- CBSA CBSA urban/ Transition
code County name MSA No. rural based based No. rural wage index
WI WI *
----------------------------------------------------------------------------------------------------------------
01000............ Autauga County, 5240 Urban 0.8618 0.8618 33860 Urban 0.8618
Alabama.
01010............ Baldwin County, 5160 Urban 0.7861 0.7446 99901 Rural 0.7654
Alabama.
01020............ Barbour County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01030............ Bibb County, Alabama. 01 Rural 0.7432 0.8959 13820 Urban 0.8196
01040............ Blount County, 1000 Urban 0.9000 0.8959 13820 Urban 0.8980
Alabama.
01050............ Bullock County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01060............ Butler County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01070............ Calhoun County, 0450 Urban 0.7682 0.7682 11500 Urban 0.7682
Alabama.
01080............ Chambers County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01090............ Cherokee County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01100............ Chilton County, 01 Rural 0.7432 0.8959 13820 Urban 0.8196
Alabama.
01110............ Choctaw County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01120............ Clarke County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01130............ Clay County, Alabama. 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01140............ Cleburne County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01150............ Coffee County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01160............ Colbert County, 2650 Urban 0.8272 0.8272 22520 Urban 0.8272
Alabama.
01170............ Conecuh County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01180............ Coosa County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01190............ Covington County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01200............ Crenshaw County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01210............ Cullman County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01220............ Dale County, Alabama. 2180 Urban 0.7701 0.7446 99901 Rural 0.7574
01230............ Dallas County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01240............ De Kalb County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01250............ Elmore County, 5240 Urban 0.8618 0.8618 33860 Urban 0.8618
Alabama.
01260............ Escambia County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01270............ Etowah County, 2880 Urban 0.7938 0.7938 23460 Urban 0.7938
Alabama.
01280............ Fayette County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01290............ Franklin County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
[[Page 45080]]
01300............ Geneva County, 01 Rural 0.7432 0.7721 20020 Urban 0.7577
Alabama.
01310............ Greene County, 01 Rural 0.7432 0.8645 46220 Urban 0.8039
Alabama.
01320............ Hale County, Alabama. 01 Rural 0.7432 0.8645 46220 Urban 0.8039
01330............ Henry County, Alabama 01 Rural 0.7432 .7721 20020 Urban 0.7577
01340............ Houston County, 2180 Urban 0.7701 0.7721 20020 Urban 0.7711
Alabama.
01350............ Jackson County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01360............ Jefferson County, 1000 Urban 0.9000 0.8959 13820 Urban 0.8980
Alabama.
01370............ Lamar County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01380............ Lauderdale County, 2650 Urban 0.8272 0.8272 22520 Urban 0.8272
Alabama.
01390............ Lawrence County, 2030 Urban 0.8469 0.8469 19460 Urban 0.8469
Alabama.
01400............ Lee County, Alabama.. 0580 Urban 0.8100 0.8100 12220 Urban 0.8100
01410............ Limestone County, 3440 Urban 0.9146 0.9146 26620 Urban 0.9146
Alabama.
01420............ Lowndes County, 01 Rural 0.7432 0.8618 33860 Urban 0.8025
Alabama.
01430............ Macon County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01440............ Madison County, 3440 Urban 0.9146 0.9146 26620 Urban 0.9146
Alabama.
01450............ Marengo County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01460............ Marion County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01470............ Marshall County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01480............ Mobile County, 5160 Urban 0.7861 0.7891 33660 Urban 0.7876
Alabama.
01490............ Monroe County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01500............ Montgomery County, 5240 Urban 0.8618 0.8618 33860 Urban 0.8618
Alabama.
01510............ Morgan County, 2030 Urban 0.8469 0.8469 19460 Urban 0.8469
Alabama.
01520............ Perry County, Alabama 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01530............ Pickens County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01540............ Pike County, Alabama. 01 Rural 0.7432 0.7446 99901 Rural 0.7439
01550............ Randolph County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01560............ Russell County, 1800 Urban 0.8560 0.8560 17980 Urban 0.8560
Alabama.
01570............ St Clair County, 1000 Urban 0.9000 0.8959 13820 Urban 0.8980
Alabama.
01580............ Shelby County, 1000 Urban 0.9000 0.8959 13820 Urban 0.8980
Alabama.
01590............ Sumter County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01600............ Talladega County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01610............ Tallapoosa County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01620............ Tuscaloosa County, 8600 Urban 0.8764 0.8645 46220 Urban 0.8705
Alabama.
01630............ Walker County, 01 Rural 0.7432 0.8959 13820 Urban 0.8196
Alabama.
01640............ Washington County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01650............ Wilcox County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
01660............ Winston County, 01 Rural 0.7432 0.7446 99901 Rural 0.7439
Alabama.
02013............ Aleutians County 02 Rural 1.1888 1.1977 99902 Rural 1.1933
East, Alaska.
02016............ Aleutians County 02 Rural 1.1888 1.1977 99902 Rural 1.1933
West, Alaska.
02020............ Anchorage County, 0380 Urban 1.1784 1.1895 11260 Urban 1.1840
Alaska.
02030............ Angoon County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02040............ Barrow-North Slope 02 Rural 1.1888 1.1977 99902 Rural 1.1933
County, Alaska.
02050............ Bethel County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02060............ Bristol Bay Borough 02 Rural 1.1888 1.1977 99902 Rural 1.1933
County, Alaska.
02068............ Denali County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02070............ Bristol Bay County, 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Alaska.
02080............ Cordova-Mc Carthy 02 Rural 1.1888 1.1977 99902 Rural 1.1933
County, Alaska.
02090............ Fairbanks County, 02 Rural 1.1888 1.1408 21820 Urban 1.1648
Alaska.
02100............ Haines County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02110............ Juneau County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02120............ Kenai-Cook Inlet 02 Rural 1.1888 1.1977 99902 Rural 1.1933
County, Alaska.
02122............ Kenai Peninsula 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Borough, Alaska.
02130............ Ketchikan County, 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Alaska.
02140............ Kobuk County, Alaska. 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02150............ Kodiak County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02160............ Kuskokwin County, 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Alaska.
02164............ Lake and Peninsula 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Borough, Alaska.
02170............ Matanuska County, 02 Rural 1.1888 1.1895 11260 Urban 1.1892
Alaska.
02180............ Nome County, Alaska.. 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02185............ North Slope Borough, 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Alaska.
02188............ Northwest Arctic 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Borough, Alaska.
02190............ Outer Ketchikan 02 Rural 1.1888 1.1977 99902 Rural 1.1933
County, Alaska.
02200............ Prince Of Wales 02 Rural 1.1888 1.1977 99902 Rural 1.1933
County, Alaska.
02201............ Prince of Wales-Outer 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Ketchikan Census
Area, Alaska.
02210............ Seward County, Alaska 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02220............ Sitka County, Alaska. 02 Rural 1.1888 1.1977 99902 Rural 1.1933
02230............ Skagway-Yakutat 02 Rural 1.1888 1.1977 99902 Rural 1.1933
County, Alaska.
02231............ Skagway-Yakutat- 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Angoon Census Area,
Alaska.
[[Page 45081]]
02232............ Skagway-Hoonah-Angoon 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Census Area, Alaska.
02240............ Southeast Fairbanks 02 Rural 1.1888 1.1977 99902 Rural 1.1933
County, Alaska.
02250............ Upper Yukon County, 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Alaska.
02260............ Valdz-Chitna-Whitier 02 Rural 1.1888 1.1977 99902 Rural 1.1933
County, Alaska.
02261............ Valdex-Cordove Census 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Area, Alaska.
02270............ Wade Hampton County, 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Alaska.
02280............ Wrangell-Petersburg 02 Rural 1.1888 1.1977 99902 Rural 1.1933
County, Alaska.
02282............ Yakutat Borough, 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Alaska.
02290............ Yukon-Koyukuk County, 02 Rural 1.1888 1.1977 99902 Rural 1.1933
Alaska.
03000............ Apache County, 03 Rural 0.9045 0.8768 99903 Rural 0.8907
Arizona.
03010............ Cochise County, 03 Rural 0.9045 0.8768 99903 Rural 0.8907
Arizona.
03020............ Coconino County, 2620 Urban 1.1845 1.2092 22380 Urban 1.1969
Arizona.
03030............ Gila County, Arizona. 03 Rural 0.9045 0.8768 99903 Rural 0.8907
03040............ Graham County, 03 Rural 0.9045 0.8768 99903 Rural 0.8907
Arizona.
03050............ Greenlee County, 03 Rural 0.9045 0.8768 99903 Rural 0.8907
Arizona.
03055............ La Paz County, 03 Rural 0.9045 0.8768 99903 Rural 0.8907
Arizona.
03060............ Maricopa County, 6200 Urban 1.0127 1.0127 38060 Urban 1.0127
Arizona.
03070............ Mohave County, 4120 Urban 1.1155 0.8768 99903 Rural 0.9962
Arizona.
03080............ Navajo County, 03 Rural 0.9045 0.8768 99903 Rural 0.8907
Arizona.
03090............ Pima County, Arizona. 8520 Urban 0.9007 0.9007 46060 Urban 0.9007
03100............ Pinal County, Arizona 6200 Urban 1.0127 1.0127 38060 Urban 1.0127
03110............ Santa Cruz County, 03 Rural 0.9045 0.8768 99903 Rural 0.8907
Arizona.
03120............ Yavapai County, 03 Rural 0.9045 0.9869 39140 Urban 0.9457
Arizona.
03130............ Yuma County, Arizona. 9360 Urban 0.9126 0.9126 49740 Urban 0.9126
04000............ Arkansas County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04010............ Ashley County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04020............ Baxter County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04030............ Benton County, 2580 Urban 0.8661 0.8661 22220 Urban 0.8661
Arkansas.
04040............ Boone County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04050............ Bradley County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04060............ Calhoun County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04070............ Carroll County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04080............ Chicot County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04090............ Clark County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04100............ Clay County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04110............ Cleburne County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04120............ Cleveland County, 04 Rural 0.7744 0.8680 38220 Urban 0.8212
Arkansas.
04130............ Columbia County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04140............ Conway County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04150............ Craighead County, 3700 Urban 0.7911 0.7911 27860 Urban 0.7911
Arkansas.
04160............ Crawford County, 2720 Urban 0.8246 0.8230 22900 Urban 0.8238
Arkansas.
04170............ Crittenden County, 4920 Urban 0.9416 0.9397 32820 Urban 0.9407
Arkansas.
04180............ Cross County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04190............ Dallas County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04200............ Desha County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04210............ Drew County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04220............ Faulkner County, 4400 Urban 0.8747 0.8747 30780 Urban 0.8747
Arkansas.
04230............ Franklin County, 04 Rural 0.7744 0.8230 22900 Urban 0.7987
Arkansas.
04240............ Fulton County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04250............ Garland County, 04 Rural 0.7744 0.9005 26300 Urban 0.8375
Arkansas.
04260............ Grant County, 04 Rural 0.7744 0.8747 30780 Urban 0.8246
Arkansas.
04270............ Greene County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
4280............. Hempstead County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04290............ Hot Spring County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04300............ Howard County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04310............ Independence County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04320............ Izard County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04330............ Jackson County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04340............ Jefferson County, 6240 Urban 0.8680 0.8680 38220 Urban 0.8680
Arkansas.
04350............ Johnson County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04360............ Lafayette County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04370............ Lawrence County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04380............ Lee County, Arkansas. 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04390............ Lincoln County, 04 Rural 0.7744 0.8680 38220 Urban 0.8212
Arkansas.
04400............ Little River County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04410............ Logan County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04420............ Lonoke County, 4400 Urban 0.8747 0.8747 30780 Urban 0.8747
Arkansas.
04430............ Madison County, 04 Rural 0.7744 0.8661 22220 Urban 0.8203
Arkansas.
[[Page 45082]]
04440............ Marion County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04450............ Miller County, 8360 Urban 0.8283 0.8283 45500 Urban 0.8283
Arkansas.
04460............ Mississippi County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04470............ Monroe County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04480............ Montgomery County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04490............ Nevada County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04500............ Newton County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04510............ Ouachita County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04520............ Perry County, 04 Rural 0.7744 0.8747 30780 Urban 0.8246
Arkansas.
04530............ Phillips County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04540............ Pike County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04550............ Poinsett County, 04 Rural 0.7744 0.7911 27860 Urban 0.7828
Arkansas.
04560............ Polk County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04570............ Pope County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
04580............ Prairie County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04590............ Pulaski County, 4400 Urban 0.8747 0.8747 30780 Urban 0.8747
Arkansas.
04600............ Randolph County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04610............ St Francis County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04620............ Saline County, 4400 Urban 0.8747 0.8747 30780 Urban 0.8747
Arkansas.
04630............ Scott County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04640............ Searcy County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04650............ Sebastian County, 2720 Urban 0.8246 0.8230 22900 Urban 0.8238
Arkansas.
04660............ Sevier County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04670............ Sharp County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04680............ Stone County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04690............ Union County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04700............ Van Buren County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04710............ Washington County, 2580 Urban 0.8661 0.8661 22220 Urban 0.8661
Arkansas.
04720............ White County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04730............ Woodruff County, 04 Rural 0.7744 0.7466 99904 Rural 0.7605
Arkansas.
04740............ Yell County, Arkansas 04 Rural 0.7744 0.7466 99904 Rural 0.7605
05000............ Alameda County, 5775 Urban 1.5346 1.5346 36084 Urban 1.5346
California.
05010............ Alpine County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05020............ Amador County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05030............ Butte County, 1620 Urban 1.0511 1.0511 17020 Urban 1.0511
California.
05040............ Calaveras County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05050............ Colusa County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05060............ Contra Costa County, 5775 Urban 1.5346 1.5346 36084 Urban 1.5346
California.
05070............ Del Norte County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05080............ Eldorado County, 6920 Urban 1.3143 1.2969 40900 Urban 1.3056
California.
05090............ Fresno County, 2840 Urban 1.0428 1.0538 23420 Urban 1.0483
California.
05100............ Glenn County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05110............ Humboldt County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05120............ Imperial County, 05 Rural 1.0775 0.8906 20940 Urban 0.9841
California.
05130............ Inyo County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05140............ Kern County, 0680 Urban 1.0470 1.0470 12540 Urban 1.0470
California.
05150............ Kings County, 05 Rural 1.0775 1.0036 25260 Urban 1.0406
California.
05160............ Lake County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05170............ Lassen County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05200............ Los Angeles County, 4480 Urban 1.1783 1.1783 31084 Urban 1.1783
California.
05210............ Los Angeles County, 4480 Urban 1.1783 1.1783 31084 Urban 1.1783
California.
05300............ Madera County, 2840 Urban 1.0428 0.8713 31460 Urban 0.9571
California.
05310............ Marin County, 7360 Urban 1.4994 1.4994 41884 Urban 1.4994
California.
05320............ Mariposa County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05330............ Mendocino County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05340............ Merced County, 4940 Urban 1.1109 1.1109 32900 Urban 1.1109
California.
05350............ Modoc County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05360............ Mono County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05370............ Monterey County, 7120 Urban 1.4128 1.4128 41500 Urban 1.4128
California.
05380............ Napa County, 8720 Urban 1.3983 1.2643 34900 Urban 1.3313
California.
05390............ Nevada County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05400............ Orange County, 5945 Urban 1.1559 1.1559 42044 Urban 1.1559
California.
05410............ Placer County, 6920 Urban 1.3143 1.2969 40900 Urban 1.3056
California.
05420............ Plumas County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05430............ Riverside County, 6780 Urban 1.1027 1.1027 40140 Urban 1.1027
California.
05440............ Sacramento County, 6920 Urban 1.3143 1.2969 40900 Urban 1.3056
California.
05450............ San Benito County, 05 Rural 1.0775 1.5099 41940 Urban 1.2937
California.
05460............ San Bernardino 6780 Urban 1.1027 1.1027 40140 Urban 1.1027
County, California.
[[Page 45083]]
05470............ San Diego County, 7320 Urban 1.1413 1.1413 41740 Urban 1.1413
California.
05480............ San Francisco County, 7360 Urban 1.4994 1.4994 41884 Urban 1.4994
California.
05490............ San Joaquin County, 8120 Urban 1.1307 1.1307 44700 Urban 1.1307
California.
05500............ San Luis Obispo 7460 Urban 1.1349 1.1349 42020 Urban 1.1349
County, California.
05510............ San Mateo County, 7360 Urban 1.4994 1.4994 41884 Urban 1.4994
California.
05520............ Santa Barbara County, 7480 Urban 1.1694 1.1694 42060 Urban 1.1694
California.
05530............ Santa Clara County, 7400 Urban 1.5118 1.5099 41940 Urban 1.5109
California.
05540............ Santa Cruz County, 7485 Urban 1.5166 1.5166 42100 Urban 1.5166
California.
05550............ Shasta County, 6690 Urban 1.2203 1.2203 39820 Urban 1.2203
California.
05560............ Sierra County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05570............ Siskiyou County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05580............ Solano County, 8720 Urban 1.3983 1.4936 46700 Urban 1.4460
California.
05590............ Sonoma County, 7500 Urban 1.3493 1.3493 42220 Urban 1.3493
California.
05600............ Stanislaus County, 5170 Urban 1.1885 1.1885 33700 Urban 1.1885
California.
05610............ Sutter County, 9340 Urban 1.0921 1.0921 49700 Urban 1.0921
California.
05620............ Tehama County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05630............ Trinity County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05640............ Tulare County, 8780 Urban 1.0123 1.0123 47300 Urban 1.0123
California.
05650............ Tuolumne County, 05 Rural 1.0775 1.1054 99905 Rural 1.0915
California.
05660............ Ventura County, 8735 Urban 1.1622 1.1622 37100 Urban 1.1622
California.
05670............ Yolo County, 9270 Urban 0.9950 1.2969 40900 Urban 1.1460
California.
05680............ Yuba County, 9340 Urban 1.0921 1.0921 49700 Urban 1.0921
California.
06000............ Adams County, 2080 Urban 1.0723 1.0723 19740 Urban 1.0723
Colorado.
06010............ Alamosa County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06020............ Arapahoe County, 2080 Urban 1.0723 1.0723 19740 Urban 1.0723
Colorado.
06030............ Archuleta County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06040............ Baca County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06050............ Bent County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06060............ Boulder County, 1125 Urban 0.9734 0.9734 14500 Urban 0.9734
Colorado.
06070............ Chaffee County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06080............ Cheyenne County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06090............ Clear Creek County, 06 Rural 0.9380 1.0723 19740 Urban 1.0052
Colorado.
06100............ Conejos County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06110............ Costilla County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06120............ Crowley County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06130............ Custer County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06140............ Delta County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06150............ Denver County, 2080 Urban 1.0723 1.0723 19740 Urban 1.0723
Colorado.
06160............ Dolores County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06170............ Douglas County, 2080 Urban 1.0723 1.0723 19740 Urban 1.0723
Colorado.
06180............ Eagle County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06190............ Elbert County, 06 Rural 0.9380 1.0723 19740 Urban 1.0052
Colorado.
06200............ El Paso County, 1720 Urban 0.9468 0.9468 17820 Urban 0.9468
Colorado.
06210............ Fremont County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06220............ Garfield County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06230............ Gilpin County, 06 Rural 0.9380 1.0723 19740 Urban 1.0052
Colorado.
06240............ Grand County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06250............ Gunnison County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06260............ Hinsdale County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06270............ Huerfano County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06280............ Jackson County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06290............ Jefferson County, 2080 Urban 1.0723 1.0723 19740 Urban 1.0723
Colorado.
06300............ Kiowa County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06310............ Kit Carson County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06320............ Lake County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06330............ La Plata County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06340............ Larimer County, 2670 Urban 1.0122 1.0122 22660 Urban 1.0122
Colorado.
06350............ Las Animas County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06360............ Lincoln County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06370............ Logan County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06380............ Mesa County, Colorado 2995 Urban 0.9550 0.9550 24300 Urban 0.9550
06390............ Mineral County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06400............ Moffat County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06410............ Montezuma County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06420............ Montrose County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06430............ Morgan County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06440............ Otero County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06450............ Ouray County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
[[Page 45084]]
06460............ Park County, Colorado 06 Rural 0.9380 1.0723 19740 Urban 1.0052
06470............ Phillips County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06480............ Pitkin County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06490............ Prowers County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06500............ Pueblo County, 6560 Urban 0.8623 0.8623 39380 Urban 0.8623
Colorado.
06510............ Rio Blanco County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06520............ Rio Grande County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06530............ Routt County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06540............ Saguache County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06550............ San Juan County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06560............ San Miguel County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06570............ Sedgwick County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06580............ Summit County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06590............ Teller County, 06 Rural 0.9380 0.9468 17820 Urban 0.9424
Colorado.
06600............ Washington County, 06 Rural 0.9380 0.9380 99906 Rural 0.9380
Colorado.
06610............ Weld County, Colorado 3060 Urban 0.9570 0.9570 24540 Urban 0.9570
06620............ Yuma County, Colorado 06 Rural 0.9380 0.9380 99906 Rural 0.9380
06630............ Broomfield County, 2080 Urban 1.0723 1.0723 19740 Urban 1.0723
Colorado.
07000............ Fairfield County, 5483 Urban 1.2196 1.2592 14860 Urban 1.2394
Connecticut.
07010............ Hartford County, 3283 Urban 1.1073 1.1073 25540 Urban 1.1073
Connecticut.
07020............ Litchfield County, 3283 Urban 1.1073 1.1073 25540 Urban 1.1073
Connecticut.
07030............ Middlesex County, 3283 Urban 1.1073 1.1073 25540 Urban 1.1073
Connecticut.
07040............ New Haven County, 5483 Urban 1.2196 1.1887 35300 Urban 1.2042
Connecticut.
07050............ New London County, 5523 Urban 1.1345 1.1345 35980 Urban 1.1345
Connecticut.
07060............ Tolland County, 3283 Urban 1.1073 1.1073 25540 Urban 1.1073
Connecticut.
07070............ Windham County, 07 Rural 1.1730 1.1730 99907 Rural 1.1730
Connecticut.
08000............ Kent County, Delaware 2190 Urban 0.9776 0.9776 20100 Urban 0.9776
08010............ New Castle County, 9160 Urban 1.0527 1.0471 48864 Urban 1.0499
Delaware.
08020............ Sussex County, 08 Rural 0.9579 0.9579 99908 Rural 0.9579
Delaware.
09000............ Washington Dc County, 8840 Urban 1.0976 1.0926 47894 Urban 1.0951
Dist Of Col.
10000............ Alachua County, 2900 Urban 0.9388 0.9388 23540 Urban 0.9388
Florida.
10010............ Baker County, Florida 10 Rural 0.8677 0.9290 27260 Urban 0.8984
10020............ Bay County, Florida.. 6015 Urban 0.8005 0.8005 37460 Urban 0.8005
10030............ Bradford County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10040............ Brevard County, 4900 Urban 0.9839 0.9839 37340 Urban 0.9839
Florida.
10050............ Broward County, 2680 Urban 1.0432 1.0432 22744 Urban 1.0432
Florida.
10060............ Calhoun County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10070............ Charlotte County, 6580 Urban 0.9255 0.9255 39460 Urban 0.9255
Florida.
10080............ Citrus County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10090............ Clay County, Florida. 3600 Urban 0.9299 0.9290 27260 Urban 0.9295
10100............ Collier County, 5345 Urban 1.0139 1.0139 34940 Urban 1.0139
Florida.
10110............ Columbia County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10120............ Dade County, Florida. 5000 Urban 0.9750 0.9750 33124 Urban 0.9750
10130............ De Soto County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10140............ Dixie County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10150............ Duval County, Florida 3600 Urban 0.9299 0.9290 27260 Urban 0.9295
10160............ Escambia County, 6080 Urban 0.8096 0.8096 37860 Urban 0.8096
Florida.
10170............ Flagler County, 2020 Urban 0.9325 0.8568 99910 Rural 0.8947
Florida.
10180............ Franklin County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10190............ Gadsden County, 8240 Urban 0.8688 0.8688 45220 Urban 0.8688
Florida.
10200............ Gilchrist County, 10 Rural 0.8677 0.9388 23540 Urban 0.9033
Florida.
10210............ Glades County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10220............ Gulf County, Florida. 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10230............ Hamilton County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10240............ Hardee County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10250............ Hendry County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10260............ Hernando County, 8280 Urban 0.9233 0.9233 45300 Urban 0.9233
Florida.
10270............ Highlands County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10280............ Hillsborough County, 8280 Urban 0.9233 0.9233 45300 Urban 0.9233
Florida.
10290............ Holmes County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10300............ Indian River County, 10 Rural 0.8677 0.9434 46940 Urban 0.9056
Florida.
10310............ Jackson County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10320............ Jefferson County, 10 Rural 0.8677 0.8688 45220 Urban 0.8683
Florida.
10330............ Lafayette County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10340............ Lake County, Florida. 5960 Urban 0.9464 0.9464 36740 Urban 0.9464
10350............ Lee County, Florida.. 2700 Urban 0.9356 0.9356 15980 Urban 0.9356
10360............ Leon County, Florida. 8240 Urban 0.8688 0.8688 45220 Urban 0.8688
10370............ Levy County, Florida. 10 Rural 0.8677 0.8568 99910 Rural 0.8623
[[Page 45085]]
10380............ Liberty County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10390............ Madison County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10400............ Manatee County, 7510 Urban 0.9639 0.9639 42260 Urban 0.9639
Florida.
10410............ Marion County, 5790 Urban 0.8925 0.8925 36100 Urban 0.8925
Florida.
10420............ Martin County, 2710 Urban 1.0123 1.0123 38940 Urban 1.0123
Florida.
10430............ Monroe County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10440............ Nassau County, 3600 Urban 0.9299 0.9290 27260 Urban 0.9295
Florida.
10450............ Okaloosa County, 2750 Urban 0.8872 0.8872 23020 Urban 0.8872
Florida.
10460............ Okeechobee County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10470............ Orange County, 5960 Urban 0.9464 0.9464 36740 Urban 0.9464
Florida.
10480............ Osceola County, 5960 Urban 0.9464 0.9464 36740 Urban 0.9464
Florida.
10490............ Palm Beach County, 8960 Urban 1.0067 1.0067 48424 Urban 1.0067
Florida.
10500............ Pasco County, Florida 8280 Urban 0.9233 0.9233 45300 Urban 0.9233
10510............ Pinellas County, 8280 Urban 0.9233 0.9233 45300 Urban 0.9233
Florida.
10520............ Polk County, Florida. 3980 Urban 0.8912 0.8912 29460 Urban 0.8912
10530............ Putnam County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10540............ Johns County, Florida 3600 Urban 0.9299 0.9290 27260 Urban 0.9295
10550............ St Lucie County, 2710 Urban 1.0123 1.0123 38940 Urban 1.0123
Florida.
10560............ Santa Rosa County, 6080 Urban 0.8096 0.8096 37860 Urban 0.8096
Florida.
10570............ Sarasota County, 7510 Urban 0.9639 0.9639 42260 Urban 0.9639
Florida.
10580............ Seminole County, 5960 Urban 0.9464 0.9464 36740 Urban 0.9464
Florida.
10590............ Sumter County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10600............ Suwannee County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10610............ Taylor County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10620............ Union County, Florida 10 Rural 0.8677 0.8568 99910 Rural 0.8623
10630............ Volusia County, 2020 Urban 0.9325 0.9299 19660 Urban 0.9312
Florida.
10640............ Wakulla County, 10 Rural 0.8677 0.8688 45220 Urban 0.8683
Florida.
10650............ Walton County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
10660............ Washington County, 10 Rural 0.8677 0.8568 99910 Rural 0.8623
Florida.
11000............ Appling County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11010............ Atkinson County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11011............ Bacon County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11020............ Baker County, Georgia 11 Rural 0.8166 0.8628 10500 Urban 0.8397
11030............ Baldwin County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11040............ Banks County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11050............ Barrow County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11060............ Bartow County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11070............ Ben Hill County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11080............ Berrien County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11090............ Bibb County, Georgia. 4680 Urban 0.9277 0.9443 31420 Urban 0.9360
11100............ Bleckley County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11110............ Brantley County, 11 Rural 0.8166 0.9311 15260 Urban 0.8739
Georgia.
11120............ Brooks County, 11 Rural 0.8166 0.8866 46660 Urban 0.8516
Georgia.
11130............ Bryan County, Georgia 7520 Urban 0.9461 0.9461 42340 Urban 0.9461
11140............ Bulloch County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11150............ Burke County, Georgia 11 Rural 0.8166 0.9748 12260 Urban 0.8957
11160............ Butts County, Georgia 11 Rural 0.8166 0.9793 12060 Urban 0.8980
11161............ Calhoun County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11170............ Camden County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11180............ Candler County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11190............ Carroll County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11200............ Catoosa County, 1560 Urban 0.9088 0.9088 16860 Urban 0.9088
Georgia.
11210............ Charlton County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11220............ Chatham County, 7520 Urban 0.9461 0.9461 42340 Urban 0.9461
Georgia.
11230............ Chattahoochee County, 1800 Urban 0.8560 0.8560 17980 Urban 0.8560
Georgia.
11240............ Chattooga County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11250............ Cherokee County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11260............ Clarke County, 0500 Urban 0.9855 0.9855 12020 Urban 0.9855
Georgia.
11270............ Clay County, Georgia. 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11280............ Clayton County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11281............ Clinch County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11290............ Cobb County, Georgia. 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11291............ Coffee County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11300............ Colquitt County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11310............ Columbia County, 0600 Urban 0.9808 0.9748 12260 Urban 0.9778
Georgia.
11311............ Cook County, Georgia. 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11320............ Coweta County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11330............ Crawford County, 11 Rural 0.8166 0.9443 31420 Urban 0.8805
Georgia.
[[Page 45086]]
11340............ Crisp County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11341............ Dade County, Georgia. 1560 Urban 0.9088 0.9088 16860 Urban 0.9088
11350............ Dawson County, 11 Rural 0.8166 0.9793 12060 Urban 0.8980
Georgia.
11360............ Decatur County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11370............ De Kalb County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11380............ Dodge County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11381............ Dooly County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11390............ Dougherty County, 0120 Urban 0.8628 0.8628 10500 Urban 0.8628
Georgia.
11400............ Douglas County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11410............ Early County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11420............ Echols County, 11 Rural 0.8166 0.8866 46660 Urban 0.8516
Georgia.
11421............ Effingham County, 7520 Urban 0.9461 0.9461 42340 Urban 0.9461
Georgia.
11430............ Elbert County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11440............ Emanuel County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11441............ Evans County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11450............ Fannin County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11451............ Fayette County, 0520 Urban 9793 0.9793 12060 Urban 0.9793
Georgia.
11460............ Floyd County, Georgia 11 Rural 0.8166 0.9414 40660 Urban 0.8790
11461............ Forsyth County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11462............ Franklin County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11470............ Fulton County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11471............ Gilmer County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11480............ Glascock County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11490............ Glynn County, Georgia 11 Rural 0.8166 0.9311 15260 Urban 0.8739
11500............ Gordon County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11510............ Grady County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11520............ Greene County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11530............ Gwinnett County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11540............ Habersham County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11550............ Hall County, Georgia. 11 Rural 0.8166 0.8874 23580 Urban 0.8520
11560............ Hancock County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11570............ Haralson County, 11 Rural 0.8166 0.9793 12060 Urban 0.8980
Georgia.
11580............ Harris County, 1800 Urban 0.8560 0.8560 17980 Urban 0.8560
Georgia.
11581............ Hart County, Georgia. 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11590............ Heard County, Georgia 11 Rural 0.8166 0.9793 12060 Urban 0.8980
11591............ Henry County, Georgia 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
11600............ Houston County, 4680 Urban 0.9277 0.8645 47580 Urban 0.8961
Georgia.
11601............ Irwin County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11610............ Jackson County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11611............ Jasper County, 11 Rural 0.8166 0.9793 12060 Urban 0.8980
Georgia.
11612............ Jeff Davis County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11620............ Jefferson County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11630............ Jenkins County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11640............ Johnson County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11650............ Jones County, Georgia 4680 Urban 0.9277 0.9443 31420 Urban 0.9360
11651............ Lamar County, Georgia 11 Rural 0.8166 0.9793 12060 Urban 0.8980
11652............ Lanier County, 11 Rural 0.8166 0.8866 46660 Urban 0.8516
Georgia.
11660............ Laurens County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11670............ Lee County, Georgia.. 0120 Urban 0.8628 0.8628 10500 Urban 0.8628
11680............ Liberty County, 11 Rural 0.8166 (\1\) 25980 Urban 0.8973
Georgia.
11690............ Lincoln County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11691............ Long County, Georgia. 11 Rural 0.8166 (\1\) 25980 Urban 0.8973
11700............ Lowndes County, 11 Rural 0.8166 0.8866 46660 Urban 0.8516
Georgia.
11701............ Lumpkin County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11702............ Mc Duffie County, 0600 Urban 0.9808 0.9748 12260 Urban 0.9778
Georgia.
11703............ Mc Intosh County, 11 Rural 0.8166 0.9311 15260 Urban 0.8739
Georgia.
11710............ Macon County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11720............ Madison County, 0500 Urban 0.9855 0.9855 12020 Urban 0.9855
Georgia.
11730............ Marion County, 11 Rural 0.8166 0.8560 17980 Urban 0.8363
Georgia.
11740............ Meriwether County, 11 Rural 0.8166 0.9793 12060 Urban 0.8980
Georgia.
11741............ Miller County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11750............ Mitchell County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11760............ Monroe County, 11 Rural 0.8166 0.9443 31420 Urban 0.8805
Georgia.
11770............ Montgomery County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11771............ Morgan County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11772............ Murray County, 11 Rural 0.8166 0.9079 19140 Urban 0.8623
Georgia.
11780............ Muscogee County, 1800 Urban 0.8560 0.8560 17980 Urban 0.8560
Georgia.
11790............ Newton County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
[[Page 45087]]
11800............ Oconee County, 0500 Urban 0.9855 0.9855 12020 Urban 0.9855
Georgia.
11801............ Oglethorpe County, 11 Rural 0.8166 0.9855 12020 Urban 0.9011
Georgia.
11810............ Paulding County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11811............ Peach County, Georgia 4680 Urban 0.9277 0.7662 99911 Rural 0.8470
11812............ Pickens County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11820............ Pierce County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11821............ Pike County, Georgia. 11 Rural 0.8166 0.9793 12060 Urban 0.8980
11830............ Polk County, Georgia. 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11831............ Pulaski County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11832............ Putnam County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11833............ Quitman County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11834............ Rabun County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11835............ Randolph County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11840............ Richmond County, 0600 Urban 0.9808 0.9748 12260 Urban 10.9778
Georgia.
11841............ Rockdale County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11842............ Schley County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11850............ Screven County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11851............ Seminole County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11860............ Spalding County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11861............ Stephens County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11862............ Stewart County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11870............ Sumter County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11880............ Talbot County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11881............ Taliaferro County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11882............ Tattnall County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11883............ Taylor County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11884............ Telfair County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11885............ Terrell County, 11 Rural 0.8166 0.8628 10500 Urban 0.8397
Georgia.
11890............ Thomas County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11900............ Tift County, Georgia. 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11901............ Toombs County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11902............ Towns County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11903............ Treutlen County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11910............ Troup County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11911............ Turner County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11912............ Twiggs County, 4680 Urban 0.9277 0.9443 31420 Urban 0.9360
Georgia.
11913............ Union County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11920............ Upson County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11921............ Walker County, 1560 Urban 0.9088 0.9088 16860 Urban 0.9088
Georgia.
11930............ Walton County, 0520 Urban 0.9793 0.9793 12060 Urban 0.9793
Georgia.
11940............ Ware County, Georgia. 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11941............ Warren County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11950............ Washington County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11960............ Wayne County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11961............ Webster County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11962............ Wheeler County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11963............ White County, Georgia 11 Rural 0.8166 0.7662 99911 Rural 0.7914
11970............ Whitfield County, 11 Rural 0.8166 0.9079 19140 Urban 0.8623
Georgia.
11971............ Wilcox County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11972............ Wilkes County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11973............ Wilkinson County, 11 Rural 0.8166 0.7662 99911 Rural 0.7914
Georgia.
11980............ Worth County, Georgia 11 Rural 0.8166 0.8628 10500 Urban 0.8397
12005............ Kalawao County, 12 Rural 1.0551 1.0551 99912 Rural 1.0551
Hawaii.
12010............ Hawaii County, Hawaii 12 Rural 1.0551 1.0551 99912 Rural 1.0551
12020............ Honolulu County, 3320 Urban 1.1214 1.1214 26180 Urban 1.1214
Hawaii.
12040............ Kauai County, Hawaii. 12 Rural 1.0551 1.0551 99912 Rural 1.0551
12050............ Maui County, Hawaii.. 12 Rural 1.0551 1.0551 99912 Rural 1.0551
13000............ Ada County, Idaho.... 1080 Urban 0.9052 0.9052 14260 Urban 0.9052
13010............ Adams County, Idaho.. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13020............ Bannock County, Idaho 6340 Urban 0.9351 0.9351 38540 Urban 0.9351
13030............ Bear Lake County, 13 Rural 0.9097 0.8037 99913 Rural 0.8567
Idaho.
13040............ Benewah County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13050............ Bingham County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13060............ Blaine County, Idaho. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13070............ Boise County, Idaho.. 13 Rural 0.9097 0.9052 14260 Urban 0.9075
13080............ Bonner County, Idaho. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13090............ Bonneville County, 13 Rural 0.9097 0.9420 26820 Urban 0.9259
Idaho.
13100............ Boundary County, 13 Rural 0.9097 0.8037 99913 Rural 0.8567
Idaho.
[[Page 45088]]
13110............ Butte County, Idaho.. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13120............ Camas County, Idaho.. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13130............ Canyon County, Idaho. 1080 Urban 0.9052 0.9052 14260 Urban 0.9052
13140............ Caribou County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13150............ Cassia County, Idaho. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13160............ Clark County, Idaho.. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13170............ Clearwater County, 13 Rural 0.9097 0.8037 99913 Rural 0.8567
Idaho.
13180............ Custer County, Idaho. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13190............ Elmore County, Idaho. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13200............ Franklin County, 13 Rural 0.9097 0.9164 30860 Urban 0.9131
Idaho.
13210............ Fremont County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13220............ Gem County, Idaho.... 13 Rural 0.9097 0.9052 14260 Urban 0.9075
13230............ Gooding County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13240............ Idaho County, Idaho.. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13250............ Jefferson County, 13 Rural 0.9097 0.9420 26820 Urban 0.9259
Idaho.
13260............ Jerome County, Idaho. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13270............ Kootenai County, 13 Rural 0.9097 0.9647 17660 Urban 0.9372
Idaho.
13280............ Latah County, Idaho.. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13290............ Lemhi County, Idaho.. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13300............ Lewis County, Idaho.. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13310............ Lincoln County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13320............ Madison County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13330............ Minidoka County, 13 Rural 0.9097 0.8037 99913 Rural 0.8567
Idaho.
13340............ Nez Perce County, 13 Rural 0.9097 0.9886 30300 Urban 0.9492
Idaho.
13350............ Oneida County, Idaho. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13360............ Owyhee County, Idaho. 13 Rural 0.9097 0.9052 14260 Urban 0.9075
13370............ Payette County, Idaho 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13380............ Power County, Idaho.. 13 Rural 0.9097 0.9351 38540 Urban 0.9224
13390............ Shoshone County, 13 Rural 0.9097 0.8037 99913 Rural 0.8567
Idaho.
13400............ Teton County, Idaho.. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13410............ Twin Falls County, 13 Rural 0.9097 0.8037 99913 Rural 0.8567
Idaho.
13420............ Valley County, Idaho. 13 Rural 0.9097 0.8037 99913 Rural 0.8567
13430............ Washington County, 13 Rural 0.9097 0.8037 99913 Rural 0.8567
Idaho.
14000............ Adams County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14010............ Alexander County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14020............ Bond County, Illinois 14 Rural 0.8301 0.8954 41180 Urban 0.8628
14030............ Boone County, 6880 Urban 0.9984 0.9984 40420 Urban 0.9984
Illinois.
14040............ Brown County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14050............ Bureau County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14060............ Calhoun County, 14 Rural 0.8301 0.8954 41180 Urban 0.8628
Illinois.
14070............ Carroll County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14080............ Cass County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14090............ Champaign County, 1400 Urban 0.9594 0.9594 16580 Urban 0.9594
Illinois.
14100............ Christian County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14110............ Clark County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14120............ Clay County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14130............ Clinton County, 7040 Urban 0.8962 0.8954 41180 Urban 0.8958
Illinois.
14140............ Coles County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14141............ Cook County, Illinois 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
14150............ Crawford County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14160............ Cumberland County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14170............ De Kalb County, 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
Illinois.
14180............ De Witt County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14190............ Douglas County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14250............ Du Page County, 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
Illinois.
14310............ Edgar County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14320............ Edwards County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14330............ Effingham County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14340............ Fayette County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14350............ Ford County, Illinois 14 Rural 0.8301 0.9594 16580 Urban 0.8948
14360............ Franklin County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14370............ Fulton County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14380............ Gallatin County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14390............ Greene County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14400............ Grundy County, 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
Illinois.
14410............ Hamilton County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14420............ Hancock County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14421............ Hardin County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
[[Page 45089]]
14440............ Henderson County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14450............ Henry County, 1960 Urban 0.8724 0.8724 19340 Urban 0.8724
Illinois.
14460............ Iroquois County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14470............ Jackson County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14480............ Jasper County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14490............ Jefferson County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14500............ Jersey County, 7040 Urban 0.8962 0.8954 41180 Urban 0.8958
Illinois.
14510............ Jo Daviess County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14520............ Johnson County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14530............ Kane County, Illinois 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
14540............ Kankakee County, 3740 Urban 1.0721 1.0721 28100 Urban 1.0721
Illinois.
14550............ Kendall County, 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
Illinois.
14560............ Knox County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14570............ Lake County, Illinois 1600 Urban 1.0783 1.0429 29404 Urban 1.0606
14580............ La Salle County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14590............ Lawrence County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14600............ Lee County, Illinois. 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14610............ Livingston County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14620............ Logan County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14630............ Mc Donough County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14640............ Mc Henry County, 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
Illinois.
14650............ Mclean County, 1040 Urban 0.9075 0.9075 14060 Urban 0.9075
Illinois.
14660............ Macon County, 2040 Urban 0.8067 0.8067 19500 Urban 0.8067
Illinois.
14670............ Macoupin County, 14 Rural 0.8301 0.8954 41180 Urban 0.8628
Illinois.
14680............ Madison County, 7040 Urban 0.8962 0.8954 41180 Urban 0.8958
Illinois.
14690............ Marion County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14700............ Marshall County, 14 Rural 0.8301 0.8870 37900 Urban 0.8586
Illinois.
14710............ Mason County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14720............ Massac County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14730............ Menard County, 7880 Urban 0.8792 0.8792 44100 Urban 0.8792
Illinois.
14740............ Mercer County, 14 Rural 0.8301 0.8724 19340 Urban 0.8513
Illinois.
14750............ Monroe County, 7040 Urban 0.8962 0.8954 41180 Urban 0.8958
Illinois.
14760............ Montgomery County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14770............ Morgan County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14780............ Moultrie County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14790............ Ogle County, Illinois 6880 Urban 0.9984 0.8271 99914 Rural 0.9128
14800............ Peoria County, 6120 Urban 0.8870 0.8870 37900 Urban 0.8870
Illinois.
14810............ Perry County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14820............ Piatt County, 14 Rural 0.8301 0.9594 16580 Urban 0.8948
Illinois.
14830............ Pike County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14831............ Pope County, Illinois 14 Rural 0.8301 0.8271 99914 Rural 0.8286
14850............ Pulaski County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14860............ Putnam County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14870............ Randolph County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14880............ Richland County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14890............ Rock Island County, 1960 Urban 0.8724 0.8724 19340 Urban 0.8724
Illinois.
14900............ St Clair County, 7040 Urban 0.8962 0.8954 41180 Urban 0.8958
Illinois.
14910............ Saline County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14920............ Sangamon County, 7880 Urban 0.8792 0.8792 44100 Urban 0.8792
Illinois.
14921............ Schuyler County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14940............ Scott County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14950............ Shelby County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14960............ Stark County, 14 Rural 0.8301 0.8870 37900 Urban 0.8586
Illinois.
14970............ Stephenson County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14980............ Tazewell County, 6120 Urban 0.8870 0.8870 37900 Urban 0.8870
Illinois.
14981............ Union County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14982............ Vermilion County, 14 Rural 0.8301 0.9028 19180 Urban 0.8665
Illinois.
14983............ Wabash County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14984............ Warren County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14985............ Washington County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14986............ Wayne County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14987............ White County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14988............ Whiteside County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14989............ Will County, Illinois 1600 Urban 1.0783 1.0790 16974 Urban 1.0787
14990............ Williamson County, 14 Rural 0.8301 0.8271 99914 Rural 0.8286
Illinois.
14991............ Winnebago County, 6880 Urban 0.9984 0.9984 40420 Urban 0.9984
Illinois.
14992............ Woodford County, 6120 Urban 0.8870 0.8870 37900 Urban 0.8870
Illinois.
15000............ Adams County, Indiana 2760 Urban 0.9706 0.8624 99915 Rural 0.9165
[[Page 45090]]
15010............ Allen County, Indiana 2760 Urban 0.9706 0.9793 23060 Urban 0.9750
15020............ Bartholomew County, 15 Rural 0.8739 0.9588 18020 Urban 0.9164
Indiana.
15030............ Benton County, 15 Rural 0.8739 0.8736 29140 Urban 0.8738
Indiana.
15040............ Blackford County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15050............ Boone County, Indiana 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
15060............ Brown County, Indiana 15 Rural 0.8739 0.9920 26900 Urban 0.9330
15070............ Carroll County, 15 Rural 0.8739 0.8736 29140 Urban 0.8738
Indiana.
15080............ Cass County, Indiana. 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15090............ Clark County, Indiana 4520 Urban 0.9293 0.9251 31140 Urban 0.9272
15100............ Clay County, Indiana. 8320 Urban 0.8337 0.8304 45460 Urban 0.8321
15110............ Clinton County, 3920 Urban 0.8736 0.8624 99915 Rural 0.8680
Indiana.
15120............ Crawford County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15130............ Daviess County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15140............ Dearborn County, 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
Indiana.
15150............ Decatur County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15160............ De Kalb County, 2760 Urban 0.9706 0.8624 99915 Rural 0.9165
Indiana.
15170............ Delaware County, 5280 Urban 0.8930 0.8930 34620 Urban 0.8930
Indiana.
15180............ Dubois County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15190............ Elkhart County, 2330 Urban 0.9627 0.9627 21140 Urban 0.9627
Indiana.
15200............ Fayette County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15210............ Floyd County, Indiana 4520 Urban 0.9293 0.9251 31140 Urban 0.9272
15220............ Fountain County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15230............ Franklin County, 15 Rural 0.8739 0.9615 17140 Urban 0.9177
Indiana.
15240............ Fulton County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15250............ Gibson County, 15 Rural 0.8739 0.8713 21780 Urban 0.8726
Indiana.
15260............ Grant County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15270............ Greene County, 15 Rural 0.8739 0.8447 14020 Urban 0.8593
Indiana.
15280............ Hamilton County, 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
Indiana.
15290............ Hancock County, 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
Indiana.
15300............ Harrison County, 4520 Urban 0.9293 0.9251 31140 Urban 0.9272
Indiana.
15310............ Hendricks County, 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
Indiana.
15320............ Henry County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15330............ Howard County, 3850 Urban 0.9508 0.9508 29020 Urban 0.9508
Indiana.
15340............ Huntington County, 2760 Urban 0.9706 0.8624 99915 Rural 0.9165
Indiana.
15350............ Jackson County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15360............ Jasper County, 15 Rural 0.8739 0.9395 23844 Urban 0.9067
Indiana.
15370............ Jay County, Indiana.. 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15380............ Jefferson County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15390............ Jennings County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15400............ Johnson County, 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
Indiana.
15410............ Knox County, Indiana. 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15420............ Kosciusko County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15430............ Lagrange County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15440............ Lake County, Indiana. 2960 Urban 0.9395 0.9395 23844 Urban 0.9395
15450............ La Porte County, 15 Rural 0.8739 0.9399 33140 Urban 0.9069
Indiana.
15460............ Lawrence County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15470............ Madison County, 3480 Urban 0.9865 0.8586 11300 Urban 0.9226
Indiana.
15480............ Marion County, 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
Indiana.
15490............ Marshall County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15500............ Martin County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15510............ Miami County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15520............ Monroe County, 1020 Urban 0.8447 0.8447 14020 Urban 0.8447
Indiana.
15530............ Montgomery County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15540............ Morgan County, 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
Indiana.
15550............ Newton County, 15 Rural 0.8739 0.9395 23844 Urban 0.9067
Indiana.
15560............ Noble County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15570............ Ohio County, Indiana. 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
15580............ Orange County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15590............ Owen County, Indiana. 15 Rural 0.8739 0.8447 14020 Urban 0.8593
15600............ Parke County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15610............ Perry County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15620............ Pike County, Indiana. 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15630............ Porter County, 2960 Urban 0.9395 0.9395 23844 Urban 0.9395
Indiana.
15640............ Posey County, Indiana 2440 Urban 0.8713 0.8713 21780 Urban 0.8713
15650............ Pulaski County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15660............ Putnam County, 15 Rural 0.8739 0.9920 26900 Urban 0.9330
Indiana.
15670............ Randolph County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15680............ Ripley County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
[[Page 45091]]
15690............ Rush County, Indiana. 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15700............ St Joseph County, 7800 Urban 0.9788 0.9788 43780 Urban 0.9788
Indiana.
15710............ Scott County, Indiana 4520 Urban 0.9293 0.8624 99915 Rural 0.8959
15720............ Shelby County, 3480 Urban 0.9865 0.9920 26900 Urban 0.9893
Indiana.
15730............ Spencer County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15740............ Starke County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15750............ Steuben County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15760............ Sullivan County, 15 Rural 0.8739 0.8304 45460 Urban 0.8522
Indiana.
15770............ Switzerland County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15780............ Tippecanoe County, 3920 Urban 0.8736 0.8736 29140 Urban 0.8736
Indiana.
15790............ Tipton County, 3850 Urban 0.9508 0.9508 29020 Urban 0.9508
Indiana.
15800............ Union County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15810............ Vanderburgh County, 2440 Urban 0.8713 0.8713 21780 Urban 0.8713
Indiana.
15820............ Vermillion County, 8320 Urban 0.8337 0.8304 45460 Urban 0.8321
Indiana.
15830............ Vigo County, Indiana. 8320 Urban 0.8337 0.8304 45460 Urban 0.8321
15840............ Wabash County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15850............ Warren County, 15 Rural 0.8739 0.8624 99915 Rural 0.8682
Indiana.
15860............ Warrick County, 2440 Urban 0.8713 0.8713 21780 Urban 0.8713
Indiana.
15870............ Washington County, 15 Rural 0.8739 0.9251 31140 Urban 0.8995
Indiana.
15880............ Wayne County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15890............ Wells County, Indiana 2760 Urban 0.9706 0.9793 23060 Urban 0.9750
15900............ White County, Indiana 15 Rural 0.8739 0.8624 99915 Rural 0.8682
15910............ Whitley County, 2760 Urban 0.9706 0.9793 23060 Urban 0.9750
Indiana.
16000............ Adair County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16010............ Adams County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16020............ Allamakee County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16030............ Appanoose County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16040............ Audubon County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16050............ Benton County, Iowa.. 16 Rural 0.8594 0.8825 16300 Urban 0.8710
16060............ Black Hawk County, 8920 Urban 0.8557 0.8557 47940 Urban 0.8557
Iowa.
16070............ Boone County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16080............ Bremer County, Iowa.. 16 Rural 0.8594 0.8557 47940 Urban 0.8576
16090............ Buchanan County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16100............ Buena Vista County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16110............ Butler County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16120............ Calhoun County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16130............ Carroll County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16140............ Cass County, Iowa.... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16150............ Cedar County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16160............ Cerro Gordo County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16170............ Cherokee County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16180............ Chickasaw County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16190............ Clarke County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16200............ Clay County, Iowa.... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16210............ Clayton County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16220............ Clinton County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16230............ Crawford County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16240............ Dallas County, Iowa.. 2120 Urban 0.9669 0.9669 19780 Urban 0.9669
16250............ Davis County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16260............ Decatur County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16270............ Delaware County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16280............ Des Moines County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16290............ Dickinson County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16300............ Dubuque County, Iowa. 2200 Urban 0.9024 0.9024 20220 Urban 0.9024
16310............ Emmet County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16320............ Fayette County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16330............ Floyd County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16340............ Franklin County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16350............ Fremont County, Iowa. 6 Rural 0.8594 0.8509 99916 Rural 0.8552
16360............ Greene County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16370............ Grundy County, Iowa.. 16 Rural 0.8594 0.8557 47940 Urban 0.8576
16380............ Guthrie County, Iowa. 16 Rural 0.8594 0.9669 19780 Urban 0.9132
16390............ Hamilton County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16400............ Hancock County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16410............ Hardin County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16420............ Harrison County, Iowa 16 Rural 0.8594 0.9560 36540 Urban 0.9077
16430............ Henry County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16440............ Howard County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
[[Page 45092]]
16450............ Humboldt County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16460............ Ida County, Iowa..... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16470............ Iowa County, Iowa.... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16480............ Jackson County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16490............ Jasper County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16500............ Jefferson County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16510............ Johnson County, Iowa. 3500 Urban 0.9747 0.9747 26980 Urban 0.9747
16520............ Jones County, Iowa... 16 Rural 0.8594 0.8825 16300 Urban 0.8710
16530............ Keokuk County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16540............ Kossuth County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16550............ Lee County, Iowa..... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16560............ Linn County, owa..... 1360 Urban 0.8825 0.8825 16300 Urban 0.8825
16570............ Louisa County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16580............ Lucas County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16590............ Lyon County, Iowa.... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16600............ Madison County, Iowa. 16 Rural 0.8594 0.9669 19780 Urban 0.9132
16610............ Mahaska County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16620............ Marion County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16630............ Marshall County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16640............ Mills County, Iowa... 16 Rural 0.8594 0.9560 36540 Urban 0.9077
16650............ Mitchell County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16660............ Monona County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16670............ Monroe County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16680............ Montgomery County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16690............ Muscatine County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16700............ O Brien County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16710............ Osceola County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16720............ Page County, Iowa.... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16730............ Palo Alto County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16740............ Plymouth County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16750............ Pocahontas County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16760............ Polk County, Iowa.... 2120 Urban 0.9669 0.9669 19780 Urban 0.9669
16770............ Pottawattamie County, 5920 Urban 0.9560 0.9560 36540 Urban 0.9560
Iowa.
16780............ Poweshiek County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16790............ Ringgold County, Iowa 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16800............ Sac County, Iowa..... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16810............ Scott County, Iowa... 1960 Urban 0.8724 0.8724 19340 Urban 0.8724
16820............ Shelby County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16830............ Sioux County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16840............ Story County, Iowa... 16 Rural 0.8594 0.9536 11180 Urban 0.9065
16850............ Tama County, Iowa.... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16860............ Taylor County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16870............ Union County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16880............ Van Buren County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16890............ Wapello County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16900............ Warren County, Iowa.. 2120 Urban 0.9669 0.9669 19780 Urban 0.9669
16910............ Washington County, 16 Rural 0.8594 0.9747 26980 Urban 0.9171
Iowa.
16920............ Wayne County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16930............ Webster County, Iowa. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16940............ Winnebago County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16950............ Winneshiek County, 16 Rural 0.8594 0.8509 99916 Rural 0.8552
Iowa.
16960............ Woodbury County, Iowa 7720 Urban 0.9416 0.9381 43580 Urban 0.9399
16970............ Worth County, Iowa... 16 Rural 0.8594 0.8509 99916 Rural 0.8552
16980............ Wright County, Iowa.. 16 Rural 0.8594 0.8509 99916 Rural 0.8552
17000............ Allen County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17010............ Anderson County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17020............ Atchison County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17030............ Barber County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17040............ Barton County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17050............ Bourbon County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17060............ Brown County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17070............ Butler County, Kansas 9040 Urban 0.9175 0.9153 48620 Urban 0.9164
17080............ Chase County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17090............ Chautauqua County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17100............ Cherokee County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17110............ Cheyenne County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17120............ Clark County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17130............ Clay County, Kansas.. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
[[Page 45093]]
17140............ Cloud County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17150............ Coffey County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17160............ Comanche County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17170............ Cowley County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17180............ Crawford County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17190............ Decatur County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17200............ Dickinson County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17210............ Doniphan County, 17 Rural 0.8040 0.9519 41140 Urban 0.8780
Kansas.
17220............ Douglas County, 4150 Urban 0.8537 0.8537 29940 Urban 0.8537
Kansas.
17230............ Edwards County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17240............ Elk County, Kansas... 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17250............ Ellis County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17260............ Ellsworth County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17270............ Finney County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17280............ Ford County, Kansas.. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17290............ Franklin County, 17 Rural 0.8040 0.9476 28140 Urban 0.8758
Kansas.
17300............ Geary County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17310............ Gove County, Kansas.. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17320............ Graham County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17330............ Grant County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17340............ Gray County, Kansas.. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17350............ Greeley County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17360............ Greenwood County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17370............ Hamilton County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17380............ Harper County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17390............ Harvey County, Kansas 9040 Urban 0.9175 0.9153 48620 Urban 0.9164
17391............ Haskell County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17410............ Hodgeman County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17420............ Jackson County, 17 Rural 0.8040 0.8920 45820 Urban 0.8480
Kansas.
17430............ Jefferson County, 17 Rural 0.8040 0.8920 45820 Urban 0.8480
Kansas.
17440............ Jewell County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17450............ Johnson County, 3760 Urban 0.9490 0.9476 28140 Urban 0.9483
Kansas.
17451............ Kearny County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17470............ Kingman County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17480............ Kiowa County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17490............ Labette County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17500............ Lane County, Kansas.. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17510............ Leavenworth County, 3760 Urban 0.9490 0.9476 28140 Urban 0.9483
Kansas.
17520............ Lincoln County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17530............ Linn County, Kansas.. 17 Rural 0.8040 0.9476 28140 Urban 0.8758
17540............ Logan County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17550............ Lyon County, Kansas.. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17560............ Mc Pherson County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17570............ Marion County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17580............ Marshall County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17590............ Meade County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17600............ Miami County, Kansas. 3760 Urban 0.9490 0.9476 28140 Urban 0.9483
17610............ Mitchell County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17620............ Montgomery County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17630............ Morris County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17640............ Morton County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17650............ Nemaha County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17660............ Neosho County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17670............ Ness County, Kansas.. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17680............ Norton County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17690............ Osage County, Kansas. 17 Rural 0.8040 0.8920 45820 Urban 0.8480
17700............ Osborne County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17710............ Ottawa County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17720............ Pawnee County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17730............ Phillips County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17740............ Pottawatomie County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17750............ Pratt County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17760............ Rawlins County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17770............ Reno County, Kansas.. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17780............ Republic County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17790............ Rice County, Kansas.. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17800............ Riley County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17810............ Rooks County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
[[Page 45094]]
17820............ Rush County, Kansas.. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17830............ Russell County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17840............ Saline County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17841............ Scott County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17860............ Sedgwick County, 9040 Urban 0.9175 0.9153 48620 Urban 0.9164
Kansas.
17870............ Seward County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17880............ Shawnee County, 8440 Urban 0.8920 0.8920 45820 Urban 0.8920
Kansas.
17890............ Sheridan County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17900............ Sherman County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17910............ Smith County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17920............ Stafford County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17921............ Stanton County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17940............ Stevens County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17950............ Sumner County, Kansas 17 Rural 0.8040 0.9153 48620 Urban 0.8597
17960............ Thomas County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17970............ Trego County, Kansas. 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17980............ Wabaunsee County, 17 Rural 0.8040 0.8920 45820 Urban 0.8480
Kansas.
17981............ Wallace County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17982............ Washington County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17983............ Wichita County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17984............ Wilson County, Kansas 17 Rural 0.8040 0.8035 99917 Rural 0.8038
17985............ Woodson County, 17 Rural 0.8040 0.8035 99917 Rural 0.8038
Kansas.
17986............ Wyandotte County, 3760 Urban 0.9490 0.9476 28140 Urban 0.9483
Kansas.
18000............ Adair County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18010............ Allen County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18020............ Anderson County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18030............ Ballard County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18040............ Barren County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18050............ Bath County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18060............ Bell County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18070............ Boone County, 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
Kentucky.
18080............ Bourbon County, 4280 Urban 0.8988 0.9075 30460 Urban 0.9032
Kentucky.
18090............ Boyd County, Kentucky 3400 Urban 0.9477 0.9477 26580 Urban 0.9477
18100............ Boyle County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18110............ Bracken County, 18 Rural 0.7858 0.9615 17140 Urban 0.8737
Kentucky.
18120............ Breathitt County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18130............ Breckinridge County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18140............ Bullitt County, 4520 Urban 0.9293 0.9251 31140 Urban 0.9272
Kentucky.
18150............ Butler County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18160............ Caldwell County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18170............ Calloway County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18180............ Campbell County, 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
Kentucky.
18190............ Carlisle County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18191............ Carroll County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18210............ Carter County, 3400 Urban 0.9477 0.7766 99918 Rural 0.8622
Kentucky.
18220............ Casey County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18230............ Christian County, 1660 Urban 0.8284 0.8284 17300 Urban 0.8284
Kentucky.
18240............ Clark County, 4280 Urban 0.8988 0.9075 30460 Urban 0.9032
Kentucky.
18250............ Clay County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18260............ Clinton County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18270............ Crittenden County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18271............ Cumberland County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18290............ Daviess County, 5990 Urban 0.8780 0.8780 36980 Urban 0.8780
Kentucky.
18291............ Edmonson County, 18 Rural 0.7858 0.8211 14540 Urban 0.8035
Kentucky.
18310............ Elliott County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18320............ Estill County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18330............ Fayette County, 4280 Urban 0.8988 0.9075 30460 Urban 0.9032
Kentucky.
18340............ Fleming County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18350............ Floyd County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18360............ Franklin County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18361............ Fulton County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18362............ Gallatin County, 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
Kentucky.
18390............ Garrard County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18400............ Grant County, 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
Kentucky.
18410............ Graves County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18420............ Grayson County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18421............ Green County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18440............ Greenup County, 3400 Urban 0.9477 0.9477 26580 Urban 0.9477
Kentucky.
[[Page 45095]]
18450............ Hancock County, 18 Rural 0.7858 0.8780 36980 Urban 0.8319
Kentucky.
18460............ Hardin County, 18 Rural 0.7858 0.8802 21060 Urban 0.8330
Kentucky.
18470............ Harlan County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18480............ Harrison County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18490............ Hart County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18500............ Henderson County, 2440 Urban 0.8713 0.8713 21780 Urban 0.8713
Kentucky.
18510............ Henry County, 18 Rural 0.7858 0.9251 31140 Urban 0.8555
Kentucky.
18511............ Hickman County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18530............ Hopkins County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18540............ Jackson County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18550............ Jefferson County, 4520 Urban 0.9293 0.9251 31140 Urban 0.9272
Kentucky.
18560............ Jessamine County, 4280 Urban 0.8988 0.9075 30460 Urban 0.9032
Kentucky.
18570............ Johnson County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18580............ Kenton County, 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
Kentucky.
18590............ Knott County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18600............ Knox County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18610............ Larue County, 18 Rural 0.7858 0.8802 21060 Urban 0.8330
Kentucky.
18620............ Laurel County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18630............ Lawrence County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18640............ Lee County, Kentucky. 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18650............ Leslie County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18660............ Letcher County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18670............ Lewis County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18680............ Lincoln County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18690............ Livingston County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18700............ Logan County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18710............ Lyon County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18720............ Mc Cracken County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18730............ Mc Creary County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18740............ Mc Lean County, 18 Rural 0.7858 0.8780 36980 Urban 0.8319
Kentucky.
18750............ Madison County, 4280 Urban 0.8988 0.7766 99918 Rural 0.8377
Kentucky.
18760............ Magoffin County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18770............ Marion County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18780............ Marshall County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18790............ Martin County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18800............ Mason County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18801............ Meade County, 18 Rural 0.7858 0.9251 31140 Urban 0.8555
Kentucky.
18802............ Menifee County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18830............ Mercer County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18831............ Metcalfe County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18850............ Monroe County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18860............ Montgomery County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18861............ Morgan County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18880............ Muhlenberg County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18890............ Nelson County, 18 Rural 0.7858 0.9251 31140 Urban 0.8555
Kentucky.
18900............ Nicholas County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18910............ Ohio County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18920............ Oldham County, 4520 Urban 0.9293 0.9251 31140 Urban 0.9272
Kentucky.
18930............ Owen County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18931............ Owsley County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18932............ Pendleton County, 1640 Urban 0.9734 0.9615 17140 Urban 0.9675
Kentucky.
18960............ Perry County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18970............ Pike County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18971............ Powell County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18972............ Pulaski County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18973............ Robertson County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18974............ Rockcastle County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18975............ Rowan County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18976............ Russell County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18977............ Scott County, 4280 Urban 0.8988 0.9075 30460 Urban 0.9032
Kentucky.
18978............ Shelby County, 18 Rural 0.7858 0.9251 31140 Urban 0.8555
Kentucky.
18979............ Simpson County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18980............ Spencer County, 18 Rural 0.7858 0.9251 31140 Urban 0.8555
Kentucky.
18981............ Taylor County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18982............ Todd County, Kentucky 18 Rural 0.7858 0.7766 99918 Rural 0.7812
18983............ Trigg County, 18 Rural 0.7858 0.8284 17300 Urban 0.8071
Kentucky.
18984............ Trimble County, 18 Rural 0.7858 0.9251 31140 Urban 0.8555
Kentucky.
18985............ Union County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
[[Page 45096]]
18986............ Warren County, 18 Rural 0.7858 0.8211 14540 Urban 0.8035
Kentucky.
18987............ Washington County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18988............ Wayne County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18989............ Webster County, 18 Rural 0.7858 0.8713 21780 Urban 0.8286
Kentucky.
18990............ Whitley County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18991............ Wolfe County, 18 Rural 0.7858 0.7766 99918 Rural 0.7812
Kentucky.
18992............ Woodford County, 4280 Urban 0.8988 0.9075 30460 Urban 0.9032
Kentucky.
19000............ Acadia County, 3880 Urban 0.8251 0.7411 99919 Rural 0.7831
Louisiana.
19010............ Allen County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19020............ Ascension County, 0760 Urban 0.8643 0.8593 12940 Urban 0.8618
Louisiana.
19030............ Assumption County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19040............ Avoyelles County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19050............ Beauregard County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19060............ Bienville County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19070............ Bossier County, 7680 Urban 0.8737 0.8760 43340 Urban 0.8749
Louisiana.
19080............ Caddo County, 7680 Urban 0.8737 0.8760 43340 Urban 0.8749
Louisiana.
19090............ Calcasieu County, 3960 Urban 0.7858 0.7833 29340 Urban 0.7846
Louisiana.
19100............ Caldwell County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19110............ Cameron County, 19 Rural 0.7340 0.7833 29340 Urban 0.7587
Louisiana.
19120............ Catahoula County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19130............ Claiborne County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19140............ Concordia County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19150............ De Soto County, 19 Rural 0.7340 0.8760 43340 Urban 0.8050
Louisiana.
19160............ East Baton Rouge 0760 Urban 0.8643 0.8593 12940 Urban 0.8618
County, Louisiana.
19170............ East Carroll County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19180............ East Feliciana 19 Rural 0.7340 0.8593 12940 Urban 0.7967
County, Louisiana.
19190............ Evangeline County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19200............ Franklin County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19210............ Grant County, 19 Rural 0.7340 0.8033 10780 Urban 0.7687
Louisiana.
19220............ Iberia County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19230............ Iberville County, 19 Rural 0.7340 0.8593 12940 Urban 0.7967
Louisiana.
19240............ Jackson County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19250............ Jefferson County, 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
Louisiana.
19260............ Jefferson Davis 19 Rural 0.7340 0.7411 99919 Rural 0.7376
County, Louisiana.
19270............ Lafayette County, 3880 Urban 0.8251 0.8428 29180 Urban 0.8340
Louisiana.
19280............ Lafourche County, 3350 Urban 0.7894 0.7894 26380 Urban 0.7894
Louisiana.
19290............ La Salle County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19300............ Lincoln County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19310............ Livingston County, 0760 Urban 0.8643 0.8593 12940 Urban 0.8618
Louisiana.
19320............ Madison County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19330............ Morehouse County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19340............ Natchitoches County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19350............ Orleans County, 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
Louisiana.
19360............ Ouachita County, 5200 Urban 0.8044 0.8031 33740 Urban 0.8038
Louisiana.
19370............ Plaquemines County, 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
Louisiana.
19380............ Pointe Coupee County, 19 Rural 0.7340 0.8593 12940 Urban 0.7967
Louisiana.
19390............ Rapides County, 0220 Urban 0.8033 0.8033 10780 Urban 0.8033
Louisiana.
19400............ Red River County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19410............ Richland County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19420............ Sabine County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19430............ St Bernard County, 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
Louisiana.
19440............ St Charles County, 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
Louisiana.
19450............ St Helena County, 19 Rural 0.7340 0.8593 12940 Urban 0.7967
Louisiana.
19460............ St James County, 5560 Urban 0.8995 0.7411 99919 Rural 0.8203
Louisiana.
19470............ St John Baptist 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
County, Louisiana.
19480............ St Landry County, 3880 Urban 0.8251 0.7411 99919 Rural 0.7831
Louisiana.
19490............ St Martin County, 3880 Urban 0.8251 0.8428 29180 Urban 0.8340
Louisiana.
19500............ St Mary County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19510............ St Tammany County, 5560 Urban 0.8995 0.8995 35380 Urban 0.8995
Louisiana.
19520............ Tangipahoa County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19530............ Tensas County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19540............ Terrebonne County, 3350 Urban 0.7894 0.7894 26380 Urban 0.7894
Louisiana.
19550............ Union County, 19 Rural 0.7340 0.8031 33740 Urban 0.7686
Louisiana.
19560............ Vermilion County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19570............ Vernon County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19580............ Washington County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19590............ Webster County, 7680 Urban 0.8737 0.7411 99919 Rural 0.8074
Louisiana.
19600............ West Baton Rouge 0760 Urban 0.8643 0.8593 12940 Urban 0.8618
County, Louisiana.
[[Page 45097]]
19610............ West Carroll County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
19620............ West Feliciana 19 Rural 0.7340 0.8593 12940 Urban 0.7967
County, Louisiana.
19630............ Winn County, 19 Rural 0.7340 0.7411 99919 Rural 0.7376
Louisiana.
20000............ Androscoggin County, 4243 Urban 0.9331 0.9331 30340 Urban 0.9331
Maine.
20010............ Aroostook County, 20 Rural 0.8843 0.8843 99920 Rural 0.8843
Maine.
20020............ Cumberland County, 6403 Urban 1.0382 1.0382 38860 Urban 1.0382
Maine.
20030............ Franklin County, 20 Rural 0.8843 0.8843 99920 Rural 0.8843
Maine.
20040............ Hancock County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20050............ Kennebec County, 20 Rural 0.8843 0.8843 99920 Rural 0.8843
Maine.
20060............ Knox County, Maine... 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20070............ Lincoln County, Maine 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20080............ Oxford County, Maine. 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20090............ Penobscot County, 0733 Urban 0.9993 0.9993 12620 Urban 0.9993
Maine.
20100............ Piscataquis County, 20 Rural 0.8843 0.8843 99920 Rural 0.8843
Maine.
20110............ Sagadahoc County, 6403 Urban 1.0382 1.0382 38860 Urban 1.0382
Maine.
20120............ Somerset County, 20 Rural 0.8843 0.8843 99920 Rural 0.8843
Maine.
20130............ Waldo County, Maine.. 20 Rural 0.8843 0.8843 99920 Rural 0.8843
20140............ Washington County, 20 Rural 0.8843 0.8843 99920 Rural 0.8843
Maine.
20150............ York County, Maine... 6403 Urban 1.0382 1.0382 38860 Urban 1.0382
21000............ Allegany County, 1900 Urban 0.9317 0.9317 19060 Urban 0.9317
Maryland.
21010............ Anne Arundel County, 0720 Urban 0.9897 0.9897 12580 Urban 0.9897
Maryland.
21020............ Baltimore County, 0720 Urban 0.9897 0.9897 12580 Urban 0.9897
Maryland.
21030............ Baltimore City 0720 Urban 0.9897 0.9897 12580 Urban 0.9897
County, Maryland.
21040............ Calvert County, 8840 Urban 1.0976 1.0926 47894 Urban 1.0951
Maryland.
21050............ Caroline County, 21 Rural 0.9230 0.9353 99921 Rural 0.9292
Maryland.
21060............ Carroll County, 0720 Urban 0.9897 0.9897 12580 Urban 0.9897
Maryland.
21070............ Cecil County, 9160 Urban 1.0527 1.0471