[Federal Register: January 23, 2006 (Volume 71, Number 14)]
[Proposed Rules]
[Page 3615-3752]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr23ja06-19]
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Part II
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 412 and 424
Medicare Program; Inpatient Psychiatric Facilities Prospective Payment
System Payment Update for Rate Year Beginning July 1, 2006 (RY 2007);
Proposed Rule
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 412 and 424
[CMS-1306-P]
Medicare Program; Inpatient Psychiatric Facilities Prospective
Payment System Payment Update for Rate Year Beginning July 1, 2006 (RY
2007)
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
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SUMMARY: This proposed rule would update the prospective payment rates
for Medicare inpatient hospital services provided by inpatient
psychiatric facilities (IPFs). These changes are applicable to IPF
discharges occurring during the rate year beginning July 1, 2006
through June 30, 2007. We are proposing to adopt the new Office of
Management and Budget (OMB) labor market area definitions for the
purpose of geographic classification and the wage index. In addition,
we are proposing other new polices and making changes to existing
policies.
DATES: We will consider comments if we receive them at the appropriate
address provided below, no later than 5 p.m. on March 14, 2006.
ADDRESSES: In commenting, please refer to file code CMS-1306-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of three ways (no duplicates,
please):
1. Electronically. You may submit electronic comments on specific
issues in this regulation to http://www.cms.hhs.gov/eRulemaking.
(Attachments should be in Microsoft Word, WordPerfect, or Excel;
however, we prefer Microsoft Word.)
2. By mail. You may mail written comments (one original and two
copies) to the following address ONLY: Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Attention: CMS-1306-
P, P.O. Box 8010, Baltimore, MD 21244.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments (one original and two copies) before the
close of the comment period to one of the following addresses. If you
intend to deliver your comments to the Baltimore address, please call
telephone number (410) 786-9994 in advance to schedule your arrival
with one of our staff members. Room 445-G, Hubert H. Humphrey Building,
200 Independence Avenue, SW., Washington, DC 20201; or 7500 Security
Boulevard, Baltimore, MD 21244-1850.
(Because access to the interior of the Humphrey Building is not
readily available to persons without Federal Government identification,
commenters are encouraged to leave their comments in the CMS drop slots
located in the main lobby of the building. A stamp-in clock is
available for persons wishing to retain a proof of filing by stamping
in and retaining an extra copy of the comments being filed.)
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
Submission of comments on paperwork requirements. You may submit
comments on this document's paperwork requirements by mailing your
comments to the addresses provided at the end of the ``Collection of
Information Requirements'' section in this document.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Janet Samen, (410) 786-4533 for
general information. Mary Lee Seifert, (410) 786-0030 for information
regarding the market basket and labor-related share. Theresa Bean,
(410) 786-2287 for impact. Matthew Quarrick, (410) 786-9867 for wage
index.
SUPPLEMENTARY INFORMATION:
Submitting Comments: We welcome comments from the public on all
issues set forth in this rule to assist us in fully considering issues
and developing policies. You can assist us by referencing the file code
CMS-1306-P and the specific ``issue identifier'' that precedes the
section on which you choose to comment.
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. CMS posts all electronic
comments received before the close of the comment period on its public
Web site as soon as possible after they have been received. Hard copy
comments received timely will be available for public inspection as
they are received, generally beginning approximately 3 weeks after
publication of a document, at the headquarters of the Centers for
Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore,
Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4
p.m. To schedule an appointment to view public comments, phone 1-800-
743-3951.
Table of Contents
I. Background
A. General and Legislative History
B. Overview of the Establishment of the IPF PPS
C. Applicability of the IPF PPS
II. Overview for Updating the IPF PPS
A. Requirements for Updating the IPF PPS
B. Proposed Updates to the IPF PPS
C. Transition Period for Implementation of the IPF PPS
III. Proposed Updates to the IPF PPS for Rate Year beginning July 1,
2006
A. Calculation of the Average Per Diem Cost
B. Determining the Standardized Budget-Neutral Federal Per Diem
Rate
1. Standardization of the Federal Per Diem Base Rate
2. Calculation of the Budget Neutrality Adjustment
a. Outlier Adjustment
b. Stop-Loss Provision Adjustment
c. Behavioral Offset
3. Revision of Standardization Factor
C. Update of the Federal Per Diem Base Rate
1. Market Basket for IPFs Reimbursed under the IPF PPS
a. Proposed IPF Market Basket Index
b. Overview of the Proposed RPL Market Basket
2. Proposed Methodology for Operating Portion of the RPL Market
Basket
3. Proposed Methodology for Capital Portion of the RPL Market
Basket
4. Proposed Labor-Related Share
IV. Update of the IPF PPS Adjustment Factors
A. Overview of the IPF PPS Adjustment Factors
B. Proposed Patient-Level Adjustments
1. Proposed Adjustment for DRG Assignment
2. Proposed Payment for Comorbid Conditions
3. Proposed Patient Age Adjustment
4. Proposed Variable Per Diem Adjustment
C. Facility-Level Adjustments
1. Wage Index Adjustment
a. Proposed Revisions of the IPF PPS Geographic Classifications
b. Current IPF PPS Labor Market Areas Based on MSAs
c. Core-Based Statistical Areas
d. Proposed Revision of the IPF PPS Labor Market Areas
i. New England MSAs
ii. Metropolitan Divisions
iii. Micropolitan Areas
e. Implementation of the Proposed Revised Labor Market Area
under the IPF PPS
f. Wage Index Budget Neutrality
1. Proposed Adjustment for Rural Location
2. Proposed Teaching Adjustment
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3. Proposed Cost of Living Adjustment for IPFs Located in Alaska
and Hawaii
4. Proposed Adjustment for IPFs with a Qualifying Emergency
Department
a. Proposed New Source of Admission Code to Implement the ED
Adjustment
b. Applicability of the ED Adjustment to IPFs in Critical Access
Hospitals
D. Other Payment Adjustments and Policies
1. Outlier Payments
a. Proposed Update to the Outlier Fixed Dollar Loss Amount
b. Proposed Statistical Accuracy of Cost-to-Charge Ratio
2. Proposed Stop-loss Provision
3. Patients who Receive Electroconvulsive Therapy
4. Physician Certification and Recertification Requirements
5. Provisions of Therapeutic Recreation in IPFs
6. Same Day Transfers
V. Provisions of the Proposed Rule
VI. Collection of Information Requirements
VII. Regulatory Impact Analysis
Acronyms
Because of the many terms to which we refer by acronym in this
proposed rule, we are listing the acronyms used and their corresponding
terms in alphabetical order below:
BBA Balanced Budget Act of 1997, (Pub. L. 105-33)
BBRA Medicare, Medicaid and SCHIP [State Children's Health Insurance
Program] Balanced Budget Refinement Act of 1999, (Pub. L. 106-113)
BIPA Medicare, Medicaid, and SCHIP [State Children's Health Insurance
Program] Benefits Improvement and Protection Act of 2000, (Pub. L. 106-
554)
CBSA Core-Based Statistical Areas
CCR Cost-to-charge ratio
CMS Centers for Medicare & Medicaid Services
CMSA Consolidated Metropolitan Statistical Area
DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders Fourth
Edition--Text Revision
DRGs Diagnosis-related groups
FY Federal fiscal year
HCRIS Hospital Cost Report Information System
ICD-9-CM International Classification of Diseases, 9th Revision,
Clinical Modification
IPFs Inpatient psychiatric facilities
IRFs Inpatient rehabilitation facilities
LTCHs Long-term care hospitals
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
OMB Office of Management and Budget
PIP Periodic interim payments
RY Rate Year (July 1 through June 30)
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, (Pub. L. 97-
248)
I. Background
[If you choose to comment on issues in this section, please include the
caption ``BACKGROUND'' at the beginning of your comments.]
A. General and Legislative History
The Congress directed implementation of a prospective payment
system (PPS) for acute care hospitals with the enactment of Public Law
98-21. Section 601 of the Social Security Amendments of 1983 (Pub. L.
98-21) added a new section 1886(d) to the Social Security Act (the Act)
that replaced the reasonable cost-based payment system for most
hospital inpatient services with a PPS.
Although most hospital inpatient services became subject to the
PPS, certain hospitals, including IPFs, inpatient rehabilitation
facilities (IRFs), long term care hospitals (LTCHs), and children's
hospitals were excluded from the PPS for acute care hospitals. These
hospitals and units were paid their reasonable costs for inpatient
services, subject to a per discharge limitation or target amount under
the authority of the Tax Equity and Fiscal Responsibility Act of 1982
(TEFRA), Public Law 97-248. The regulations implementing the TEFRA
(reasonable cost-based) payment provisions are located at 42 CFR part
413. Cancer hospitals were added to the list of excluded hospitals by
section 6004(a) of the Omnibus Budget Reconciliation Act of 1989, (Pub.
L. 101-239).
The Congress enacted various provisions in the Balanced Budget Act
of 1997 (BBA) (Pub. L. 105-33), the Medicare, Medicaid, and SCHIP
(State Children's Health Insurance Program) Balanced Budget Refinement
Act of 1999 (BBRA) (Pub. L. 106-113), and the Medicare, Medicaid, and
SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Pub. L.
106-554) to replace the reasonable cost-based method of reimbursement
with a PPS for IRFs, LTCHs, and IPFs. Section 124 of the BBRA required
implementation of the IPF PPS.
Section 124 of the BBRA mandated that the Secretary--(1) develop a
per diem PPS for inpatient hospital services furnished in psychiatric
hospitals and psychiatric units; (2) include in the PPS an adequate
patient classification system that reflects the differences in patient
resource use and costs among psychiatric hospitals and psychiatric
units; (3) maintain budget neutrality; (4) permit the Secretary to
require psychiatric hospitals and psychiatric units to submit
information necessary for the development of the PPS; and (5) submit a
report to the Congress describing the development of the PPS. Section
124 of the BBRA also required that the IPF PPS be implemented for cost
reporting periods beginning on or after October 1, 2002.
Section 405(g)(2) of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (MMA) (Pub. L. 108-173) extended the IPF
PPS to distinct part psychiatric units of critical access hospitals
(CAHs).
B. Overview of the Establishment of the IPF PPS
On November 28, 2003, we published a proposed rule in the Federal
Register (68 FR 66920) that proposed to implement section 124 of the
BBRA. In the November 15, 2004 Federal Register (69 FR 66922) our final
rule implemented the IPF PPS for cost reporting periods beginning on or
after January 1, 2005. Although section 124 of the BBRA directed that
the IPF PPS be implemented for cost reporting periods beginning on or
after October 1, 2002, we explained in the proposed and final rules
that the creation of a PPS requires an extraordinary amount of lead-
time to create a completely new payment system and that we were unable
to perform the analysis required in time for an October 1, 2002
implementation, to ensure that a system based on CMS administrative
data would fulfill the statutory mandate of section 124 of the BBRA. We
explained that despite our best efforts, we could not engage in notice
and comment rulemaking and achieve implementation of the IPF PPS by
October 1, 2002.
The November 2004 final rule (hereinafter referred to as the IPF
PPS final rule) established regulations for the IPF PPS under 42 CFR
412, subpart N.
The IPF PPS established the Federal per diem base rate for each
patient day in an IPF derived from the national average daily routine
operating, ancillary, and capital costs in IPFs in FY 2002. The average
per diem cost was updated to the midpoint of the first year under the
IPF PPS, standardized to account for the overall positive effects of
the IPF PPS payment adjustments, and adjusted for budget neutrality.
The Federal per diem payment under the IPF PPS is comprised of the
Federal per diem base rate described above and certain patient and
facility payment adjustments that were found in the regression analysis
to be associated with
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statistically significant per diem cost differences (see 69 FR 66933
through 66936 for a description of the regression analysis). The
patient-level adjustments include age, DRG assignment, comorbidities,
and variable per diem adjustments to reflect the higher cost incurred
in the early days of a psychiatric stay. Facility-level adjustments
include adjustments for the IPF's wage index, rural location, teaching
status, a cost of living adjustment for IPFs located in Alaska and
Hawaii, and presence of a qualifying emergency department (ED). The IPF
PPS provides additional payments for outlier cases, stop-loss
protection which is applicable only during the IPF PPS transition
period, includes special payment provisions for interrupted stays, and
a per treatment adjustment for patients who undergo electroconvulsive
therapy (ECT). We refer readers to the IPF PPS final rule for a
comprehensive discussion of the research and data that supported the
establishment of the IPF PPS.
On April 1, 2005, we published a correction to the IPF PPS final
rule in the Federal Register (70 FR 16724). Any reference to the IPF
PPS final rule in this proposed rule includes the provisions in the
correction notice. We established a CMS website that contains useful
information regarding the IPF PPS including the proposed rule, final
rule, and the correction notice. The website URL is http://www.cms.hhs.gov/InpatientPsychFacilPPS/
and may be accessed to download
or view publications and other information pertinent to the IPF PPS.
C. Applicability of the IPF PPS
The IPF PPS is applicable to freestanding psychiatric hospitals,
including government-operated psychiatric hospitals, and distinct part
psychiatric units of acute care hospitals and CAHs.
The regulations at Sec. 412.402 define an IPF as a hospital that
meets the requirements specified in Sec. 412.22, Sec. 412.23(a),
Sec. 482.60, Sec. 482.61, and Sec. 482.62, and units that meet the
requirements specified in Sec. 412.22, Sec. 412.25, and Sec. 412.27.
However, the following hospitals are paid under a special payment
provision, as described in Sec. 412.22(c) and, therefore, are not
subject to the IPF PPS rules:
Veterans Administration hospitals.
Hospitals that are reimbursed under State cost control
systems approved under 42 CFR part 403.
Hospitals that are reimbursed in accordance with
demonstration projects specified in section 402(a) of Public Law 90-248
(42 U.S.C. 1395b-1) or section 222(a) of Public Law 92-603 (42 U.S.C.
1395b-1(note)).
Non-participating hospitals furnishing emergency services
to Medicare beneficiaries.
II. Overview for Updating the IPF PPS
[If you choose to comment on issues in this section, please include the
caption ``OVERVIEW FOR UPDATING THE IPF PPS'' at the beginning of your
comments.]
A. Requirements for Updating the IPF PPS
Section 124 of the BBRA does not specify an update strategy for the
IPF PPS and is broadly written to give the Secretary discretion in
establishing an update methodology. Therefore, we reviewed the update
approach used in other hospital PPSs (specifically, the IRF and LTCH
PPS update methodologies). As a result of this analysis, we stated in
the IPF PPS final rule (69 FR 66966) that we would implement the IPF
PPS using the following update strategy--(1) calculate the final
Federal per diem base rate to be budget neutral for the 18-month period
(that is, January 1, 2005 through June 30, 2006); (2) use a July 1
through June 30 annual update cycle; and (3) allow the IPF PPS first
update to be effective for discharges July 1, 2006 through June 30,
2007. In this proposed rule, we are proposing updates to the IPF PPS
for the period of July 1, 2006 through June 30, 2007.
As explained in the IPF PPS final rule, we believe it is important
to delay updating the adjustment factors derived from the regression
analysis until we have IPF PPS data that include as much information as
possible regarding the patient-level characteristics of the population
that each IPF serves. For this reason, we do not intend to update the
regression analysis and recalculate the Federal per diem base rate
until we have analyzed 1 year of IPF PPS claims and cost report data
(that is, no earlier than FY 2008). Until that analysis is complete, we
stated our intention to publish a notice in the Federal Register each
spring to update the IPF PPS as specified in Sec. 412.428 to include:
A description of the methodology and data used to
calculate the updated Federal per diem base payment amount.
The rate of increase factor as described in Sec.
412.424(a)(2)(iii), which is based on the excluded hospital with
capital market basket under the update methodology of 1886(b)(3)(B)(ii)
of the Act for each year.
The best available hospital wage index and information
regarding whether an adjustment to the Federal per diem base rate is
needed to maintain budget neutrality.
Updates to the fixed dollar loss amount in order to
maintain the appropriate outlier percentage.
Describe the ICD-9-CM coding and DRG classification
changes discussed in the annual update to the hospital inpatient
prospective payment system regulations.
Update the ECT adjustment by a factor specified by CMS.
B. Proposed Updates to the IPF PPS
As discussed above, we intended to publish a notice in the Federal
Register in the spring of 2006 that would announce the updates to the
IPF PPS in accordance with Sec. 412.428 rather than update through
rulemaking (69 FR 66966). However, since the implementation of the IPF
PPS, a new market basket index was announced in the August 2005 IPPS
final rule. We believe that this new market basket should be
implemented in the IPF PPS as well in order to update the system using
the best data available. Therefore, rather than publish a notice to
update the IPF PPS in 2006, we are proposing changes in this proposed
rule to give interested parties the opportunity to comment.
Furthermore, we indicated in the IPF PPS final rule (69 FR 66952)
that we were not adopting the new labor market definitions developed by
the OMB and adopted under the IPPS. Rather, we explained that we
intended to use the metropolitan statistical areas (MSAs) developed by
OMB in 1993 for the wage index under the IPF PPS. At the time we
published the proposed IPF PPS rule, the 2003 MSA definitions had not
been implemented for any Medicare programs. In addition, we indicated
that we believe that the adoption of the new labor market area
definitions may have a significant impact on the wage index applied to
IPFs and associated payments and that we would assess the implications
of the new MSA definitions on IPFs before proposing to adopt them.
We believe that IPFs should be afforded an opportunity to comment
on the use of the new labor market definitions before we adopt them
under the IPF PPS. For this reason also, we are publishing this
proposed rule, rather than a notice, in order to give interested
parties an opportunity to comment on the new labor market definitions
(see section III.C.1. of this proposed rule).
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C. Transition Period for Implementation of the IPF PPS
In the IPF PPS final rule, we established Sec. 412.426 to provide
for a 3-year transition period from reasonable cost-based reimbursement
to full prospective payment for IPFs. New IPFs are paid 100 percent of
the Federal per diem rate. However, for those IPFs that are
transitioning to a new system, during the 3-year period as specified in
the IPF PPS final rule, payment is based on an increasing percentage of
the PPS payment and a decreasing percentage of each IPF's facility-
specific TEFRA reimbursement rate. The blend percentages are as
follows:
Table 1.--IPF PPS Final Rule Transition Blend Factors
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IPF PPS
Transition year Cost reporting periods beginning TEFRA rate Federal rate
on or after percentage percentage
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1............................................. January 1, 2005................. 75 25
2............................................. January 1, 2006................. 50 50
3............................................. January 1, 2007................. 25 75
January 1, 2008................. 0 100
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Changes to the blend percentages occur at the beginning of an IPF's
cost reporting period. As a result, for discharges occurring during IPF
cost reporting periods beginning in CY 2006, IPFs would receive a
blended payment consisting of 50 percent of the facility-specific TEFRA
payment and 50 percent of the IPF PPS payment amount. However,
regardless of when an IPF's cost reporting year begins, the payment
update we are proposing would be effective for discharges occurring on
or after July 1, 2006 through June 30, 2007. We are not proposing any
changes to the transition approach established in the IPF PPS final
rule.
III. Proposed Updates to the IPF PPS for Rate Year beginning July 1,
2006
The IPF PPS is based on a standardized Federal per diem base rate
calculated from IPF average per diem costs and adjusted for budget-
neutrality in the implementation year. The Federal per diem base rate
is used as the standard payment per day under the IPF PPS and is
adjusted by the applicable wage index factor and the patient-level and
facility-level adjustments that are applicable to the IPF stay.
The following is an explanation of how we calculated the Federal
per diem base rate and the standardization and budget neutrality
factors as described in the IPF PPS final rule.
A. Calculation of the Average Per Diem Cost
[If you choose to comment on issues in this section, please include the
caption ``PER DIEM COST'' at the beginning of your comments.]
As indicated in the IPF PPS final rule, to calculate the Federal
per diem base rate, we estimated the average cost per day for--(1)
routine services from FY 2002 cost reports (supplemented with FY 2001
cost reports if the FY 2002 cost report was missing); and (2) ancillary
services using data from the FY 2002 Medicare claims and corresponding
data from facility cost reports.
For routine services, the per diem operating and capital costs were
used to develop the average per diem cost amount. The per diem routine
costs were obtained from each facility's Medicare cost report. To
estimate the costs for routine services included in the Federal per
diem base rate calculation, we added the total routine costs (including
costs for capital) submitted on the cost report for each provider and
divided it by the total Medicare days.
Some average routine costs per day were determined to be aberrant,
that is, the costs were extraordinarily high or low and most likely
contained data errors. We provided a detailed discussion in the IPF PPS
final rule (69 FR 66926 through 66927) of the method used to trim
extraordinarily high or low cost values from the per diem rate
development file in order to improve the accuracy of our results. For
ancillary services, we calculated the costs by converting charges from
the FY 2002 Medicare claims into costs using facility-specific, cost-
center specific cost-to-charge ratios obtained from each provider's
applicable cost reports. We matched each provider's departmental cost-
to-charge ratios from their Medicare cost report to each charge on
their claims reported in the MedPAR file. Multiplying the total charges
for each type of ancillary service by the corresponding cost-to-charge
ratio provided an estimate of the costs for all ancillary services
received by the patient during the stay. We determined the average
ancillary amount per day by dividing the total ancillary costs for all
stays by the total number of covered Medicare days.
Adding the average ancillary costs per day and the average routine
costs per day including capital costs provided the estimated average
per diem cost for each patient day of inpatient psychiatric care in FY
2002.
B. Determining the Standardized Budget-Neutral Federal Per Diem Base
Rate
[If you choose to comment on issues in this section, please include the
caption ``BUDGET NEUTRAL BASE RATE'' at the beginning of your
comments.]
Section 124(a)(1) of the BBRA requires that the implementing IPF
PPS be budget neutral. In other words, the amount of total payments
under the IPF PPS, including any payment adjustments, must be projected
to be equal to the amount of total payments that would have been made
if the IPF PPS were not implemented. Therefore, in the IPF PPS final
rule, we calculated the budget-neutrality factor by setting the total
estimated IPF PPS payments to be equal to the total estimated payments
that would have been made under the TEFRA methodology had the IPF PPS
not been implemented. The IPF PPS final rule includes a step-by-step
description of the methodology we used to estimate payments under the
TEFRA payment system (69 FR 66930). For the IPF PPS methodology, we
calculated the final Federal per diem base rate to be budget neutral
during the implementation period under the IPF PPS using a July 1
update cycle. Thus, the implementation period for the IPF PPS is the
18-month period January 1, 2005 through June 30, 2006.
We updated the average cost per day to the midpoint of the IPF PPS
implementation period (that is, October 1, 2005). We used the most
recent projection of the full percentage increase in the 1997-based
excluded hospital with capital market basket index for FY 2003 and
later in accordance with Sec. 413.40(c)(3)(viii). The updated average
cost per day of $724.43 was used in the payment model to
[[Page 3620]]
establish the budget neutrality adjustment.
1. Standardization of the Federal Per Diem Base Rate
In the IPF PPS final rule, we standardized the IPF PPS Federal per
diem base rate in order to account for the overall positive effects of
the IPF PPS payment adjustment factors. To standardize the IPF PPS
payments, we compared the IPF PPS payment amounts calculated from the
psychiatric stays in the FY 2002 MedPAR file to the projected TEFRA
payments from the FY 2002 cost report file updated to the midpoint of
the IPF PPS implementation period (that is October 2005). The
standardization factor was calculated by dividing total estimated
payments under the TEFRA payment system by estimated payments under the
IPF PPS. The standardization factor was calculated to be 0.8367. As a
result, in the IPF PPS final rule, the $724.43 average cost per day was
reduced by 16.33 percent (100 percent minus 83.67 percent).
2. Calculation of the Budget Neutrality Adjustment
To compute the budget neutrality adjustment for the IPF PPS, we
separately identified each component of the adjustment, that is, the
outlier adjustment, stop-loss adjustment, and behavioral offset.
a. Outlier Adjustment
Since the IPF PPS payment amount for each IPF includes applicable
outlier amounts, we reduced the standardized Federal per diem base rate
to account for aggregate IPF PPS payments estimated to be made as
outlier payments. The appropriate outlier amount was determined by
comparing the adjusted prospective payment for the entire stay to the
computed cost per case. If costs were above the prospective payment
plus the adjusted fixed dollar loss threshold amount, an outlier
payment was computed using the applicable risk-sharing percentages, as
explained in greater detail in section IV.D.1 of this proposed rule.
The outlier amount was computed for all stays, and the total outlier
amount was added to the final IPF PPS payment. The outlier adjustment
was calculated to be 2 percent. As a result, the standardized Federal
per diem base rate was reduced by 2 percent to account for projected
outlier payments.
b. Stop-Loss Provision Adjustment
As explained in the IPF PPS final rule, we provide a stop-loss
payment to ensure that an IPF's total PPS payments are no less than a
minimum percentage of their TEFRA payment, had the IPF PPS not been
implemented. We reduced the standardized Federal per diem base rate by
the percentage of aggregate IPF PPS payments estimated to be made for
stop-loss payments.
The stop-loss payment amount was determined by comparing aggregate
prospective payments that the provider would receive under the IPF PPS
to aggregate TEFRA payments that the provider would have otherwise
received without implementation of the IPF PPS. If an IPF's aggregate
IPF PPS payments are less than 70 percent of its aggregate payments
under TEFRA, a stop-loss payment was computed for that IPF. The stop-
loss payment amounts were computed for those IPFs that were projected
to receive the payments, and the total amount was added to the final
IPF PPS payment amount. As a result, the standardized Federal per diem
base rate was reduced by 0.39 percent in order to maintain budget
neutrality in the IPF PPS.
c. Behavioral Offset
As explained in the IPF PPS final rule, implementation of the IPF
PPS may result in certain changes in IPF practices especially with
respect to coding for comorbid medical conditions. As a result,
Medicare may incur higher payments than assumed in our calculations.
Accounting for these effects through an adjustment is commonly known as
a behavioral offset.
Based on accepted actuarial practices and consistent with the
assumptions made in other prospective payment systems, we assumed in
determining the behavioral offset that IPFs would regain 15 percent of
potential ``losses'' and augment payment increases by 5 percent. We
applied this actuarial assumption, which is based on our historical
experience with new payment systems, to the estimated ``losses'' and
``gains'' among the IPFs. The behavioral offset for the IPF PPS was
calculated to be 2.66 percent. As a result, we reduced the standardized
Federal per diem base rate by 2.66 percent to maintain budget
neutrality.
To summarize, the $724.43 updated average per diem cost was reduced
by 16.33 percent to account for standardization to projected TEFRA per
diem payments for the implementation period, by 2 percent to account
for outlier payments, by 0.39 percent to account for stop-loss
payments, and by 2.66 percent reduction to account for the behavioral
offset. The final standardized budget-neutral Federal per diem base
rate for the IPF PPS implementation year was calculated to be $575.95.
We discuss the Federal per diem base rate for RY 2007 in section III
B.3. of this proposed rule.
3. Revision of Standardization Factor
In reviewing the methodology used to simulate the IPF PPS payments
used for the IPF PPS final rule, we discovered that the computer code
incorrectly assigned non-teaching status to most teaching facilities.
As a result, total IPF PPS payments were underestimated by about 1.36
percent. The IPF PPS estimated payment total was used in calculating
the IPF PPS standardization factor. The standardization factor
indicates the proportion by which the IPF PPS per diem payment rate and
the ECT rate must be reduced in order to make total IPF PPS payments
equal to estimated total TEFRA payments assuming IPFs continued to be
paid solely under TEFRA for the first PPS payment year. The
standardization factor is calculated as the ratio of estimated total
TEFRA payments to estimated total IPF PPS payments assuming no
reduction to the per diem and ECT payment rates. Since the IPF PPS
payment total should have been larger than the estimated figure, the
standardization factor should have been smaller (0.8254 vs. 0.8367). In
turn, the per diem rate and the ECT rate should have been reduced by
0.8254 instead of 0.8367.
To resolve this issue, we are proposing to amend the Federal per
diem base rate prospectively. Using the standardization factor of
0.8254, the base rate should have been $568.17 for the implementation
year of the IPF PPS. It is this base rate that we propose to update
using the market basket rate of increase of 4.5 percent and the budget-
neutral wage index factor of 1.00156 (as discussed in section IV.C.1.f.
of this proposed rule). Applying these factors yields a proposed
Federal per diem base rate of $594.66 for the rate year (RY) beginning
July 1, 2006 through June 30, 2007.
C. Update of the Federal Per Diem Base Rate
[If you choose to comment on issues in this section, please include the
caption ``UPDATE ON PER DIEM BASE RATE'' at the beginning of your
comments.]
1. Market Basket for IPFs Reimbursed under the IPF PPS
a. Proposed IPF Market Basket Index
The market basket index used to develop the IPF PPS is the excluded
hospital with capital market basket. This market basket was based on
1997 Medicare cost report data and includes data for Medicare
participating IPFs,
[[Page 3621]]
IRFs, LTCHs, cancer, and children's hospitals.
We are presently unable to create a separate market basket
specifically for psychiatric hospitals due to the small number of
facilities and the limited data that are provided (for instance,
approximately 4 percent of psychiatric facilities reported contract
labor cost data for 2002). However, since all IRFs, LTCHs, and IPFs are
now paid under a PPS, we are proposing to update PPS payments made
under the IRF PPS, the LTCH PPS, and the IPF PPS, in their respective
Federal Register updates, using a market basket reflecting the
operating and capital cost structures for IRFs, IPFs, and LTCHs,
hereafter referred to as the RPL (rehabilitation, psychiatric, long-
term care) market basket. We are excluding children's and cancer
hospitals from the RPL market basket because their payments are based
entirely on reasonable costs subject to rate-of-increase limits
established under the authority of section 1886(b) of the Act, which is
implemented in Sec. 413.40 of the regulations. They are not reimbursed
under a PPS. Also, the FY 2002 cost structures for children's and
cancer hospitals are noticeably different than the cost structures of
the IRFs, IPFs, and LTCHs.
The services offered in IRFs, IPFs, and LTCHs are typically more
labor-intensive than those offered in cancer and children's hospitals.
Therefore, the compensation cost weights for IRFs, IPFs, and LTCHs are
larger than those in cancer and children's hospitals. In addition, the
depreciation cost weights for IRFs, IPFs, and LTCHs are noticeably
smaller than those for children's and cancer hospitals.
In the following discussion, we provide an overview on the market
basket and describe the methodologies we propose to use for purposes of
determining the operating and capital portions of the proposed FY 2002-
based RPL market basket.
b. Overview of the Proposed RPL Market Basket
The proposed RPL market basket is a fixed weight, Laspeyres-type
price index that is constructed in three steps. First, a base period is
selected (in this case, FY 2002) and total base period expenditures are
estimated for a set of mutually exclusive and exhaustive spending
categories based upon type of expenditure. Then the proportion of total
costs that each category represents is determined. These proportions
are called cost or expenditure weights. Second, each expenditure
category is matched to an appropriate price or wage variable, referred
to as a price proxy. In nearly every instance, these price proxies are
price levels derived from publicly available statistical series that
are published on a consistent schedule, preferably at least on a
quarterly basis.
Finally, the expenditure weight for each cost category is
multiplied by the level of its respective price proxy for a given
period. The sum of these products (that is, the expenditure weights
multiplied by their price levels) for all cost categories yields the
composite index level of the market basket in a given period. Repeating
this step for other periods produces a series of market basket levels
over time. Dividing an index level for a given period by an index level
for an earlier period produces a rate of growth in the input price
index over that time period.
A market basket is described as a fixed-weight index because it
answers the question of how much it would cost, at another time, to
purchase the same mix of goods and services purchased to provide
hospital services in a base period. The effects on total expenditures
resulting from changes in the quantity or mix of goods and services
(intensity) purchased subsequent to the base period are not measured.
In this manner, the market basket measures only pure price change. Only
when the index is rebased would the quantity and intensity effects be
captured in the cost weights. Therefore, we rebase the market basket
periodically so that cost weights reflect changes in the mix of goods
and services that hospitals purchase (hospital inputs) to furnish
patient care between base periods.
The terms rebasing and revising, while often used interchangeably,
actually denote different activities. Rebasing means moving the base
year for the structure of costs of an input price index (for example,
shifting the base year cost structure from FY 1997 to FY 2002).
Revising means changing data sources, methodology, or price proxies
used in the input price index. We propose to rebase and revise the
market basket used to update the IPF PPS.
2. Proposed Methodology for Operating Portion of the RPL Market Basket
The operating portion of the proposed FY 2002-based RPL market
basket consists of several major cost categories derived from the FY
2002 Medicare cost reports for IRFs, IPFs, and LTCHs: wages, drugs,
professional liability insurance, and a residual. We choose to use FY
2002 as the base year because we believe this is the most recent,
complete year of Medicare cost report data and is consistent with the
data year on which the IPF PPS is based. Due to insufficient Medicare
cost report data for IRFs, IPFs, and LTCHs, we propose to develop cost
weights for benefits, contract labor, and blood and blood products
using the FY 2002-based IPPS market basket (70 FR 23384), which we
explain in more detail later in this section. For example, less than 30
percent of IRFs, IPFs, and LTCHs reported benefit cost data in FY 2002.
We have noticed an increase in cost data for these expense categories
over the last 4 years. The next time we rebase the RPL market basket
there may be sufficient IRFs, IPFs, and LTCHs cost report data to
develop the weights for these expenditure categories.
Since the cost weights for the RPL market basket are based on
facility costs, we are proposing to limit our sample to hospitals with
a Medicare average length of stay (LOS) within a comparable range of
the total facility average LOS. We believe this provides a more
accurate reflection of the structure of costs for Medicare covered
days. Our goal is to measure cost shares that are reflective of case
mix and practice patterns associated with providing services to
Medicare beneficiaries.
We propose to use those cost reports for IRFs and LTCHs whose
Medicare average LOS is within 15 percent (that is, 15 percent higher
or lower) of the total facility average LOS for the hospital. This is
the same edit applied to the FY 1992-based and FY 1997-based excluded
hospital with capital market basket. We are proposing 15 percent
because it includes those LTCHs and IRFs whose Medicare LOS is within
approximately 5 days of the facility LOS.
However, we are proposing to use a less stringent measure of
Medicare LOS for IPFs whose average LOS is within 30 or 50 percent
(depending on the total facility average LOS) of the total facility
average LOS. Using this less stringent edit allows us to increase our
sample size by over 150 cost reports and produce a cost weight more
consistent with the overall facility. The edit we applied to IPFs when
developing the FY 1997-based excluded hospital with capital market
basket was based on the best available data at the time.
The detailed cost categories under the residual (that is, the
remaining portion of the market basket after excluding wages and
salaries, drugs, and professional liability cost weights) are derived
from the FY 2002-based IPPS market basket and the 1997 Benchmark Input-
Output (I-O) Tables published by the Bureau of Economic Analysis, U.S.
Department of Commerce. The FY 2002-based IPPS market basket was
developed using FY 2002 Medicare hospital cost reports with the most
[[Page 3622]]
recent and detailed cost data (see the IPPS final rule in the August
12, 2005 Federal Register (70 FR 47388)). The 1997 Benchmark I-O is the
most recent, comprehensive source of cost data for all hospitals. The
proposed RPL cost weights for benefits, contract labor, and blood and
blood products were derived using the FY 2002-based IPPS market basket.
For example, the ratio of the benefit cost weight to the wages and
salaries cost weight in the FY 2002-based IPPS market basket was
applied to the RPL wages and salaries cost weight to derive a benefit
cost weight for the RPL market basket. The remaining proposed RPL
operating cost categories were derived using the 1997 Benchmark I-O
Tables, aged to 2002 using relative price changes. (The methodology we
used to age the data involves applying the annual price changes from
the price proxies to the appropriate cost categories. We repeat this
practice for each year.) Therefore, using this methodology, roughly 59
percent of the proposed RPL market basket is accounted for by wages,
drugs, and professional liability insurance data from FY 2002 Medicare
cost report data for IRFs, LTCHs, and IPFs.
Table 2 below sets forth the complete proposed 2002-based RPL
market basket including cost categories, weights, and price proxies.
For comparison purposes, the corresponding FY 1997-based excluded
hospital with capital market basket is listed as well.
Wages and salaries are 52.895 percent of total costs in the
proposed FY 2002-based RPL market basket compared to 47.335 percent for
the FY 1997-based excluded hospital with capital market basket.
Employee benefits are 12.982 percent in the proposed FY 2002-based RPL
market basket compared to 10.244 percent for the FY 1997-based excluded
hospital with capital market basket. As a result, compensation costs
(wages and salaries plus employee benefits) for the proposed FY 2002-
based RPL market basket are 65.877 percent of costs compared to 57.579
percent for the FY 1997-based excluded hospital with capital market
basket. Of the 8 percentage-point difference between the compensation
shares, approximately 3 percentage points are due to the proposed new
base year (FY 2002 instead of FY 1997), 3 percentage points are due to
revised length of stay edit, and the remaining 2 percentage points are
due to the proposed exclusion of other hospitals (that is, only
including IPFs, IRFs, and LTCHs in the market basket).
Following the table is a summary outlining the choice of the
proxies we propose to use for the operating portion of the market
basket. The price proxies for the capital portion are described in more
detail in the capital methodology section (see section III.C.3 of this
proposed rule).
Table 2.--Proposed FY 2002-Based RPL Market Basket Cost Categories, Weights, and Proxies With FY 1997-Based
Excluded Hospital With Capital Market Basket Used for Comparison
----------------------------------------------------------------------------------------------------------------
FY 1997-based
excluded Proposed FY
Expense categories hospital with 2002-based RPL Proposed FY 2002 RPL market basket
capital market market basket price proxies
basket
----------------------------------------------------------------------------------------------------------------
Total...................................... 100.000 100.000 ...................................
Compensation............................... 57.579 65.877 ...................................
Wages and Salaries*.................... 47.335 52.895 ECI-Wages and Salaries, Civilian
Hospital Workers.
Employee Benefits*..................... 10.244 12.982 ECI-Benefits, Civilian Hospital
Workers.
Professional Fees, Non-Medical......... 4.423 2.892 ECI-Compensation for Professional,
Specialty & Technical Workers.
Utilities.................................. 1.180 0.656 ...................................
Electricity............................ 0.726 0.351 PPI-Commercial Electric Power.
Fuel Oil, Coal, etc.................... 0.248 0.108 PPI-Refined Petroleum Products.
Water and Sewage....................... 0.206 0.197 CPI-U--Water & Sewage Maintenance.
Professional Liability Insurance........... 0.733 1.161 CMS Professional Liability Premium
Index.
All Other Products and Services............ 27.117 19.265 ...................................
All Other Products......................... 17.914 13.323 ...................................
Pharmaceuticals............................ 6.318 5.103 PPI Prescription Drugs.
Food: Direct Purchase.................. 1.122 0.873 PPI Processed Foods & Feeds.
Food: Contract Service................. 1.043 0.620 CPI-U Food Away From Home.
Chemicals.............................. 2.133 1.100 PPI Industrial Chemicals.
Blood and Blood Products**............. 0.748 .............. ...................................
Medical Instruments.................... 1.795 1.014 PPI Medical Instruments &
Equipment.
Photographic Supplies.................. 0.167 0.096 PPI Photographic Supplies.
Rubber and Plastics.................... 1.366 1.052 PPI Rubber & Plastic Products.
Paper Products......................... 1.110 1.000 PPI Converted Paper & Paperboard
Products.
Apparel................................ 0.478 0.207 PPI Apparel.
Machinery and Equipment................ 0.852 0.297 PPI Machinery & Equipment.
Miscellaneous.......................... 0.783 1.963 PPI Finished Goods less Food &
Energy.
All Other Services......................... 9.203 5.942 ...................................
Telephone.............................. 0.348 0.240 CPI-U Telephone Services.
Postage................................ 0.702 0.682 CPI-U Postage.
All Other: Labor Intensive................. 4.453 2.219 ECI-Compensation for Intensive
Private Service Occupations.
All Other: Non-labor Intensive............. 3.700 2.800 CPI-U All Items.
Capital-Related Costs...................... 8.968 10.149 ...................................
Depreciation........................... 5.586 6.186 ...................................
Fixed Assets........................... 3.503 4.250 Boeckh Institutional Construction
23-year useful life.
Movable Equipment...................... 2.083 1.937 WPI Machinery & Equipment 11-year
useful life.
Interest Costs............................. 2.682 2.775 ...................................
Nonprofit.............................. 2.280 2.081 Average yield on domestic municipal
bonds (Bond Buyer 20 bonds)
vintage- weighted (23 years).
[[Page 3623]]
For Profit............................. 0.402 0.694 Average yield on Moody's Aaa bonds
vintage weighted (23 years).
Other Capital-Related Costs................ 0.699 1.187 CPI-U Residential Rent.
----------------------------------------------------------------------------------------------------------------
* Labor-related.
** Blood and blood-related products is included in miscellaneous products.
Note: Due to rounding, weights may not sum to total.
Below we provide the proxies that we are proposing to use for the
FY 2002-based RPL market basket. With the exception of the Professional
Liability proxy, all the proposed price proxies for the operating
portion of the proposed RPL market basket are based on Bureau of Labor
Statistics (BLS) data and are grouped into one of the following BLS
categories:
Producer Price Indexes--Producer Price Indexes (PPIs)
measure price changes for goods sold in other than retail markets. PPIs
are preferable price proxies for goods that hospitals purchase as
inputs in producing their outputs because the PPIs better reflect the
prices faced by hospitals. For example, we use a special PPI for
prescription drugs, rather than the Consumer Price Index (CPI) for
prescription drugs because hospitals generally purchase drugs directly
from the wholesaler. The PPIs that we use measure price change at the
final stage of production.
Consumer Price Indexes--Consumer Price Indexes (CPIs)
measure change in the prices of final goods and services bought by the
typical consumer. Because they may not represent the price faced by a
producer, we use CPIs only if an appropriate PPI is not available, or
if the expenditures are more similar to those of retail consumers in
general rather than purchases at the wholesale level. For example, the
CPI for food purchases away from home is used as a proxy for contracted
food services.
Employment Cost Indexes--Employment Cost Indexes (ECIs)
measure the rate of change in employee wage rates and employer costs
for employee benefits per hour worked. These indexes are fixed-weight
indexes and strictly measure the change in wage rates and employee
benefits per hour. Appropriately, they are not affected by shifts in
employment mix.
We evaluated the price proxies using the criteria of reliability,
timeliness, availability, and relevance. Reliability indicates that the
index is based on valid statistical methods and has low sampling
variability. Timeliness implies that the proxy is published regularly,
preferably at least once a quarter. Availability means that the proxy
is publicly available. Finally, relevance means that the proxy is
applicable and representative of the cost category weight to which it
is applied. The CPIs, PPIs, and ECIs selected by us to be proposed in
this regulation meet these criteria.
We note that the proxies are the same as those used for the FY
1997-based excluded hospital with capital market basket. Because these
proxies meet our criteria of reliability, timeliness, availability, and
relevance, we believe they continue to be the best measure of price
changes for the cost categories. For further discussion on the FY 1997-
based excluded hospital with capital market basket, see the IPPS final
rule published in the Federal Register on August 1, 2002 (67 FR at
50042).
Wages and Salaries
For measuring the price growth of wages in the proposed FY 2002-
based RPL market basket, we propose to use the ECI for wages and
salaries for civilian hospital workers as the proxy for wages in the
RPL market basket.
Employee Benefits
The proposed FY 2002-based RPL market basket uses the ECI for
employee benefits for civilian hospital workers.
Nonmedical Professional Fees
The ECI for compensation for professional and technical workers in
private industry would be applied to this category since it includes
occupations such as management and consulting, legal, accounting, and
engineering services.
Fuel, Oil, and Gasoline
The percentage change in the price of gas fuels as measured by the
PPI (Commodity Code 0552) would be applied to this component.
Electricity
The percentage change in the price of commercial electric power as
measured by the PPI (Commodity Code 0542) would be applied to
this component.
Water and Sewage
The percentage change in the price of water and sewage maintenance
as measured by the Consumer Price Index (CPI) for all urban consumers
(CPI Code CUUR0000SEHG01) would be applied to this component.
Professional Liability Insurance
The proposed FY 2002-based RPL market basket would use the
percentage change in hospital professional liability insurance (PLI)
premiums as estimated by the CMS Hospital Professional Liability Index
for the proxy of this category. In the FY 1997-based excluded hospital
with capital market basket, the same proxy was used.
We continue to research options for improving our proxy for
professional liability insurance. This research includes exploring
various options for expanding our current survey, including the
identification of another entity that would be willing to work with us
to collect more complete and comprehensive data. We are also exploring
other options such as third party or industry data that might assist us
in creating a more precise measure of PLI premiums. At this time we
have not identified a preferred option, therefore no change is proposed
for the proxy in this proposed rule.
Pharmaceuticals
The percentage change in the price of prescription drugs as
measured by the PPI (PPI Code PPI32541DRX) would be used as a
proxy for this cost category. This is a special index produced by BLS
as a proxy in the 1997-based excluded hospital with capital market
basket.
[[Page 3624]]
Food, Direct Purchases
The percentage change in the price of processed foods and feeds as
measured by the PPI (Commodity Code 02) would be applied to
this component.
Food, Contract Service
The percentage change in the price of food purchased away from home
as measured by the CPI for all urban consumers (CPI Code
CUUR0000SEFV) would be applied to this component.
Chemicals
The percentage change in the price of industrial chemical products
as measured by the PPI (Commodity Code 061) would be applied
to this component. While the chemicals hospitals purchase include
industrial as well as other types of chemicals, the industrial
chemicals component constitutes the largest proportion by far. Thus we
believe that Commodity Code 061 is the appropriate proxy.
Medical Instruments
The percentage change in the price of medical and surgical
instruments as measured by the PPI (Commodity Code 1562) would
be applied to this component.
Photographic Supplies
The percentage change in the price of photographic supplies as
measured by the PPI Commodity Code 1542) would be applied to
this component.
Rubber and Plastics
The percentage change in the price of rubber and plastic products
as measured by the PPI (Commodity Code 07) would be applied to
this component.
Paper Products
The percentage change in the price of converted paper and
paperboard products as measured by the PPI (Commodity Code
0915) would be applied to this component.
Apparel
The percentage change in the price of apparel as measured by the
PPI (Commodity Code 381) would be applied to this component.
Machinery and Equipment
The percentage change in the price of machinery and equipment as
measured by the PPI (Commodity Code 11) would be applied to
this component.
Miscellaneous Products
The percentage change in the price of all finished goods less food
and energy as measured by the PPI (Commodity Code SOP3500)
would be applied to this component. Using this index would remove the
double-counting of food and energy prices, which are captured elsewhere
in the market basket. The weight for this cost category is higher, in
part, than in the 1997-based index because the weight for blood and
blood products (1.188) is added to it. In the 1997-based excluded
hospital with capital market basket, we included a separate cost
category for blood and blood products, using the BLS PPI for blood and
derivatives as a price proxy. A review of recent trends in the PPI for
blood and derivatives suggests that its movements may not be consistent
with the trends in blood costs faced by hospitals. While this proxy did
not match exactly with the product hospitals are buying, its trend over
time appears to be reflective of the historical price changes of blood
purchased by hospitals. However, an apparent divergence over recent
years led us to reevaluate whether the PPI for blood and derivatives
was an appropriate measure of the changing price of blood. We ran test
market baskets classifying blood in three separate cost categories:
blood and blood products, contained within chemicals as was done for
the 1992-based excluded hospital with capital market basket, and within
miscellaneous products. These categories use as proxies the following
PPIs: The PPI for blood and blood products, the PPI for chemicals, and
the PPI for finished goods less food and energy, respectively. Of these
three proxies, the PPI for finished goods less food and energy moved
most like the recent blood cost and price trends. In addition, the
impact on the overall market basket by using different proxies for
blood was negligible, mostly due to the relatively small weight for
blood in the market basket.
Therefore, we are proposing to use the PPI for finished goods less
food and energy for the blood proxy because we believe it more
appropriately proxies the price changes (not quantities or required
tests) associated with blood purchased by hospitals. We will continue
to evaluate this proxy for its appropriateness and will explore the
development of alternative price indexes to proxy the price changes
associated with this cost.
Telephone
The percentage change in the price of telephone services as
measured by the CPI for all urban consumers (CPI Code
CUUR0000SEED) would be applied to this component.
Postage
The percentage change in the price of postage as measured by the
CPI for all urban consumers (CPI Code CUUR0000SEEC01) would be
applied to this component.
All Other Services, Labor Intensive
The percentage change in the ECI for compensation paid to service
workers employed in private industry would be applied to this
component.
All Other Services, Nonlabor Intensive
The percentage change in the all items component of the CPI for all
urban consumers (CPI Code CUUR0000SA0) would be applied to
this component.
3. Proposed Methodology for Capital Portion of the RPL Market Basket
Unlike for the operating costs of the proposed FY 2002-based RPL
market basket, we did not have IRF, IPF, and LTCH FY 2002 Medicare cost
report data for the capital cost weights, due to a change in the FY
2002 reporting requirements. Rather, we used these hospitals'
expenditure data for the capital cost categories of depreciation,
interest, and other capital expenses for FY 2001, and aged the data to
a FY 2002 base year using relevant price proxies.
We calculated weights for the proposed RPL market basket capital
costs using the same set of Medicare cost reports used to develop the
operating share for IRFs, IPFs, and LTCHs. The resulting proposed
capital weight for the FY 2002 base year is 10.149 percent. This is
based on FY 2001 Medicare cost report data for IRFs, IPFs, and LTCHs,
aged to FY 2002 using relevant price proxies.
Lease expenses are not a separate cost category in the market
basket, but are distributed among the cost categories of depreciation,
interest, and other, reflecting the assumption that the underlying cost
structure of leases is similar to capital costs in general. We assumed
10 percent of lease expenses are overhead and assigned them to the
other capital expenses cost category as overhead. We base this
assignment of 10 percent of lease expenses to overhead on the common
assumption that overhead is 10 percent of costs. The remaining lease
expenses were distributed to the three cost categories based on the
weights of depreciation, interest, and other capital expenses not
including lease expenses.
Depreciation contains two subcategories: building and fixed
equipment and movable equipment. The split between building and fixed
equipment and movable equipment was determined using the FY 2001
Medicare
[[Page 3625]]
cost reports for IRFs, IPFs, and LTCHs. This methodology was also used
to compute the 1997-based index (67 FR at 50044).
The total interest expense cost category is split between the
government/nonprofit and for-profit hospitals. The 1997-based excluded
hospital with capital market basket allocated 85 percent of the total
interest cost weight to the government nonprofit interest, proxies by
average yield on domestic municipal bonds, and 15 percent to for-profit
interest, proxies by average yield on Moody's Aaa bonds.
We propose to derive the split using the relative FY 2001 Medicare
cost report data for PPS hospitals on interest expenses for the
government/nonprofit and for-profit hospitals. Due to insufficient
Medicare cost report data for IPFs, IRFs, and LTCHs, we propose to use
the same split used in the IPPS capital input price index. We believe
it is important that this split reflect the latest relative cost
structure of interest expenses for hospitals and, therefore, we propose
to use a 75-25 split to allocate interest expenses to government/
nonprofit and for-profit (70 FR at 47408).
Since capital is acquired and paid for over time, capital expenses
in any given year are determined by both past and present purchases of
physical and financial capital. The vintage-weighted capital index is
intended to capture the long-term consumption of capital, using vintage
weights for depreciation (physical capital) and interest (financial
capital). These vintage weights reflect the purchase patterns of
building and fixed equipment and movable equipment over time.
Depreciation and interest expenses are determined by the amount of past
and current capital purchases. Therefore we are proposing to use the
vintage weights to compute vintage-weighted price changes associated
with depreciation and interest expense.
Vintage weights are an integral part of the proposed FY 2002-based
RPL market basket. Capital costs are inherently complicated and are
determined by complex capital purchasing decisions, over time, based on
such factors as interest rates and debt financing. In addition, capital
is depreciated over time instead of being consumed in the same period
it is purchased. The capital portion of the proposed FY 2002-based RPL
market basket would reflect the annual price changes associated with
capital costs, and would be a useful simplification of the actual
capital investment process. By accounting for the vintage nature of
capital, we are able to provide an accurate, stable annual measure of
price changes. Annual non-vintage price changes for capital are
unstable due to the volatility of interest rate changes and, therefore,
do not reflect the actual annual price changes for Medicare capital-
related costs. The capital component of the proposed FY 2002-based RPL
market basket would reflect the underlying stability of the capital
acquisition process and provide hospitals with the ability to plan for
changes in capital payments.
To calculate the vintage weights for depreciation and interest
expenses, we needed a time series of capital purchases for building and
fixed equipment and movable equipment. We found no single source that
provides the best time series of capital purchases by hospitals for all
of the above components of capital purchases. The early Medicare Cost
Reports did not have sufficient capital data to meet this need. While
the American Hospital Association (AHA) Panel Survey provided a
consistent database back to 1963, it did not provide annual capital
purchases. However, the AHA Panel Survey provided a time series of
depreciation expenses through 1997 which could be used to infer capital
purchases over time. From 1998 to 2001, hospital depreciation expenses
were calculated by multiplying the AHA Annual Survey total hospital
expenses by the ratio of depreciation to total hospital expenses from
the Medicare cost reports. Beginning in 2001, the AHA Annual Survey
began collecting depreciation expenses. We hope to be able to use these
data in future rebasings.
In order to estimate capital purchases from AHA data on
depreciation and interest expenses, the expected life for each cost
category (building and fixed equipment, movable equipment, and debt
instruments) is needed. Due to insufficient Medicare cost report data
for IPFs, IRFs, and LTCHs, we propose to use FY 2001 Medicare Cost
Reports for IPPS hospitals to determine the expected life of building
and fixed equipment and movable equipment. We believe this data source
reflects the latest relative cost structure of depreciation expenses
for hospitals and is analogous to IPFs, IRFs, and LTCHs. The expected
life of any piece of equipment can be determined by dividing the value
of the asset (excluding fully depreciated assets) by its current year
depreciation amount. This calculation yields the estimated useful life
of an asset if depreciation were to continue at current year levels,
assuming straight-line depreciation. From the FY 2001 Medicare cost
reports for IPPS hospitals the expected life of building and fixed
equipment was determined to be 23 years, and the expected life of
movable equipment was determined to be 11 years.
We also propose to use the fixed and movable weights derived from
FY 2001 Medicare cost reports for IPFs, IRFs, and LTCHs to separate the
depreciation expenses into annual amounts of building and fixed
equipment depreciation and movable equipment depreciation. By
multiplying the annual depreciation amounts by the expected life
calculations from the FY 2001 Medicare cost reports, year-end asset
costs for building and fixed equipment and movable equipment were
determined. We then calculated a time series back to 1963 of annual
capital purchases by subtracting the previous year asset costs from the
current year asset costs. From this capital purchase time series we
were able to calculate the vintage weights for building and fixed
equipment, movable equipment, and debt instruments. An explanation of
each of these sets of vintage weights follows.
For proposed building and fixed equipment vintage weights, the real
annual capital purchase amounts for building and fixed equipment
derived from the AHA Panel Survey were used. The real annual purchase
amount was used to capture the actual amount of the physical
acquisition, net of the effect of price inflation. This real annual
purchase amount for building and fixed equipment was produced by
deflating the nominal annual purchase amount by the building and fixed
equipment price proxy, the Boeckh Institutional Construction Index.
This is the same proxy used for the FY 1997-based excluded hospital
with capital market basket. We believe this proxy continues to meet our
criteria of reliability, timeliness, availability, and relevance. Since
building and fixed equipment has an expected life of 23 years, the
vintage weights for building and fixed equipment are deemed to
represent the average purchase pattern of building and fixed equipment
over 23-year periods. With real building and fixed equipment purchase
estimates back to 1963, sixteen 23-year periods could be averaged to
determine the average vintage weights for building and fixed equipment
that are representative of average building and fixed equipment
purchase patterns over time. Vintage weights for each 23-year period
are calculated by dividing the real building and fixed capital purchase
amount in any given year by the total amount of purchases in the 23-
year period. This calculation is done for each year in the 23-year
period, and for each of the
[[Page 3626]]
sixteen 23-year periods. The average of each year across the sixteen
23-year periods is used to determine the 2002 average building and
fixed equipment vintage weights.
For proposed movable equipment vintage weights, the real annual
capital purchase amounts for movable equipment derived from the AHA
Panel Survey were used to capture the actual amount of the physical
acquisition, net of price inflation. This real annual purchase amount
for movable equipment was calculated by deflating the nominal annual
purchase amount by the movable equipment price proxy, the PPI for
Machinery and Equipment. This is the same proxy used for the FY 1997-
based excluded hospital with capital market basket. We believe this
proxy, which meets our criteria, is the best measure of price changes
for this cost category. Since movable equipment has an expected life of
11 years, the vintage weights for movable equipment are deemed to
represent the average purchase pattern of movable equipment over an 11-
year period. With real movable equipment purchase estimates available
back to 1963, twenty-eight 11-year periods could be averaged to
determine the average vintage weights for movable equipment that are
representative of average movable equipment purchase patterns over
time. Vintage weights for each 11-year period would be calculated by
dividing the real movable capital purchase amount for any given year by
the total amount of purchases in the 11-year period. This calculation
is done for each year in the 11-year period, and for each of the
twenty-eight 11-year periods. The average of the twenty-eight 11-year
periods would be used to determine the FY 2002 average movable
equipment vintage weights.
For proposed interest vintage weights, the nominal annual capital
purchase amounts for total equipment (building and fixed and movable)
derived from the AHA Panel and Annual Surveys were used. Nominal annual
purchase amounts were used to capture the value of the debt instrument.
Since hospital debt instruments have an expected life of 23 years, the
vintage weights for interest are deemed to represent the average
purchase pattern of total equipment over 23-year periods. With nominal
total equipment purchase estimates available back to 1963, sixteen 23-
year periods could be averaged to determine the average vintage weights
for interest that are representative of average capital purchase
patterns over time. Vintage weights for each 23-year period would be
calculated by dividing the nominal total capital purchase amount for
any given year by the total amount of purchases in the 23-year period.
This calculation would be done for each year in the 23-year period and
for each of the sixteen 23-year periods. The average of the sixteen 23-
year periods would be used to determine the FY 2002 average interest
vintage weights. The vintage weights for the index are presented in
Table 3 below.
In addition to the price proxies for depreciation and interest
costs described above in the vintage weighted capital section, we
propose to use the CPI-U for Residential Rent as a price proxy for
other capital-related costs. The price proxies for each of the capital
cost categories are the same as those used for the IPPS final rule (67
FR at 50044) capital input price index.
Table 3.--Proposed CMS FY 2002-Based RPL Market Basket Capital Vintage Weights
----------------------------------------------------------------------------------------------------------------
Interest:
Fixed assets Movable Capital-
Year (23 year assets (11 related (23
weights) year weights) year weights)
----------------------------------------------------------------------------------------------------------------
1............................................................... 0.021 0.065 0.010
2............................................................... 0.022 0.071 0.012
3............................................................... 0.025 0.077 0.014
4............................................................... 0.027 0.082 0.016
5............................................................... 0.029 0.086 0.019
6............................................................... 0.031 0.091 0.023
7............................................................... 0.033 0.095 0.026
8............................................................... 0.035 0.100 0.029
9............................................................... 0.038 0.106 0.033
10.............................................................. 0.040 0.112 0.036
11.............................................................. 0.042 0.117 0.039
12.............................................................. 0.045 .............. 0.043
13.............................................................. 0.047 .............. 0.048
14.............................................................. 0.049 .............. 0.053
15.............................................................. 0.051 .............. 0.056
16.............................................................. 0.053 .............. 0.059
17.............................................................. 0.056 .............. 0.062
18.............................................................. 0.057 .............. 0.064
19.............................................................. 0.058 .............. 0.066
20.............................................................. 0.060 .............. 0.070
21.............................................................. 0.060 .............. 0.071
22.............................................................. 0.061 .............. 0.074
23.............................................................. 0.061 .............. 0.076
-----------------
Total....................................................... 1.000 1.000 1.000
----------------------------------------------------------------------------------------------------------------
The proposed rate year (that is, beginning July 1, 2006) update for
the IPF PPS using the proposed FY 2002-based RPL market basket and
Global Insight's 3rd quarter 2005 forecast would be 4.5 percent. This
reflects increases in both the operating and capital portions of the
market basket from the 18-month period (that is, January 1, 2005
through June 30, 2006). Global Insight, Inc. is a nationally recognized
economic and financial forecasting firm that contracts with CMS to
forecast the components of the market baskets. Using the current FY
1997-based excluded hospital with capital market basket (66 FR 41427),
Global Insight's 3rd quarter 2005 forecast for
[[Page 3627]]
the proposed rate year beginning July 1, 2006 would be 4.5 percent.
Table 4 below compares the proposed FY 2002-based RPL market basket and
the FY 1997-based excluded hospital with capital market basket percent
changes. For both the historical and forecasted periods between RY 2000
and RY 2008, the difference between the two market baskets is minor
with the exception of RY 2002, where the proposed FY 2002-based RPL
market basket increased three tenths of a percentage point higher than
the FY 1997-based excluded hospital with capital market basket. This is
primarily due to the proposed FY 2002-based RPL having a larger
compensation (that is, the sum of wages and salaries and benefits) cost
weight than the FY 1997-based index and the price changes associated
with compensation costs increasing much faster than the prices of other
market basket components. Also contributing is the ``all other nonlabor
intensive'' cost weight, which is smaller in the proposed FY 2002-based
RPL market basket than in the FY 1997-based index, as well as the
slower price changes associated with these costs.
Table 4.--Proposed FY 2002-based RPL Market Basket and FY 1997-Based
Excluded Hospital With Capital Market Basket, Percent Changes: 2000-2008
------------------------------------------------------------------------
FY 1997-based
Proposed excluded
Rate year (RY) rebased FY hospital
2002-based RPL market basket
market basket with capital
------------------------------------------------------------------------
Historical data:
RY 2000............................. 2.8 2.7
RY 2001............................. 3.8 3.9
RY 2002............................. 4.1 3.8
RY 2003............................. 3.8 3.7
RY 2004............................. 3.6 3.6
Average RY 2000-2004............ 3.6 3.5
Forecast:
RY 2005............................. 3.8 3.9
RY 2006............................. 3.7 3.8
RY 2007............................. 3.6 3.6
RY 2008............................. 3.5 3.5
Average RY 2005-2008............ 3.7 3.7
------------------------------------------------------------------------
TL0805.SIM
Note: The RY forecasts are based on the standard 12-month period of July
1 to June 30. For this proposed rule, we are moving from an 18-month
period to a 12-month period.
4. Proposed Labor-Related Share
As described in section IV.C.1 of this proposed rule, due to the
variations in costs and geographic wage levels, we are proposing that
payment rates under the IPF PPS continue to be adjusted by a geographic
wage index. This wage index would apply to the labor-related portion of
the proposed Federal per diem base rate, hereafter referred to as the
labor-related share.
The labor-related share is determined by identifying the national
average proportion of operating costs that are related to, influenced
by, or vary with the local labor market. Using our current definition
of labor-related, the labor-related share is the sum of the relative
importance of wages and salaries, fringe benefits, professional fees,
labor-intensive services, and a portion of the capital share from an
appropriate market basket.
We are proposing to use the FY 2002-based RPL market basket costs
to determine the proposed labor-related share for the IPF PPS. The
proposed labor-related share for RY 2007 would be the sum of the
proposed RY 2007 relative importance of each labor-related cost
category, and would reflect the different rates of price change for
these cost categories between the base year (FY 2002) and RY 2007. The
sum of the proposed relative importance for RY 2007 for operating costs
(wages and salaries, employee benefits, professional fees, and labor-
intensive services) would be 71.845, as shown in Table 5 below. The
portion of capital that is influenced by the local labor market would
be estimated to be 46 percent, which is the same percentage used in the
FY 1997-based IRF and IPF payment systems. Since the relative
importance for capital would be 8.866 (RY 2007) percent of the proposed
FY 2002-based RPL market basket in RY 2007, we are proposing to take 46
percent of 8.866 percent to determine the proposed labor-related share
of capital for RY 2007. The result would be 4.078 percent, which we
propose to add to 71.845 percent for the operating cost amount to
determine the total proposed labor-related share for RY 2007. Thus, the
labor-related share that we propose to use for IPF PPS in RY 2007 would
be 75.923 percent. This proposed labor-related share is determined
using the same methodology as employed in calculating all previous IPF
labor-related shares (69 FR at 66952).
Table 5 below shows the proposed RY 2007 relative importance labor-
related share using the proposed FY 2002-based RPL market basket and
the FY 1997-based excluded hospital with capital market basket. We note
that the revised and rebased labor-related share would benefit those
hospitals with a wage index greater than or equal to 1.000.
[[Page 3628]]
Table 5.--Total Labor-Related Share--Relative Importance for RY 2007
------------------------------------------------------------------------
FY 1997
FY 2002-based excluded
RPL market hospital with
basket capital market
Cost category relative basket
importance relative
(Percent) RY importance
2007 (Percent) RY
2007
------------------------------------------------------------------------
Wages and salaries...................... 52.761 48.301
Employee benefits....................... 14.008 11.517
Professional fees....................... 2.903 4.527
All other labor-intensive services...... 2.173 4.457
-----------------------------------------
Subtotal............................ 71.845 68.802
-----------------------------------------
Labor-related share of capital costs.... 4.078 3.225
-----------------
Total........................... 75.923 72.027
------------------------------------------------------------------------
IPFs Paid Based on a Blend of the Reasonable Cost-based Payments
Under the broad authority of sections 1886(b)(3)(A) and (b)(3)(B)
of the Act and as stated in the FY 2006 IPPS final rule (70 FR 47399),
for IPFs that are transitioning to the fully Federal prospective
payment rate, we are now using the rebased and revised FY 2002-based
excluded hospital market basket to update the reasonable cost-based
portion of their payments. We rebase the market basket periodically so
that the cost weights reflect changes in the mix of goods and services
that hospitals purchase to furnish inpatient care between base periods.
We chose FY 2002 as the base year for the excluded hospital market
basket because we believe this is the most recent, complete year of
Medicare cost report data.
The reasonable cost-based payments, subject to TEFRA limits, are
determined on a FY basis. For purposes of the update factor for FY
2006, the portion of the IPF PPS transitional blend payment based on
reasonable costs was determined by updating the IPF's TEFRA limit by
the FY 2002-based excluded hospital market basket (or 3.8 percent) (70
FR 47691).
As discussed in section III.B.3 of this proposed rule, the proposed
Federal per diem base rate is $594.66 for the RY beginning July 1, 2006
and ending June 30, 2007.
IV. Update of the IPF PPS Adjustment Factors
[If you choose to comment on issues in this section, please include the
caption ``ADJUSTMENT FACTORS'' at the beginning of your comments.]
A. Overview of the IPF PPS Adjustment Factors
In developing the IPF PPS, in order to ensure that the IPF PPS
would be able to account adequately for each IPF's case-mix, we
performed an extensive regression analysis of the relationship between
the per diem costs and certain patient and facility characteristics to
determine those characteristics associated with statistically
significant cost differences on a per diem basis. For characteristics
with statistically significant cost differences, we used the regression
coefficients of those variables to determine the size of the
corresponding payment adjustments.
The IPF PPS payment adjustments were derived from a regression
analysis of 100 percent of the FY 2002 MedPAR data file which contained
483,038 cases. We propose to use the same results of this regression
analysis for this proposed rule. For a more detailed description of the
data file used for the regression analysis, see the IPF PPS final rule.
We computed a per diem cost for each Medicare inpatient psychiatric
stay, including routine operating, ancillary, and capital components
using information from the FY 2002 MedPAR file and data from the FY
2002 Medicare cost reports. To calculate the cost per day for each
inpatient psychiatric stay, routine costs were estimated by multiplying
the routine cost per day from the IPF's FY 2002 Medicare cost report by
the number of Medicare covered days on the FY 2002 MedPAR stay record.
Ancillary costs were estimated by multiplying each departmental cost-
to-charge ratio by the corresponding ancillary charges on the MedPAR
stay record. The total cost per day was calculated by summing routine
and ancillary costs for the stay and dividing it by the number of
Medicare covered days for each day of the stay.
As discussed in more detail in section IV.C.5 of this proposed
rule, the IPF PPS includes a payment adjustment for IPFs with
qualifying Emergency Departments (EDs), and IPFs that are part of acute
care hospitals and CAHs with qualifying EDs. As a result, ED costs were
excluded from the dependent variable used in the cost regression in
order to remove the effects of ED costs from other payment adjustment
factors with which ED costs may be correlated and thus avoid overpaying
ED costs.
The log of per diem cost, like most health care cost measures,
appeared to be normally distributed. Therefore, the natural logarithm
of the per diem cost was the dependent variable in the regression
analysis. We included variables in the regression to control for
psychiatric hospitals that do not bill ancillary costs and for ECT
costs that we pay separately. The per diem cost was adjusted for
differences in labor cost across geographic areas using the FY 2005
hospital wage index unadjusted for geographic reclassifications, in
order to be consistent with our use of the market basket labor share in
applying the wage index adjustment.
As discussed in the IPF PPS final rule (69 FR 66936), we computed a
wage adjustment factor for each case by multiplying the Medicare 2005
hospital wage index based on MSA definitions defined by OMB in 1993 for
each facility by the labor-related share and adding the non-labor
share. We used the 1997-based excluded hospital with capital market
basket to determine the labor-related share. The per diem cost for each
case was divided by this factor before taking the natural logarithm.
The payment adjustment for the wage index was computed consistently
with the wage adjustment factor, which is equivalent to separating the
per diem cost into a labor portion and a non-labor portion and
adjusting the labor portion by the wage index.
[[Page 3629]]
With the exception of the teaching adjustment, the independent
variables were specified as one or more categorical variables. Once the
regression model was finalized based on the log normal variables, the
regression coefficients for these variables were converted to payment
adjustment factors by treating each coefficient as an exponent of the
base ``e'' for natural logarithms, which is approximately equal to
2.718. The payment adjustment factors represent the proportional effect
of each variable relative to a reference variable. As a result of the
regression analysis, we established patient-level payment adjustments
for age, DRG assignment based on patients' principal diagnoses,
selected comorbidities, and a day of stay adjustment (the variable per
diem adjustments) to reflect higher resource use in the early days of
an IPF stay. We also established facility-level payment adjustments for
wage area, rural location, teaching status, cost of living adjustment
for IPFs located in Alaska and Hawaii, and an adjustment for IPFs with
a qualifying ED. We do not intend to update the regression analysis
until we can analyze 1 year of IPF PPS claims and cost report data
(that is, no earlier than RY 2008). CMS plans to monitor claims and
payment data independently from cost report data to assess issues, or
whether changes in case-mix or payment shifts have occurred between
free-standing governmental, non-profit, and private psychiatric
hospitals, and/or psychiatric units of general hospital, and other
impact issues of importance to psychiatric facilities.
B. Proposed Patient-Level Adjustments
[If you choose to comment on issues in this section, please include the
caption ``PATIENT-LEVEL ADJUSTMENTS'' at the beginning of your
comments.]
We provided payment adjustments for the following payment-level
characteristics in the IPF PPS final rule: DRG assignment of the
patient's principal diagnosis, selected comorbidities, patient age, and
the variable per diem adjustments.
1. Proposed Adjustment for DRG Assignment
The IPF PPS includes payment adjustments for the psychiatric DRG
assigned to the claim based on each patient's principal diagnosis. In
the IPF PPS final rule, we explained that the IPF PPS includes 15
diagnosis-related group (DRG) adjustment factors (69 FR 66936). The
adjustment factors were expressed relative to the most frequently
reported DRG in FY 2002, that is, DRG 430. The coefficient values and
adjustment factors were derived from the regression analysis.
In accordance with Sec. 412.27, payment under the IPF PPS is made
for claims with a principal diagnosis included in the Diagnostic and
Statistical Manual of Mental Disorder--Fourth Edition--Text Revision
(DSM-IV-TR) or Chapter Five of the International Classification of
Diseases--9th Revision--Clinical Modifications (ICD-9-CM). The
Standards for Electronic Transaction final rule published in the
Federal Register on August 17, 2000 (65 FR 50312), adopted the ICD-9-CM
as the designated code set for reporting diseases, injuries,
impairments, other health related problems, their manifestations, and
causes of injury, disease, impairment, or other health-related
problems. As a result, the DSM-IV-TR, while essential for the diagnosis
and treatment of mentally ill patients, may not be reported on Medicare
claims. However, in order to recognize the importance of the DSM-IV-TR
in mental health treatment, we updated the reference to the DSM in
Sec. 412.27 from DSM-III-TR to DSM-IV-TR in the IPF PPS final rule. As
a result, under the revised Sec. 412.27, IPFs that are distinct part
psychiatric units of acute care hospitals and CAHs may only admit
patients who have a principal diagnosis in the DSM-IV-TR or Chapter
Five of the ICD-9-CM although DSM codes may not be reported on medical
claims.
IPF claims with a principal diagnosis included in Chapter Five of
the ICD-9-CM or the DSM-IV-TR will be paid the Federal per diem base
rate payment under the IPF PPS. Psychiatric principal diagnoses that do
not group to one of the 15 designated DRGs receive the Federal per diem
base rate and all other applicable adjustments, but the payment does
not include a DRG adjustment. Only those claims with diagnoses that
group to one of these psychiatric DRGs would receive a DRG adjustment.
We believe it is vital to maintain the same diagnostic coding and
DRG classification for IPFs that is used under the IPPS for providing
the same psychiatric care. As we explained in the IPF PPS proposed rule
(68 FR 66924), all changes to the ICD-9-CM coding system that would
impact the IPF PPS are addressed annually in the IPPS proposed and
final rules published each year. The updated codes are effective
October 1 of each year and must be used to report diagnostic or
procedure information. The official version of the ICD-9-CM is
available on CD-ROM from the U.S. Government Printing Office. The FY
2005 version can be ordered by contacting the Superintendent of
Documents, U.S. Government Printing Office, Department 50, Washington,
D.C. 20402-9329, telephone number (202) 512-1800. The stock number is
017-022-01544-7, and the price is $25.00. In addition, private vendors
publish the ICD-9-CM. Questions concerning the ICD-9-CM should be
directed to Patricia E. Brooks, Co-Chairperson, ICD-9-CM Coordination
and Maintenance Committee, CMS, Center for Medicare Management,
Purchasing Policy Group, Division of Acute Care, Mailstop C4-08-06,
7500 Security Boulevard, Baltimore, Maryland 21244-1850. Questions and
comments may be sent via e-mail to: Patricia.Brooks1@cms.hhs.gov.
Further information concerning the Official Version of the ICD-9-CM
can be found in the IPPS final regulation, ``Changes to the Hospital
Inpatient Prospective Payment Systems and Fiscal Year 2006 Rates; Final
Rule,'' in the August 12, 2005 Federal Register (70 FR 47278) and at
http://www.cms.hhs.gov/QuarterlyProviderUpdates/downloads/cms1500f.pdf.
The following two tables below list the FY 2006 new ICD diagnosis
codes and FY 2006 revised diagnosis code titles, respectively. These
tables are only a listing of FY 2006 changes and do not reflect all of
the currently valid and applicable ICD codes classified in the DRGs.
Table 6 below lists the new FY 2006 ICD diagnosis codes that are
classified to one of the 15 DRGs that are provided a DRG adjustment in
the IPF PPS. When coded as a principal code or diagnosis, these codes
would receive the correlating DRG adjustment.
Table 6.--FY 2006 New Diagnosis Codes Diagnosis
----------------------------------------------------------------------------------------------------------------
Diagnosis code Description DRG
----------------------------------------------------------------------------------------------------------------
291.82........................................ Alcohol-induced sleep disorders................. 521, 522, 523
292.85........................................ Drug-induced sleep disorders.................... 521, 522, 523
327.00........................................ Organic insomnia, unspecified................... 432
[[Page 3630]]
327.01........................................ Insomnia due to medical condition classified 432
elsewhere.
327.02........................................ Insomnia due to mental disorder................. 432
327.09........................................ Other organic insomnia.......................... 432
327.10........................................ Organic hypersomnia, unspecified................ 432
327.11........................................ Idiopathic hypersomnia with long sleep time..... 432
327.12........................................ Idiopathic hypersomnia without long sleep time.. 432
327.13........................................ Recurrent hypersomnia........................... 432
327.14........................................ Hypersomnia due to medical condition classified 432
elsewhere.
327.15........................................ Hypersomnia due to mental disorder.............. 432
327.19........................................ Other organic hypersomnia....................... 432
----------------------------------------------------------------------------------------------------------------
Table 7 below lists ICD diagnosis codes whose titles have been
modified in FY 2006. Title changes do not impact the DRG adjustment.
When used as a principal diagnosis, these codes would still receive the
correlating DRG adjustment.
Table 7.--Revised Diagnosis Code Titles
------------------------------------------------------------------------
Diagnosis code Description DRG
------------------------------------------------------------------------
307.45........................ Circadian rhythm sleep 432
disorder of nonorganic
origin.
780.52........................ Insomnia, unspecified... 432
780.54........................ Hypersomnia, unspecified 432
780.55........................ Disruption of 24 hour 432
sleep wake cycle,
unspecified.
780.58........................ Sleep related movement 432
disorder, unspecified.
------------------------------------------------------------------------
In addition to the aforementioned, in the August 2005 IPPS final
rule, we finalized ICD code 305.1, Tobacco Use Disorder, in order to
designate this code as a noncovered Medicare service when reported as
the principal diagnosis. Below we have republished the explanation that
was included in the IPPS final rule (70 FR 47312) and published on the
CMS website at http://www.cms.hhs.gov/ QuarterlyProviderUpdates/
downloads/cms1500f.pdf.
We have become aware of the possible need to add code 305.1
(Tobacco use disorder) to the MCE in order to make admissions for
tobacco use disorder a noncovered Medicare service when code 305.1
is reported as the principal diagnosis. On March 22, 2005, CMS
published a final decision memorandum and related national coverage
determination (NCD) on smoking cessation counseling services on its
Web site: (http://www.cms.hhs.gov/coverage/). Among other things,
this NCD provides that: `Inpatient hospital stays with the principal
diagnosis of 305.1, Tobacco Use Disorder, are not reasonable and
necessary for the effective delivery of tobacco cessation counseling
services. Therefore, we will not cover tobacco cessation services if
tobacco cessation is the primary reason for the patient's hospital
stay.' Therefore, in order to maintain internal consistency with CMS
programs and decisions, we proposed to add code 305.1 to the MCE
edit ``Questionable Admission--Principal Diagnosis Only'' in order
to make tobacco use disorder a noncovered admission. (70 FR 47312).
In order to maintain consistency with the IPPS, for discharges on
or after October 1, 2005, ICD code 305.1, Tobacco Use Disorder, would
not be a covered principal diagnosis under the IPF PPS.
Although we are updating the IPF PPS to reflect ICD-9-CM coding
changes and DRG classification changes discussed in the annual update
to the IPPS, we are proposing that the DRG adjustment factors currently
being paid to IPFs would remain the same for discharges occurring
during the rate year July 1, 2006 through June 30, 2007. As indicated
in the IPF PPS final rule, we do not intend to update the regression
analysis until we have analyzed 1 year of IPF PPS claims and cost
report data. As a result, we are proposing to adopt the DRG adjustments
that are currently being paid as indicated in Table 8 below.
Table 8.--FY 2006 Proposed DRGs and Adjustment Factor
------------------------------------------------------------------------
Adjustment
DRG DRG definition factor
------------------------------------------------------------------------
DRG 424....................... O.R. Procedure with 1.22
Principal Diagnosis of
Mental Illness.
DRG 425....................... Acute Adjustment 1.05
Reaction & Psychosocial
Dysfunction.
DRG 426....................... Depressive Neurosis..... 0.99
DRG 427....................... Neurosis, Except 1.02
Depressive.
DRG 428....................... Disorders of Personality 1.02
& Impulse Control.
DRG 429....................... Organic Disturbances & 1.03
Mental Retardation.
DRG 430....................... Psychoses............... 1.00
DRG 431....................... Childhood Mental 0.99
Disorders.
DRG 432....................... Other Mental Disorder 0.92
Diagnoses.
DRG 433....................... Alcohol/Drug Abuse or 0.97
Dependence, Leave
Against Medical Advice
(LAMA).
DRG 521....................... Alcohol/Drug Abuse or 1.02
Dependence with CC.
DRG 522....................... Alcohol/Drug Abuse or 0.98
Dependence with
Rehabilitation Therapy
without CC.
DRG 523....................... Alcohol/Drug Abuse or 0.88
Dependence without
Rehabilitation Therapy
without CC.
DRG 12........................ Degenerative Nervous 1.05
System Disorders.
[[Page 3631]]
DRG 23........................ Non-traumatic Stupor & 1.07
Coma.
------------------------------------------------------------------------
Section Sec. 412.424(d) separately identifies both ``Diagnosis-
related group assignment'' and ``Principal diagnosis'' as patient level
adjustments. Since publication of the IPF PPS final rule, we have
received inquiries related to whether the IPF PPS includes two patient-
level payment adjustments for principal diagnosis, an adjustment for
the diagnosis-related group assignment and a separate adjustment for
providing a principal diagnosis in general. We intended that the IPF
PPS provide one patient-level adjustment for principal diagnosis, that
is ``Diagnosis-related group assignment.''
In order to clarify our policy, we are proposing to modify the
language in section Sec. 412.424(d). We are proposing to delete sub-
paragraph Sec. 412.424(d)(2)(iii).
2. Proposed Payment for Comorbid Conditions
In the IPF PPS final rule, we established 17 comorbidity categories
and identified the ICD-9-CM diagnosis codes that generate a payment
adjustment under the IPF PPS.
Comorbidities are specific patient conditions that are secondary to
the patient's primary diagnosis, and that require treatment during the
stay. Diagnoses that relate to an earlier episode of care and have no
bearing on the current hospital stay are excluded and not reported on
IPF claims. Comorbid conditions must co-exist at the time of admission,
develop subsequently, affect the treatment received, affect the length
of stay or affect both treatment and length of stay.
The intent of the comorbidity adjustments was to recognize the
increased cost associated with comorbid conditions by providing
additional payments for certain concurrent medical or psychiatric
conditions that are expensive to treat. An IPF may receive only one
comorbidity adjustment per comorbidity category, but it may receive an
adjustment for more than one comorbidity category. Billing instructions
require that IPFs must enter the full ICD-9-CM codes for up to 8
additional diagnoses if they co-exist at the time of admission or
developed subsequently.
The comorbidity adjustments were determined based on regression
analysis using the diagnoses reported by hospitals as other diagnoses
in FY 2002. The principal diagnoses were used to establish the DRG
adjustment and were not accounted for in establishing the comorbidity
category adjustments, except where ICD-9-CM ``code first'' instructions
apply. As we explained in the IPF PPS final rule, the code first rule
applies when a condition has both an underlying etiology and a
manifestation due to the underlying etiology. For these conditions, the
ICD-9-CM has a coding convention that requires the underlying
conditions to be sequenced first followed by the manifestation.
Whenever a combination exists, there is a ``use additional code'' note
at the etiology code and a ``code first'' note at the manifestation
code.
Although we are updating the IPF PPS to reflect updates to the ICD-
9-CM codes, we are proposing that the comorbidity adjustment factors
currently in effect would remain in effect for the rate year beginning
July 1, 2006. As we indicated in the IPF PPS final rule, we do not
intend to update the regression analysis until we have analyzed 1 year
of IPF PPS claims and cost report data. The proposed comorbidity
adjustments are shown in Table 9 below.
As previously discussed in the DRG section, we believe it is
essential to maintain the same diagnostic coding set for IPFs that is
used under the IPPS for providing the same psychiatric care. Therefore,
we are proposing to use the most current FY 2006 ICD codes. They are
reflected in the FY 2006 GROUPER, version 23.0 and are effective for
discharges occurring on or after October 1, 2005.
Table 9 lists the updated FY 2006 new ICD diagnosis codes that
impact the comorbidity adjustment under the IPF PPS and Table 10 lists
the invalid ICD codes no longer applicable for the comorbidity
adjustment. Table 9 only lists the FY 2006 new codes and does not
reflect all of the currently valid ICD codes applicable for the IPF PPS
comorbidity adjustment.
We note that ICD diagnosis code 585 Chronic Renal Failure was
modified in two ways--(1) by expanding the level of specificity to
include seven new codes; and (2) by changing the original code of 585
to invalid, thereby leaving the remaining more specific codes
reportable. Since diagnosis code 585 is no longer valid, we are
proposing to eliminate this code from the comorbidity category ``Renal
Failure, Chronic.''
ICD diagnosis code 585 chronic Renal Failure is defined in the ICD-
9-CM as ``Progressive, persistent inadequate kidney function
characterized by anuria, accumulation of urea and other nitrogenous
bodies in the blood, nausea, vomiting, gastrointestinal bleeding, and
yellowish-brown discoloration of the skin.'' This code included the
various stages of chronic kidney disease, but it is no longer valid.
The new codes listed below reflect the various stages of chronic kidney
failure. Since diagnosis code 585 is no longer valid, we are proposing
to eliminate it from the comorbidity category, ``Renal Failure,
Chronic''.
We are proposing to provide comorbidity adjustments for 585.3,
``Chronic kidney disease, Stage III (moderate),'' 585.4, ``Chronic
kidney disease, Stage IV (severe),'' 585.5, ``Chronic kidney disease,
Stage V,'' 585.6, ``End Stage renal disease,'' and 585.9, ``Chronic
kidney disease, unspecified.'' However, since the purpose of the
comorbidity adjustment is to account for the higher resource costs
associated with comorbid conditions that are expensive to treat on a
per diem basis, we are not proposing a comorbidity adjustment for
585.1, ``Chronic kidney disease, Stage I'' and 585.2, ``Chronic kidney
disease, Stage II (mild).''
We believe that these conditions (585.1 and 585.2) are less costly
to treat on a per diem basis because patients with these conditions are
either asymptomatic or may have only mild symptoms. These conditions
represent a minimal to mild decrease in kidney function that is almost
completely compensated such that the only finding is typically an
abnormal laboratory test. Unlike patients with more significant kidney
dysfunction, these patients do not usually require more costly patient
care interventions such as additional lab tests to monitor renal
function, special pharmacy attention to reduced dosages or kidney-
sparing medications, or fluid and electrolyte precautions with special
diets, frequent weights, Input/Output balance, and fluid restriction.
As such, the resources and costs that these patients require for staff
time,
[[Page 3632]]
medications and supplies, and administrative services are expected to
be similar to other patients without these conditions.
Table 9.--FY 2006 New ICD Codes Applicable for the Comorbidity Adjustment
----------------------------------------------------------------------------------------------------------------
Diagnosis code Description DRG Comorbidity category
----------------------------------------------------------------------------------------------------------------
585.3................................. Chronic kidney disease, 315-316 Renal Failure, Chronic.
Stage III (moderate).
585.4................................. Chronic kidney disease, 315-316 Renal Failure, Chronic.
Stage IV (severe).
585.5................................. Chronic kidney disease, 315-316 Renal Failure, Chronic.
Stage V.
585.6................................. End stage renal disease.... 315-316 Renal Failure, Chronic.
585.9................................. Chronic kidney disease, 315-316 Renal Failure, Chronic.
unspecified.
V46.13................................ Encounter for weaning from 467 Chronic Obstructive
respirator [ventilator]. Pulmonary Disease.
V46.14................................ Mechanical complication of 467 Chronic Obstructive
respirator [ventilator]. Pulmonary Disease.
----------------------------------------------------------------------------------------------------------------
In Table 10 below, we list the FY 2006 invalid ICD diagnosis code
585 that we are proposing to remove from the comorbidity adjustment
under the IPF PPS. This table does not reflect all of the currently
valid ICD codes applicable for the IPF PPS comorbidity adjustment.
Table 10.--FY 2006 Invalid ICD Codes No Longer Applicable for the Comorbidity Adjustment
----------------------------------------------------------------------------------------------------------------
Diagnosis code Description DR Comorbidity category
----------------------------------------------------------------------------------------------------------------
585................................... Chronic renal failure...... 315-36 Renal Failure, Chronic.
----------------------------------------------------------------------------------------------------------------
We are aware that ICD code 404.03, Hypertensive Heart and Renal
Disease, Malignant, with Heart Failure and Renal Failure, has caused
confusion since this ICD code is currently used to code an adjustment
in two separate IPF comorbidity categories, (that is, both ``Renal
Failure, Chronic'' and ``Cardiac Conditions''). After a careful review
of this code, we believe that it more appropriately corresponds to the
``Cardiac Conditions'' comorbidity than to the ``Renal Failure,
Chronic'' comorbidity. Therefore, to be more clinically cohesive and to
eliminate confusion, we are proposing to remove ICD code 404.03 from
the comorbidity adjustment category ``Renal Failure, Chronic,'' but
retaining it in the ``Cardiac Conditions'' comorbidity category. Since
both comorbidity categories have the same adjustment factor of 1.11, no
negative payment consequence would result from this change.
The seventeen comorbidity categories for which we are proposing to
provide an adjustment, their respective codes including the new FY 2006
ICD codes, and their respective adjustment factors are listed below in
Table 11.
Table 11.--FY 2006 Diagnosis Codes and Adjustment Factors for Comorbidity Categories
----------------------------------------------------------------------------------------------------------------
Adjustment
Description of comorbidity ICD-9CM Code factor
----------------------------------------------------------------------------------------------------------------
Development Disabilities...................... 317, 3180, 3181, 3182, and 319.................. 1.04
Coagulation Factor deficits................... 2860 through 2864............................... 1.13
Tracheotomy................................... 51900--through 51909 and V440................... 1.06
Renal Failure, Acute.......................... 5845 through 5849, 63630, 63631, 63632, 63730, 1.11
63731, 63732, 6383, 6393, 66932, 66934, 9585.
Renal Failure, Chronic........................ 40301, 40311, 40391, 40402, 40412, 40413, 40492, 1.11
40493, 5853, 5854, 5855, 5856, 5859, 586, V451,
V560, V561, and V562.
Oncology Treatment............................ 1400 through 2399 with a radiation therapy code 1.07
92.21-92.29 or chemotherapy code 99.25.
Uncontrolled Diabetes-Mellitus with or without 25002, 25003, 25012, 25013, 25022, 25023, 25032, 1.05
complications. 25033, 25042, 25043, 25052, 25053, 25062,
25063, 25072, 25073, 25082, 25083, 25092, and
25093.
Severe Protein calorie malnutrition........... 260 through 262................................. 1.13
Eating and Conduct Disorders.................. 3071, 30750, 31203, 31233, and 31234............ 1.12
Infectious Disease............................ 01000 through 04110, 042, 04500 through 05319, 1.07
05440 through 05449, 0550 through 0770, 0782
through 07889, and 07950 through 07959.
Drug and/or Alcohol Induced Mental Disorders.. 2910, 2920, 29212, 2922, 30300, and 30400....... 1.03
Cardiac Conditions............................ 3910, 3911, 3912, 40201, 40403, 4160, 4210, 1.11
4211, and 4219.
Gangrene...................................... 44024 and 7854.................................. 1.10
Chronic Obstructive Pulmonary Disease......... 49121, 4941, 5100, 51883, 51884, V4611 and 1.12
V4612, V4613 and V4614.
Artificial Openings--Digestive and Urinary.... 56960 through 56969, 9975, and V441 through V446 1.08
Severe Musculoskeletal and Connective Tissue 6960, 7100, 73000 through 73009, 73010 through 1.11
Diseases. 73019, and 73020 through 73029.
Poisoning..................................... 96500 through 96509, 9654, 9670 through 9699, 1.11
9770, 9800 through 9809, 9830 through 9839,
986, 9890 through 9897.
----------------------------------------------------------------------------------------------------------------
[[Page 3633]]
3. Proposed Patient Age Adjustments
As explained in the IPF PPS final rule, we analyzed the impact of
age on per diem cost by examining the age variable (that is, the range
of ages) for payment adjustments.
In general, we found that the cost per day increases with
increasing age. The older age groups are more costly than the under 45
years of age group, the differences in per diem cost increase for each
successive age group, and the differences are statistically
significant.
Based on the results of the regression analysis, we established 8
adjustment factors for age beginning with age groupings, 45 and under
50, 50 and under 55, 55 and under 60, 60 and under 65, 65 and under 70,
70 and under 75, 75 and under 80, and 80 years of age and over.
Patients under 45 years of age are assigned an age adjustment factor of
1.00. As we indicated in the IPF PPS final rule, we do not intend to
update the regression analysis until we can analyze 1 year of IPF PPS
claims and cost report data. As a result, in this proposed rule, we are
proposing to adopt the patient age adjustments currently in effect and
shown in Table 12 below.
Table 12.--Age Groupings and Adjustment Factors
------------------------------------------------------------------------
Adjustment
Age factor
------------------------------------------------------------------------
Under 45................................................... 1.00
45 and under 50............................................ 1.01
50 and under 55............................................ 1.02
55 and under 60............................................ 1.04
60 and under 65............................................ 1.07
65 and under 70............................................ 1.10
70 and under 75............................................ 1.13
75 and under 80............................................ 1.15
80 and over................................................ 1.17
------------------------------------------------------------------------
4. Proposed Variable Per Diem Adjustments
We explained in the IPF PPS final rule that cost regressions
indicated that per diem cost declines as the length of stay increases
(69 FR 66947). The variable per diem adjustments to the Federal per
diem base rate account for ancillary and administrative costs that
occur disproportionately in the first days after admission to an IPF.
We used regression analysis to estimate the average differences in
per diem cost among stays of different length. Regression analysis
simultaneously controls for cost differences associated with the other
variables (for example, age, DRG, and presence of specific
comorbidities). The regression coefficients measure the relative
average cost per day for stays of differing lengths compared to a
reference group's length of stay. We analyzed through cost regression,
the relative cost per day for day 1 through day 30. We determined that
the average per diem cost declined smoothly until the 22nd day. As a
result of this analysis, we established variable per diem adjustments
that begin on day 1 and decline gradually until day 21 of a patient's
stay. For day 22 and thereafter, the variable per diem adjustment
remains the same each day for the remainder of the stay. However, the
adjustment applied to day 1 depends upon whether the IPF has a
qualifying Emergency Department (ED). If an IPF has a qualifying ED, it
receives a 1.31 adjustment for day 1 of each patient stay. If an IPF
does not have a qualifying ED, it receives a 1.19 adjustment for day 1
of the stay. The ED adjustment is explained in more detail in section
IV.C.5. of this proposed rule.
As we indicated in the IPF PPS final rule, we do not intend to make
changes to the regression analysis until we can analyze 1 year of IPF
PPS claims and cost report data. As a result, for the rate year
beginning July 1, 2006, we are proposing to adopt the variable per diem
adjustment factors currently in effect. Table 13 below shows the
variable per diem adjustments we are proposing for updating the IPF
PPS. Higher payments for the early days of stay in IPFs are not fully
compensated by the lower payments after day 10, but are paid for by the
standardization portion which is applied to the federal per diem base
rate.
Table 13.--Variable Per Diem Adjustments
------------------------------------------------------------------------
Adjustment
Day-of-stay factor
------------------------------------------------------------------------
Day 1-IPF Without a Qualified ED........................... 1.19
Day 1-IPF With a Qualified ED.............................. 1.31
Day 2...................................................... 1.12
Day 3...................................................... 1.08
Day 4...................................................... 1.05
Day 5...................................................... 1.04
Day 6...................................................... 1.02
Day 7...................................................... 1.01
Day 8...................................................... 1.01
Day 9...................................................... 1.00
Day 10..................................................... 1.00
Day 11..................................................... 0.99
Day 12..................................................... 0.99
Day 13..................................................... 0.99
Day 14..................................................... 0.99
Day 15..................................................... 0.98
Day 16..................................................... 0.97
Day 17..................................................... 0.97
Day 18..................................................... 0.96
Day 19..................................................... 0.95
Day 20..................................................... 0.95
Day 21..................................................... 0.95
After Day 21............................................... 0.92
------------------------------------------------------------------------
C. Facility-Level Adjustments
[If you choose to comment on issues in this section, please include the
caption ``FACILITY-LEVEL ADJUSTMENTS'' at the beginning of your
comments.]
The IPF PPS includes facility-level adjustments for the wage index,
IPFs located in rural areas, teaching IPFs, cost of living adjustments
for IPFs located in Alaska and Hawaii, and IPFs with a qualifying ED.
1. Wage Index Adjustment
a. Proposed Revisions of IPF PPS Geographic Classifications
In the IPF PPS final rule, we explained that in establishing an
adjustment for area wage levels, the labor-related portion of an IPF's
Federal prospective payment is adjusted by using an appropriate wage
index. We also explained that an IPF's wage index is determined based
on the location of the IPF in an urban or rural area as defined in
Sec. 412.62(f)(1)(ii) and (f)(1)(iii), respectively. An urban area
under the IPF PPS is defined at Sec. 412.62(f)(1)(ii)(A) and (B). In
general, an urban area is defined as a Metropolitan Statistical Area
(MSA) or New England County Metropolitan Area (NECMA) as defined by the
Office of Management and Budget (OMB). In addition, a few counties
located outside of MSAs are considered urban as specified at Sec.
412.62(f)(1)(ii)(B). Under Sec. 412.62(f)(1)(iii), a rural area is
defined as any area outside of an urban area. The geographic
classifications defined in Sec. 412.62(f)(1)(ii) and (f)(1)(iii), were
used under the IPPS from FYs 1984 through 2004 (Sec. 412.62(f) and
Sec. 412.63(b)), and have been used under the IPF PPS since it was
implemented for cost reporting periods beginning on or after January 1,
2005.
Under the IPPS, the wage index is calculated and assigned to
hospitals on the basis of the labor market area in which the hospital
is located or geographically reclassified to in accordance with
sections 1886(d)(8) and (d)(10) of the Act. Under the IPF PPS, the wage
index is calculated using IPPS wage index data (as discussed below in
section IV C.1.d of this preamble) on the basis of the labor market
area in which the IPF is located, without taking into account
geographic reclassification under sections 1886(d)(8) and (d)(10) of
[[Page 3634]]
the Act and without applying the ``rural floor'' established under
section 4410 of the BBA. (Section 4410 of the BBA provides that for the
purposes of section 1886(d)(3)(E) of the Act, the area wage index
applicable to hospitals located in an urban area of a State may not be
less than the area wage index applicable to hospitals located in rural
areas in the State. This provision is commonly referred to as the
``rural floor'' under the IPPS.) However, when we established the IPF
PPS, we did not apply the rural floor to IPFs. For this reason, the
hospital wage index used for IPFs is commonly referred to as the ``pre-
floor'' hospital wage index indicating that the ``rural floor''
provision of the BBA is not applied. As a result, the applicable IPF
wage index value is assigned to the IPF on the basis of the labor
market area in which the IPF is geographically located.
As noted above, the current IPF PPS labor market areas are defined
based on the definitions of MSAs, Primary MSAs (PMSAs), and NECMAs
issued by the OMB (commonly referred to collectively as ``MSAs''). The
MSA definitions, which are discussed in greater detail below, are
currently used under the IPF PPS and other PPSs (that is, the IRF PPS,
the LTCH PPS, and the PPSs for home health agencies (HHA PPS) and
skilled nursing facilities (SNF PPS)). In the FY 2005 IPPS final rule
(69 FR 49026 through 49034), revised labor market area definitions were
adopted under the IPPS (Sec. 412.64(b)), which were effective October
1, 2004. These new standards, called Core-Based Statistical Areas
(CBSAs), were announced by the OMB late in 2000 and are discussed in
greater detail below.
b. Current IPF PPS Labor Market Areas Based on MSAs
When we published the IPF PPS final rule, we explained that we were
not adopting the new statistical area definitions defined by OMB for
the following reasons. First, the change in labor market areas under
the IPPS had not changed at the time we published the IPF PPS proposed
rule on November 28, 2003. As a result, IPFs and other interested
parties were not afforded an opportunity to comment on the use of the
new labor market area definitions under the IPF PPS. Second, we wanted
to conduct a thorough analysis of the impact of the new labor market
area definitions on payments under the IPF PPS. Finally, in the IPF PPS
final rule, we indicated our intent to publish in a proposed rule any
changes we were considering for new labor market definitions.
The analysis of the impact of the new labor market definitions has
been completed and we are proposing to adopt new labor market area
definitions under the IPF PPS. As a result, we believe it is helpful to
provide a detailed description of the current IPF PPS labor market
areas, in order to better understand the proposed changes to the IPF
PPS labor market areas presented in this proposed rule.
As mentioned earlier, since the implementation of the IPF PPS, we
have used labor market areas to further characterize urban and rural
areas as determined under Sec. 412.62(f)(1)(ii) and (iii). To this
end, we have defined labor market areas under the IPF PPS based on the
definitions of MSAs, PMSAs, and NECMAs issued by the OMB in 1993, which
is consistent with the IPPS approach prior to FY 2005. We note that OMB
also defines Consolidated MSAs (CMSAs). A CMSA is a metropolitan area
with a population of 1 million or more, comprising two or more PMSAs
(identified by their separate economic and social character). However,
for purposes of the wage index, we use the PMSAs rather than CMSAs
because they allow a more precise breakdown of labor costs. If a
metropolitan area is not designated as part of a PMSA, we use the
applicable MSA.
These different designations use counties as the building blocks
upon which they are based. Therefore, under the IPF PPS, hospitals are
assigned to either an MSA, PMSA, or NECMA based on whether the county
in which the IPF is located is part of that area. All of the counties
in a State outside a designated MSA, PMSA, or NECMA are designated as
rural.
c. Core-Based Statistical Areas
The OMB reviews its Metropolitan Area definitions preceding each
decennial census. As discussed in the FY 2005 IPPS final rule (69 FR
49026), in the fall of 1998, OMB chartered the Metropolitan Area
Standards Review Committee to examine the Metropolitan Area standards
and develop recommendations for possible changes to those standards.
Three notices related to the review of the standards, providing an
opportunity for public comment on the recommendations of the Committee,
were published in the Federal Register on the following dates: December
21, 1998 (63 FR 70526); October 20, 1999 (64 FR 56628); and August 22,
2000 (65 FR 51060).
In the December 27, 2000 Federal Register (65 FR 82228 through
82238), OMB announced its new standards. In that notice, OMB defines a
Core-Based Statistical Area (CBSA), beginning in 2003, as ``a
geographic entity associated with at least one core of 10,000 or more
population, plus adjacent territory that has a high degree of social
and economic integration with the core as measured by commuting ties.
The standards designate and define two categories of CBSAs:
Metropolitan Statistical Areas and Micropolitan Statistical Areas.''
(65 FR 82236 through 82238).
According to the OMB, MSAs are based on urbanized areas of 50,000
or more population, and Micropolitan Statistical Areas (referred to in
this discussion as Micropolitan Areas) are based on urban clusters of
at least 10,000 population, but less than 50,000 population. Counties
that do not fall within CBSAs (either MSAs or Micropolitan Areas) are
deemed ``Outside CBSAs.'' In the past, OMB defined MSAs around areas
with a minimum core population of 50,000, and smaller areas were
``Outside MSAs.'' On June 6, 2003, the OMB announced the new CBSAs,
comprised of MSAs and the new Micropolitan Areas based on Census 2000
data. (A copy of the announcement may be obtained at the following
Internet address: http://www.whitehouse.gov/omb/bulletins/fy04/b04-03.html.
)
The new CBSA designations recognize 49 new MSAs and 565 new
Micropolitan Areas, and extensively revise the composition of many of
the existing MSAs. There are 1,090 counties in MSAs under the new CBSA
designations (previously, there were 848 counties in MSAs). Of these
1,090 counties, 737 are in the same MSA as they were prior to the
change in designations, 65 are in a different MSA, and 288 were not
previously designated to any MSA. There are 674 counties in
Micropolitan Areas. Of these, 41 were previously in an MSA, while 633
were not previously designated to an MSA. There are five counties that
previously were designated to an MSA but are no longer designated to
either an MSA or a new Micropolitan Area: Carter County, KY; St. James
Parish, LA; Kane County, UT; Culpepper County, VA; and King George
County, VA. For a more detailed discussion of the conceptual basis of
the new CBSAs, refer to the FY 2005 IPPS final rule (67 FR 49026
through 49034).
d. Proposed Revision of the IPF PPS Labor Market Areas
In its June 6, 2003 announcement, OMB cautioned that these new
definitions ``should not be used to develop and implement Federal,
State, and local nonstatistical programs and policies without full
consideration of the effects of using these definitions for such
purposes. These areas should not serve as a general-purpose geographic
[[Page 3635]]
framework for nonstatistical activities, and they may or may not be
suitable for use in program funding formulas.''
We currently use MSAs to define labor market areas for purposes of
Medicare wage indices in the IPF PPS since its implementation for cost
reporting periods beginning on or after January 1, 2005. Until
recently, MSAs were used to define labor market areas for purposes of
the wage index for many of the other Medicare payment systems (for
example, IRF PPS, SNF PPS, HHA PPS, and Outpatient PPS). While we
recognize MSAs are not designed specifically to define labor market
areas, we believe they represent a useful proxy for this purpose,
because they are based upon characteristics we believe also generally
reflect the characteristics of unified labor market areas. For example,
CBSAs consist of a core population plus an adjacent territory that
reflects a high degree of social and economic integration. This
integration is measured by commuting ties, thus demonstrating that
these areas may draw workers from the same general areas. In addition,
the most recent CBSAs reflect the most up-to-date information. Our
analysis and discussion here are focused on issues related to adopting
the new CBSA designations to define labor market areas for the purposes
of the IPF PPS.
Historically, Medicare PPSs have utilized Metropolitan Area
definitions developed by the OMB. As noted above, the labor market
areas currently used under the IPF PPS are based on the Metropolitan
Area definitions issued by the OMB and the OMB reviews its Metropolitan
Area definitions preceding each decennial census to reflect more recent
population changes. The CBSAs are OMB's latest Metropolitan Area
definitions based on the Census 2000 data. Because we believe that the
OMB's latest Metropolitan Area designations more accurately reflect the
local economies and wage levels of the areas in which hospitals are
currently located, we adopted revised labor market area designations
based on the OMB's CBSA designations under the IPPS effective October
1, 2004. When we implemented the wage index adjustment at Sec.
412.424(d)(1)(i) under the IPF PPS final rule (69 FR 66952 through
66954), we explained that the IPF PPS wage index adjustment was
intended to reflect the relative hospital wage levels in the geographic
area of the hospital as compared to the national average hospital wage
level. The OMB's CBSA designations based on Census 2000 data reflect
the most recent available geographic classifications (Metropolitan Area
definitions). Therefore, we are proposing to revise the labor market
area definitions used under the IPF PPS based on the OMB's CBSA
designations. This change would ensure that the IPF PPS wage index
adjustment most appropriately accounts for and reflects the relative
hospital wage levels in the geographic area of the hospital as compared
to the national average hospital wage level.
Specifically, we are proposing to revise the IPF PPS labor market
definitions based on the OMB's new CBSA designations (as discussed in
greater detail below) effective for IPF PPS discharges occurring on or
after July 1, 2006. Accordingly, we are proposing to revise Sec.
412.402, definitions for rural and urban areas, effective for
discharges occurring on or after July 1, 2006 would be defined in Sec.
412.64(b)(1)(ii)(A) through (C). These definitions are the labor market
definitions based on OMB's CBSA designations. For clarity, we are
proposing to revise the regulation text to explicitly reference urban
and rural definitions for a cost reporting period beginning on or after
January 1, 2005, with respect to discharges occurring during the period
covered by such cost reports but before July 1, 2006 under Sec.
412.62(f)(1)(ii) and Sec. 412.62(f)(1)(iii).
We note that these are the same labor market area definitions
(based on the OMB's new CBSA designations) implemented for acute care
hospitals under the IPPS at Sec. 412.64(b), which were effective for
those hospitals beginning October 1, 2004 as discussed in the FY 2005
IPPS final rule (69 FR 49026-49034). The IPF PPS uses the acute care
inpatient hospitals' wage data in calculating the IPF PPS wage index.
However, unlike the IPPS, and similar to other Medicare payment systems
(for example, SNF PPS and IRF PPS), the IPF PPS uses the pre-floor,
pre-reclassified hospital wage index.
Below, we discuss the composition of the proposed IPF PPS labor
market areas based on OMB's new CBSA designations. It should be noted
that OMB's new CBSA designations are comprised of several county-based
area definitions as explained above, which include Metropolitan Areas,
Micropolitan Areas, and areas ``outside CBSAs.'' We implemented the IPF
PPS using two types of labor market areas, that is, urban and rural. In
this proposed rule, we are proposing to adopt the revised labor market
areas based on OMB's new CBSA-based designations. We are also proposing
to continue to have 2 types of labor market areas (urban and rural). In
the discussion that follows, we explain our proposal to recognize
Metropolitan Areas, which include New England MSAs and Metropolitan
Divisions, as urban. We also explain our proposal to recognize
Micropolitan Areas and areas ``outside CBSAs'' as rural. The following
discussion describes the proposed methodology for mapping OMB's CBSA-
based designations into the IPF PPS (urban area or rural area) format.
i. New England MSAs
As stated above, we currently use NECMAs to define labor market
areas in New England, because these are county-based designations,
rather than the 1990 MSA definitions for New England, which used minor
civil divisions such as cities and towns. Under the current MSA
definitions, NECMAs provided more consistency in labor market
definitions for New England compared with the rest of the country,
where MSAs are county-based. Under the new CBSAs, the OMB has now
defined the MSAs and Micropolitan Areas in New England on the basis of
counties. The OMB also established New England City and Town Areas,
which are similar to the previous New England MSAs.
In order to create consistency across all IPF labor market areas,
we are proposing to use the county-based areas for all MSAs in the
nation, including those in New England. The OMB has now defined the New
England area based on counties, creating a city- and town-based system
as an alternative. We believe that adopting county-based labor market
areas for the entire country except those in New England would lead to
inconsistencies in our designations. Adopting county-based labor market
areas for the entire country provides consistency and stability in
Medicare program payment because all of the labor market areas
throughout the country, including New England, would be defined using
the same system (that is, counties) rather than different systems in
different areas of the county, and minimizes programmatic complexity.
In addition, we have consistently employed a county-based system
for New England for precisely that reason: to maintain consistency with
the labor market definitions used throughout the country. Since we have
never used cities and towns for defining IPF labor market areas,
employing a county-based system in New England maintains that
consistent practice. We note that this is consistent with the
implementation of the CBSA-based designations under the IPPS for New
England (69 FR 49028). Accordingly, for the IPF PPS, we are proposing
to use the New England MSAs as determined under the proposed new CBSA-
based labor market area definitions in defining the
[[Page 3636]]
proposed revised IPF PPS labor market areas.
ii. Metropolitan Divisions
Under OMB's new CBSA designations, a Metropolitan Division is a
county or group of counties within a CBSA that contains a core
population of at least 2.5 million, representing an employment center,
plus adjacent counties associated with the main county or counties
through commuting ties. A county qualifies as a main county if 65
percent or more of its employed residents work within the county and
the ratio of the number of jobs located in the county to the number of
employed residents is at least 0.75. A county qualifies as a secondary
county if 50 percent or more, but less than 65 percent, of its employed
residents work within the county and the ratio of the number of jobs
located in the county to the number of employed residents is at least
0.75. After all the main and secondary counties are identified and
grouped, each additional county that already has qualified for
inclusion in the MSA falls within the Metropolitan Division associated
with the main/secondary county or counties with which the county at
issue has the highest employment interchange measure. Counties in a
Metropolitan Division must be contiguous (65 FR 82236).
The construct of relatively large MSAs being comprised of
Metropolitan Divisions is similar to the current construct of CMSAs
comprised of PMSAs. As noted above, in the past, the OMB designated
CMSAs as Metropolitan Areas with a population of 1 million or more and
comprised of two or more PMSAs. Under the IPF PPS, we currently use the
PMSAs rather than CMSAs to define labor market areas because they
comprise a smaller geographic area with potentially varying labor costs
due to different local economies. We believe that CMSAs may be too
large of an area with a relatively large number of hospitals, to
accurately reflect the local labor costs of all of the individual
hospitals included in that relatively ``large'' area. A large market
area designation increases the likelihood of including many hospitals
located in areas with very different labor market conditions within the
same market area designation. This variation could increase the
difficulty in calculating a single wage index that would be relevant
for all hospitals within the market area designation. Similarly, we
believe that MSAs with a population of 2.5 million or greater may be
too large of an area to accurately reflect the local labor costs of all
of the individual hospitals included in that relatively ``large'' area.
Furthermore, as indicated above, Metropolitan Divisions represent the
closest approximation to PMSAs, the building block of the current IPF
PPS labor market area definitions, and therefore, would most accurately
maintain our current structuring of the IPF PPS labor market areas.
Therefore, as implemented under the IPPS (69 FR 49029), we are
proposing to use the Metropolitan Divisions where applicable (as
described below) under the proposed new CBSA-based labor market area
definitions.
In addition to being comparable to the organization of the labor
market areas under current MSA designations (that is, the use of PMSAs
rather than CMSAs), we believe that using Metropolitan Divisions where
applicable (as described below) under the IPF PPS would result in a
more accurate adjustment for the variation in local labor market areas
for IPFs. Specifically, if we would recognize the relatively ``larger''
CBSA that comprises two or more Metropolitan Divisions as an
independent labor market area for purposes of the wage index, it would
be too large and would include the data from too many hospitals to
compute a wage index that would accurately reflect the various local
labor costs of all of the individual hospitals included in that
relatively ``large'' CBSA. As mentioned earlier, a large market area
designation increases the likelihood of including many hospitals
located in areas with very different labor market conditions within the
same market area designation. This variation could increase the
difficulty in calculating a single wage index that would be relevant
for all hospitals within the market area designation. Rather, by
proposing to recognize Metropolitan Divisions where applicable (as
described below) under the proposed new CBSA-based labor market area
definitions under the IPF PPS, we believe that in addition to more
accurately maintaining the current structuring of the IPF PPS labor
market areas, the local labor costs would be more accurately reflected,
thereby resulting in a wage index adjustment that better reflects the
variation in the local labor costs of the local economies of the IPFs
located in these relatively ``smaller'' areas.
Below we describe where Metropolitan Divisions would be applicable
under the proposed new CBSA-based labor market area definitions under
the IPF PPS.
Under OMB's new CBSA-based designations, there are 11 MSAs
containing Metropolitan Divisions: Boston; Chicago; Dallas; Detroit;
Los Angeles; Miami; New York; Philadelphia; San Francisco; Seattle; and
Washington, DC. Although these MSAs were also CMSAs under the prior
definitions, in some cases these areas have been significantly altered.
Under the current IPF PPS MSA designations, Boston is a single NECMA.
Under the proposed CBSA-based labor market area designations, it would
be comprised of four Metropolitan Divisions. Los Angeles would go from
four PMSAs under the current IPF PPS MSA designations to two
Metropolitan Divisions under the proposed CBSA-based labor market area
designations because two MSAs became separate MSAs. The New York CMSA
would go from 15 PMSAs under the current IPF PPS MSA designations down
to only four Metropolitan Divisions under the proposed CBSA-based labor
market area designations. The five PMSAs in Connecticut under the
current IPF PPS MSA designations would become separate MSAs under the
proposed CBSA-based labor market area designations, and the number of
PMSAs in New Jersey under the current IPF PPS MSA designations would go
from five to two, with the consolidation of two New Jersey PMSAs
(Bergen-Passaic and Jersey City) into the New York-Wayne-White Plains,
NY-NJ Division, under the proposed CBSA-based labor market area
designations. In San Francisco, under the proposed CBSA-based labor
market area designations, there are only two Metropolitan Divisions.
Currently, there are six PMSAs, some of which are now separate MSAs
under the current IPF PPS labor market area designations.
Under the current IPF PPS labor market area designations,
Cincinnati, Cleveland, Denver, Houston, Milwaukee, Portland,
Sacramento, and San Juan are all designated as CMSAs, but would no
longer be designated as CMSAs under the proposed CBSA-based labor
market area designations. As noted previously, the population threshold
to be designated as a CMSA under the current IPF PPS labor market area
designations is 1 million. In most of these cases, counties currently
in a PMSA under the current IPF PPS labor market area designations
would become separate, independent MSAs under the proposed CBSA-based
labor market area designations.
iii. Micropolitan Areas
Under OMB's new CBSA-based designations, Micropolitan Areas are
essentially a third area definition consisting primarily of currently
rural areas, but also include some or all of
[[Page 3637]]
areas that are currently designated as an urban MSA. As discussed in
greater detail in the FY 2005 IPPS final rule (69 FR 49029 through
49032), how these areas are treated would have significant impacts on
the calculation and application of the wage index. Specifically,
whether or not Micropolitan Areas are included as part of the
respective statewide rural wage indices would impact the value of
statewide rural wage index of any State that contains a Micropolitan
Area because a hospital's classification as urban or rural affects
which hospitals' wage data are included in the statewide rural wage
index. As discussed above in section IV.C.1.b. we combine all of the
counties in a State outside a designated urban area together to
calculate the statewide rural wage index for each State.
Including Micropolitan Areas as part of the statewide rural labor
market area would result in an increase to the statewide rural wage
index because hospitals located in those Micropolitan Areas typically
have higher labor costs than other rural hospitals in the State.
Alternatively, if Micropolitan Areas would be recognized as independent
labor market areas, because there would be so few hospitals in each
labor market area, the wage indices for IPFs in those areas could
become relatively unstable as they would change considerably from year
to year.
We currently use MSAs to define urban labor market areas and group
all the hospitals in counties within each State that are not assigned
to an MSA together into a statewide rural labor market area. We have
used the terms ``urban'' and ``rural'' wage indexes in the past for
ease of reference. However, the introduction of Micropolitan Areas by
the OMB potentially complicates this terminology because these areas
include many hospitals that are currently included in the statewide
rural labor market areas.
We are proposing to treat Micropolitan Areas as rural labor market
areas under the IPF PPS for the reasons outlined below. That is,
counties that are assigned to a Micropolitan Area under the CBSA-based
designations would be treated the same as other ``rural'' counties that
are not assigned to either an MSA (Metropolitan Statistical Area) or a
Micropolitan Area. Therefore, in determining an IPF's applicable wage
index (based on IPPS hospital wage index data), we are proposing that
an IPF in a Micropolitan Area under OMB's CBSA-based designations would
be classified as ``rural'' and would be assigned the statewide rural
wage index for the State in which it resides.
In the FY 2005 IPPS final rule (69 FR 49029 through 49032), we
discuss our evaluation of the impact of treating Micropolitan Areas as
part of the statewide rural labor market area instead of treating
Micropolitan Areas as independent labor market areas for hospitals paid
under the IPPS. As discussed in that same final rule, one of the
reasons Micropolitan Areas have such a dramatic impact on the wage
index is because Micropolitan Areas encompass smaller populations than
MSAs. In addition, they tend to include fewer hospitals per
Micropolitan Area. Currently, there are only 25 MSAs with one hospital
in the MSA. However, under the new proposed CBSA-based definitions,
there are 373 Micropolitan Areas with one hospital, and 49 MSAs with
only one hospital.
Since Micropolitan Areas encompass smaller populations than MSAs,
they tend to include fewer hospitals per Micropolitan Area, recognizing
Micropolitan Areas as independent labor market areas would generally
increase the potential for dramatic shifts in those areas' wage indices
from one year to the next because a single hospital (or group of
hospitals) could have a disproportionate effect on the wage index of
the area. The large number of labor market areas with only one hospital
and the increased potential for dramatic shifts in the wage indexes
from 1 year to the next is a problem for several reasons. First, it
creates instability in the wage index from year to year for a large
number of hospitals. Second, it reduces the averaging effect (averaging
effect allows for more data points to be used to calculate a
representative standard of measured labor costs within a market area.)
lessening some of the incentive for hospitals to operate efficiently.
This incentive is inherent in a system based on the average hourly
wages for a large number of hospitals, as hospitals could profit more
by operating below that average. In labor market areas with a single
hospital, high wage costs are passed directly into the wage index with
no counterbalancing averaging with lower wages paid at nearby competing
hospitals. Third, it creates an arguably inequitable system when so
many hospitals have wage indexes based solely on their own wages, while
other hospitals' wage indexes are based on an average hourly wage
across many hospitals.
For the reasons noted above, and consistent with the treatment of
these areas under the IPPS, we are proposing not to adopt Micropolitan
Areas as independent labor market areas under the IPF PPS. However, we
are proposing that Micropolitan Areas, under the CBSA-based labor
market area definitions, would be considered part of the statewide
rural labor market area. Accordingly, we are proposing that the IPF PPS
statewide rural wage index would be determined using acute-care IPPS
hospital wage data (the rationale for using IPPS hospital wage data is
discussed in greater detail above in section IV.C.1.d.iii of this
proposed rule) from hospitals located in non-MSA areas (for example,
rural areas, including Micropolitan Areas) and that statewide rural
wage index would be assigned to IPFs located in those non-MSA areas.
e. Implementation of the Proposed Revised Labor Market Areas Under the
IPF PPS
Section 124 of the BBRA, is broadly written and gives the Secretary
discretion in developing and making adjustments to the IPF PPS.
When the revised labor market areas based on the OMB's new CBSA-
based designations were adopted under the acute care hospital IPPS
beginning on October 1, 2004, a transition to the new labor market area
designations was established due to the scope and substantial
implications of these new boundaries and to buffer the subsequent
significant impacts it may have on payments to numerous hospitals. As
discussed in the FY 2005 IPPS final rule (69 FR 49032), during FY 2005,
a blend of wage indexes is calculated for those acute care IPPS
hospitals experiencing a drop in their wage indexes because of the
adoption of the new labor market areas.
While we recognize that, just like IPPS hospitals, some IPFs may
experience decreases in their wage index as a result of the proposed
labor market area changes, our analysis shows that a majority of IPFs
either expect no change in wage index or an increase in wage index
based on CBSA definitions. In addition, a very small number of IPFs
(fewer than 3 percent) would experience a decline of 5 percent or more
in the wage index based on CBSA designations. We also found that a very
small number of IPFs (approximately 5 percent) would experience a
change in either rural or urban designation under the CBSA-based
definitions. Since a majority of IPFs would not be significantly
impacted by the proposed labor market areas, we believe it is not
necessary to propose a transition to the proposed new CBSA-based labor
market area for the purposes of the IPF PPS wage index.
In addition, because we are in the midst of a transition to a full
wage-index
[[Page 3638]]
adjustment under the IPF PPS, we believe that the effects on the IPF
PPS wage index from the proposed changes to the IPF PPS labor market
areas definitions would be mitigated. Specifically, most IPFs would be
in their FY 2006 cost reporting period and therefore would be in the
second year of the 3-year phase-in of the IPF PPS wage index adjustment
when the revised labor market area designations would be applied.
During the second year of the transition to the IPF PPS, the applicable
wage index value is one-half (50 percent) of the applicable full IPF
PPS wage index adjustment. Since most IPFs would be in the second year
of the 3-year phase-in of the wage index adjustment, for most IPFs, the
labor-related portion of the standard Federal rate is only adjusted by
50 percent of the applicable full wage index (that is, one-half wage
index value). As noted above, the IPF PPS wage index adjustment is made
by multiplying the labor-related share of the IPF PPS standard Federal
per diem base rate by the applicable wage index value, and the proposed
IPF PPS labor related-share is 75.923 percent. Consequently, for most
IPFs, only 38 percent of the standard Federal per diem base rate is
affected by the wage index adjustment (75.923 percent x 0.50 = 37.9615
percent), and the proposed revision to the labor market area
definitions based on OMB's new CBSA-based designations would only have
a minimal impact on IPF PPS payments. Therefore, because the impact of
the proposed revision to the labor market area definitions would only
have a minimal impact on IPF PPS payments, we do not believe it is
necessary to propose a transition policy for the proposed revision to
the IPF PPS labor market area definitions.
For the reasons discussed above, we are not proposing a transition
under the IPF PPS from the current MSA-based labor market areas
designations to the new CBSA-based labor market area designations.
Rather, we are proposing under the IPF PPS to adopt the new CBSA-based
labor market area definitions beginning with the July 1, 2006 IPF PPS
rate year without a transition period.
As discussed below, the IPPS adopted a hold-harmless policy and an
``out-commuting'' adjustment. We are also not proposing a hold harmless
policy or an ``out-commuting'' adjustment under the IPF PPS from the
current MSA-based labor market areas designations to the new CBSA-based
labor market area designations as discussed below. We are proposing to
adopt the new CBSA-based labor market area definitions beginning with
the July 1, 2006 IPF PPS rate year without a hold harmless policy and
without an ``out-commuting'' adjustment.
We believe that our proposed policies are appropriate for IPFs
because, despite some similarities between the IPF PPS and the IPPS,
there are clear distinctions between the payment systems, particularly
regarding wage index issues. Where a wage index adjustment has been a
stable feature of the acute care hospital IPPS since its 1983
implementation and had utilized the prior MSA-based labor market area
designation for over 10 years, this is not the case for the IPF PPS,
which has only been implemented since January 1, 2005.
The most significant distinction between acute care hospitals under
the IPPS and IPFs under the IPF PPS, is that acute care hospitals have
been paid using full wage index adjusted payments since 1983 and had
used the previous IPPS MSA-based labor market area designations for
over 10 years, whereas under the IPF PPS, a wage index adjustment is
being phased-in over a 3-year period. As previously explained, the
impact that the wage index can have on IPF PPS payments is limited at
this point, since only a small percentage of the IPF PPS Federal per
diem base rate is affected by the wage index (approximately 38 percent
in most cases) because of the 3-year phase-in of the wage index
adjustment. In contrast, a transition policy to the revised IPPS labor
market area definitions under the IPPS was appropriate because there is
no phase-in of a wage index adjustment under the IPPS and the full
labor-related share of the IPPS standardized amount (that is, Federal
rate) is affected by the IPPS wage index adjustment, which resulted in
a more significant projected impact for acute care hospitals under the
IPPS.
As discussed in the August 11, 2004 IPPS final rule (69 FR 49032),
during FY 2005, a hold harmless policy was implemented to minimize the
overall impact of hospitals that were in FY 2004 designated as urban
under the MSA designations, but would become rural under the CBSA
designations. In the same final rule, hospitals were afforded a 3-year
hold harmless policy because the IPPS determined that acute-care
hospitals that changed designations from urban to rural would be
substantially impacted by the significant change in wage index.
Currently, under the IPF PPS urban facilities that become rural would
receive the rural facility adjustment (that is, 17 percent). As
discussed in section IV.C.2 of this proposed rule, we are proposing to
keep the rural adjustment at 17 percent. The rural facility adjustment
would be applied in the same way to urban facilities that would become
rural under the CBSA-based definitions, if we were to adopt them. Thus,
we believe that the impact on any urban facilities that become rural
under the new definitions would be mitigated by the rural adjustment.
Therefore, we do not believe it is appropriate or necessary to adopt a
hold harmless policy for facilities that would experience a change in
designation under the CBSA-based definitions.
In addition, we note that section 505 of the MMA established new
section 1886(d)(13) of the Act. The new section 1886(d)(13) of the Act
requires that the Secretary establish a process to make adjustments to
the hospital wage index based on commuting patterns of hospital
employees. We believe that this requirement for an ``out-commuting'' or
``out-migration'' adjustment applies specifically to the IPPS.
Therefore, we are not proposing an adjustment for the IPF PPS.
We note that for the CBSA designations, we identified some
geographic areas where there were no hospitals, and thus no hospital
wage index data on which to base the calculation of the July 1, 2006
rate year IPF PPS proposed wage index. In addressing this situation, we
are proposing approaches that we believe serve as proxies for hospital
wage data and would provide an appropriate standard that accounts for
geographic variation in labor costs.
The first situation involves rural locations in Massachusetts and
Puerto Rico. We have determined that there are no rural hospitals in
those locations. Since there is no reasonable proxy for more recent
rural data within those areas, we are proposing to use last year's wage
index value for rural Massachusetts and rural Puerto Rico. This
approach is consistent with other Medicare PPSs (for example, SNF PPS
and IRF PPS).
The second situation has to do with the urban area of Hinesville,
GA (CBSA 25980). Under the proposed new labor market areas there are no
urban hospitals within this area. We propose to use all of the urban
areas within the State to serve as a reasonable proxy for the urban
areas without specific hospital wage index data in determining the IPF
PPS wage index. Therefore, in this proposed rule, we are calculating
the urban wage index value for purposes of the wage index for these
areas without urban hospital data as the average wage index for all
urban areas within the State. This approach is consistent with other
Medicare PPSs
[[Page 3639]]
(for example, SNF PPS and IRF PPS). We could not apply a similar
averaging in rural areas because in the rural areas there are no State
rural hospital wage data available for averaging on a State-wide basis.
We solicit comments on these approaches to calculating the wage index
values for areas without hospitals for RY 2007 and subsequent years.
To facilitate an understanding of the proposed policies related to
the proposed change to the IPF PPS labor market areas discussed above,
in the MSA/CBSA Crosswalk included as Addendum B of this proposed rule,
we are providing a listing of each Social Security Administration (SSA)
State and county location code; State and county name; existing MSA-
based labor market area designation; MSA-based wage index value; CBSA-
based labor market area; and the new CBSA-based wage index value. We
are also providing in Addenda C1 and C2 the proposed wage index for
urban and rural areas based on CBSA labor market areas.
f. Wage Index Budget Neutrality
Any proposed adjustment or update to the IPF wage index would be
made in a budget neutral manner that assures that the estimated
aggregated payments under this subsection in the RY beginning July 1,
2006 are not greater or less than those that would have been made in
the year without such an adjustment. Therefore, we would calculate a
budget-neutral wage index adjustment factor. We propose to calculate
this factor using the following steps:
Steps 1: Determine the total amount of the estimated IPF PPS
payments for the implementation year using the labor-related share and
wage indices from FY 2005 (based on MSAs).
Step 2: Calculate the total amount of estimated IPF PPS payments
for RY 2007 using the proposed labor-related share and wage indices
from FY 2006 (based on CBSAs).
Step 3: Divide the amount calculated in Step 1 by the amount
calculated in Step 2 which yields a RY 2007 budget-neutral wage
adjustment of 1.00156.
This factor would be applied in the update of the Federal per diem
base rate for RY 2007.
1. Proposed Adjustment for Rural Location
In the IPF PPS Final Rule (69 FR 66954), we provided a 17 percent
payment adjustment for IPFs located in a rural area. This adjustment
was based on the regression analysis which indicated that the per diem
cost of rural facilities was 17 percent higher than that of urban
facilities after accounting for the influence of the other variables
included in the regression. Many rural IPFs are small psychiatric units
within small general acute care hospitals. We also stated in the IPF
PPS final rule that small-scale facilities are more costly on a per
diem basis because there are minimum levels of fixed costs that cannot
be avoided, and they do not have the economies of size advantage.
Based on the results of our regression analysis for the final rule
using the most recent complete data available (that is, FY 2002 data),
we provided a payment adjustment for IPFs located in rural areas of 17
percent. In this proposed rule, we are not proposing to change this
adjustment factor. In addition, we stated that we do not intend to
conduct another regression analysis until we are able to analyze 1 year
of IPF PPS claims and cost report data. At that time, we can compare
rural and urban IPFs to determine how much more costly rural facilities
are on a per diem basis under the IPF PPS. In the meantime, we are
proposing to apply a 17 percent payment adjustment for IPFs located in
a rural area as defined at Sec. 412.64(b)(1)(ii)(C).
2. Proposed Teaching Adjustment
In the IPF PPS final rule, we established a facility-level
adjustment for IPFs that are, or are part of, teaching institutions.
The teaching status adjustment accounts for the higher indirect
operating costs experienced by facilities that participate in graduate
medical education (GME) programs. We have received numerous requests
for clarification of the IPF PPS teaching adjustment, especially with
regard to comparisons with the IPPS IME adjustment that were included
in the IPF PPS final rule. As a result, we are including an expanded
explanation of the IPF PPS teaching status adjustment and are proposing
clarifying changes to Sec. 412.424(d)(1)(iii) regarding the teaching
adjustment.
Medicare makes direct GME payments (for direct costs such as
resident and teaching physician salaries, and other direct teaching
costs) to all teaching hospitals including those paid under the IPPS,
and those that were once paid under the TEFRA rate-of-increase limits
but are now paid under other PPSs. These direct GME payments are made
separately from payments for hospital operating costs and are not part
of the PPSs. However, the direct GME payments do not address the higher
indirect operating costs experienced by teaching hospitals. For
teaching hospitals paid under the TEFRA rate-of-increase limits,
Medicare did not make separate medical education payments because
payments to these hospitals were based on the hospitals' reasonable
costs. Since payments under TEFRA were based on hospitals' reasonable
costs, the higher indirect costs that might be associated with teaching
programs would automatically have been factored into the TEFRA
payments.
As previously mentioned, we conducted regression analysis of FY
2002 IPF data as the basis for the payment adjustments included in the
IPF PPS final rule. In conducting the analysis, we used the resident
counts reported on hospital cost reports (worksheet S-3, Part 1, line
12, column 7 for freestanding psychiatric hospitals and worksheet S-3,
Part 1, line 14 (or line 14.01 for subprovider 2), column 7 for
psychiatric units of acute care hospitals). That is, for the
freestanding psychiatric hospitals, we used the number of residents and
interns reported for the entire hospital. For the psychiatric units of
acute care hospitals, we used the number of residents and interns
reported for the psychiatric unit, which are reported separately on the
cost report from the number reported for the rest of the hospital.
The regression analysis (with the logarithm of costs as the
dependent variable) showed that the indirect teaching cost variable is
significant in explaining the higher costs of IPFs that have teaching
programs. We calculated the teaching adjustment based on the IPF's
``teaching variable,'' which is one plus the ratio of the number of
full-time equivalent (FTE) residents training in the IPF (subject to
limitations described below) to the IPF's average daily census (ADC).
In the cost regressions conducted for the IPF PPS final rule, the
logarithm of the teaching variable had a coefficient value of 0.5150.
We converted this cost effect to a teaching payment adjustment by
treating the regression coefficient as an exponent and raising the
teaching variable to a power equal to the coefficient value. In other
words, the teaching adjustment is calculated by raising the teaching
variable (1 + FTE residents/ADC) to the 0.5150 power. To compute the
percentage increase in the IPF PPS payment attributable to the teaching
adjustment (that is, the amount to be reconciled at cost report
settlement), raise the teaching variable (1 + FTE residents/ADC) to the
0.5150 power. For example, for an IPF with a teaching variable of 0.10
and using a coefficient value of 0.5150, the per diem payment would
increase by 5.03 percent; for an IPF with a teaching variable of 0.05,
the per diem payment would increase by 2.54 percent. We note
[[Page 3640]]
that the coefficient value of 0.5150 was based on regression analysis
holding all other components of the payment system constant.
In addition, we established the teaching adjustment in a manner
that limited the incentives for IPFs to add FTE residents for the
purpose of increasing their teaching adjustment. We imposed a cap on
the number of FTE residents that may be counted for purposes of
calculating the teaching adjustment, similar to that established by
sections 4621 (IME FTE cap for IPPS hospitals) and 4623 (direct GME FTE
cap for all hospitals) of the BBA. We emphasize that the cap limits the
number of FTE residents that teaching IPFs may count for the purposes
of calculating the IPF PPS teaching adjustment, not the number of
residents teaching institutions can hire or train.
The FTE resident cap is applied the same way in freestanding
teaching psychiatric hospitals and in distinct part psychiatric units
with GME programs. Similar to the regulations for counting FTE
residents under the IPPS as described in Sec. 412.105(f), we
calculated the number of FTE residents that trained in the IPF during a
``base year'' and use that FTE resident number as the cap. An IPF's FTE
resident cap would ultimately be determined based on the final
settlement of the IPF's most recent cost report filed before November
15, 2004 (that is, the publication date of the IPF PPS final rule).
Similar to teaching hospitals under the IPPS, IPFs that first begin
training residents after November 15, 2004 initially receive an FTE cap
of ``0''. The FTE caps for teaching IPFs (whether they are new or
existing IPFs) that start training residents in a new GME program (may
be subsequently adjusted in accordance with the IPPS policies described
in Sec. 412.105(f)(1)(vii) and GME policies described in Sec.
413.79(e)(1)(i) and (ii). For purposes of this section, a new medical
residency training program means a medical residency that receives
initial accreditation by the appropriate accrediting body or begins
training residents on or after November 15, 2004. However, contrary to
the policy for IME FTE resident caps under the IPPS, we do not allow
IPFs to aggregate the FTE resident caps used to compute the IPF PPS
teaching adjustment through affiliation agreements. We included these
policies because we believe it is important to limit the total pool of
resident FTE cap positions within the IPF community and avoid
incentives for IPFs to add FTE residents in order to increase their
payments.
Residents with less than full-time status and residents rotating
through the psychiatric hospital or unit for less than a full year are
counted in proportion to the time they spend in their assignment with
the IPF (for example, a resident on a full-time, 3-month rotation to
the IPF would be counted as 0.25 FTE for purposes of counting residents
to calculate the ratio). No FTE resident time counted for purposes of
the IPPS IME adjustment is counted for purposes of the teaching status
adjustment for the IPF PPS.
As noted previously, the denominator used to calculate the teaching
adjustment under the IPF PPS is the IPF's average daily census (ADC)
from the current cost reporting period. We chose to use the ADC because
it is closely related to the IPF's patient load, which affects the
number of interns and residents the IPF can train. We also believe the
ADC is a measure that can be defined precisely and is difficult to
manipulate. Although the IPPS IME adjustment uses the hospital's number
of beds as the denominator, the capital PPS (as specified at Sec.
412.322) and the IRF PPS (as specified at Sec. 412.624(e)(4) both use
the ADC as the denominator for the indirect medical education and
teaching adjustments, respectively.
If a psychiatric hospital's or unit's FTE count of residents in a
given year is higher than the FTE count in the base year (the base year
being used to establish the cap), we base payments in that year on the
lower number (the cap amount). This approach is consistent with the IME
adjustment under the IPPS and the teaching adjustment under the IRF
PPS. The IPF remains free to add FTE residents above the cap amount,
but it cannot count the number of FTE residents above the cap for
purposes of calculating the teaching adjustment. This means that the
cap serves as an upper limit on the number of FTE residents that may be
counted for purposes of calculating the teaching status adjustment.
IPFs can adjust their number of FTE residents counted for purposes of
calculating the teaching adjustment as long as they remain under the
cap. On the other hand, if a psychiatric hospital or unit were to have
fewer FTE residents in a given year than in the base year (that is,
fewer residents than its FTE resident cap), teaching adjustment
payments in that year would be based on the lower number (that is, the
current year's FTE count of resident).
In response to inquiries about how the teaching adjustment is
applied under the IPF PPS, we are proposing to add a new paragraph
Sec. 412.424(d)(1)(iii)(E) to clarify that the teaching adjustment is
made on a claim basis as an interim payment and the final payment for
the claim would be made in full during the final settlement of the cost
report. The difference between those interim payments and the actual
teaching adjustment amount computed in the cost report would be
adjusted through lump sum payments/recoupments when the cost report is
filed and later settled.
As noted in section III.B.3 of this proposed rule, in reviewing the
methodology used to simulate the IPF PPS payments used for the IPF PPS
final rule, we discovered that the computer code incorrectly assigned
non-teaching status to most teaching facilities. As a result, total IPF
PPS payments were underestimated by about 1.36 percent. To resolve the
issue, as discussed in section III.B.3 of this proposed rule, we are
proposing to amend the Federal per diem base rate prospectively for all
IPFs.
As with other adjustment factors derived through the regression
analysis, we do not intend to rerun the regression analysis until we
can analyze 1 year of IPF PPS claims and cost report data. Until then,
we are proposing to retain the 0.5150 teaching adjustment to the
Federal per diem base rate.
3. Proposed Cost of Living Adjustment for IPFs Located in Alaska and
Hawaii
The IPF PPS includes a payment adjustment for IPFs located in
Alaska and Hawaii based upon the county in which the IPF is located. As
we explained in the IPF PPS final rule, the FY 2002 data demonstrated
that IPFs in Alaska and Hawaii had per diem costs that were
disproportionately higher than other IPFs. Other Medicare prospective
payment systems (for example, IPPS and IRF PPS) have adopted a cost of
living adjustment (COLA) to account for the cost differential of care
furnished in Alaska and Hawaii. We analyzed the effect of applying a
COLA to payments for IPFs located in Alaska and Hawaii. The results of
our analysis demonstrated that a COLA for IPFs located in Alaska and
Hawaii would improve payment equity for these facilities. As a result
of this analysis, we provided a COLA adjustment in the IPF PPS final
rule.
In general, the COLA would account for the higher costs in the IPF
and eliminate the projected loss that IPFs in Alaska and Hawaii would
experience absent the COLA. A COLA adjustment for IPFs located in
Alaska and Hawaii is made by multiplying the non-labor share of the
Federal per diem base rate by the applicable COLA factor based on the
county in which the IPF is located.
Table 14 lists the specific COLA for Alaska and Hawaii IPFs. The
COLA factors were obtained from the U.S.
[[Page 3641]]
Office of Personnel Management (OPM). The COLA factors are published on
the U.S. Office of Personnel Management (OPM) website (http://www.opm.gov/oca/cola/rates.asp
). We are proposing to adopt the COLA
adjustments obtained from OPM. We propose to update the COLA factors if
OPM updates them and as updated by OPM. Any change in the COLA factors
would be made in one of our IPF PPS RY update documents. We are
proposing to amend Sec. 412.428 to update the COLA factors if
appropriate.
Table 14.--Proposed COLA Factors for Alaska and Hawaii IPFs
------------------------------------------------------------------------
Location COLA
------------------------------------------------------------------------
Alaska:
All areas............................................... 1.25
Hawaii:
Honolulu County......................................... 1.25
Hawaii County........................................... 1.165
Kauai County............................................ 1.2325
Maui County............................................. 1.2375
Kalawao County.......................................... 1.2375
------------------------------------------------------------------------
4. Proposed Adjustment for IPFs With a Qualifying Emergency Department
(ED)
Currently, the IPF PPS includes a facility-level adjustment for
IPFs with qualifying EDs. As explained in the IPF PPS final rule, we
provide an adjustment to the standardized Federal per diem base rate to
account for the costs associated with maintaining a full-service ED.
The adjustment is intended to account for ED costs allocated to the
hospital's distinct part psychiatric unit for preadmission services
otherwise payable under Medicare Part B furnished to a beneficiary
during the day immediately preceding the date of admission to the IPF
(see Sec. 413.40(c)) and the overhead cost of maintaining the ED. This
payment is a facility-level adjustment that applies to all IPF
admissions (with the one exception as described below), regardless of
whether a particular patient receives preadmission services in the
hospital's ED.
The ED adjustment is incorporated into the variable per diem
adjustment for the first day of each stay for IPFs with a qualifying
ED. That is, IPFs with a qualifying ED receive a 31 percent adjustment
as the variable per diem adjustment for day 1 of each stay. If an IPF
does not have a qualifying ED, it receives a 19 percent adjustment as
the variable per diem adjustment for day 1 of each patient stay.
While any IPF with a qualifying ED receives the adjustment, the
adjustment is paid most often to IPFs that are psychiatric units of
acute care hospitals or CAHs because these providers are more likely to
have an ED that meets the definition of a qualified ED in Sec.
412.424(d)(1)(v). We defined a qualifying ED in order to avoid
providing the ED adjustment to an intake unit that is not comparable to
a full-service ED with respect to the array of emergency services
available or cost. We defined a qualifying ED as one that is staffed
and equipped to furnish a comprehensive array of emergency services and
that meets the definition of a ``dedicated emergency department'' as
specified in Sec. 489.24(b) and the definition of ``provider-based
status'' as specified in Sec. 413.65. We intended that a qualifying ED
provide a comprehensive array of medical and psychiatric services.
Therefore, in order to clarify that a comprehensive array of
emergency services includes medical as well as psychiatric services, we
are proposing to amend Sec. 412.424(d)(1)(V)(A).
As specified in Sec. 489.24, a dedicated ED means ``any department
or facility of the hospital, regardless of whether it is located on or
off the main hospital campus, that meets at least one of the following
requirements:
It is licensed by the State in which it is located under
applicable State law as an emergency room or emergency department;
It is held out to the public (by name, posted signs,
advertising, or other means) as a place that provides care for
emergency medical conditions on an urgent basis without requiring a
previously scheduled appointment; or
During the calendar year immediately preceding the
calendar year in which a determination under this section is being
made, based on a representative sample of patient visits that occurred
during the calendar year, it provides at least one-third of all its
outpatient visits for the treatment of emergency medical conditions on
an urgent basis without requiring a previously scheduled appointment.''
As specified in Sec. 413.65, provider-based status means ``the
relationship between a main provider and a provider-based entity or a
department of a provider, remote location of a hospital, or satellite
facility that complies with the provisions.'' Including provider-based
status in the definition of a qualifying ED reflects the common
ownership of the hospital and the distinct part psychiatric unit.
As discussed in the IPF PPS final rule, three steps were involved
in the calculation of the ED adjustment factor.
Step 1: We estimated the proportion by which the ED costs of a case
would increase the cost of the first day of the stay. Using the IPFs
with ED admissions in FY 2002, we divided their average ED cost per
stay admitted through the ED ($198) by their average cost per day
($715), which equals 0.28.
Step 2: We adjusted the factor estimated in Step 1 to account for
the fact that we would pay the higher first day adjustment for all
cases in the qualifying IPFs, not just the cases admitted through the
ED. Since on average, 44 percent of the cases in IPFs with ED
admissions are admitted through the ED, we multiplied 0.28 by 0.44,
which equals 0.12.
Step 3: We added the adjusted factor calculated in the previous 2
steps to the variable per diem adjustment derived from the regression
equation that we used to derive our other payment adjustment factors.
The first day payment factor from this regression is 1.19. Adding the
0.12, we obtained a first day variable per diem adjustment for IPFs
with a qualifying ED equal to 1.31.
The ED adjustment is made on every qualifying claim except as
described below. As specified in Sec. 412.424(d)(1)(V)(B), the ED
adjustment is not made where a patient is discharged from an acute care
hospital or CAH and admitted to the same hospital's or CAH's
psychiatric unit. An ED adjustment is not made in this case because the
costs associated with ED services are reflected in the DRG payment to
the acute care hospital or through the reasonable cost payment made to
the CAH. As we explained in the IPF PPS final rule, if we provided the
ED adjustment in these cases, the hospital would be paid twice for the
overhead costs of the ED (69 FR 66960).
Therefore, when patients are discharged from an acute care hospital
or CAH and admitted to the same hospital's or CAH's psychiatric unit,
the IPF receives the 1.19 adjustment factor as the variable per diem
adjustment for the first day of the patient's stay in the IPF. As with
other adjustment factors under the IPF PPS, we do not intend to conduct
a new regression analysis for this IPF PPS update. Rather, we intend to
wait until we can analyze 1 year of IPF PPS claims and cost report
data. Therefore, we are proposing to retain the 1.31 adjustment factor
for IPFs with qualifying EDs for the rate year beginning July 1, 2006.
As we indicated in the final rule, in FY 2002, one third of the IPFs
admissions were through the ED. Commenters on the IPF PPS proposed rule
indicated that the percentage of admissions through the ED were
understated. We plan to monitor claims data to determine the number of
IPF admissions admitted through the ED.
[[Page 3642]]
a. Proposed New Source of Admission Code To Implement the ED Adjustment
In order to ensure that the ED adjustment is not paid for patients
who are discharged from an acute care hospital or CAH and admitted to
the same hospital's or CAH's psychiatric unit, we directed IPFs to
enter source of admission code 4 (transfers from hospital inpatient) on
those claims. The source of admission code is a required field on
Medicare claims and indicates the source of the patient admissions.
However, as we have implemented the IPF PPS, we have realized that
admission code 4 is too broad to distinguish these claims because it
reflects transfers from any acute care hospital or CAH. Currently,
where admission code 4 is entered on a claim, the ED adjustment is not
paid, even if the patient is transferred from a different acute
hospital or CAH.
In order to pay these IPF claims appropriately, CMS requested a new
source of admission code from the National Uniform Billing Committee to
identify transfers from the same hospital or CAH. On June 7, 2005, the
National Uniform Billing Committee granted our request to establish a
new source of admission code to indicate transfers from the same
hospital or CAH. The new source of admission code ``D'' is effective
April 1, 2006. We are proposing that the new code would be used by IPFs
to identify IPF patients who have been transferred to the IPF from the
same hospital or CAH. Claims with source of admission code ``D'' would
not receive the ED adjustment.
b. Applicability of the ED Adjustment to IPFs in Critical Access
Hospitals
The BBA created the CAH program, designed to represent a separate
provider type to provide acute care services in rural areas. Generally,
in order to qualify as a CAH, a hospital must be located in a rural
area, provide 24-hour emergency care services, have an average length
of stay of 96 hours or less, operate up to 25 beds for inpatient
critical access care, be located more than 35 miles from a hospital or
another CAH or more than 15 miles in mountainous terrain or only
secondary roads, or be certified by the State as of December 31, 2005
as being a ``necessary provider'' of health care services to residents
in the area.
Section 405(g) of the MMA authorizes CAHs to establish distinct
part psychiatric and rehabilitation units of up to 10 beds effective
for cost reporting periods beginning on or after October 1, 2004.
Services in these units are paid under the payment methodology that
would apply if such services were provided in a distinct part
psychiatric or rehabilitation unit of a hospital. As a result, IPFs
that are distinct part units of CAHs are paid the same as if they were
a distinct part unit of a hospital. Otherwise, the CAH is paid on a
reasonable cost basis for inpatient critical access services.
In the IPF PPS final rule, we amended Sec. 413.70(e) to clarify
that payments for services of distinct part psychiatric units in CAHs
are made in accordance with the IPF PPS. In order to pay CAHs the same
as other IPFs, CAHs would be subject to the 1-day preadmission services
bundling provision specified in Sec. 413.40(c)(2) for patients who are
admitted to the CAH's IPF. As a result, the cost of preadmission
services, including ED services furnished to CAH IPF patients would be
allocated to the IPF.
D. Other Payment Adjustments and Policies
[If you choose to comment on issues in this section, please include the
caption ``OTHER ADJUSTMENTS AND POLICIES'' at the beginning of your
comments.]
The IPF PPS includes the following payment adjustments: (1) An
outlier policy to promote access to IPF care for those patients who
require expensive care and to limit the financial risk of IPFs treating
unusually costly patients; (2) a stop-loss provision, applicable during
the transition period, to reduce financial risk to IPFs projected to
experience substantial reductions in Medicare payments under the IPF
PPS; (3) an interrupted stay policy to avoid overpaying stays that
include a brief absence from the IPF followed by readmission to the
IPF; and (4) a payment for patients who receive ECT. We are proposing
to update those policies in this proposed rule. We are also proposing
clarifications to the physician certification and recertification
requirements in order to ensure consistent practices across IPFs. In
addition, we are clarifying coverage of recreation therapy.
1. Outlier Payments
In the IPF PPS final rule, we implemented regulations at Sec.
412.424(d)(3)(i) to provide a payment adjustment for IPF stays that
have extraordinarily high costs. Providing additional payments for
outlier cases to IPFs that are beyond the IPF's control strongly
improves the accuracy of the IPF PPS in determining resource costs at
the patient and facility level because facilities receive additional
compensation over and above the adjusted Federal prospective payment
amount for uniquely high-cost cases. These additional payments reduce
the financial losses that would otherwise be caused by treating
patients who require more costly care and, therefore, reduce the
incentives to under-serve these patients.
Under the IPF PPS, outlier payments are made on a per case basis
rather than on a per diem basis because it is the overall financial
``gain'' or ``loss'' of the case, and not of individual days, that
determines an IPF's financial risk. In addition, because patient-level
charges (from which costs are estimated) are typically aggregated for
the entire IPF stay, they are not reported in a manner that would
permit accurate accounting on a daily basis.
Currently, we make outlier payments for discharges in which an
IPF's estimated total cost for a case exceeds a fixed dollar loss
threshold amount (multiplied by the IPF's facility-level adjustments)
plus the Federal per diem payment amount for the case.
In instances when the case qualifies for an outlier payment, we pay
80 percent of the difference between the estimated cost for the case
and the adjusted threshold amount for days 1 through 9 of the stay
(consistent with the median length of stay for IPFs in FY 2002), and 60
percent of the difference for day 10 and thereafter. We established the
80 percent and 60 percent loss sharing ratios because we were concerned
that a single ratio established at 80 percent (like other Medicare
hospital PPSs) might provide an incentive under the IPF per diem
payment system to increase length of stay in order to receive
additional payments. After establishing the loss sharing ratios, we
determined the current fixed dollar loss threshold amount of $5,700
through payment simulations designed to compute a dollar loss beyond
which payments are estimated to meet the 2 percent outlier spending
target.
a. Proposed Update to the Outlier Fixed Dollar Loss Threshold Amount
As indicated in section II.A of this proposed rule, in accordance
with the update methodology described in Sec. 412.428(d), we are
proposing to update the fixed dollar loss threshold amount used under
the IPF PPS outlier policy. Based on the regression analysis and
payment simulations used to develop the IPF PPS, we established a 2
percent outlier policy to make an appropriate balance between
protecting IPFs from extraordinarily costly cases while ensuring the
adequacy of the Federal
[[Page 3643]]
per diem base rate for all other cases that are not outlier cases.
We continue to believe a 2 percent outlier policy is an appropriate
target percentage and are proposing to retain the 2 percent outlier
policy. However, we believe it is necessary to update the fixed dollar
loss threshold amount because analysis of the latest available data
indicates adjusting the fixed dollar loss amount is necessary in order
to maintain an outlier percentage that equals 2 percent of total
estimated IPF PPS payments. We intend to continue to analyze estimated
outlier payments for subsequent years using the best available data in
order to maintain estimated outlier payments at 2 percent of total
estimated IPF PPS payments.
We have determined that in certain sections of the IPF PPS final
rule, we used the phrase ``Fixed-dollar loss threshold'' and, in other
sections, we used the phrase ``Fixed-dollar loss amount'' to describe
the dollar amount by which the costs of a case exceed payment in order
to qualify for an outlier payment. In order to avoid confusion
regarding these phrases, we are proposing to use the term ``fixed-
dollar loss threshold amount'' when we are referring to the dollar
amount by which the costs of a case exceed payment in order to qualify
for an outlier payment.
As a result of this clarification, in Sec. 412.402, we are
proposing to revise the term ``Fixed dollar loss threshold'' to ``Fixed
dollar loss threshold amount.'' We are also proposing clarifying
changes to Sec. 412.424(d)(3)(i) and Sec. 412.424(d)(3)(i)(A) to
state that we would provide an outlier payment if an IPF's estimated
total cost for a case exceeds a ``fixed dollar loss threshold amount''
plus the total IPF adjusted payment amount for the stay, and that it is
the fixed dollar loss threshold amount that is adjusted by the IPF's
facility-level adjustments.
Aside from updating the terminology ``fixed dollar loss threshold
amount'' and making the conforming changes to the regulation text
described above, we are not proposing any other changes to the outlier
policy. Therefore, we would continue to adjust the fixed dollar loss
threshold amount by the applicable facility-level payment adjustments
and add this amount to the IPF PPS payment amount in order to determine
if a case qualifies for an outlier payment. For cases that meet the
threshold amount, we would pay 80 percent for days 1 through 9 and 60
percent for day 10 and thereafter.
In the IPF PPS final rule, we described the process by which we
calculate the outlier fixed dollar loss threshold amount. We are
proposing to continue to use this process in this proposed rule. We
begin by simulating aggregate payments with and without an outlier
policy, and applying an iterative process to a fixed dollar loss amount
that would result in outlier payments being equal to 2 percent of total
simulated payments under the simulation. Based on this process, we are
proposing $6200 as the fixed dollar loss threshold amount in the
outlier calculation in order to maintain the proposed 2 percent outlier
policy.
We note that the simulation analysis used to calculate the proposed
$6200 fixed dollar loss threshold amount includes all of the proposed
changes to the IPF PPS discussed in this proposed rule. As a result,
for the RY beginning July 1, 2006, the final fixed dollar loss
threshold amount is subject to change in the final rule depending on
the policies contained in the final rule.
b. Proposed Statistical Accuracy of Cost-to-Charge Ratios
As stated previously, under the IPF PPS, an outlier payment is made
if an IPF's cost for a stay exceeds a fixed dollar loss threshold
amount. In order to establish an IPF's cost for a particular case, we
multiply the IPF's reported charges on the discharge bill by their
overall cost to charge ratio (CCR). This approach to determining a
provider's cost is consistent with the approach used under the IPPS and
other prospective payment systems. In FY 2004, we implemented changes
to the IPPS outlier policy used to determine CCRs for acute care
hospitals because we became aware that payment vulnerabilities resulted
in inappropriate outlier payments. Under the IPPS, we established a
statistical measure of accuracy for CCRs in order to ensure that
aberrant CCR data did not result in inappropriate outlier payments. As
we indicated in the IPF PPS final rule, because we believe the IPF
outlier policy is susceptible to the same payment vulnerabilities as
the IPPS, we adopted an approach to ensure the statistical accuracy of
CCRs under the IPF PPS. Therefore, we adopted the following two
procedures in the IPF PPS final rule:
We calculated two national ceilings, one for IPFs located
in rural areas and one for IPFs located in urban areas. We computed the
ceilings by first calculating the national average and the standard
deviation of the CCR for both urban and rural IPFs.
To determine the rural and urban ceilings, we multiplied each of
the standard deviations by 3 and added the result to the appropriate
national CCR average (either rural or urban). The current upper
threshold CCR for IPFs is 1.8853 for rural IPFs, and 1.8040 for urban
IPFs, based upon MSA-based geographic designations. If an IPF's CCR is
above the applicable ceiling, the ratio is considered statistically
inaccurate and we assign the appropriate national (either rural or
urban) median CCR to the IPF.
Additional information regarding the national median CCRs is
included in the IPF PPS final rule (69 FR 66961).
We do not apply the applicable national median CCR when an
IPF's CCR falls below a floor. We made this decision because using the
national median CCR in place of the provider's actual CCR would
overstate the IPF's costs. We are proposing to apply the national CCRs
to the following situations:
++ New IPFs that have not yet submitted their first Medicare cost
report.
++ IPFs whose operating or capital CCR is in excess of 3 standard
deviations above the corresponding national geometric mean (that is,
above the ceiling).
++ Other IPFs for whom the fiscal intermediary obtains inaccurate
or incomplete data with which to calculate either an operating or
capital CCR or both.
The current national CCRs were estimated to be 0.7115 for rural
IPFs and 0.5658 for urban IPFs and would be used in each of the three
situations cited above. These estimates were based on the IPF's
location (either urban or rural) using the MSA-based geographic
designations. For new facilities, we are proposing to use these
national ratios until the facility's actual CCR can be computed using
the first tentatively settled or final settled cost report, which would
then be used for the subsequent cost report period.
We are not proposing any changes to the procedures for ensuring the
statistical accuracy of CCRs in RY 2007. However, we are proposing to
update the national urban and rural CCRs (ceilings and medians) for
IPFs for RY 2007 based on the full calendar year 2005 CCRs entered in
the Provider-Specific File. In addition, we are proposing that the
updated ceilings and national median CCRs would be based on CBSA-based
geographic designations because the CBSAs are the geographic
designations we are proposing to adopt for purposes of computing the
proposed wage index adjustment to IPF payments beginning July 1, 2006.
We would include the updated ceiling and national median CCRs in the
final RY 2007 regulations.
[[Page 3644]]
In subsequent years, we are proposing to update the national urban
and rural CCRs (median and ceilings) based on the previous full
calendar year's Provider-Specific File. These CCRs would be announced
in each year's annual notice of prospective payment rates published in
the Federal Register. We are proposing to add a new paragraph (g) to
Sec. 412.428 to clarify that we intend to update the national urban
and rural ceilings and medians as part of the annual update of the IPF
PPS and to specify when the national median urban and rural CCRs would
be used.
1. Proposed Stop-Loss Provision
In the IPF PPS final rule, we implemented a stop-loss policy to
reduce financial risk for those facilities expected to experience
substantial reductions in Medicare payments during the IPF PPS
transition period. This stop-loss policy guarantees that each facility
receives total IPF PPS payments that are no less than 70 percent of its
TEFRA payments, had the IPF PPS not been implemented.
This policy is applied to the IPF PPS portion of Medicare payments
during the 3-year transition. Hence, during year 1, three-quarters of
the payment were based on TEFRA and one-quarter on the IPF PPS. Under
the 70 percent policy, 75 percent of total payment is TEFRA payments,
and the 25 percent is IPF PPS payments, which are at least 70 percent
of the TEFRA payments. The resulting 92.5 percent of TEFRA payments in
year 1 is the sum of 75 percent and 25 percent times 70 percent.
In year 2, one-half of the payment will be based on TEFRA and one-
half on the IPF PPS. In year 3, one-quarter of the payment will be
based on TEFRA and three-quarters on the IPF PPS. In year 4 of the IPF
PPS, Medicare payments are based 100 percent on the IPF PPS.
The combined effects of the transition and the stop-loss policies
will be to ensure that the total estimated IPF PPS payments were no
less than 92.5 percent in year 1, 85 percent in year 2, and 77.5
percent in year 3.
The 70 percent of TEFRA payment stop-loss policy will require a
reduction in the Federal per diem and ECT base rates of 0.39 percent in
order to make the stop-loss payments budget neutral. We estimate that
about 10 percent of IPFs would receive stop-loss payments under the 70
percent policy.
We are not proposing to make any changes to the stop-loss policy.
2. Patients Who Receive Electroconvulsive Therapy (ECT)
In developing the IPF PPS, we received numerous public comments
recommending that we include a payment adjustment for patients who
receive ECT treatments during their IPF stay because furnishing ECT
treatment, either directly or under arrangements, adds significantly to
the cost of these stays. When we analyzed the FY 2002 MedPAR data, we
found that ECT cases comprised about 6 percent of all cases and that
almost 95 percent of ECT cases were treated in IPFs that are
psychiatric units of acute care hospitals. Even among psychiatric
units, ECT cases are concentrated among a relatively small number of
facilities. Overall, approximately 450 facilities had cases with ECT.
Among these facilities, we estimated the mean number of ECT cases per
facility to be approximately 25. In addition, approximately one-half of
the IPFs providing ECT had no more than 15 cases in FY 2002.
Our analysis confirmed that cases with ECT are substantially more
costly than cases without ECT. We found that on a per case basis, ECT
cases are approximately twice as expensive as non-ECT cases ($16,287
compared to $7,684). Most of this difference is due to variation in
length of stay (20.5 days for ECT cases compared to 11.6 days for non-
ECT cases). In addition, the ancillary costs per case for ECT cases are
$2,740 higher than those for non-ECT cases.
Although we are able to determine the cost of stays with ECT, we
are unable to develop an ECT cost per treatment using the FY 2002 IPF
claims data because the claims do not include the number of treatments.
As a result, in the IPF PPS final rule, we established the following
methodology for calculating the IPF PPS ECT payment adjustment.
We established an ECT base rate using the pre-scaled and pre-
adjusted median hospital cost for CPT procedure code 90870 used for
payment under hospital outpatient PPS (OPPS), based on hospital claims
data. The median cost for all OPPS services are posted after
publication of the OPPS proposed rule at the following address: http://www.cms.hhs.gov/hospitaloutpatientPPS.
We used unadjusted hospital
claims data under the OPPS, that is, the pre-scaled and pre-adjusted
median hospital cost per treatment, to establish the ECT base rate
because we did not want the ECT payment under the IPF PPS to be
affected by factors that are relevant to OPPS but not specifically
applicable to IPFs. The median cost ($311.88) was then standardized and
adjusted for budget neutrality, resulting in an ECT payment adjustment
of $247.96 per treatment. The ECT base rate is adjusted for wage and
COLA differences in the same manner that we adjust the Federal per diem
base rate.
In order to receive the payment adjustment, IPFs must indicate on
their claims the revenue code for ECT (901), along with the total
number of units (ECT treatments) provided to the patient during their
IPF stay. In addition, IPFs must include the ICD-9-CM procedure code
for ECT (94.27) and the date of the last ECT treatment the patient
received.
As we stated in the IPF PPS final rule, although we established the
ECT adjustment as a distinct payment under the IPF PPS, our preferred
approach would be to include a patient level adjustment as a component
of the model (for example, determined through the regression analyses)
to account for the higher costs associated with ECT (69 FR 66951).
Although our analysis will continue, we do not intend to redo the
regression analysis until we are able to analyze 1 year of IPF PPS
claims and cost report data. However, we believe the data currently
being submitted by IPFs may permit development of an IPF-specific ECT
base rate, rather than using hospital outpatient claims data.
It is important to note that since ECT treatment is a specialized
procedure, not all providers are equipped to provide the treatment.
Therefore, many patients who need ECT treatment during their IPF stay
must be referred to other providers to receive the ECT treatments, and
then return to the IPF. In accordance with Sec. 412.404(d)(3), in
these cases where the IPF is not able to furnish necessary treatment
directly, the IPF would furnish ECT under arrangements with another
provider. While a patient is an inpatient of the IPF, the IPF is
responsible for all services furnished, including those furnished under
arrangements by another provider. As a result, the IPF claim for these
cases should reflect the services furnished under arrangements by other
providers.
Therefore, in accordance with the update methodology specified in
Sec. 412.428(f), we are proposing to update the ECT base rate using
the pre-scaled pre-adjusted hospital median cost for ECT used for the
CY 2006 update of the OPPS. The median cost would then be standardized,
adjusted for budget neutrality, and adjusted for wage and COLA
differences in the same manner that we adjust the per diem rate.
We are proposing to pay the median cost for an ECT treatment,
posted as part of the calendar year (CY) 2006 OPPS update, which is
based on CY 2004 outpatient hospital claims. The median cost is
$324.44. After applying the standardization factor and the wage index
budget neutrality factor (as
[[Page 3645]]
described in section III.C.1.f. of this proposed rule), the adjusted
proposed ECT payment for RY 2007 is $268.21.
We would monitor this area to ensure that the increased payments
for ECT do not lead to changes in the frequency of utilization by
reviewing the CY 2005 MedPAR claims data.
3. Physician Certification and Recertification Requirements
Since the publication of the IPF PPS final rule, we have received
inquiries related to physician certification and recertification. It
appears that some psychiatric units in acute care hospitals have been
following the timeframes that are applicable to the acute care hospital
of which they are a part (as specified in Sec. 424.13) rather than
those that apply to psychiatric hospitals (as specified in Sec.
424.14).
To eliminate the confusion that we believe may be caused by the
titles of Sec. 424.13 and Sec. 424.14, to ensure consistency in
compliance of the requirements among all IPFs, we are proposing to
revise the title of Sec. 424.14 from ``Requirements for inpatient
services of psychiatric hospitals'' to ``Requirements for inpatient
services of inpatient psychiatric facilities.'' We are proposing that
for the purposes of payment under the IPF PPS, all IPFs would follow
the physician certification and recertification requirements as
specified in Sec. 424.14.
In the IPF proposed rule published on November 28, 2003 (68 FR
66920), we proposed to--(1) amend Sec. 424.14 to state that in
recertifying a patient's need for continued inpatient care in an IPF, a
physician must indicate that the patient continues to need, on a daily
basis, inpatient psychiatric care (furnished directly by or requiring
the supervision of IPF personnel) or other professional services that,
as a practical matter, can be provided only on an inpatient basis; and
(2) revise Sec. 424.14(d) to require that a physician recertify a
patient's continued need for inpatient psychiatric care on the 10th day
following admission to the IPF rather than the 18th day following
admission to the IPF (68 FR 66939).
However, in the IPF PPS final rule, we did not include the proposed
physician recertification requirement changes because most of the
public comments we received on this issue did not support the proposed
changes and indicated that there are inconsistencies in the timeframes
currently required for IPFs that warranted additional analysis.
Instead, we stated that we would continue to require that a physician
recertify a patient's continued need for inpatient psychiatric care on
the 18th day following admission to the IPF.
Since publication of the final rule, we have received additional
inquiries related to the physician certification and recertification
timeframes that currently apply to IPFs. As noted above, it appears
that some psychiatric units in acute care hospitals have been following
the timeframes that are applicable to the acute care hospital of which
they are a part (as specified in Sec. 424.13) rather than those that
apply to psychiatric hospitals (as specified in Sec. 424.14). Section
424.13(d) requires the initial certification no later than as of the
12th day of hospitalization and the first recertification is required
no later than as of the 18th day of hospitalization. Section Sec.
424.14(d) requires certification at the time of admission or as soon
thereafter as is reasonable and practicable and the first
recertification is required as of the 18th day of hospitalization.
We are proposing that, for purposes of payment under the IPF PPS,
all IPFs (distinct part units of acute care hospitals and CAHs and
psychiatric hospitals) would meet the following physician certification
and recertification timeframes. We would revise Sec. 424.14(d) to
provide that the initial physician certification would be required at
the time of admission or as soon thereafter as is reasonable and
practicable and the first recertification would be required as of the
12th day of hospitalization. Subsequent recertifications would be
required at intervals established by the hospital's UR committee (on a
case-by-case basis if desired), but no less frequently than every 30
days. We chose the 12th day because it is more in line with the average
LOS and it is current practice for certification in psychiatric units.
We have also received inquiries from Fiscal Intermediaries
requesting guidance on the content requirement of physician
certifications at Sec. 424.14(c), relating to the medical necessity of
continued inpatient psychiatric care. As a result, we are proposing to
add language to clarify that for purposes of payment under the IPF PPS,
the physician would also recertify that the patient continues to need,
on a daily basis, active treatment furnished directly by or requiring
the supervision of inpatient psychiatric facility personnel.
4. Provision of Therapeutic Recreation in IPFs
Before the implementation of the IPPS payment methodology, Medicare
coverage guidelines gave specific recognition to therapeutic recreation
in inpatient psychiatric hospitals. The guidelines in Sec. 3102.1.A of
the Medicare Intermediary Manual, Part 3 (MIM-3), and in Sec. 212.1 of
the Medicare Hospital Manual (which now appear in the CMS Internet
Online Manual at Pub. 100-02, Chapter 2, Sec. Sec. 20.1ff.)
specifically identify therapeutic recreation as one of the services
that can constitute ``active treatment'' in this setting when they
are--
Provided under an individualized treatment or diagnostic
plan;
Reasonably expected to improve the patient's condition or
for the purpose of diagnosis; and
Supervised and evaluated by a physician.
However, these guidelines refer to therapeutic recreation in terms
of being an ``adjunctive'' therapy, indicating that even in this
setting, it would not independently serve as a patient's sole or
primary form of therapeutic treatment, but rather, would be furnished
in support of (but subordinate to) some other, primary form of therapy.
When the IPPS was developed in 1983, to the extent that therapeutic
recreation and other services had been furnished during the IPPS base
period, the bundled IPPS payment for that setting would reflect these
costs. However, during the IPPS rulemaking process, we received public
comments stating ``* * * concern that the cost-saving incentives of the
prospective payment system would lead hospitals paid under the system
to stop providing recreational therapy services.'' In response, in the
January 3, 1984 IPPS final rule (49 FR 242) we indicated that
implementation of the IPPS would not, in fact, prohibit the provision
of recreational therapy services, and that ``* * * these services will
continue to be covered to the same extent they always have been under
existing Medicare policies''.
In implementing the IPPS regulations, we included criteria for
identifying certain types of institutions (for example, psychiatric
hospitals) that would be excluded from the IPPS and, thus, would
continue to be paid under some other methodology. The regulations also
introduced criteria for identifying an IPPS-excluded inpatient
psychiatric unit housed within a larger acute-care hospital that would
itself be subject to the IPPS. One of these identifying criteria at 42
CFR 405.471(c)(4)(ii)(B) (later recodified at 42 CFR 412.27(b)) was the
provision, through the use of qualified personnel, of a number of
specified types of services, including psychological services, social
work services,
[[Page 3646]]
psychiatric nursing, occupational therapy, and recreational therapy.
As we explained in the IPPS interim final rule published on
September 1, 1983 (48 FR 39758), the regulations designated these
particular services because their provision ``* * * is typical of units
which treat patients whose characteristics are like those in
psychiatric hospitals. Consequently, the provision of these services is
an identifier of such a patient population''. We note that the
designation of these particular services in this context did not serve
to define the scope of their coverage under Medicare, nor to mandate
their provision in this setting, but merely to identify them as being
characteristic of the type of psychiatric unit that would qualify for
exclusion from the IPPS.
At the same time the IPPS was being developed, a parallel evolution
was taking place in the certification requirements that facilities must
meet in order to participate in the Medicare program: A shift from
primarily ``process-oriented'' requirements to more ``outcome-
oriented'' requirements, which focus more on direct indicators of the
quality of care actually being furnished to the facility's patients (as
reflected in the presence of positive results and the absence of
negative ones), and less on the specific ``process'' through which the
facility achieves the desired outcome.
In order to participate in the Medicare program, psychiatric
hospitals not only had to meet the conditions of participation (COPs)
that apply to general, acute-care hospitals, but additionally had to
meet special conditions related to medical records and staffing.
Consistent with the recognition of therapeutic recreation as
constituting active treatment in this one particular setting (as
discussed above), the original COPs for psychiatric hospitals at 42 CFR
405.1038(g) mandated the presence of qualified therapists, assistants,
or aides ``* * * sufficient in number to provide comprehensive
therapeutic activities, including at least occupational, recreational
and physical therapy, as needed, to assure that appropriate treatment
is rendered for each patient, and to establish and maintain a
therapeutic milieu.'' Furthermore, 42 CFR 405.1038(g)(3) further
specified that ``recreational or activity therapy services are
available under the direct supervision of a member of the staff who has
demonstrated competence in therapeutic recreation programs,'' and
Sec. Sec. 405.1038(g)(4) and (5) went on to prescribe additional
standards regarding therapy assistants or aides and overall staffing
for recreational and activity therapy.
However, when the special medical record and staffing COPs for
psychiatric hospitals were subsequently recodified at 42 CFR 482.62(g),
the specific references to recreation therapy were deleted and replaced
with a more general requirement to provide a therapeutic activities
program. In response to public comments that recommended us to restore
the deleted requirements, we indicated that we believe that the deleted
requirements concerning therapeutic activities were overly and
unnecessarily prescriptive and that the hospital should have the
flexibility to determine which activities are most appropriate to its
patient population and to determine the criteria to be met by employees
providing these services. (see the IPPS PPS rule published on June 17,
1986 (51 FR 22032)).
When the 1986 COP changes applicable to psychiatric hospitals were
made, we inadvertently retained specific references to recreation
therapy in Sec. 412.27. Since the intent of Sec. 412.27(b) is to
identify services provided in psychiatric units that are characteristic
of services furnished in psychiatric hospitals, we believe it is no
longer appropriate to include references to specific therapies in Sec.
412.27. In order to have consistent requirements among IPFs, we are
proposing to remove recreational therapy from Sec. 412.27(b).
Although we are proposing to remove the specific reference to
recreation therapy, we want to emphasize that recreation therapy is,
and would continue to be, an accepted therapeutic intervention in
psychiatric treatment. In addition, we believe the IPF PPS base rate
which was developed using FY 2002 data, reflects the provision of
recreation therapy.
5. Same Day Transfers
Currently, when a transfer, discharge, or death occurs on the same
day as an admission to an IPF, the IPF PPS PRICER does not recognize
any covered IPF days and the IPF claims are suspended. Based on review
of a limited sample of the IPF and subsequent IPPS claims, it appears
that many of these patients are first seen in a hospital's ED, are
admitted to the hospital's psychiatric unit and, later the same day,
determined to be too medically compromised to be managed in the
psychiatric unit. This scenario may occur because the patient presents
at the ED and is admitted to the psychiatric unit in the middle of the
night, and when the patient's admission to the unit is reviewed by a
psychiatrist the next morning, the physician determines that the
patient should be discharged for acute care. In other cases, a patient
may have been admitted to a freestanding psychiatric hospital based on
the information furnished by an ED of an acute care hospital. However,
after admission, the psychiatric hospital staff evaluates the patient
and determines that the patient has medical needs that they are not
staffed or equipped to meet.
The Provider Reimbursement Manual addresses the same day transfer
issue from the perspective of counting Medicare days for the purpose of
Medicare cost reporting. Section 2205 indicates that only full patient
days may be used to apportion inpatient routine care service costs and
that a day begins at midnight and ends 24 hours later. However, section
2205.1 explains how to count a day if the day of admission and the day
of discharge are the same. Section 2205.1 indicates that when a patient
is admitted and then transferred from one participating provider to
another before midnight of the same day, a day (except for utilization
purposes) is counted at both providers. A day of Medicare utilization
is charged only for the admission to the second provider. This
distinction is important for psychiatric admissions because IPF stays
are subject to the 190-day lifetime limit on inpatient psychiatric
care.
Section 1812(b) of the Act and 42 CFR 409.62 indicate that payment
is not available for inpatient psychiatric hospital services furnished
beyond the 190-day lifetime limit. Thus, Medicare coverage of IPF
services, specifically IPF services furnished in freestanding
psychiatric hospitals is limited to 190 days. In consideration of the
limit on coverage of IPF services, where there is a same day transfer
between Medicare participating providers, we only count the second
admission for utilization purposes. Therefore, the initial admission to
the IPF does not count against a beneficiary's lifetime psychiatric
services limit.
We have some concerns regarding same day transfers from an IPF.
Under TEFRA, a hospital receives its cost up to the hospital's TEFRA
limit. The TEFRA limit is based on the hospital's average cost per
discharge in a base period. When an admission and discharge occur on
the same day, the hospital's cost is unlikely to exceed the TEFRA
limit, so the hospital receives its cost for the day. These same day
transfers also improve the hospital's payment under TEFRA by slightly
reducing its cost per discharge. We are also concerned that when the
transfer occurs in the same hospital, this practice circumvents
bundling rules
[[Page 3647]]
under the IPPS, in that it unbundles the ED charges from the IPPS claim
and allocates the ED costs to the psychiatric unit even though the
patient may have been inappropriately admitted to the unit.
Based on the review of IPF PPS claims we conducted, it did not
appear that the admissions to the IPF were medically reasonable and
necessary. However, we believe it is important to base a decision
regarding coverage of these days on a comprehensive review of the
claims. Therefore, we are not proposing a change in payment policy in
this proposed rule. However, we are considering several alternative
methods for addressing same day transfers under the IPF PPS which are
described below. Any change to treatment of same day transfers would be
made prospectively.
We could treat these days as covered days under the IPF PPS.
However, under the IPF PPS, a 19 percent adjustment to the base rate is
applied to day 1 of the stay to reflect the additional administrative
and clinical costs associated with admission and the day 1 adjustment
is increased to 31 percent when the IPF has a qualifying ED. The IPF
may also receive, for example, a teaching adjustment or rural
adjustment, for these partial days of care. Several of the claims in
our analysis indicate a stay of 2 hours. We are concerned that this
approach would overpay IPFs and encourage inappropriate admissions and
transfers.
Another option would be to make no PPS payment, but continue making
TEFRA payments during the IPF PPS transition period. For example, for
cost reporting periods beginning in 2006, IPFs will receive a blended
payment consisting of 50 percent PPS and 50 percent TEFRA. Therefore,
under this approach we would allow some payment for these days for cost
reporting periods in 2006 and 2007, but once the IPF PPS transition
period is over, the IPFs would receive no payment for these days. We
think this approach would encourage changes in admission practices in
order to avoid the need to transfer patients. However, once the IPF PPS
transition is over, there would be no payment mechanism to pay IPFs for
stays in which there is a circumstance, not reasonably foreseeable by
the admitting IPF such as a serious change in health status on the day
of admission.
We could treat these same day transfer cases as covered days under
the IPF PPS but limit payment to the Federal per diem base rate or some
other payment amount, for example, half the Federal per diem base rate.
This approach would limit payment to IPFs in order to provide an
incentive for IPFs to make medical clearance determinations as early in
the IPF stay as possible. However, we are concerned that this approach
would not lead to changes in admission practices to avoid inappropriate
admissions and the need for subsequent transfers.
It is important to note that the cost for these days was included
in the cost reports used to develop the IPF PPS, and, as a result, the
average cost per day that was used to establish the Federal per diem
base rate is higher than it would otherwise have been had those days
not been included.
We specifically request public comment from IPFs on this issue to
help us to develop a payment policy that pays IPFs appropriately for
these days and provides an incentive to avoid same day transfers
wherever possible.
V. Provisions of the Proposed Rule
[If you choose to comment on issues in this section, please include the
caption ``PROVISIONS'' at the beginning of your comments.]
We are proposing to make revisions to the regulation in order to
implement the proposed prospective payment for IPFs for discharges
occurring during the RY beginning July 1, 2006. As part of the update,
we are proposing to incorporate OMB's revised definitions for MSAs and
its new definitions of Micropolitan Statistical Areas and Core-Based
Statistical Areas. In addition, we are proposing the following--
Update payments for IPF facilities using a market basket
reflecting the operating and capital cost structures for the RPL market
basket.
Develop cost weights for benefits, contract labor, and
blood and blood products using the FY 2002-based IPPS market.
Provide weights and proxies for the FY 2002-based RPL
market basket.
Indicate the methodology for the capital portion of the FY
2002-based RPL market basket.
Update the outlier threshold amount to maintain total
outlier payments at 2 percent of total estimated payments.
Use source code ``D'' to identify IPF patients who have
been transferred to the IPF from the same hospital or CAH.
Retain the 17 percent adjustment for IPFs located in rural
areas, the 1.31 adjustment for IPFs with a qualifying ED, the 0.5150
teaching adjustment to the Federal per diem base rate, and the DRG
adjustment factor currently being paid to IPFs for discharges occurring
during RY 2007.
Update the payment rate for ECT.
Update the DRG listing and comorbidity categories to
reflect the ICD-9-CM revisions effective October 1, 2005.
In addition to discussing these general issues in the IPF PPS 2007
RY, we also proposed making the following specific revisions to the
existing text of the regulations. Specifically, we are proposing to
make conforming changes in 42 CFR part 412 and 424 as discussed through
out this preamble.
In Sec. 412.27, we are proposing to revise paragraph (b) to remove
the reference to recreational therapy.
In Sec. 412.402, we are proposing to revise the heading of ``Fixed
dollar loss-threshold'' to ``Fixed dollar loss threshold amount'' and
revise the definitions of ``Fixed dollar loss threshold amount'',
``Qualifying emergency department'', ``Rural area'' and ``Urban area.''
For consistency, we are proposing to make conforming changes to these
terminologies wherever they appear in the regulations text.
In Sec. 412.424, we are also proposing to add paragraph
(d)(1)(iii)(E) to clarify that the teaching adjustment is made on a
claim basis as an interim payment and the final payment in full is made
during the final settlement of the cost report. For clarity, we are
proposing to revise paragraph (d)(2) introductory text. The current
language in (d)(2)(iii) would become the introductory text for
paragraph (d)(2) and paragraph (d)(2)(iii) would be removed. In
addition, we are proposing to revise Sec. 412.424(d)(3)(i)(A) to
clarify that an outlier payment is made if an IPF's estimated total
cost for a case exceeds a fixed dollar loss threshold amount plus the
Federal payment amount for the case.
In Sec. 412.426(a), we are proposing to correct the cross
reference to the Federal per diem payment amount. We incorrectly
referenced the Federal per diem base rate at Sec. 424.424(c). The
correct cross reference to the Federal per diem payment amount is Sec.
424.424(d).
In Sec. 412.428, we are proposing to revise paragraph (b) to
specify that for discharges occurring on or after January 1, 2005 but
before July 1, 2006 the rate of increase factor for the Federal portion
of the payment is based on the FY 1997-based excluded hospital with
capital market basket and for discharges occurring on or after July 1,
2006, the rate of increase factor for the Federal portion of the
payment is based on the FY 2002-based RPL market basket.
In addition, we are proposing to add a new paragraph (g) to state
that we would update the national urban and rural cost to charge ratio
median and ceiling. Paragraph (1) through (3) would
[[Page 3648]]
specify the types of IPFs in which to apply the national cost to charge
ratio. Furthermore, we are proposing to add a new paragraph (h) to
update the cost of living adjustment factors if appropriate.
In Sec. 424.14, we are proposing to revise the title to read,
``Requirements for inpatient services of inpatient psychiatric
facilities,'' to ensure consistency in compliance with the requirements
among all IPFs. We are proposing to add a new paragraph (c)(3) to
clarify for purposes of payment under the IPF PPS, that the physician
would also recertify that the patient continues to need, on a daily
basis, active inpatient psychiatric care (furnished directly by or
requiring the supervision of inpatient psychiatric facility personnel)
or other professional services that can only be provided on an
inpatient basis.
In addition, we are revising paragraph (d)(2) to state that the
first recertification is required as of the 12th day of
hospitalization. Subsequent recertifications are required at intervals
established by the UR committee (on a case-by-case basis if it so
chooses), but no less frequently than every 30 days.
VI. Collection of Information Requirement
[If you choose to comment on issues in this section, please include the
caption ``INFORMATION COLLECTION'' at the beginning of your comments.]
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.
VII. Regulatory Impact Analysis
[If you choose to comment on issues in this section, please include the
caption ``IMPACT'' at the beginning of your comments.]
A. Overall Impact
We have examined the impact of this proposed rule as required by
Executive Order 12866 (September 1993, Regulatory Planning and Review),
the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-
354), section 1102(b) of the Social Security Act, the Unfunded Mandates
Reform Act of 1995 (UMRA) (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).
Based on the impact analysis, we estimate the expenditures from the
IPF PPS implementation year to the 2007 IPF PPS RY will be increased by
$180 million. The updates to the IPF labor-related share and wage
indices are made in a budget neutral manner and thus have no effect on
estimated costs to the Medicare program. Therefore, the estimated
increased cost to the Medicare program is the result of a combination
of the updated IPF market baskets, which is offset by the transition
blend and the revision of the standardization factor.
CMS notes that aspects of the transition, including the stop-loss
policy and the transition to the 50/50 percent blend in the 2007 IPF
PPS RY and the transition to the 75/25 percent blend in the 2008 IPF
PPS RY, were included in the 2004 final rule and are thus not
incremental to this rulemaking. Nevertheless, it is essential to
analyze the impact of the transition blend in order to calculate the
increase in cost to the Medicare program.
The impact of the transition blend is an approximately .2 percent
(about $10 million) decrease in overall payments for the 2007 IPF PPS
RY and the distribution of that impact is summarized in Table 15.
Therefore, the impact attributable to the policy changes proposed in
this rulemaking, primarily the market basket update and the
standardization correction, is approximately $180 million in the 2007
IPF PPS RY.
Since costs to the Medicare program are estimated to be greater
than $100 million, this proposed rule is considered a major economic
rule, as defined in 5 U.S.C. 40(2).
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 governmental
jurisdictions. Most IPFs and most other providers and suppliers are
considered small entities, either by nonprofit status or by having
revenues of $6 million to $29 million in any 1 year. (For details, see
the Small Business Administration's regulation that set forth size
standards for health care industries at 65 FR 69432.)
HHS considers that a substantial number of entities are affected if
the rule impacts more than 5 percent of the total number of small
entities as it does in this rule. We included all freestanding
psychiatric hospitals (79 are non-profit hospitals) in the analysis
since their total revenues do not exceed the $29 million threshold. We
also included psychiatric units of small hospitals, that is, those
hospitals with fewer than 100 beds. We did not include psychiatric
units within larger hospitals in the analysis because we believe this
proposed rule would not significantly impact total revenues of the
entire hospital that supports the unit. We have provided the following
RFA analysis in section B to emphasize that, although the proposed rule
would impact a substantial number of IPFs that were identified as small
entities, we do not believe it would have a significant economic
impact. Based on the analysis of the 1063 psychiatric facilities that
were classified as small entities as described above, we estimate the
combined impact of the IPF PPS will be a 4.6-percent increase in
payments in RY 2007 relative to their payments in the implementation
year of the IPF PPS. Based on the information available, we believe
that Medicare payments may constitute a small portion of governmental
IPF's revenue stream. We have prepared the impact analysis in section
VI.B.2 to describe the impact of the proposed rule in order to provide
a factual basis for our conclusions regarding small business impact.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a proposed 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. With the exception of hospitals located in certain New
England counties, for purposes of section 1102(b) of the Act, we
previously defined a small rural hospital as a hospital with fewer than
100 beds that is located outside of a Metropolitan Statistical Area
(MSA) or New England County Metropolitan Area (NECMA). However, under
the new labor market definitions that we are proposing to adopt, we
would no longer employ NECMAs to define urban areas in New England.
Therefore, for purposes of this analysis, we now define a small rural
hospital as a hospital with fewer than 100 beds that is located outside
of an MSA. We have determined that this proposed rule would have a
substantial impact on hospitals classified as located in rural areas.
As discussed earlier in this preamble, we are proposing to continue to
provide a payment adjustment of 17 percent for IPFs
[[Page 3649]]
located in rural areas. In addition, we have established a 3-year
transition to the new system to allow IPFs an opportunity to adjust to
the new system. Therefore, the impacts shown in Table 15 below reflect
the adjustments that are designed to minimize or eliminate any
potentially significant negative impact that the IPF PPS may otherwise
have on small rural IPFs.
Section 202 of the Unfunded Mandates Reform Act of 1995 also
requires that agencies assess anticipated costs and benefits before
issuing any proposed rule whose mandates require spending in any 1 year
of $100 million in 1995 dollars, updated annually for inflation. That
threshold level is currently approximately $120 million. This proposed
rule would not mandate any requirements for State, local, or tribal
governments, nor would it affect private sector costs.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule that imposes
substantial direct requirement costs on State and local governments,
preempts State law, or otherwise has Federalism implications.
We have reviewed this proposed rule under the criteria set forth in
Executive Order 13132 and have determined that the proposed rule would
not have any substantial impact on the rights, roles, and
responsibilities of State, local, or tribal governments.
B. Anticipated Effects of the Proposed Rule
We discuss below the impact of this proposed rule on the Federal
Medicare budget and on IPFs.
1. Budgetary Impact
As discussed in detail in the IPF PPS final rule and summarized in
section III.B. of this proposed rule, we applied a budget neutrality
factor to the Federal per diem and ECT base rates to ensure that total
payments under the IPF PPS in the implementation period would equal the
amount that would have been paid if the IPF PPS had not been
implemented. In addition, as discussed in section IV.C.1 of this
proposed rule, we are proposing to adopt the new CBSAs and labor market
share in a budget neutral manner by applying a wage index budget
neutrality factor to the Federal per diem and ECT base rates. Thus, the
budgetary impact to the Medicare program by the update of the IPF PPS
will be the combination of the proposed market basket updates (see
section III.C of this proposed rule), the proposed revision of the
standardization factor (see section III.B.3 of this proposed rule), and
the planned update of the payment blend discussed below.
2. Impacts on Providers
To understand the impact of the changes to the IPF PPS discussed in
this proposed rule on providers, it is necessary to compare estimated
payments under the IPF PPS rates and factors for the 2007 IPF rate year
to estimated payments under the IPF PPS rates and factors for the IPF
PPS implementation year. The estimated payments for the IPF
implementation year are a blend of: 75 percent of the facility-specific
TEFRA payment and 25 percent of the IPF PPS payment with stop loss
payment. The estimated payments for the 2007 IPF rate year are a blend
of: 50 percent of the facility-specific TEFRA payment and 50 percent of
the IPF PPS payment with stop loss payment. We determined the percent
change of estimated 2007 IPF PPS rate year payments to estimated IPF
PPS implementation year payments for each category of IPFs. In
addition, for each category of IPFs, we have included the estimated
percent change in payments resulting from the revision of the
standardization factor (as discussed in section III.B.3 of this
proposed rule, the ratio of estimated total TEFRA payments to estimated
total PPS payments in the implementation year was overestimated and
therefore needed to be reduced. We are proposing to apply the revised
standardization factor prospectively to the Federal per diem base rate
and ECT amount), the wage index changes for the 2007 IPF PPS rate year,
the proposed market basket update to IPF PPS payments, and the
transition blend for the 2007 rate year of the IPF PPS payment and the
facility-specific TEFRA payment.
To illustrate the impacts of the proposed RY 2007 changes, our
analysis begins with an implementation year baseline simulation model
based on FY 2002 IPF payments inflated to 2005 with market baskets; the
estimated outlier payments in 2005; the estimated stop-loss payments in
2005; the MSA designations for IPFs based on OMB's MSA definitions
before June 2003; the 2005 MSA wage index; the implementation year
labor-market share; and the implementation year percentage amount of
the rural adjustment. During the simulation, the outlier payment is
maintained at the target of 2 percent of total PPS payments.
Each of the following proposed changes is added incrementally to
this baseline model in order for us to isolate the effects of each
change:
IPF PPS payments adjusted by the revised standardization
factor.
The new CBSAs based on new geographic area definitions
announced by OMB in June 2003 and the RY 2007 proposed budget-neutral
labor-related share and wage index adjustment.
A blended market basket update of 4.7 percent resulting in
an update to the hospital-specific TEFRA target amount and an update to
the IPF PPS base rates as discussed below.
++ As discussed in section III.C.4 of this proposed rule and in the
IPPS final rule published August 12, 2005 (70 FR 47707), we established
an update factor of 3.8 percent effective for cost reporting periods
beginning on or after October 1, 2005 using the 2002-based excluded
hospital market basket. The 3.8 percent update is applied to the IPF's
target cost per discharge established under TEFRA for cost reporting
periods beginning on or after October 1, 2005. However, since the
midpoints of the 2007 rate year and the IPF PPS implementation period
are 15 months apart, the TEFRA payment increase is projected to be 4.8
percent.
++ An update to the Federal per diem base rate of 4.5 percent based
on the 2002-based RPL market basket (see section III.C.1.b of this
proposed rule). The market basket update is based on a 15-month time
period (from the midpoint of the IPF PPS implementation period to the
midpoint of the 2007 rate year).
The transition to 50 percent IPF PPS payment and 50
percent facility-specific TEFRA payment.
Our final comparison illustrates the percent change in payments
from the IPF PPS implementation year (that is, January 1, 2005 to June
30, 2006) to RY 2007 (that is, July 1, 2006 to June 30, 2007).
[[Page 3650]]
Table 15.--Projected Impacts
--------------------------------------------------------------------------------------------------------------------------------------------------------
Standardization CBSA wage
Facility by type Number of factor index and Market basket Transition Total
facilities correction labor share blend
(1) (2) (3) (4) (5) (6) (7)
--------------------------------------------------------
All Facilities......................................... 1,806 -0.3% 0.0% 4.7% -0.2% 4.2%
By Type of Ownership:
Psychiatric Hospitals..............................
Government..................................... 178 -0.4% 0.0% 4.7% 11.0% 15.7%
Non-profit..................................... 79 -0.3% 0.1% 4.7% 1.6% 6.1%
For-profit..................................... 150 -0.4% 0.1% 4.7% 4.3% 8.9%
Psychiatric Units.............................. 1,399 -0.3% 0.0% 4.7% -1.8% 2.5%
Rural.................................................. 384 -0.3% -0.2% 4.7% -1.1% 3.0%
Urban.................................................. 1,422 -0.3% 0.0% 4.7% -0.1% 4.3%
By Urban or Rural Classification:
Urban by Facility Type.............................
Psychiatric Hospitals..............................
Government..................................... 144 -0.4% 0.1% 4.7% 10.8% 15.6%
Non-profit..................................... 73 -0.3% 0.1% 4.7% 1.7% 6.2%
For-profit..................................... 143 -0.4% 0.1% 4.7% 4.4% 9.0%
Psychiatric Units.............................. 1,062 -0.3% 0.0% 4.7% -1.7% 2.6%
Rural by Facility Type.............................
Psychiatric Hospitals..............................
Government..................................... 34 -0.5% -0.3% 4.7% 11.8% 16.1%
Non-profit..................................... 6 -0.3% 0.3% 4.7% -0.7% 3.9%
For-profit..................................... 7 -0.2% -0.1% 4.7% -1.8% 2.4%
Psychiatric Units.............................. 337 -0.3% -0.2% 4.7% -2.2% 1.8%
By Teaching Status:
Non-teaching....................................... 1,537 -0.3% 0.0% 4.7% -0.3% 4.0%
Less than 10% interns and residents to beds.... 148 -0.3% 0.0% 4.7% 0.4% 4.8%
10% to 30% interns and residents to beds....... 72 -0.3% -0.1% 4.7% 0.4% 4.6%
More than 30% interns and residents to beds.... 49 -0.3% 0.1% 4.7% -0.1% 4.4%
By Region:
New England........................................ 126 -0.3% 0.0% 4.7% -0.5% 3.9%
Mid-Atlantic....................................... 306 -0.4% 0.1% 4.7% 2.8% 7.3%
South Atlantic..................................... 238 -0.3% -0.1% 4.7% 0.2% 4.5%
East North Central................................. 325 -0.3% -0.1% 4.7% -1.5% 2.8%
East South Central................................. 159 -0.3% 0.0% 4.7% -0.2% 4.2%
West North Central................................. 169 -0.3% -0.2% 4.7% -1.1% 3.1%
West South Central................................. 237 -0.3% -0.1% 4.7% -2.7% 1.6%
Mountain........................................... 83 -0.3% 0.0% 4.7% -0.4% 4.0%
Pacific............................................ 156 -0.3% 0.3% 4.7% -0.6% 4.1%
By Bed Size:
Psychiatric Hospitals..............................
Under 12 beds.................................. 26 -0.1% 0.1% 4.7% -3.8% 0.8%
12 to 25 beds.................................. 46 -0.2% -0.1% 4.7% 0.3% 4.7%
25 to 50 beds.................................. 91 -0.4% 0.2% 4.7% 4.3% 8.9%
50 to 75 beds.................................. 82 -0.4% 0.1% 4.7% 3.8% 8.4%
Over 75 beds................................... 162 -0.4% 0.0% 4.7% 8.5% 13.1%
Psychiatric Units..................................
Under 12 beds.................................. 600 -0.2% 0.0% 4.7% -4.5% -0.2%
12 to 25 beds.................................. 474 -0.3% 0.0% 4.7% -1.9% 2.4%
25 to 50 beds.................................. 228 -0.3% 0.0% 4.7% -0.6% 3.7%
50 to 75 beds.................................. 58 -0.3% 0.0% 4.7% 0.1% 4.4%
Over 75 beds................................... 39 -0.3% -0.1% 4.7% 1.2% 5.5%
--------------------------------------------------------------------------------------------------------------------------------------------------------
3. Results
Table 15 above displays the results of our analysis. The table
groups IPFs into the categories listed below based on characteristics
provided in the Online Survey and Certification and Reporting (OSCAR)
file and the 2002 cost report data from HCRIS:
Facility Type
Location
Teaching Status Adjustment
Census Region
Size
The top row of the table shows the overall impact on the 1,806 IPFs
included in the analysis.
In column 3, we present the effects of the revised standardization
factor (refer to section III.B.3 of this proposed rule for a discussion
of this revision). This is defined to be the comparison of the
simulated implementation year payment under the revised budget neutral
factor to the simulated implementation year payment under the original
budget neutral factor. In aggregate, the proposed revision would result
in a 0.3 percent decrease in overall payments to IPFs. There are small
distributional effects among different categories of IPFs. For example,
rural government psychiatric hospitals would receive the largest
decrease of 0.5 percent while
[[Page 3651]]
rural for-profit psychiatric hospitals would receive a 0.2 percent
decrease. Also psychiatric hospitals with over 75 beds would receive a
decrease of 0.4 percent while psychiatric hospitals with fewer than 12
beds would receive the smallest decrease of 0.1 percent.
In column 4, we present the effects of the budget-neutral update to
the labor-related share and the wage index adjustment under the new
CBSA geographic area definitions announced by OMB in June 2003. This is
a comparison of the simulated implementation year payment under revised
budget neutral factor and labor-related share and wage index under CBSA
classification to the simulated implementation year payment under
revised budget neutral factor and labor-related share and wage index
under current MSA classification. There is no change in aggregate
payments to IPFs as indicated in the first row of column 4. There
would, however, be small distributional effects among different
categories of IPFs. For example, rural IPFs would experience a 0.2
percent decrease in payments while urban IPFs would experience no
change in payments. Rural government hospitals would receive the
largest decrease of 0.3 percent while rural non-profit hospitals would
receive the largest increase of 0.3 percent.
In column 5, we present the effects of the proposed market basket
update to the IPF PPS payments by applying the TEFRA and PPS updates to
payments under revised budget neutral factor and labor-related share
and wage index under CBSA classification. In the aggregate the proposed
update would result in a 4.7 percent increase in overall payments to
IPFs. This 4.7 percent reflects the current blend of the 4.8 percent
update for IPF TEFRA payments and the 4.5 percent update for the IPF
PPS payments.
In column 6, we present the effects of the payment change in
transition blend percentages to transition year 2 (TEFRA Rate
Percentage = 50 percent, IPF PPS Federal Rate Percentage = 50 percent)
from transition year 1 (TEFRA Rate Percentage = 75 percent, IPF PPS
Federal Rate Percentage = 25 percent) of the IPF PPS under revised
budget neutral factor, labor-related share and wage index under CBSA
classification, and TEFRA and PPS updates to RY 2007. The overall
aggregate effect, across all hospital groups, would be a 0.2 percent
decrease in payments to IPFs. There are distributional effects of these
changes among different categories of IPFs. The largest increases would
be among government psychiatric hospitals, with rural government
hospitals receiving an 11.8 percent increase and urban government
hospitals receiving a 10.8 percent increase. Alternatively, psychiatric
hospitals and units with fewer than 12 beds would receive the largest
decreases of 3.8 percent and 4.5 percent respectively.
Column 7 compares our estimates of proposed changes reflected in
this proposed rule for RY 2007, to our estimates of payments in the
implementation year (without these proposed changes). This column
reflects all RY 2007 proposed changes relative to the implementation
year, shown in columns 3 through 6. The average increase for all IPFs
is approximately 4.2 percent. This increase includes the effects of the
market basket updates resulting in a 4.7 percent increase in total RY
2007 payments. It also includes a 0.3 percent decrease in RY 2007
payments for the standardization factor revision and a 0.2 percent
decrease in RY 2007 payments for the transition blend.
Overall, the largest payment increase would be among government
IPFs. Urban government psychiatric hospitals would receive a 15.6
percent increase and rural government psychiatric hospitals would
receive a 16.1 percent increase. Psychiatric hospitals with fewer than
12 beds would receive a 0.8 percent increase and psychiatric units with
fewer than 12 beds would receive a 0.2 percent decrease.
4. Effect on the Medicare Program
Based on actuarial projections resulting from our experience with
other PPSs, we estimate that Medicare spending (total Medicare program
payments) for IPF services over the next 5 years would be as follows:
Table 16.--Estimated Payments
------------------------------------------------------------------------
Dollars in
Rate year millions
------------------------------------------------------------------------
July 1, 2006 to June 30, 2007........................... $4,257
July 1, 2007 to June 30, 2008........................... 4,382
July 1, 2008 to June 30, 2009........................... 4,559
July 1, 2009 to June 30, 2010........................... 4,762
July 1, 2010 to June 30, 2011........................... 4,979
------------------------------------------------------------------------
These estimates are based on the current estimate of increases in
the excluded hospital with capital market basket as follows:
3.6 percent for RY 2007;
3.5 percent for RY 2008;
3.1 percent for RY 2009;
2.6 percent for RY 2010; and
3.0 percent for RY 2011.
We estimate that there would be a change in fee-for-service
Medicare beneficiary enrollment as follows:
-2.3 percent in RY 2007;
-1.0 percent in RY 2008;
0.3 percent in RY 2009;
0.3 percent in RY 2010; and
0.6 percent in RY 2011.
In the implementation year we estimated aggregate payments under
the IPF PPS to equal the estimated aggregate payments that would be
made if the IPF PPS were not implemented. Our methodology for
estimating payments for purposes of the budget-neutrality calculations
uses the best available data.
We will evaluate the accuracy of the assumptions used to compute
the budget-neutrality calculation in the implementation year. We intend
to analyze claims and cost report data from the implementation year of
the IPF PPS to determine whether the factors used to develop the
Federal per diem base rate are not significantly different from the
actual results experienced in that year. We are planning to compare
payments under the final IPF PPS (which relies on an estimate of cost-
based TEFRA payments using historical data from a base year and
assumptions that trend the data to the initial implementation period)
to estimated cost-based TEFRA payments based on actual data from the
first year of the IPF PPS. If we find that an adjustment is necessary,
the percent difference (either positive or negative) would be applied
prospectively to the established prospective payment rates to ensure
the rates accurately reflect the payment levels intended by the
statute.
Section 124 of Public Law 106-113 provides the Secretary broad
authority to make an adjustment. We intend to perform this analysis
within the first 5 years of the implementation of the IPF PPS.
5. Effect on Beneficiaries
Under the IPF PPS, IPFs would receive payment based on the average
resources consumed by patients for each day. We do not expect changes
in the quality of care or access to services for Medicare beneficiaries
under the IPF PPS. In fact, we believe that access to IPF services
would be enhanced due to the patient and facility level adjustment
factors, all of which are intended to adequately reimburse IPFs for
expensive cases. Finally, the stop-loss policy is intended to assist
IPFs during the transition. In addition, we expect that paying
prospectively for IPF services would enhance the efficiency of the
Medicare program.
[[Page 3652]]
6. Computer Hardware and Software
We do not anticipate that IPFs would incur additional systems
operating costs in order to effectively participate in the IPF PPS. We
believe that IPFs and CAHs possess the computer hardware capability to
handle the billing requirements under the IPF PPS. Our belief is based
on indications that approximately 99 percent of hospital inpatient
claims are submitted electronically. In addition, we are not adopting
significant changes in claims processing (see section IV.C of this
proposed rule).
C. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf
), in Table 17 below, we
have prepared an accounting statement showing the classification of the
expenditures associated with the provisions of this proposed rule. This
table provides our best estimate of the increase in Medicare payments
under the IPF PPS as a result of the changes presented in this proposed
rule based on the data for 1,806 IPFs in our database. All expenditures
are classified as transfers to Medicare providers (that is, IPFs).
Table 17.--Accounting Statement: Classification of Estimated
Expenditures, from the 2006 IPF PPS RY to the 2007 IPF PPS RY
(In millions)
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers......... $180.
From Whom To Whom?..................... Federal Government To IPFs
Medicare Providers.
------------------------------------------------------------------------
D. Alternatives Considered
We considered the following alternatives in developing the update
to the IPF PPS:
One option we considered was incorporating a transition from MSA-
based labor market definitions to CBSA-based labor market definitions
for the purpose of applying the area wage index. As stated in section
IV.C.1.e of this proposed rule, we are not adopting a transition policy
here because IPFs are already in a transition from reasonable cost
based reimbursement to IPF PPS payments. In addition, as evident in
Table 15 above, the wage index change does not appear to have a large
impact on IPFs.
We also considered increasing our outlier percentage so that
outlier payments would be projected to be 3 percent (or higher) of
total PPS payments. However, this approach would not target the truly
costly cases. Instead, implementing such a policy would have the effect
of lowering the fixed dollar loss amount, therefore spreading outlier
payments across more IPFs. In addition, the Federal per diem base rate
would have to be reduced by another percentage point.
It is also worth noting that in this proposed rule, we used the
best available complete data set (that is, FY 2002 claims and cost
report data) to assess the impact of the various policy changes. As
previously stated, we won't know the true impact of the wage index
changes, the transition blend period, or the market basket increases
until we are able to analyze 1 year of IPF PPS claims and cost report
data.
We considered alternative policies in order to reduce financial
risk to facilities in the event that they experience substantial
reductions in Medicare payments during the period of transition to the
IPF PPS. As discussed previously in this proposed rule, we have adopted
a provision that would guarantee each facility an average payment per
case under the IPF PPS that is estimated to be no less than a minimum
proportion of its average payment per case under TEFRA. We analyzed the
impact on losses if we were to make a payment adjustment to ensure that
the minimum IPF PPS per case payment to an IPF is at least 70 percent
of its TEFRA payment.
The stop-loss adjustment is applied to the IPF PPS portion of
Medicare payments during the transition. For example, during year 2 of
the 3-year transition period, half of the payment is based on TEFRA,
and half of the payment is based on the Federal rate. We apply the
stop-loss adjustment to the portion of the IPF's payments during the
transition based on the Federal rate. We estimate that the combined
effects of the transition and the stop-loss policies will ensure that
per case payments relative to pre-IPF PPS TEFRA per case payments are
no less than 92.5 percent in year 1, 85 percent in year 2, and 77.5
percent in year 3. We estimate that about 10 percent of IPFs would
receive additional payments under the stop-loss policy.
The 70 percent of TEFRA stop-loss policy required a reduction in
the per diem rate to make the stop-loss policy budget neutral during
the implementation year. As a result, in the IPF PPS final rule, we
made a reduction to the Federal per diem base rate of 0.4 percent in
order to maintain budget neutrality.
In the IPF PPS final rule, we considered an 80 percent stop-loss
policy as well as a 70 percent policy. In order to target the stop-loss
policy to the IPFs that experience the greatest impact relative to
current payments and to limit the size of the reduction to the Federal
per diem base rate, we adopted the 70 percent policy. In developing
this proposed rule, we again considered an 80 percent stop-loss policy
for RY 2007. Adopting an 80 percent policy would require a reduction in
the Federal per diem base rate of over 2.5 percent, and we estimate
that about 29 percent of IPFs would receive additional payments. We
chose to stay with the 70 percent policy for the same reasons discussed
in the IPF PPS final rule. Specifically, the 70 percent stop-loss
policy targets the IPFs that experience the greatest impact relative to
current payments, and it limits the size of the reduction to the
Federal per diem base rate.
In accordance with the provisions of Executive Order 12866, this
rule was previously reviewed by OMB.
List of Subjects
42 CFR Part 412
Administrative practice and procedure, Health facilities, Medicare,
Puerto Rico, Reporting and recordkeeping requirements.
42 CFR Part 424
Emergency medical services, Health facilities, Health professions,
Medicare, Reporting and recordkeeping requirements.
For the reasons set forth in the preamble, the Centers for Medicare
& Medicaid Services proposes to amend 42 CFR chapter IV as follows:
[[Page 3653]]
PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR HOSPITAL SERVICES
1. The authority citation for part 412 is revised to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh), Sec. 124 of Pub. L. 106-113, 113 Stat.
1515, and Sec. 405 of Pub. L. of 108-173, 117 Stat. 2266.
2. Amend Sec. 412.27 by revising paragraph (b) to read as follows:
Sec. 412.27 Excluded psychiatric units: Additional requirements.
* * * * *
(b) Furnish, through the use of qualified personnel, psychological
services, social work services, psychiatric nursing, and occupational
therapy.
* * * * *
3. Section 412.402 is amended by--
A. Republishing the introductory text.
B. Revising the heading of ``Fixed dollar loss threshold,'' to read
``Fixed dollar loss threshold amount.''
C. Revising the definition of ``Fixed dollar loss threshold
amount,'' ``Qualifying emergency department,'' ``Rural area,'' and
``Urban area.''
The revisions read as follows:
Sec. 412.402 Definitions.
As used in this subpart--
* * * * *
Fixed dollar loss threshold amount means a dollar amount which,
when added to the Federal payment amount for case, the estimated costs
of a case must exceed in order for the case to qualify for an outlier
payment.
* * * * *
Qualifying emergency department means an emergency department that
is staffed and equipped to furnish a comprehensive array of emergency
services and meeting the definitions of a dedicated emergency
department as specified in Sec. 489.24(b) of this chapter and the
definition of ``provider-based status'' as specified in Sec. 413.65 of
this chapter.
Rural area means for cost reporting periods beginning January 1,
2005, with respect to discharges occurring during the period covered by
such cost reports but before July 1, 2006, an area as defined in Sec.
412.62(f)(1)(iii). For discharges occurring on or after July 1, 2006,
rural area means an area as defined in Sec. 412.64(b)(1)(ii)(C).
Urban area means for cost reporting periods beginning on or after
January 1, 2005, with respect to discharges occurring during the period
covered by such cost reports but before July 1, 2006, an area as
defined in Sec. 412.62(f)(1)(ii). For discharges occurring on or after
July 1, 2006, urban area means an area as defined in Sec.
412.64(b)(1)(ii)(A) and Sec. 412.64(b)(1)(ii)(B).
4. Section 412.424 is amended by--
A. Revising paragraph (d)(1)(iii).
B. Republishing the heading of paragraph (d)(1)(v).
C. Revising paragraph (d)(1)(v)(A).
D. Adding paragraph (d)(2) introductory text.
E. Removing and reserving paragraph (d)(2)(iii).
F. Revising paragraphs (d)(3)(i) introductory text and
(d)(3)(i)(A).
The revisions and additions read as follows:
Sec. 412.424 Methodology for calculating the Federal per diem payment
amount.
* * * * *
(d) * * *
(1) * * *
(iii) Teaching adjustment. CMS adjusts the Federal per diem base
rate by a factor to account for indirect teaching costs.
(A) An inpatient psychiatric facility's teaching adjustment is
based on the ratio of the number of full-time equivalent residents
training in the inpatient psychiatric facility divided by the
facility's average daily census.
(B) Residents with less than full-time status and residents
rotating through the inpatient psychiatric facility for less than a
full year will be counted in proportion to the time they spend in the
inpatient psychiatric facility.
(C) Except as described in paragraph (d)(1)(iii)(D) of this
section, the actual number of current year full-time equivalent
residents used in calculating the teaching adjustment is limited to the
number of full-time equivalent residents in the inpatient psychiatric
facility's most recently filed cost report filed with its fiscal
intermediary before November 15, 2004 (base year).
(D) If the inpatient psychiatric facility first begins training
residents in a new approved graduate medical education program after
November 15, 2004, the number of full-time equivalent residents
determined under paragraph (d)(1)(iii)(C) of this section may be
adjusted using the method described in Sec. 413.79(e)(1)(i) and (ii)
of this chapter.
(E) The teaching adjustment is made on a claim basis as an interim
payment, and the final payment in full for the claim is made during the
final settlement of the cost report.
* * * * *
(v) Adjustment for IPF with qualifying emergency departments. (A)
CMS adjusts the Federal per diem base rate to account for the costs
associated with maintaining a qualifying emergency department. A
qualifying emergency department is staffed and equipped to furnish a
comprehensive array of emergency services (medical and psychiatric) and
meets the requirements of Sec. 489.24(b) and Sec. 413.65 of this
chapter.
(2) Patient-level adjustments. The inpatient psychiatric facility
must identify a principal psychiatric diagnosis as specified in Sec.
412.27(a) for each patient. CMS adjusts the Federal per diem base rate
by a factor to account for the diagnosis-related group assignment
associated with the principal diagnosis, as specified by CMS.
* * * * *
(3) Other adjustments. (i) Outlier payments. CMS provides an
outlier payment if an inpatient psychiatric facility's estimated total
cost for a case exceeds a fixed dollar loss threshold amount for an
inpatient psychiatric facility as defined in Sec. 412.402 plus the
Federal payment amount for the case.
(A) The fixed dollar loss threshold amount is adjusted for the
inpatient psychiatric facility's adjustments for wage area, teaching,
rural locations, and cost of living adjustment for facilities located
in Alaska and Hawaii.
* * * * *
Sec. 412.426 [Amended]
5. In Sec. 412.426, paragraph (a) introductory text is amended by
removing the reference ``Sec. 412.424(c)'' and adding the reference
``Sec. 412.424(d)'' in its place.
6. Section 412.428 is amended by--
A. Republishing the introductory text.
B. Revising paragraph (b) and (d).
C. Adding a new paragraph (g).
D. Adding a new paragraph (h).
The revision and additions reads as follows:
Sec. 412.428 Publication of updates to the inpatient psychiatric
facility prospective payment system.
CMS will publish annually in the Federal Register information
pertaining to updates to the inpatient psychiatric facility prospective
payment system. This information includes:
* * * * *
(b)(1) For discharges occurring on or after January 1, 2005 but
before July 1, 2006, the rate of increase factor, described in Sec.
412.424(a)(2)(iii), for the Federal portion of the inpatient
psychiatric facility's payment is based on the excluded hospital with
capital market basket under the update methodology described in section
1886(b)(3)(B)(ii) of the Act for each year.
(2) For discharges occurring on or after July 1, 2006, the rate of
increase factor for the Federal portion of the
[[Page 3654]]
inpatient psychiatric facility's payment is based on the
Rehabilitation, Psychiatric, and Long-Term Care (RPL) market basket.
(3) For discharges occurring on or after January 1, 2005 but before
July 1, 2006, the rate of increase factor, described in Sec.
412.424(a)(2)(iii), for the reasonable cost portion of the inpatient
psychiatric facility's payment is based on the 1997-based excluded
hospital market basket under the updated methodology described in
section 1886(b)(3)(B)(ii) of the Act for each year.
(4) For discharges occurring on or after July 1, 2006, the rate of
increase factor for the reasonable cost portion of the inpatient
psychiatric facility's payment is based on the 2002-based excluded
hospital market basket.
* * * * *
(d) Updates to the fixed dollar loss threshold amount in order to
maintain the appropriate outlier percentage.
* * * * *
(g) Update the national urban and rural cost to charge ratio median
and ceilings. CMS will apply the national cost to charge ratio to--
(1) New inpatient psychiatric facilities that have not submitted
their first Medicare cost report.
(2) Inpatient psychiatric facilities whose operating or capital
cost to charge ratio is in excess of 3 standard deviations above the
corresponding national geometric mean.
(3) Other inpatient psychiatric facilities for which the fiscal
intermediary obtains inaccurate or incomplete date with which to
calculate either an operating or capital cost to charge ratio or both.
(h) Update the cost of living adjustment factor if appropriate.
PART 424--CONDITIONS FOR MEDICARE PAYMENT
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).
2. Section 424.14 is amended by--
A. Revising the heading.
B. Adding a new paragraph (c)(3).
C. Revising paragraph (d)(2).
The addition and revisions read as follows:
Sec. 424.14 Requirements for inpatient services of inpatient
psychiatric facilities.
* * * * *
(c) * * *
(3) The patient continues to need, on a daily basis, active
inpatient psychiatric care (furnished directly by or requiring the
supervision of inpatient psychiatric facility personnel) or other
professional services that can only be provided on an inpatient basis.
(d) * * *
(2) The first recertification is required as of the 12th day of
hospitalization. Subsequent recertifications are required at intervals
established by the UR committee (on a case-by-case basis if it so
chooses), but no less frequently than every 30 days.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.778, Medical
Assistance Program)
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: November 3, 2005.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
Approved: January 13, 2006.
Michael O. Leavitt,
Secretary.
Note: The following addenda will not appear in the Code of
Federal Regulations.
Addendum A--Rate and Adjustment Factors
Per Diem Rate
------------------------------------------------------------------------
------------------------------------------------------------------------
Federal Per Diem Base Rate................................. $594.66
Labor Share (0.75923)...................................... $451.48
Non-Labor Share (0.24077).................................. $143.18
------------------------------------------------------------------------
Fixed Dollar Loss Threshold Amount
------------------------------------------------------------------------
-------------------------------------------------------------------------
$6200
------------------------------------------------------------------------
Facility Adjustments
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Rural Adjustment Factor.................................... 1.17.
Teaching Adjustment Factor................................. 0.5150.
Wage Index................................................. Pre-reclass Hospital Wage Index (FY2006).
----------------------------------------------------------------------------------------------------------------
Cost of Living Adjustments (COLAs)
------------------------------------------------------------------------
------------------------------------------------------------------------
Alaska..................................................... 1.25
Hawaii
Honolulu County........................................ 1.25
Hawaii County.......................................... 1.165
Kauai County........................................... 1.2325
Maui County............................................ 1.2375
Kalawao County......................................... 1.2375
------------------------------------------------------------------------
Patient Adjustments
------------------------------------------------------------------------
------------------------------------------------------------------------
ECT--Per Treatment......................................... $268.21
------------------------------------------------------------------------
[[Page 3655]]
Variable Per Diem Adjustments
------------------------------------------------------------------------
Adjustment
Factor
------------------------------------------------------------------------
Day 1--Facility Without a 24/7 Full-service Emergency 1.19
Department................................................
Day 1--Facility With a 24/7 Full-service Emergency 1.31
Department................................................
Day 2...................................................... 1.12
Day 3...................................................... 1.08
Day 4...................................................... 1.05
Day 5...................................................... 1.04
Day 6...................................................... 1.02
Day 7...................................................... 1.01
Day 8...................................................... 1.01
Day 9...................................................... 1.00
Day 10..................................................... 1.00
Day 11..................................................... 0.99
Day 12..................................................... 0.99
Day 13..................................................... 0.99
Day 14..................................................... 0.99
Day 15..................................................... 0.98
Day 16..................................................... 0.97
Day 17..................................................... 0.97
Day 18..................................................... 0.96
Day 19..................................................... 0.95
Day 20..................................................... 0.95
Day 21..................................................... 0.95
After Day 21............................................... 0.92
------------------------------------------------------------------------
Age Adjustments
------------------------------------------------------------------------
Adjustment
Age (in years) Factor
------------------------------------------------------------------------
Under 45................................................... 1.00
45 and under 50............................................ 1.01
50 and under 55............................................ 1.02
55 and under 60............................................ 1.04
60 and under 65............................................ 1.07
65 and under 70............................................ 1.10
70 and under 75............................................ 1.13
75 and under 80............................................ 1.15
80 and over................................................ 1.17
------------------------------------------------------------------------
DRG Adjustments
------------------------------------------------------------------------
DRG
DRG DRG Definition Adjustment
Factor
------------------------------------------------------------------------
DRG 424 Procedure with principal 1.22
diagnosis of mental illness.
DRG 425 Acute adjustment reaction....... 1.05
DRG 426 Depressive neurosis............. 0.99
DRG 427 Neurosis, except depressive..... 1.02
DRG 428 Disorders of personality........ 1.02
DRG 429 Organic disturbances............ 1.03
DRG 430 Psychosis....................... 1.00
DRG 431 Childhood disorders............. 0.99
DRG 432 Other mental disorders.......... 0.92
DRG 433 Alcohol/Drug use Leave against 0.97
Medical Advice (LAMA).
DRG 521 Alcohol/Drug use with comorbid 1.02
conditions.
DRG 522 Alcohol/Drug use without 0.98
comorbid conditions.
DRG 523 Alcohol/Drug use without 0.88
rehabilitation.
DRG 12 Degenerative nervous system 1.05
disorders.
DRG 23 Non-traumatic stupor & coma..... 1.07
------------------------------------------------------------------------
Comorbidity Adjustments
------------------------------------------------------------------------
Adjustment
Comorbidity Factor
------------------------------------------------------------------------
Developmental Disabilities................................. 1.04
Coagulation Factor Deficit................................. 1.13
Tracheostomy............................................... 1.06
[[Page 3656]]
Eating and Conduct Disorders............................... 1.12
Infectious Diseases........................................ 1.07
Renal Failure, Acute....................................... 1.11
Renal Failure, Chronic..................................... 1.11
Oncology Treatment......................................... 1.07
Uncontrolled Diabetes Mellitus............................. 1.05
Severe Protein Malnutrition................................ 1.13
Drug/Alcohol Induced Mental Disorders...................... 1.03
Cardiac Conditions......................................... 1.11
Gangrene................................................... 1.10
Chronic Obstructive Pulmonary Disease...................... 1.12
Artificial Openings - Digestive & Urinary.................. 1.08
Musculoskeletal & Connective Tissue Diseases............... 1.09
Poisoning.................................................. 1.11
------------------------------------------------------------------------
Addendum B--RY 2007 IPF PPS Wage Index Table
----------------------------------------------------------------------------------------------------------------
2006
SSA State/County MSA MSA- CBSA 2006 CBSA-
Code County name Number MSA Urban/Rural based Number CBSA Urban/Rural based WI
WI
----------------------------------------------------------------------------------------------------------------
01000............ Autauga County, 5240 Urban........... 0.8618 33860 Urban........... 0.8618
Alabama.
01010............ Baldwin County, 5160 Urban........... 0.7861 99901 Rural........... 0.7446
Alabama.
01020............ Barbour County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01030............ Bibb County, 01 Rural........... 0.7432 13820 Urban........... 0.8959
Alabama.
01040............ Blount County, 1000 Urban........... 0.9000 13820 Urban........... 0.8959
Alabama.
01050............ Bullock County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01060............ Butler County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01070............ Calhoun County, 0450 Urban........... 0.7682 11500 Urban........... 0.7682
Alabama.
01080............ Chambers County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01090............ Cherokee County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01100............ Chilton County, 01 Rural........... 0.7432 13820 Urban........... 0.8959
Alabama.
01110............ Choctaw County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01120............ Clarke County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01130............ Clay County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01140............ Cleburne County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01150............ Coffee County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01160............ Colbert County, 2650 Urban........... 0.8272 22520 Urban........... 0.8272
Alabama.
01170............ Conecuh County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01180............ Coosa County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01190............ Covington County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01200............ Crenshaw County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01210............ Cullman County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01220............ Dale County, 2180 Urban........... 0.7701 99901 Rural........... 0.7446
Alabama.
01230............ Dallas County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01240............ De Kalb County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01250............ Elmore County, 5240 Urban........... 0.8618 33860 Urban........... 0.8618
Alabama.
01260............ Escambia County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01270............ Etowah County, 2880 Urban........... 0.7938 23460 Urban........... 0.7938
Alabama.
01280............ Fayette County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01290............ Franklin County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01300............ Geneva County, 01 Rural........... 0.7432 20020 Urban........... 0.7721
Alabama.
01310............ Greene County, 01 Rural........... 0.7432 46220 Urban........... 0.8645
Alabama.
01320............ Hale County, 01 Rural........... 0.7432 46220 Urban........... 0.8645
Alabama.
01330............ Henry County, 01 Rural........... 0.7432 20020 Urban........... 0.7721
Alabama.
01340............ Houston County, 2180 Urban........... 0.7701 20020 Urban........... 0.7721
Alabama.
01350............ Jackson County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01360............ Jefferson County, 1000 Urban........... 0.9000 13820 Urban........... 0.8959
Alabama.
01370............ Lamar County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01380............ Lauderdale County, 2650 Urban........... 0.8272 22520 Urban........... 0.8272
Alabama.
01390............ Lawrence County, 2030 Urban........... 0.8469 19460 Urban........... 0.8469
Alabama.
01400............ Lee County, Alabama 0580 Urban........... 0.8100 12220 Urban........... 0.8100
01410............ Limestone County, 3440 Urban........... 0.9146 26620 Urban........... 0.9146
Alabama.
01420............ Lowndes County, 01 Rural........... 0.7432 33860 Urban........... 0.8618
Alabama.
01430............ Macon County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01440............ Madison County, 3440 Urban........... 0.9146 26620 Urban........... 0.9146
Alabama.
01450............ Marengo County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01460............ Marion County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
[[Page 3657]]
01470............ Marshall County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01480............ Mobile County, 5160 Urban........... 0.7861 33660 Urban........... 0.7891
Alabama.
01490............ Monroe County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01500............ Montgomery County, 5240 Urban........... 0.8618 33860 Urban........... 0.8618
Alabama.
01510............ Morgan County, 2030 Urban........... 0.8469 19460 Urban........... 0.8469
Alabama.
01520............ Perry County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01530............ Pickens County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01540............ Pike County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01550............ Randolph County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01560............ Russell County, 1800 Urban........... 0.8560 17980 Urban........... 0.8560
Alabama.
01570............ St Clair County, 1000 Urban........... 0.9000 13820 Urban........... 0.8959
Alabama.
01580............ Shelby County, 1000 Urban........... 0.9000 13820 Urban........... 0.8959
Alabama.
01590............ Sumter County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01600............ Talladega County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01610............ Tallapoosa County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01620............ Tuscaloosa County, 8600 Urban........... 0.8764 46220 Urban........... 0.8645
Alabama.
01630............ Walker County, 01 Rural........... 0.7432 13820 Urban........... 0.8959
Alabama.
01640............ Washington County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01650............ Wilcox County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
01660............ Winston County, 01 Rural........... 0.7432 99901 Rural........... 0.7446
Alabama.
02013............ Aleutians County 02 Rural........... 1.1888 99902 Rural........... 1.1977
East, Alaska.
02016............ Aleutians County 02 Rural........... 1.1888 99902 Rural........... 1.1977
West, Alaska.
02020............ Anchorage County, 0380 Urban........... 1.1784 11260 Urban........... 1.1895
Alaska.
02030............ Angoon County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02040............ Barrow-North Slope 02 Rural........... 1.1888 99902 Rural........... 1.1977
County, Alaska.
02050............ Bethel County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02060............ Bristol Bay Borough 02 Rural........... 1.1888 99902 Rural........... 1.1977
County, Alaska.
02068............ Denali County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02070............ Bristol Bay County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02080............ Cordova-Mc Carthy 02 Rural........... 1.1888 99902 Rural........... 1.1977
County, Alaska.
02090............ Fairbanks County, 02 Rural........... 1.1888 21820 Urban........... 1.1408
Alaska.
02100............ Haines County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02110............ Juneau County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02120............ Kenai-Cook Inlet 02 Rural........... 1.1888 99902 Rural........... 1.1977
County, Alaska.
02122............ Kenai Peninsula 02 Rural........... 1.1888 99902 Rural........... 1.1977
Borough, Alaska.
02130............ Ketchikan County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02140............ Kobuk County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02150............ Kodiak County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02160............ Kuskokwin County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02164............ Lake and Peninsula 02 Rural........... 1.1888 99902 Rural........... 1.1977
Borough, Alaska.
02170............ Matanuska County, 02 Rural........... 1.1888 11260 Urban........... 1.1895
Alaska.
02180............ Nome County, Alaska 02 Rural........... 1.1888 99902 Rural........... 1.1977
02185............ North Slope 02 Rural........... 1.1888 99902 Rural........... 1.1977
Borough, Alaska.
02188............ Northwest Arctic 02 Rural........... 1.1888 99902 Rural........... 1.1977
Borough, Alaska.
02190............ Outer Ketchikan 02 Rural........... 1.1888 99902 Rural........... 1.1977
County, Alaska.
02200............ Prince Of Wales 02 Rural........... 1.1888 99902 Rural........... 1.1977
County, Alaska.
02201............ Prince of Wales- 02 Rural........... 1.1888 99902 Rural........... 1.1977
Outer Ketchikan
Census Area,
Alaska.
02210............ Seward County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02220............ Sitka County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02230............ Skagway-Yakutat 02 Rural........... 1.1888 99902 Rural........... 1.1977
County, Alaska.
02231............ Skagway-Yakutat- 02 Rural........... 1.1888 99902 Rural........... 1.1977
Angoon Census
Area, Alaska.
02232............ Skagway-Hoonah- 02 Rural........... 1.1888 99902 Rural........... 1.1977
Angoon Census
Area, Alaska.
02240............ Southeast Fairbanks 02 Rural........... 1.1888 99902 Rural........... 1.1977
County, Alaska.
02250............ Upper Yukon County, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02260............ Valdz-Chitna- 02 Rural........... 1.1888 99902 Rural........... 1.1977
Whitier County,
Alaska.
02261............ Valdex-Cordove 02 Rural........... 1.1888 99902 Rural........... 1.1977
Census Area,
Alaska.
02270............ Wade Hampton 02 Rural........... 1.1888 99902 Rural........... 1.1977
County, Alaska.
02280............ Wrangell-Petersburg 02 Rural........... 1.1888 99902 Rural........... 1.1977
County, Alaska.
02282............ Yakutat Borough, 02 Rural........... 1.1888 99902 Rural........... 1.1977
Alaska.
02290............ Yukon-Koyukuk 02 Rural........... 1.1888 99902 Rural........... 1.1977
County, Alaska.
03000............ Apache County, 03 Rural........... 0.9045 99903 Rural........... 0.8768
Arizona.
03010............ Cochise County, 03 Rural........... 0.9045 99903 Rural........... 0.8768
Arizona.
03020............ Coconino County, 2620 Urban........... 1.1845 22380 Urban........... 1.2092
Arizona.
03030............ Gila County, 03 Rural........... 0.9045 99903 Rural........... 0.8768
Arizona.
03040............ Graham County, 03 Rural........... 0.9045 99903 Rural........... 0.8768
Arizona.
03050............ Greenlee County, 03 Rural........... 0.9045 99903 Rural........... 0.8768
Arizona.
03055............ La Paz County, 03 Rural........... 0.9045 99903 Rural........... 0.8768
Arizona.
03060............ Maricopa County, 6200 Urban........... 1.0127 38060 Urban........... 1.0127
Arizona.
03070............ Mohave County, 4120 Urban........... 1.1155 99903 Rural........... 0.8768
Arizona.
03080............ Navajo County, 03 Rural........... 0.9045 99903 Rural........... 0.8768
Arizona.
03090............ Pima County, 8520 Urban........... 0.9007 46060 Urban........... 0.9007
Arizona.
[[Page 3658]]
03100............ Pinal County, 6200 Urban........... 1.0127 38060 Urban........... 1.0127
Arizona.
03110............ Santa Cruz County, 03 Rural........... 0.9045 99903 Rural........... 0.8768
Arizona.
03120............ Yavapai County, 03 Rural........... 0.9045 39140 Urban........... 0.9869
Arizona.
03130............ Yuma County, 9360 Urban........... 0.9126 49740 Urban........... 0.9126
Arizona.
04000............ Arkansas County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04010............ Ashley County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04020............ Baxter County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04030............ Benton County, 2580 Urban........... 0.8661 22220 Urban........... 0.8661
Arkansas.
04040............ Boone County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04050............ Bradley County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04060............ Calhoun County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04070............ Carroll County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04080............ Chicot County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04090............ Clark County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04100............ Clay County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04110............ Cleburne County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04120............ Cleveland County, 04 Rural........... 0.7744 38220 Urban........... 0.8680
Arkansas.
04130............ Columbia County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04140............ Conway County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04150............ Craighead County, 3700 Urban........... 0.7911 27860 Urban........... 0.7911
Arkansas.
04160............ Crawford County, 2720 Urban........... 0.8246 22900 Urban........... 0.8230
Arkansas.
04170............ Crittenden County, 4920 Urban........... 0.9416 32820 Urban........... 0.9397
Arkansas.
04180............ Cross County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04190............ Dallas County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04200............ Desha County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04210............ Drew County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04220............ Faulkner County, 4400 Urban........... 0.8747 30780 Urban........... 0.8747
Arkansas.
04230............ Franklin County, 04 Rural........... 0.7744 22900 Urban........... 0.8230
Arkansas.
04240............ Fulton County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04250............ Garland County, 04 Rural........... 0.7744 26300 Urban........... 0.9005
Arkansas.
04260............ Grant County, 04 Rural........... 0.7744 30780 Urban........... 0.8747
Arkansas.
04270............ Greene County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04280............ Hempstead County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04290............ Hot Spring County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04300............ Howard County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04310............ Independence 04 Rural........... 0.7744 99904 Rural........... 0.7466
County, Arkansas.
04320............ Izard County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04330............ Jackson County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04340............ Jefferson County, 6240 Urban........... 0.8680 38220 Urban........... 0.8680
Arkansas.
04350............ Johnson County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04360............ Lafayette County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04370............ Lawrence County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04380............ Lee County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04390............ Lincoln County, 04 Rural........... 0.7744 38220 Urban........... 0.8680
Arkansas.
04400............ Little River 04 Rural........... 0.7744 99904 Rural........... 0.7466
County, Arkansas.
04410............ Logan County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04420............ Lonoke County, 4400 Urban........... 0.8747 30780 Urban........... 0.8747
Arkansas.
04430............ Madison County, 04 Rural........... 0.7744 22220 Urban........... 0.8661
Arkansas.
04440............ Marion County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04450............ Miller County, 8360 Urban........... 0.8283 45500 Urban........... 0.8283
Arkansas.
04460............ Mississippi County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04470............ Monroe County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04480............ Montgomery County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04490............ Nevada County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04500............ Newton County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04510............ Ouachita County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04520............ Perry County, 04 Rural........... 0.7744 30780 Urban........... 0.8747
Arkansas.
04530............ Phillips County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04540............ Pike County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04550............ Poinsett County, 04 Rural........... 0.7744 27860 Urban........... 0.7911
Arkansas.
04560............ Polk County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04570............ Pope County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04580............ Prairie County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04590............ Pulaski County, 4400 Urban........... 0.8747 30780 Urban........... 0.8747
Arkansas.
04600............ Randolph County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04610............ St Francis County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04620............ Saline County, 4400 Urban........... 0.8747 30780 Urban........... 0.8747
Arkansas.
04630............ Scott County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04640............ Searcy County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04650............ Sebastian County, 2720 Urban........... 0.8246 22900 Urban........... 0.8230
Arkansas.
04660............ Sevier County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
[[Page 3659]]
04670............ Sharp County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04680............ Stone County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04690............ Union County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04700............ Van Buren County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04710............ Washington County, 2580 Urban........... 0.8661 22220 Urban........... 0.8661
Arkansas.
04720............ White County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04730............ Woodruff County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
04740............ Yell County, 04 Rural........... 0.7744 99904 Rural........... 0.7466
Arkansas.
05000............ Alameda County, 5775 Urban........... 1.5346 36084 Urban........... 1.5346
California.
05010............ Alpine County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05020............ Amador County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05030............ Butte County, 1620 Urban........... 1.0511 17020 Urban........... 1.0511
California.
05040............ Calaveras County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05050............ Colusa County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05060............ Contra Costa 5775 Urban........... 1.5346 36084 Urban........... 1.5346
County, California.
05070............ Del Norte County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05080............ Eldorado County, 6920 Urban........... 1.3143 40900 Urban........... 1.2969
California.
05090............ Fresno County, 2840 Urban........... 1.0428 23420 Urban........... 1.0538
California.
05100............ Glenn County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05110............ Humboldt County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05120............ Imperial County, 05 Rural........... 1.0775 20940 Urban........... 0.8906
California.
05130............ Inyo County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05140............ Kern County, 0680 Urban........... 1.0470 12540 Urban........... 1.0470
California.
05150............ Kings County, 05 Rural........... 1.0775 25260 Urban........... 1.0036
California.
05160............ Lake County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05170............ Lassen County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05200............ Los Angeles County, 4480 Urban........... 1.1783 31084 Urban........... 1.1783
California.
05210............ Los Angeles County, 4480 Urban........... 1.1783 31084 Urban........... 1.1783
California.
05300............ Madera County, 2840 Urban........... 1.0428 31460 Urban........... 0.8713
California.
05310............ Marin County, 7360 Urban........... 1.4994 41884 Urban........... 1.4994
California.
05320............ Mariposa County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05330............ Mendocino County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05340............ Merced County, 4940 Urban........... 1.1109 32900 Urban........... 1.1109
California.
05350............ Modoc County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05360............ Mono County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05370............ Monterey County, 7120 Urban........... 1.4128 41500 Urban........... 1.4128
California.
05380............ Napa County, 8720 Urban........... 1.3983 34900 Urban........... 1.2643
California.
05390............ Nevada County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05400............ Orange County, 5945 Urban........... 1.1559 42044 Urban........... 1.1559
California.
05410............ Placer County, 6920 Urban........... 1.3143 40900 Urban........... 1.2969
California.
05420............ Plumas County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05430............ Riverside County, 6780 Urban........... 1.1027 40140 Urban........... 1.1027
California.
05440............ Sacramento County, 6920 Urban........... 1.3143 40900 Urban........... 1.2969
California.
05450............ San Benito County, 05 Rural........... 1.0775 41940 Urban........... 1.5099
California.
05460............ San Bernardino 6780 Urban........... 1.1027 40140 Urban........... 1.1027
County, California.
05470............ San Diego County, 7320 Urban........... 1.1413 41740 Urban........... 1.1413
California.
05480............ San Francisco 7360 Urban........... 1.4994 41884 Urban........... 1.4994
County, California.
05490............ San Joaquin County, 8120 Urban........... 1.1307 44700 Urban........... 1.1307
California.
05500............ San Luis Obispo 7460 Urban........... 1.1349 42020 Urban........... 1.1349
County, California.
05510............ San Mateo County, 7360 Urban........... 1.4994 41884 Urban........... 1.4994
California.
05520............ Santa Barbara 7480 Urban........... 1.1694 42060 Urban........... 1.1694
County, California.
05530............ Santa Clara County, 7400 Urban........... 1.5118 41940 Urban........... 1.5099
California.
05540............ Santa Cruz County, 7485 Urban........... 1.5166 42100 Urban........... 1.5166
California.
05550............ Shasta County, 6690 Urban........... 1.2203 39820 Urban........... 1.2203
California.
05560............ Sierra County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05570............ Siskiyou County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05580............ Solano County, 8720 Urban........... 1.3983 46700 Urban........... 1.4936
California.
05590............ Sonoma County, 7500 Urban........... 1.3493 42220 Urban........... 1.3493
California.
05600............ Stanislaus County, 5170 Urban........... 1.1885 33700 Urban........... 1.1885
California.
05610............ Sutter County, 9340 Urban........... 1.0921 49700 Urban........... 1.0921
California.
05620............ Tehama County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05630............ Trinity County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05640............ Tulare County, 8780 Urban........... 1.0123 47300 Urban........... 1.0123
California.
05650............ Tuolumne County, 05 Rural........... 1.0775 99905 Rural........... 1.1054
California.
05660............ Ventura County, 8735 Urban........... 1.1622 37100 Urban........... 1.1622
California.
05670............ Yolo County, 9270 Urban........... 0.9950 40900 Urban........... 1.2969
California.
05680............ Yuba County, 9340 Urban........... 1.0921 49700 Urban........... 1.0921
California.
06000............ Adams County, 2080 Urban........... 1.0723 19740 Urban........... 1.0723
Colorado.
06010............ Alamosa County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06020............ Arapahoe County, 2080 Urban........... 1.0723 19740 Urban........... 1.0723
Colorado.
06030............ Archuleta County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
[[Page 3660]]
06040............ Baca County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06050............ Bent County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06060............ Boulder County, 1125 Urban........... 0.9734 14500 Urban........... 0.9734
Colorado.
06070............ Chaffee County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06080............ Cheyenne County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06090............ Clear Creek County, 06 Rural........... 0.9380 19740 Urban........... 1.0723
Colorado.
06100............ Conejos County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06110............ Costilla County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06120............ Crowley County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06130............ Custer County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06140............ Delta County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06150............ Denver County, 2080 Urban........... 1.0723 19740 Urban........... 1.0723
Colorado.
06160............ Dolores County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06170............ Douglas County, 2080 Urban........... 1.0723 19740 Urban........... 1.0723
Colorado.
06180............ Eagle County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06190............ Elbert County, 06 Rural........... 0.9380 19740 Urban........... 1.0723
Colorado.
06200............ El Paso County, 1720 Urban........... 0.9468 17820 Urban........... 0.9468
Colorado.
06210............ Fremont County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06220............ Garfield County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06230............ Gilpin County, 06 Rural........... 0.9380 19740 Urban........... 1.0723
Colorado.
06240............ Grand County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06250............ Gunnison County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06260............ Hinsdale County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06270............ Huerfano County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06280............ Jackson County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06290............ Jefferson County, 2080 Urban........... 1.0723 19740 Urban........... 1.0723
Colorado.
06300............ Kiowa County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06310............ Kit Carson County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06320............ Lake County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06330............ La Plata County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06340............ Larimer County, 2670 Urban........... 1.0122 22660 Urban........... 1.0122
Colorado.
06350............ Las Animas County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06360............ Lincoln County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06370............ Logan County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06380............ Mesa County, 2995 Urban........... 0.9550 24300 Urban........... 0.9550
Colorado.
06390............ Mineral County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06400............ Moffat County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06410............ Montezuma County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06420............ Montrose County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06430............ Morgan County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06440............ Otero County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06450............ Ouray County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06460............ Park County, 06 Rural........... 0.9380 19740 Urban........... 1.0723
Colorado.
06470............ Phillips County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06480............ Pitkin County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06490............ Prowers County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06500............ Pueblo County, 6560 Urban........... 0.8623 39380 Urban........... 0.8623
Colorado.
06510............ Rio Blanco County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06520............ Rio Grande County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06530............ Routt County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06540............ Saguache County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06550............ San Juan County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06560............ San Miguel County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06570............ Sedgwick County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06580............ Summit County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06590............ Teller County, 06 Rural........... 0.9380 17820 Urban........... 0.9468
Colorado.
06600............ Washington County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06610............ Weld County, 3060 Urban........... 0.9570 24540 Urban........... 0.9570
Colorado.
06620............ Yuma County, 06 Rural........... 0.9380 99906 Rural........... 0.9380
Colorado.
06630............ Broomfield County, 2080 Urban........... 1.0723 19740 Urban........... 1.0723
Colorado.
07000............ Fairfield County, 5483 Urban........... 1.2196 14860 Urban........... 1.2592
Connecticut.
07010............ Hartford County, 3283 Urban........... 1.1073 25540 Urban........... 1.1073
Connecticut.
07020............ Litchfield County, 3283 Urban........... 1.1073 25540 Urban........... 1.1073
Connecticut.
07030............ Middlesex County, 3283 Urban........... 1.1073 25540 Urban........... 1.1073
Connecticut.
07040............ New Haven County, 5483 Urban........... 1.2196 35300 Urban........... 1.1887
Connecticut.
07050............ New London County, 5523 Urban........... 1.1345 35980 Urban........... 1.1345
Connecticut.
07060............ Tolland County, 3283 Urban........... 1.1073 25540 Urban........... 1.1073
Connecticut.
07070............ Windham County, 07 Rural........... 1.1730 99907 Rural........... 1.1730
Connecticut.
08000............ Kent County, 2190 Urban........... 0.9776 20100 Urban........... 0.9776
Delaware.
08010............ New Castle County, 9160 Urban........... 1.0527 48864 Urban........... 1.0471
Delaware.
08020............ Sussex County, 08 Rural........... 0.9579 99908 Rural........... 0.9579
Delaware.
[[Page 3661]]
09000............ Washington DC 8840 Urban........... 1.0976 47894 Urban........... 1.0926
County, Dist Of
Col.
10000............ Alachua County, 2900 Urban........... 0.9388 23540 Urban........... 0.9388
Florida.
10010............ Baker County, 10 Rural........... 0.8677 27260 Urban........... 0.9290
Florida.
10020............ Bay County, Florida 6015 Urban........... 0.8005 37460 Urban........... 0.8005
10030............ Bradford County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10040............ Brevard County, 4900 Urban........... 0.9839 37340 Urban........... 0.9839
Florida.
10050............ Broward County, 2680 Urban........... 1.0432 22744 Urban........... 1.0432
Florida.
10060............ Calhoun County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10070............ Charlotte County, 6580 Urban........... 0.9255 39460 Urban........... 0.9255
Florida.
10080............ Citrus County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10090............ Clay County, 3600 Urban........... 0.9299 27260 Urban........... 0.9290
Florida.
10100............ Collier County, 5345 Urban........... 1.0139 34940 Urban........... 1.0139
Florida.
10110............ Columbia County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10120............ Dade County, 5000 Urban........... 0.9750 33124 Urban........... 0.9750
Florida.
10130............ De Soto County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10140............ Dixie County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10150............ Duval County, 3600 Urban........... 0.9299 27260 Urban........... 0.9290
Florida.
10160............ Escambia County, 6080 Urban........... 0.8096 37860 Urban........... 0.8096
Florida.
10170............ Flagler County, 2020 Urban........... 0.9325 99910 Rural........... 0.8568
Florida.
10180............ Franklin County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10190............ Gadsden County, 8240 Urban........... 0.8688 45220 Urban........... 0.8688
Florida.
10200............ Gilchrist County, 10 Rural........... 0.8677 23540 Urban........... 0.9388
Florida.
10210............ Glades County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10220............ Gulf County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10230............ Hamilton County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10240............ Hardee County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10250............ Hendry County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10260............ Hernando County, 8280 Urban........... 0.9233 45300 Urban........... 0.9233
Florida.
10270............ Highlands County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10280............ Hillsborough 8280 Urban........... 0.9233 45300 Urban........... 0.9233
County, Florida.
10290............ Holmes County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10300............ Indian River 10 Rural........... 0.8677 46940 Urban........... 0.9434
County, Florida.
10310............ Jackson County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10320............ Jefferson County, 10 Rural........... 0.8677 45220 Urban........... 0.8688
Florida.
10330............ Lafayette County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10340............ Lake County, 5960 Urban........... 0.9464 36740 Urban........... 0.9464
Florida.
10350............ Lee County, Florida 2700 Urban........... 0.9356 15980 Urban........... 0.9356
10360............ Leon County, 8240 Urban........... 0.8688 45220 Urban........... 0.8688
Florida.
10370............ Levy County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10380............ Liberty County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10390............ Madison County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10400............ Manatee County, 7510 Urban........... 0.9639 42260 Urban........... 0.9639
Florida.
10410............ Marion County, 5790 Urban........... 0.8925 36100 Urban........... 0.8925
Florida.
10420............ Martin County, 2710 Urban........... 1.0123 38940 Urban........... 1.0123
Florida.
10430............ Monroe County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10440............ Nassau County, 3600 Urban........... 0.9299 27260 Urban........... 0.9290
Florida.
10450............ Okaloosa County, 2750 Urban........... 0.8872 23020 Urban........... 0.8872
Florida.
10460............ Okeechobee County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10470............ Orange County, 5960 Urban........... 0.9464 36740 Urban........... 0.9464
Florida.
10480............ Osceola County, 5960 Urban........... 0.9464 36740 Urban........... 0.9464
Florida.
10490............ Palm Beach County, 8960 Urban........... 1.0067 48424 Urban........... 1.0067
Florida.
10500............ Pasco County, 8280 Urban........... 0.9233 45300 Urban........... 0.9233
Florida.
10510............ Pinellas County, 8280 Urban........... 0.9233 45300 Urban........... 0.9233
Florida.
10520............ Polk County, 3980 Urban........... 0.8912 29460 Urban........... 0.8912
Florida.
10530............ Putnam County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10540............ Johns County, 3600 Urban........... 0.9299 27260 Urban........... 0.9290
Florida.
10550............ St Lucie County, 2710 Urban........... 1.0123 38940 Urban........... 1.0123
Florida.
10560............ Santa Rosa County, 6080 Urban........... 0.8096 37860 Urban........... 0.8096
Florida.
10570............ Sarasota County, 7510 Urban........... 0.9639 42260 Urban........... 0.9639
Florida.
10580............ Seminole County, 5960 Urban........... 0.9464 36740 Urban........... 0.9464
Florida.
10590............ Sumter County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10600............ Suwannee County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10610............ Taylor County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10620............ Union County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10630............ Volusia County, 2020 Urban........... 0.9325 19660 Urban........... 0.9299
Florida.
10640............ Wakulla County, 10 Rural........... 0.8677 45220 Urban........... 0.8688
Florida.
10650............ Walton County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
10660............ Washington County, 10 Rural........... 0.8677 99910 Rural........... 0.8568
Florida.
11000............ Appling County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11010............ Atkinson County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11011............ Bacon County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
[[Page 3662]]
11020............ Baker County, 11 Rural........... 0.8166 10500 Urban........... 0.8628
Georgia.
11030............ Baldwin County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11040............ Banks County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11050............ Barrow County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11060............ Bartow County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11070............ Ben Hill County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11080............ Berrien County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11090............ Bibb County, 4680 Urban........... 0.9277 31420 Urban........... 0.9443
Georgia.
11100............ Bleckley County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11110............ Brantley County, 11 Rural........... 0.8166 15260 Urban........... 0.9311
Georgia.
11120............ Brooks County, 11 Rural........... 0.8166 46660 Urban........... 0.8866
Georgia.
11130............ Bryan County, 7520 Urban........... 0.9461 42340 Urban........... 0.9461
Georgia.
11140............ Bulloch County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11150............ Burke County, 11 Rural........... 0.8166 12260 Urban........... 0.9748
Georgia.
11160............ Butts County, 11 Rural........... 0.8166 12060 Urban........... 0.9793
Georgia.
11161............ Calhoun County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11170............ Camden County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11180............ Candler County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11190............ Carroll County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11200............ Catoosa County, 1560 Urban........... 0.9088 16860 Urban........... 0.9088
Georgia.
11210............ Charlton County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11220............ Chatham County, 7520 Urban........... 0.9461 42340 Urban........... 0.9461
Georgia.
11230............ Chattahoochee 1800 Urban........... 0.8560 17980 Urban........... 0.8560
County, Georgia.
11240............ Chattooga County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11250............ Cherokee County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11260............ Clarke County, 0500 Urban........... 0.9855 12020 Urban........... 0.9855
Georgia.
11270............ Clay County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11280............ Clayton County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11281............ Clinch County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11290............ Cobb County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11291............ Coffee County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11300............ Colquitt County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11310............ Columbia County, 0600 Urban........... 0.9808 12260 Urban........... 0.9748
Georgia.
11311............ Cook County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11320............ Coweta County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11330............ Crawford County, 11 Rural........... 0.8166 31420 Urban........... 0.9443
Georgia.
11340............ Crisp County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11341............ Dade County, 1560 Urban........... 0.9088 16860 Urban........... 0.9088
Georgia.
11350............ Dawson County, 11 Rural........... 0.8166 12060 Urban........... 0.9793
Georgia.
11360............ Decatur County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11370............ De Kalb County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11380............ Dodge County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11381............ Dooly County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11390............ Dougherty County, 0120 Urban........... 0.8628 10500 Urban........... 0.8628
Georgia.
11400............ Douglas County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11410............ Early County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11420............ Echols County, 11 Rural........... 0.8166 46660 Urban........... 0.8866
Georgia.
11421............ Effingham County, 7520 Urban........... 0.9461 42340 Urban........... 0.9461
Georgia.
11430............ Elbert County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11440............ Emanuel County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11441............ Evans County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11450............ Fannin County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11451............ Fayette County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11460............ Floyd County, 11 Rural........... 0.8166 40660 Urban........... 0.9414
Georgia.
11461............ Forsyth County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11462............ Franklin County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11470............ Fulton County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11471............ Gilmer County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11480............ Glascock County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11490............ Glynn County, 11 Rural........... 0.8166 15260 Urban........... 0.9311
Georgia.
11500............ Gordon County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11510............ Grady County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11520............ Greene County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11530............ Gwinnett County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11540............ Habersham County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11550............ Hall County, 11 Rural........... 0.8166 23580 Urban........... 0.8874
Georgia.
11560............ Hancock County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11570............ Haralson County, 11 Rural........... 0.8166 12060 Urban........... 0.9793
Georgia.
11580............ Harris County, 1800 Urban........... 0.8560 17980 Urban........... 0.8560
Georgia.
11581............ Hart County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11590............ Heard County, 11 Rural........... 0.8166 12060 Urban........... 0.9793
Georgia.
[[Page 3663]]
11591............ Henry County, 0520 Urban........... 0.9793 12060 Urban........... 0.9793
Georgia.
11600............ Houston County, 4680 Urban........... 0.9277 47580 Urban........... 0.8645
Georgia.
11601............ Irwin County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11610............ Jackson County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11611............ Jasper County, 11 Rural........... 0.8166 12060 Urban........... 0.9793
Georgia.
11612............ Jeff Davis County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11620............ Jefferson County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11630............ Jenkins County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11640............ Johnson County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11650............ Jones County, 4680 Urban........... 0.9277 31420 Urban........... 0.9443
Georgia.
11651............ Lamar County, 11 Rural........... 0.8166 12060 Urban........... 0.9793
Georgia.
11652............ Lanier County, 11 Rural........... 0.8166 46660 Urban........... 0.8866
Georgia.
11660............ Laurens County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11670............ Lee County, Georgia 0120 Urban........... 0.8628 10500 Urban........... 0.8628
11680............ Liberty County, 11 Rural........... 0.8166 25980 Urban........... \1\
Georgia. 0.9198
11690............ Lincoln County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11691............ Long County, 11 Rural........... 0.8166 25980 Urban........... \1\
Georgia. 0.9198
11700............ Lowndes County, 11 Rural........... 0.8166 46660 Urban........... 0.8866
Georgia.
11701............ Lumpkin County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11702............ Mc Duffie County, 0600 Urban........... 0.9808 12260 Urban........... 0.9748
Georgia.
11703............ Mc Intosh County, 11 Rural........... 0.8166 15260 Urban........... 0.9311
Georgia.
11710............ Macon County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11720............ Madison County, 0500 Urban........... 0.9855 12020 Urban........... 0.9855
Georgia.
11730............ Marion County, 11 Rural........... 0.8166 17980 Urban........... 0.8560
Georgia.
11740............ Meriwether County, 11 Rural........... 0.8166 12060 Urban........... 0.9793
Georgia.
11741............ Miller County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11750............ Mitchell County, 11 Rural........... 0.8166 99911 Rural........... 0.7662
Georgia.
11760............ Monroe County, 11 Rural........... .08166 31420 Urban........... 0.9443
Georgia.
11770............ Montgomery County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11771............ Morgan County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11772............ Murray County, 11 Rural........... .08166 19140 Urban........... 0.9079
Georgia.
11780............ Muscogee County, 1800 Urban........... .08560 17980 Urban........... 0.8560
Georgia.
11790............ Newton County, 0520 Urban........... .09793 12060 Urban........... 0.9793
Georgia.
11800............ Oconee County, 0500 Urban........... .09855 12020 Urban........... 0.9855
Georgia.
11801............ Oglethorpe County, 11 Rural........... .08166 12020 Urban........... 0.9855
Georgia.
11810............ Paulding County, 0520 Urban........... .09793 12060 Urban........... 0.9793
Georgia.
11811............ Peach County, 4680 Urban........... .09277 99911 Rural........... 0.7662
Georgia.
11812............ Pickens County, 0520 Urban........... .09793 12060 Urban........... 0.9793
Georgia.
11820............ Pierce County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11821............ Pike County, 11 Rural........... .08166 12060 Urban........... 0.9793
Georgia.
11830............ Polk County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11831............ Pulaski County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11832............ Putnam County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11833............ Quitman County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11834............ Rabun County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11835............ Randolph County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11840............ Richmond County, 0600 Urban........... .09808 12260 Urban........... 0.9748
Georgia.
11841............ Rockdale County, 0520 Urban........... .09793 12060 Urban........... 0.9793
Georgia.
11842............ Schley County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11850............ Screven County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11851............ Seminole County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11860............ Spalding County, 0520 Urban........... .09793 12060 Urban........... 0.9793
Georgia.
11861............ Stephens County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11862............ Stewart County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11870............ Sumter County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11880............ Talbot County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11881............ Taliaferro County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11882............ Tattnall County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11883............ Taylor County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11884............ Telfair County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11885............ Terrell County, 11 Rural........... .08166 10500 Urban........... 0.8628
Georgia.
11890............ Thomas County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11900............ Tift County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11901............ Toombs County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11902............ Towns County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11903............ Treutlen County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11910............ Troup County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11911............ Turner County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11912............ Twiggs County, 4680 Urban........... .09277 31420 Urban........... 0.9443
Georgia.
11913............ Union County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11920............ Upson County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
[[Page 3664]]
11921............ Walker County, 1560 Urban........... .09088 16860 Urban........... 0.9088
Georgia.
11930............ Walton County, 0520 Urban........... .09793 12060 Urban........... 0.9793
Georgia.
11940............ Ware County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11941............ Warren County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11950............ Washington County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11960............ Wayne County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11961............ Webster County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11962............ Wheeler County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11963............ White County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11970............ Whitfield County, 11 Rural........... .08166 19140 Urban........... 0.9079
Georgia.
11971............ Wilcox County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11972............ Wilkes County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11973............ Wilkinson County, 11 Rural........... .08166 99911 Rural........... 0.7662
Georgia.
11980............ Worth County, 11 Rural........... .08166 10500 Urban........... 0.8628
Georgia.
12005............ Kalawao County, 12 Rural........... 1.0551 99912 Rural........... 1.0551
Hawaii.
12010............ Hawaii County, 12 Rural........... 1.0551 99912 Rural........... 1.0551
Hawaii.
12020............ Honolulu County, 3320 Urban........... 1.1214 26180 Urban........... 1.1214
Hawaii.
12040............ Kauai County, 12 Rural........... 1.0551 99912 Rural........... 1.0551
Hawaii.
12050............ Maui County, Hawaii 12 Rural........... 1.0551 99912 Rural........... 1.0551
13000............ Ada County, Idaho.. 1080 Urban........... 0.9052 14260 Urban........... 0.9052
13010............ Adams County, Idaho 13 Rural........... 0.9097 99913 Rural........... 0.8037
13020............ Bannock County, 6340 Urban........... 0.9351 38540 Urban........... 0.9351
Idaho.
13030............ Bear Lake County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13040............ Benewah County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13050............ Bingham County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13060............ Blaine County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13070............ Boise County, Idaho 13 Rural........... 0.9097 14260 Urban........... 0.9052
13080............ Bonner County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13090............ Bonneville County, 13 Rural........... 0.9097 26820 Urban........... 0.9420
Idaho.
13100............ Boundary County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13110............ Butte County, Idaho 13 Rural........... 0.9097 99913 Rural........... 0.8037
13120............ Camas County, Idaho 13 Rural........... 0.9097 99913 Rural........... 0.8037
13130............ Canyon County, 1080 Urban........... 0.9052 14260 Urban........... 0.9052
Idaho.
13140............ Caribou County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13150............ Cassia County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13160............ Clark County, Idaho 13 Rural........... 0.9097 99913 Rural........... 0.8037
13170............ Clearwater County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13180............ Custer County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13190............ Elmore County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13200............ Franklin County, 13 Rural........... 0.9097 30860 Urban........... 0.9164
Idaho.
13210............ Fremont County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13220............ Gem County, Idaho.. 13 Rural........... 0.9097 14260 Urban........... 0.9052
13230............ Gooding County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13240............ Idaho County, Idaho 13 Rural........... 0.9097 99913 Rural........... 0.8037
13250............ Jefferson County, 13 Rural........... 0.9097 26820 Urban........... 0.9420
Idaho.
13260............ Jerome County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13270............ Kootenai County, 13 Rural........... 0.9097 17660 Urban........... 0.9647
Idaho.
13280............ Latah County, Idaho 13 Rural........... 0.9097 99913 Rural........... 0.8037
13290............ Lemhi County, Idaho 13 Rural........... 0.9097 99913 Rural........... 0.8037
13300............ Lewis County, Idaho 13 Rural........... 0.9097 99913 Rural........... 0.8037
13310............ Lincoln County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13320............ Madison County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13330............ Minidoka County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13340............ Nez Perce County, 13 Rural........... 0.9097 30300 Urban........... 0.9886
Idaho.
13350............ Oneida County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13360............ Owyhee County, 13 Rural........... 0.9097 14260 Urban........... 0.9052
Idaho.
13370............ Payette County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13380............ Power County, Idaho 13 Rural........... 0.9097 38540 Urban........... 0.9351
13390............ Shoshone County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13400............ Teton County, Idaho 13 Rural........... 0.9097 99913 Rural........... 0.8037
13410............ Twin Falls County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13420............ Valley County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
13430............ Washington County, 13 Rural........... 0.9097 99913 Rural........... 0.8037
Idaho.
14000............ Adams County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14010............ Alexander County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14020............ Bond County, 14 Rural........... 0.8301 41180 Urban........... 0.8954
Illinois.
14030............ Boone County, 6880 Urban........... 0.9984 40420 Urban........... 0.9984
Illinois.
14040............ Brown County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14050............ Bureau County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14060............ Calhoun County, 14 Rural........... 0.8301 41180 Urban........... 0.8954
Illinois.
14070............ Carroll County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
[[Continued on page 3665]]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
]
[[pp. 3665-3714]] Medicare Program; Inpatient Psychiatric Facilities Prospective
Payment System Payment Update for Rate Year Beginning July 1, 2006 (RY
2007)
[[Continued from page 3664]]
[[Page 3665]]
14080............ Cass County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14090............ Champaign County, 1400 Urban........... 0.9594 16580 Urban........... 0.9594
Illinois.
14100............ Christian County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14110............ Clark County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14120............ Clay County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14130............ Clinton County, 7040 Urban........... 0.8962 41180 Urban........... 0.8954
Illinois.
14140............ Coles County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14141............ Cook County, 1600 Urban........... 1.0783 16974 Urban........... 1.0790
Illinois.
14150............ Crawford County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14160............ Cumberland County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14170............ De Kalb County, 1600 Urban........... 1.0783 16974 Urban........... 1.0790
Illinois.
14180............ De Witt County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14190............ Douglas County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14250............ Du Page County, 1600 Urban........... 1.0783 16974 Urban........... 1.0790
Illinois.
14310............ Edgar County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14320............ Edwards County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14330............ Effingham County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14340............ Fayette County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14350............ Ford County, 14 Rural........... 0.8301 16580 Urban........... 0.9594
Illinois.
14360............ Franklin County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14370............ Fulton County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14380............ Gallatin County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14390............ Greene County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14400............ Grundy County, 1600 Urban........... 1.0783 16974 Urban........... 1.0790
Illinois.
14410............ Hamilton County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14420............ Hancock County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14421............ Hardin County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14440............ Henderson County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14450............ Henry County, 1960 Urban........... 0.8724 19340 Urban........... 0.8724
Illinois.
14460............ Iroquois County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14470............ Jackson County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14480............ Jasper County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14490............ Jefferson County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14500............ Jersey County, 7040 Urban........... 0.8962 41180 Urban........... 0.8954
Illinois.
14510............ Jo Daviess County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14520............ Johnson County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14530............ Kane County, 1600 Urban........... 1.0783 16974 Urban........... 1.0790
Illinois.
14540............ Kankakee County, 3740 Urban........... 1.0721 28100 Urban........... 1.0721
Illinois.
14550............ Kendall County, 1600 Urban........... 1.0783 16974 Urban........... 1.0790
Illinois.
14560............ Knox County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14570............ Lake County, 1600 Urban........... 1.0783 29404 Urban........... 1.0429
Illinois.
14580............ La Salle County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14590............ Lawrence County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14600............ Lee County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14610............ Livingston County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14620............ Logan County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14630............ Mc Donough County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14640............ Mc Henry County, 1600 Urban........... 1.0783 16974 Urban........... 1.0790
Illinois.
14650............ Mclean County, 1040 Urban........... 0.9075 14060 Urban........... 0.9075
Illinois.
14660............ Macon County, 2040 Urban........... 0.8067 19500 Urban........... 0.8067
Illinois.
14670............ Macoupin County, 14 Rural........... 0.8301 41180 Urban........... 0.8954
Illinois.
14680............ Madison County, 7040 Urban........... 0.8962 41180 Urban........... 0.8954
Illinois.
14690............ Marion County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14700............ Marshall County, 14 Rural........... 0.8301 37900 Urban........... 0.8870
Illinois.
14710............ Mason County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14720............ Massac County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14730............ Menard County, 7880 Urban........... 0.8792 44100 Urban........... 0.8792
Illinois.
14740............ Mercer County, 14 Rural........... 0.8301 19340 Urban........... 0.8724
Illinois.
14750............ Monroe County, 7040 Urban........... 0.8962 41180 Urban........... 0.8954
Illinois.
14760............ Montgomery County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14770............ Morgan County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14780............ Moultrie County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14790............ Ogle County, 6880 Urban........... 0.9984 99914 Rural........... 0.8271
Illinois.
14800............ Peoria County, 6120 Urban........... 0.8870 37900 Urban........... 0.8870
Illinois.
14810............ Perry County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14820............ Piatt County, 14 Rural........... 0.8301 16580 Urban........... 0.9594
Illinois.
14830............ Pike County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14831............ Pope County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14850............ Pulaski County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14860............ Putnam County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14870............ Randolph County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
[[Page 3666]]
14880............ Richland County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14890............ Rock Island County, 1960 Urban........... 0.8724 19340 Urban........... 0.8724
Illinois.
14900............ St Clair County, 7040 Urban........... 0.8962 41180 Urban........... 0.8954
Illinois.
14910............ Saline County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14920............ Sangamon County, 7880 Urban........... 0.8792 44100 Urban........... 0.8792
Illinois.
14921............ Schuyler County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14940............ Scott County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14950............ Shelby County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14960............ Stark County, 14 Rural........... 0.8301 37900 Urban........... 0.8870
Illinois.
14970............ Stephenson County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14980............ Tazewell County, 6120 Urban........... 0.8870 37900 Urban........... 0.8870
Illinois.
14981............ Union County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14982............ Vermilion County, 14 Rural........... 0.8301 19180 Urban........... 0.9028
Illinois.
14983............ Wabash County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14984............ Warren County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14985............ Washington County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14986............ Wayne County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14987............ White County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14988............ Whiteside County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14989............ Will County, 1600 Urban........... 1.0783 16974 Urban........... 1.0790
Illinois.
14990............ Williamson County, 14 Rural........... 0.8301 99914 Rural........... 0.8271
Illinois.
14991............ Winnebago County, 6880 Urban........... 0.9984 40420 Urban........... 0.9984
Illinois.
14992............ Woodford County, 6120 Urban........... 0.8870 37900 Urban........... 0.8870
Illinois.
15000............ Adams County, 2760 Urban........... 0.9706 99915 Rural........... 0.8624
Indiana.
15010............ Allen County, 2760 Urban........... 0.9706 23060 Urban........... 0.9793
Indiana.
15020............ Bartholomew County, 15 Rural........... 0.8739 18020 Urban........... 0.9588
Indiana.
15030............ Benton County, 15 Rural........... 0.8739 29140 Urban........... 0.8736
Indiana.
15040............ Blackford County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15050............ Boone County, 3480 Urban........... 0.9865 26900 Urban........... 0.9920
Indiana.
15060............ Brown County, 15 Rural........... 0.8739 26900 Urban........... 0.9920
Indiana.
15070............ Carroll County, 15 Rural........... 0.8739 29140 Urban........... 0.8736
Indiana.
15080............ Cass County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15090............ Clark County, 4520 Urban........... 0.9293 31140 Urban........... 0.9251
Indiana.
15100............ Clay County, 8320 Urban........... 0.8337 45460 Urban........... 0.8304
Indiana.
15110............ Clinton County, 3920 Urban........... 0.8736 99915 Rural........... 0.8624
Indiana.
15120............ Crawford County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15130............ Daviess County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15140............ Dearborn County, 1640 Urban........... 0.9734 17140 Urban........... 0.9615
Indiana.
15150............ Decatur County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15160............ De Kalb County, 2760 Urban........... 0.9706 99915 Rural........... 0.8624
Indiana.
15170............ Delaware County, 5280 Urban........... 0.8930 34620 Urban........... 0.8930
Indiana.
15180............ Dubois County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15190............ Elkhart County, 2330 Urban........... 0.9627 21140 Urban........... 0.9627
Indiana.
15200............ Fayette County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15210............ Floyd County, 4520 Urban........... 0.9293 31140 Urban........... 0.9251
Indiana.
15220............ Fountain County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15230............ Franklin County, 15 Rural........... 0.8739 17140 Urban........... 0.9615
Indiana.
15240............ Fulton County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15250............ Gibson County, 15 Rural........... 0.8739 21780 Urban........... 0.8713
Indiana.
15260............ Grant County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15270............ Greene County, 15 Rural........... 0.8739 14020 Urban........... 0.8447
Indiana.
15280............ Hamilton County, 3480 Urban........... 0.9865 26900 Urban........... 0.9920
Indiana.
15290............ Hancock County, 3480 Urban........... 0.9865 26900 Urban........... 0.9920
Indiana.
15300............ Harrison County, 4520 Urban........... 0.9293 31140 Urban........... 0.9251
Indiana.
15310............ Hendricks County, 3480 Urban........... 0.9865 26900 Urban........... 0.9920
Indiana.
15320............ Henry County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15330............ Howard County, 3850 Urban........... 0.9508 29020 Urban........... 0.9508
Indiana.
15340............ Huntington County, 2760 Urban........... 0.9706 99915 Rural........... 0.8624
Indiana.
15350............ Jackson County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15360............ Jasper County, 15 Rural........... 0.8739 23844 Urban........... 0.9395
Indiana.
15370............ Jay County, Indiana 15 Rural........... 0.8739 99915 Rural........... 0.8624
15380............ Jefferson County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15390............ Jennings County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15400............ Johnson County, 3480 Urban........... 0.9865 26900 Urban........... 0.9920
Indiana.
15410............ Knox County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15420............ Kosciusko County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15430............ Lagrange County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15440............ Lake County, 2960 Urban........... 0.9395 23844 Urban........... 0.9395
Indiana.
15450............ La Porte County, 15 Rural........... 0.8739 33140 Urban........... 0.9399
Indiana.
15460............ Lawrence County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15470............ Madison County, 3480 Urban........... 0.9865 11300 Urban........... 0.8586
Indiana.
[[Page 3667]]
15480............ Marion County, 3480 Urban........... 0.9865 26900 Urban........... 0.9920
Indiana.
15490............ Marshall County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15500............ Martin County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15510............ Miami County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15520............ Monroe County, 1020 Urban........... 0.8447 14020 Urban........... 0.8447
Indiana.
15530............ Montgomery County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15540............ Morgan County, 3480 Urban........... 0.9865 26900 Urban........... 0.9920
Indiana.
15550............ Newton County, 15 Rural........... 0.8739 23844 Urban........... 0.9395
Indiana.
15560............ Noble County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15570............ Ohio County, 1640 Urban........... 0.9734 17140 Urban........... 0.9615
Indiana.
15580............ Orange County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15590............ Owen County, 15 Rural........... 0.8739 14020 Urban........... 0.8447
Indiana.
15600............ Parke County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15610............ Perry County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15620............ Pike County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15630............ Porter County, 2960 Urban........... 0.9395 23844 Urban........... 0.9395
Indiana.
15640............ Posey County, 2440 Urban........... 0.8713 21780 Urban........... 0.8713
Indiana.
15650............ Pulaski County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15660............ Putnam County, 15 Rural........... 0.8739 26900 Urban........... 0.9920
Indiana.
15670............ Randolph County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15680............ Ripley County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15690............ Rush County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15700............ St Joseph County, 7800 Urban........... 0.9788 43780 Urban........... 0.9788
Indiana.
15710............ Scott County, 4520 Urban........... 0.9293 99915 Rural........... 0.8624
Indiana.
15720............ Shelby County, 3480 Urban........... 0.9865 26900 Urban........... 0.9920
Indiana.
15730............ Spencer County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15740............ Starke County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15750............ Steuben County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15760............ Sullivan County, 15 Rural........... 0.8739 45460 Urban........... 0.8304
Indiana.
15770............ Switzerland County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15780............ Tippecanoe County, 3920 Urban........... 0.8736 29140 Urban........... 0.8736
Indiana.
15790............ Tipton County, 3850 Urban........... 0.9508 29020 Urban........... 0.9508
Indiana.
15800............ Union County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15810............ Vanderburgh County, 2440 Urban........... 0.8713 21780 Urban........... 0.8713
Indiana.
15820............ Vermillion County, 8320 Urban........... 0.8337 45460 Urban........... 0.8304
Indiana.
15830............ Vigo County, 8320 Urban........... 0.8337 45460 Urban........... 0.8304
Indiana.
15840............ Wabash County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15850............ Warren County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15860............ Warrick County, 2440 Urban........... 0.8713 21780 Urban........... 0.8713
Indiana.
15870............ Washington County, 15 Rural........... 0.8739 31140 Urban........... 0.9251
Indiana.
15880............ Wayne County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15890............ Wells County, 2760 Urban........... 0.9706 23060 Urban........... 0.9793
Indiana.
15900............ White County, 15 Rural........... 0.8739 99915 Rural........... 0.8624
Indiana.
15910............ Whitley County, 2760 Urban........... 0.9706 23060 Urban........... 0.9793
Indiana.
16000............ Adair County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16010............ Adams County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16020............ Allamakee County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16030............ Appanoose County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16040............ Audubon County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16050............ Benton County, Iowa 16 Rural........... 0.8594 16300 Urban........... 0.8825
16060............ Black Hawk County, 8920 Urban........... 0.8557 47940 Urban........... 0.8557
Iowa.
16070............ Boone County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16080............ Bremer County, Iowa 16 Rural........... 0.8594 47940 Urban........... 0.8557
16090............ Buchanan County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16100............ Buena Vista County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16110............ Butler County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16120............ Calhoun County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16130............ Carroll County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16140............ Cass County, Iowa.. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16150............ Cedar County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16160............ Cerro Gordo County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16170............ Cherokee County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16180............ Chickasaw County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16190............ Clarke County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16200............ Clay County, Iowa.. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16210............ Clayton County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16220............ Clinton County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16230............ Crawford County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16240............ Dallas County, Iowa 2120 Urban........... 0.9669 19780 Urban........... 0.9669
16250............ Davis County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16260............ Decatur County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
[[Page 3668]]
16270............ Delaware County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16280............ Des Moines County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16290............ Dickinson County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16300............ Dubuque County, 2200 Urban........... 0.9024 20220 Urban........... 0.9024
Iowa.
16310............ Emmet County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16320............ Fayette County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16330............ Floyd County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16340............ Franklin County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16350............ Fremont County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16360............ Greene County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16370............ Grundy County, Iowa 16 Rural........... 0.8594 47940 Urban........... 0.8557
16380............ Guthrie County, 16 Rural........... 0.8594 19780 Urban........... 0.9669
Iowa.
16390............ Hamilton County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16400............ Hancock County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16410............ Hardin County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16420............ Harrison County, 16 Rural........... 0.8594 36540 Urban........... 0.9560
Iowa.
16430............ Henry County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16440............ Howard County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16450............ Humboldt County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16460............ Ida County, Iowa... 16 Rural........... 0.8594 99916 Rural........... 0.8509
16470............ Iowa County, Iowa.. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16480............ Jackson County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16490............ Jasper County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16500............ Jefferson County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16510............ Johnson County, 3500 Urban........... 0.9747 26980 Urban........... 0.9747
Iowa.
16520............ Jones County, Iowa. 16 Rural........... 0.8594 16300 Urban........... 0.8825
16530............ Keokuk County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16540............ Kossuth County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16550............ Lee County, Iowa... 16 Rural........... 0.8594 99916 Rural........... 0.8509
16560............ Linn County, Iowa.. 1360 Urban........... 0.8825 16300 Urban........... 0.8825
16570............ Louisa County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16580............ Lucas County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16590............ Lyon County, Iowa.. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16600............ Madison County, 16 Rural........... 0.8594 19780 Urban........... 0.9669
Iowa.
16610............ Mahaska County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16620............ Marion County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16630............ Marshall County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16640............ Mills County, Iowa. 16 Rural........... 0.8594 36540 Urban........... 0.9560
16650............ Mitchell County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16660............ Monona County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16670............ Monroe County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16680............ Montgomery County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16690............ Muscatine County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16700............ O Brien County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16710............ Osceola County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16720............ Page County, Iowa.. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16730............ Palo Alto County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16740............ Plymouth County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16750............ Pocahontas County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16760............ Polk County, Iowa.. 2120 Urban........... 0.9669 19780 Urban........... 0.9669
16770............ Pottawattamie 5920 Urban........... 0.9560 36540 Urban........... 0.9560
County, Iowa.
16780............ Poweshiek County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16790............ Ringgold County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16800............ Sac County, Iowa... 16 Rural........... 0.8594 99916 Rural........... 0.8509
16810............ Scott County, Iowa. 1960 Urban........... 0.8724 19340 Urban........... 0.8724
16820............ Shelby County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16830............ Sioux County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16840............ Story County, Iowa. 16 Rural........... 0.8594 11180 Urban........... 0.9536
16850............ Tama County, Iowa.. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16860............ Taylor County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
16870............ Union County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16880............ Van Buren County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16890............ Wapello County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16900............ Warren County, Iowa 2120 Urban........... 0.9669 19780 Urban........... 0.9669
16910............ Washington County, 16 Rural........... 0.8594 26980 Urban........... 0.9747
Iowa.
16920............ Wayne County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
16930............ Webster County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16940............ Winnebago County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16950............ Winneshiek County, 16 Rural........... 0.8594 99916 Rural........... 0.8509
Iowa.
16960............ Woodbury County, 7720 Urban........... 0.9416 43580 Urban........... 0.9381
Iowa.
16970............ Worth County, Iowa. 16 Rural........... 0.8594 99916 Rural........... 0.8509
[[Page 3669]]
16980............ Wright County, Iowa 16 Rural........... 0.8594 99916 Rural........... 0.8509
17000............ Allen County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17010............ Anderson County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17020............ Atchison County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17030............ Barber County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17040............ Barton County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17050............ Bourbon County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17060............ Brown County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17070............ Butler County, 9040 Urban........... 0.9175 48620 Urban........... 0.9153
Kansas.
17080............ Chase County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17090............ Chautauqua County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17100............ Cherokee County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17110............ Cheyenne County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17120............ Clark County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17130............ Clay County, Kansas 17 Rural........... 0.8040 99917 Rural........... 0.8035
17140............ Cloud County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17150............ Coffey County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17160............ Comanche County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17170............ Cowley County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17180............ Crawford County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17190............ Decatur County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17200............ Dickinson County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17210............ Doniphan County, 17 Rural........... 0.8040 41140 Urban........... 0.9519
Kansas.
17220............ Douglas County, 4150 Urban........... 0.8537 29940 Urban........... 0.8537
Kansas.
17230............ Edwards County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17240............ Elk County, Kansas. 17 Rural........... 0.8040 99917 Rural........... 0.8035
17250............ Ellis County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17260............ Ellsworth County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17270............ Finney County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17280............ Ford County, Kansas 17 Rural........... 0.8040 99917 Rural........... 0.8035
17290............ Franklin County, 17 Rural........... 0.8040 28140 Urban........... 0.9476
Kansas.
17300............ Geary County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17310............ Gove County, Kansas 17 Rural........... 0.8040 99917 Rural........... 0.8035
17320............ Graham County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17330............ Grant County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17340............ Gray County, Kansas 17 Rural........... 0.8040 99917 Rural........... 0.8035
17350............ Greeley County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17360............ Greenwood County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17370............ Hamilton County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17380............ Harper County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17390............ Harvey County, 9040 Urban........... 0.9175 48620 Urban........... 0.9153
Kansas.
17391............ Haskell County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17410............ Hodgeman County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17420............ Jackson County, 17 Rural........... 0.8040 45820 Urban........... 0.8920
Kansas.
17430............ Jefferson County, 17 Rural........... 0.8040 45820 Urban........... 0.8920
Kansas.
17440............ Jewell County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17450............ Johnson County, 3760 Urban........... 0.9490 28140 Urban........... 0.9476
Kansas.
17451............ Kearny County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17470............ Kingman County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17480............ Kiowa County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17490............ Labette County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17500............ Lane County, Kansas 17 Rural........... 0.8040 99917 Rural........... 0.8035
17510............ Leavenworth County, 3760 Urban........... 0.9490 28140 Urban........... 0.9476
Kansas.
17520............ Lincoln County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17530............ Linn County, Kansas 17 Rural........... 0.8040 28140 Urban........... 0.9476
17540............ Logan County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17550............ Lyon County, Kansas 17 Rural........... 0.8040 99917 Rural........... 0.8035
17560............ Mc Pherson County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17570............ Marion County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17580............ Marshall County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17590............ Meade County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17600............ Miami County, 3760 Urban........... 0.9490 28140 Urban........... 0.9476
Kansas.
17610............ Mitchell County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17620............ Montgomery County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17630............ Morris County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17640............ Morton County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17650............ Nemaha County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17660............ Neosho County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17670............ Ness County, Kansas 17 Rural........... 0.8040 99917 Rural........... 0.8035
17680............ Norton County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17690............ Osage County, 17 Rural........... 0.8040 45820 Urban........... 0.8920
Kansas.
[[Page 3670]]
17700............ Osborne County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17710............ Ottawa County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17720............ Pawnee County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17730............ Phillips County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17740............ Pottawatomie 17 Rural........... 0.8040 99917 Rural........... 0.8035
County, Kansas.
17750............ Pratt County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17760............ Rawlins County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17770............ Reno County, Kansas 17 Rural........... 0.8040 99917 Rural........... 0.8035
17780............ Republic County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17790............ Rice County, Kansas 17 Rural........... 0.8040 99917 Rural........... 0.8035
17800............ Riley County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17810............ Rooks County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17820............ Rush County, Kansas 17 Rural........... 0.8040 99917 Rural........... 0.8035
17830............ Russell County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17840............ Saline County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17841............ Scott County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17860............ Sedgwick County, 9040 Urban........... 0.9175 48620 Urban........... 0.9153
Kansas.
17870............ Seward County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17880............ Shawnee County, 8440 Urban........... 0.8920 45820 Urban........... 0.8920
Kansas.
17890............ Sheridan County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17900............ Sherman County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17910............ Smith County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17920............ Stafford County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17921............ Stanton County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17940............ Stevens County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17950............ Sumner County, 17 Rural........... 0.8040 48620 Urban........... 0.9153
Kansas.
17960............ Thomas County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17970............ Trego County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17980............ Wabaunsee County, 17 Rural........... 0.8040 45820 Urban........... 0.8920
Kansas.
17981............ Wallace County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17982............ Washington County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17983............ Wichita County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17984............ Wilson County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17985............ Woodson County, 17 Rural........... 0.8040 99917 Rural........... 0.8035
Kansas.
17986............ Wyandotte County, 3760 Urban........... 0.9490 28140 Urban........... 0.9476
Kansas.
18000............ Adair County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18010............ Allen County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18020............ Anderson County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18030............ Ballard County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18040............ Barren County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18050............ Bath County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18060............ Bell County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18070............ Boone County, 1640 Urban........... 0.9734 17140 Urban........... 0.9615
Kentucky.
18080............ Bourbon County, 4280 Urban........... 0.8988 30460 Urban........... 0.9075
Kentucky.
18090............ Boyd County, 3400 Urban........... 0.9477 26580 Urban........... 0.9477
Kentucky.
18100............ Boyle County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18110............ Bracken County, 18 Rural........... 0.7858 17140 Urban........... 0.9615
Kentucky.
18120............ Breathitt County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18130............ Breckinridge 18 Rural........... 0.7858 99918 Rural........... 0.7766
County, Kentucky.
18140............ Bullitt County, 4520 Urban........... 0.9293 31140 Urban........... 0.9251
Kentucky.
18150............ Butler County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18160............ Caldwell County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18170............ Calloway County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18180............ Campbell County, 1640 Urban........... 0.9734 17140 Urban........... 0.9615
Kentucky.
18190............ Carlisle County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18191............ Carroll County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18210............ Carter County, 3400 Urban........... 0.9477 99918 Rural........... 0.7766
Kentucky.
18220............ Casey County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18230............ Christian County, 1660 Urban........... 0.8284 17300 Urban........... 0.8284
Kentucky.
18240............ Clark County, 4280 Urban........... 0.8988 30460 Urban........... 0.9075
Kentucky.
18250............ Clay County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18260............ Clinton County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18270............ Crittenden County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18271............ Cumberland County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18290............ Daviess County, 5990 Urban........... 0.8780 36980 Urban........... 0.8780
Kentucky.
18291............ Edmonson County, 18 Rural........... 0.7858 14540 Urban........... 0.8211
Kentucky.
18310............ Elliott County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18320............ Estill County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18330............ Fayette County, 4280 Urban........... 0.8988 30460 Urban........... 0.9075
Kentucky.
18340............ Fleming County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18350............ Floyd County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
[[Page 3671]]
18360............ Franklin County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18361............ Fulton County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18362............ Gallatin County, 1640 Urban........... 0.9734 17140 Urban........... 0.9615
Kentucky.
18390............ Garrard County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18400............ Grant County, 1640 Urban........... 0.9734 17140 Urban........... 0.9615
Kentucky.
18410............ Graves County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18420............ Grayson County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18421............ Green County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18440............ Greenup County, 3400 Urban........... 0.9477 26580 Urban........... 0.9477
Kentucky.
18450............ Hancock County, 18 Rural........... 0.7858 36980 Urban........... 0.8780
Kentucky.
18460............ Hardin County, 18 Rural........... 0.7858 21060 Urban........... 0.8802
Kentucky.
18470............ Harlan County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18480............ Harrison County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18490............ Hart County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18500............ Henderson County, 2440 Urban........... 0.8713 21780 Urban........... 0.8713
Kentucky.
18510............ Henry County, 18 Rural........... 0.7858 31140 Urban........... 0.9251
Kentucky.
18511............ Hickman County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18530............ Hopkins County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18540............ Jackson County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18550............ Jefferson County, 4520 Urban........... 0.9293 31140 Urban........... 0.9251
Kentucky.
18560............ Jessamine County, 4280 Urban........... 0.8988 30460 Urban........... 0.9075
Kentucky.
18570............ Johnson County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18580............ Kenton County, 1640 Urban........... 0.9734 17140 Urban........... 0.9615
Kentucky.
18590............ Knott County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18600............ Knox County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18610............ Larue County, 18 Rural........... 0.7858 21060 Urban........... 0.8802
Kentucky.
18620............ Laurel County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18630............ Lawrence County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18640............ Lee County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18650............ Leslie County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18660............ Letcher County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18670............ Lewis County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18680............ Lincoln County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18690............ Livingston County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18700............ Logan County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18710............ Lyon County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18720............ Mc Cracken County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18730............ Mc Creary County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18740............ Mc Lean County, 18 Rural........... 0.7858 36980 Urban........... 0.8780
Kentucky.
18750............ Madison County, 4280 Urban........... 0.8988 99918 Rural........... 0.7766
Kentucky.
18760............ Magoffin County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18770............ Marion County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18780............ Marshall County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18790............ Martin County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18800............ Mason County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18801............ Meade County, 18 Rural........... 0.7858 31140 Urban........... 0.9251
Kentucky.
18802............ Menifee County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18830............ Mercer County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18831............ Metcalfe County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18850............ Monroe County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18860............ Montgomery County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18861............ Morgan County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18880............ Muhlenberg County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18890............ Nelson County, 18 Rural........... 0.7858 31140 Urban........... 0.9251
Kentucky.
18900............ Nicholas County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18910............ Ohio County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18920............ Oldham County, 4520 Urban........... 0.9293 31140 Urban........... 0.9251
Kentucky.
18930............ Owen County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18931............ Owsley County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18932............ Pendleton County, 1640 Urban........... 0.9734 17140 Urban........... 0.9615
Kentucky.
18960............ Perry County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18970............ Pike County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18971............ Powell County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18972............ Pulaski County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18973............ Robertson County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18974............ Rockcastle County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18975............ Rowan County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18976............ Russell County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18977............ Scott County, 4280 Urban........... 0.8988 30460 Urban........... 0.9075
Kentucky.
18978............ Shelby County, 18 Rural........... 0.7858 31140 Urban........... 0.9251
Kentucky.
18979............ Simpson County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
[[Page 3672]]
18980............ Spencer County, 18 Rural........... 0.7858 31140 Urban........... 0.9251
Kentucky.
18981............ Taylor County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18982............ Todd County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18983............ Trigg County, 18 Rural........... 0.7858 17300 Urban........... 0.8284
Kentucky.
18984............ Trimble County, 18 Rural........... 0.7858 31140 Urban........... 0.9251
Kentucky.
18985............ Union County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18986............ Warren County, 18 Rural........... 0.7858 14540 Urban........... 0.8211
Kentucky.
18987............ Washington County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18988............ Wayne County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18989............ Webster County, 18 Rural........... 0.7858 21780 Urban........... 0.8713
Kentucky.
18990............ Whitley County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18991............ Wolfe County, 18 Rural........... 0.7858 99918 Rural........... 0.7766
Kentucky.
18992............ Woodford County, 4280 Urban........... 0.8988 30460 Urban........... 0.9075
Kentucky.
19000............ Acadia County, 3880 Urban........... 0.8251 99919 Rural........... 0.7411
Louisiana.
19010............ Allen County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19020............ Ascension County, 0760 Urban........... 0.8643 12940 Urban........... 0.8593
Louisiana.
19030............ Assumption County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19040............ Avoyelles County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19050............ Beauregard County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19060............ Bienville County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19070............ Bossier County, 7680 Urban........... 0.8737 43340 Urban........... 0.8760
Louisiana.
19080............ Caddo County, 7680 Urban........... 0.8737 43340 Urban........... 0.8760
Louisiana.
19090............ Calcasieu County, 3960 Urban........... 0.7858 29340 Urban........... 0.7833
Louisiana.
19100............ Caldwell County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19110............ Cameron County, 19 Rural........... 0.7340 29340 Urban........... 0.7833
Louisiana.
19120............ Catahoula County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19130............ Claiborne County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19140............ Concordia County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19150............ De Soto County, 19 Rural........... 0.7340 43340 Urban........... 0.8760
Louisiana.
19160............ East Baton Rouge 0760 Urban........... 0.8643 12940 Urban........... 0.8593
County, Louisiana.
19170............ East Carroll 19 Rural........... 0.7340 99919 Rural........... 0.7411
County, Louisiana.
19180............ East Feliciana 19 Rural........... 0.7340 12940 Urban........... 0.8593
County, Louisiana.
19190............ Evangeline County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19200............ Franklin County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19210............ Grant County, 19 Rural........... 0.7340 10780 Urban........... 0.8033
Louisiana.
19220............ Iberia County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19230............ Iberville County, 19 Rural........... 0.7340 12940 Urban........... 0.8593
Louisiana.
19240............ Jackson County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19250............ Jefferson County, 5560 Urban........... 0.8995 35380 Urban........... 0.8995
Louisiana.
19260............ Jefferson Davis 19 Rural........... 0.7340 99919 Rural........... 0.7411
County, Louisiana.
19270............ Lafayette County, 3880 Urban........... 0.8251 29180 Urban........... 0.8428
Louisiana.
19280............ Lafourche County, 3350 Urban........... 0.7894 26380 Urban........... 0.7894
Louisiana.
19290............ La Salle County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19300............ Lincoln County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19310............ Livingston County, 0760 Urban........... 0.8643 12940 Urban........... 0.8593
Louisiana.
19320............ Madison County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19330............ Morehouse County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19340............ Natchitoches 19 Rural........... 0.7340 99919 Rural........... 0.7411
County, Louisiana.
19350............ Orleans County, 5560 Urban........... 0.8995 35380 Urban........... 0.8995
Louisiana.
19360............ Ouachita County, 5200 Urban........... 0.8044 33740 Urban........... 0.8031
Louisiana.
19370............ Plaquemines County, 5560 Urban........... 0.8995 35380 Urban........... 0.8995
Louisiana.
19380............ Pointe Coupee 19 Rural........... 0.7340 12940 Urban........... 0.8593
County, Louisiana.
19390............ Rapides County, 0220 Urban........... 0.8033 10780 Urban........... 0.8033
Louisiana.
19400............ Red River County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19410............ Richland County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19420............ Sabine County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19430............ St Bernard County, 5560 Urban........... 0.8995 35380 Urban........... 0.8995
Louisiana.
19440............ St Charles County, 5560 Urban........... 0.8995 35380 Urban........... 0.8995
Louisiana.
19450............ St Helena County, 19 Rural........... 0.7340 12940 Urban........... 0.8593
Louisiana.
19460............ St James County, 5560 Urban........... 0.8995 99919 Rural........... 0.7411
Louisiana.
19470............ St John Baptist 5560 Urban........... 0.8995 35380 Urban........... 0.8995
County, Louisiana.
19480............ St Landry County, 3880 Urban........... 0.8251 99919 Rural........... 0.7411
Louisiana.
19490............ St Martin County, 3880 Urban........... 0.8251 29180 Urban........... 0.8428
Louisiana.
19500............ St Mary County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19510............ St Tammany County, 5560 Urban........... 0.8995 35380 Urban........... 0.8995
Louisiana.
19520............ Tangipahoa County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19530............ Tensas County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19540............ Terrebonne County, 3350 Urban........... 0.7894 26380 Urban........... 0.7894
Louisiana.
19550............ Union County, 19 Rural........... 0.7340 33740 Urban........... 0.8031
Louisiana.
19560............ Vermilion County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19570............ Vernon County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
[[Page 3673]]
19580............ Washington County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
19590............ Webster County, 7680 Urban........... 0.8737 99919 Rural........... 0.7411
Louisiana.
19600............ West Baton Rouge 0760 Urban........... 0.8643 12940 Urban........... 0.8593
County, Louisiana.
19610............ West Carroll 19 Rural........... 0.7340 99919 Rural........... 0.7411
County, Louisiana.
19620............ West Feliciana 19 Rural........... 0.7340 12940 Urban........... 0.8593
County, Louisiana.
19630............ Winn County, 19 Rural........... 0.7340 99919 Rural........... 0.7411
Louisiana.
20000............ Androscoggin 4243 Urban........... 0.9331 30340 Urban........... 0.9331
County, Maine.
20010............ Aroostook County, 20 Rural........... 0.8843 99920 Rural........... 0.8843
Maine.
20020............ Cumberland County, 6403 Urban........... 1.0382 38860 Urban........... 1.0382
Maine.
20030............ Franklin County, 20 Rural........... 0.8843 99920 Rural........... 0.8843
Maine.
20040............ Hancock County, 20 Rural........... 0.8843 99920 Rural........... 0.8843
Maine.
20050............ Kennebec County, 20 Rural........... 0.8843 99920 Rural........... 0.8843
Maine.
20060............ Knox County, Maine. 20 Rural........... 0.8843 99920 Rural........... 0.8843
20070............ Lincoln County, 20 Rural........... 0.8843 99920 Rural........... 0.8843
Maine.
20080............ Oxford County, 20 Rural........... 0.8843 99920 Rural........... 0.8843
Maine.
20090............ Penobscot County, 0733 Urban........... 0.9993 12620 Urban........... 0.9993
Maine.
20100............ Piscataquis County, 20 Rural........... 0.8843 99920 Rural........... 0.8843
Maine.
20110............ Sagadahoc County, 6403 Urban........... 1.0382 38860 Urban........... 1.0382
Maine.
20120............ Somerset County, 20 Rural........... 0.8843 99920 Rural........... 0.8843
Maine.
20130............ Waldo County, Maine 20 Rural........... 0.8843 99920 Rural........... 0.8843
20140............ Washington County, 20 Rural........... 0.8843 99920 Rural........... 0.8843
Maine.
20150............ York County, Maine. 6403 Urban........... 1.0382 38860 Urban........... 1.0382
21000............ Allegany County, 1900 Urban........... 0.9317 19060 Urban........... 0.9317
Maryland.
21010............ Anne Arundel 0720 Urban........... 0.9897 12580 Urban........... 0.9897
County, Maryland.
21020............ Baltimore County, 0720 Urban........... 0.9897 12580 Urban........... 0.9897
Maryland.
21030............ Baltimore City 0720 Urban........... 0.9897 12580 Urban........... 0.9897
County, Maryland.
21040............ Calvert County, 8840 Urban........... 1.0976 47894 Urban........... 1.0926
Maryland.
21050............ Caroline County, 21 Rural........... 0.9230 99921 Rural........... 0.9353
Maryland.
21060............ Carroll County, 0720 Urban........... 0.9897 12580 Urban........... 0.9897
Maryland.
21070............ Cecil County, 9160 Urban........... 1.0527 48864 Urban........... 1.0471
Maryland.
21080............ Charles County, 8840 Urban........... 1.0976 47894 Urban........... 1.0926
Maryland.
21090............ Dorchester County, 21 Rural........... 0.9230 99921 Rural........... 0.9353
Maryland.
21100............ Frederick County, 8840 Urban........... 1.0976 13644 Urban........... 1.1483
Maryland.
21110............ Garrett County, 21 Rural........... 0.9230 99921 Rural........... 0.9353
Maryland.
21120............ Harford County, 0720 Urban........... 0.9897 12580 Urban........... 0.9897
Maryland.
21130............ Howard County, 0720 Urban........... 0.9897 12580 Urban........... 0.9897
Maryland.
21140............ Kent County, 21 Rural........... 0.9230 99921 Rural........... 0.9353
Maryland.
21150............ Montgomery County, 8840 Urban........... 1.0976 13644 Urban........... 1.1483
Maryland.
21160............ Prince Georges 8840 Urban........... 1.0976 47894 Urban........... 1.0926
County, Maryland.
21170............ Queen Annes County, 0720 Urban........... 0.9897 12580 Urban........... 0.9897
Maryland.
21180............ St Marys County, 21 Rural........... 0.9230 99921 Rural........... 0.9353
Maryland.
21190............ Somerset County, 21 Rural........... 0.9230 41540 Urban........... 0.9064
Maryland.
21200............ Talbot County, 21 Rural........... 0.9230 99921 Rural........... 0.9353
Maryland.
21210............ Washington County, 3180 Urban........... 0.9869 25180 Urban........... 0.9489
Maryland.
21220............ Wicomico County, 21 Rural........... 0.9230 41540 Urban........... 0.9064
Maryland.
21230............ Worcester County, 21 Rural........... 0.9230 99921 Rural........... 0.9353
Maryland.
22000............ Barnstable County, 0743 Urban........... 1.2600 12700 Urban........... 1.2600
Massachusetts.
22010............ Berkshire County, 6323 Urban........... 1.0181 38340 Urban........... 1.0181
Massachusetts.
22020............ Bristol County, 1123 Urban........... 1.1178 39300 Urban........... 1.0966
Massachusetts.
22030............ Dukes County, 22 Rural........... 1.0216 99922 Rural........... 1.0216
Massachusetts.
22040............ Essex County, 1123 Urban........... 1.1178 21604 Urban........... 1.0538
Massachusetts.
22060............ Franklin County, 22 Rural........... 1.0216 44140 Urban........... 1.0248
Massachusetts.
22070............ Hampden County, 8003 Urban........... 1.0263 44140 Urban........... 1.0248
Massachusetts.
22080............ Hampshire County, 8003 Urban........... 1.0263 44140 Urban........... 1.0248
Massachusetts.
22090............ Middlesex County, 1123 Urban........... 1.1178 15764 Urban........... 1.1172
Massachusetts.
22120............ Nantucket County, 22 Rural........... 1.0216 99922 Rural........... 1.0216
Massachusetts.
22130............ Norfolk County, 1123 Urban........... 1.1178 14484 Urban........... 1.1558
Massachusetts.
22150............ Plymouth County, 1123 Urban........... 1.1178 14484 Urban........... 1.1558
Massachusetts.
22160............ Suffolk County, 1123 Urban........... 1.1178 14484 Urban........... 1.1558
Massachusetts.
22170............ Worcester County, 1123 Urban........... 1.1178 49340 Urban........... 1.1028
Massachusetts.
23000............ Alcona County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23010............ Alger County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23020............ Allegan County, 3000 Urban........... 0.9445 99923 Rural........... 0.8895
Michigan.
23030............ Alpena County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23040............ Antrim County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23050............ Arenac County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23060............ Baraga County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23070............ Barry County, 23 Rural........... 0.8824 24340 Urban........... 0.9390
Michigan.
23080............ Bay County, 6960 Urban........... 0.9241 13020 Urban........... 0.9343
Michigan.
23090............ Benzie County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23100............ Berrien County, 0870 Urban........... 0.8879 35660 Urban........... 0.8879
Michigan.
[[Page 3674]]
23110............ Branch County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23120............ Calhoun County, 3720 Urban........... 1.0143 12980 Urban........... 0.9508
Michigan.
23130............ Cass County, 23 Rural........... 0.8824 43780 Urban........... 0.9788
Michigan.
23140............ Charlevoix County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23150............ Cheboygan County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23160............ Chippewa County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23170............ Clare County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23180............ Clinton County, 4040 Urban........... 0.9794 29620 Urban........... 0.9794
Michigan.
23190............ Crawford County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23200............ Delta County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23210............ Dickinson County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23220............ Eaton County, 4040 Urban........... 0.9794 29620 Urban........... 0.9794
Michigan.
23230............ Emmet County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23240............ Genesee County, 2640 Urban........... 1.0655 22420 Urban........... 1.0655
Michigan.
23250............ Gladwin County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23260............ Gogebic County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23270............ Grand Traverse 23 Rural........... 0.8824 99923 Rural........... 0.8895
County, Michigan.
23280............ Gratiot County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23290............ Hillsdale County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23300............ Houghton County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23310............ Huron County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23320............ Ingham County, 4040 Urban........... 0.9794 29620 Urban........... 0.9794
Michigan.
23330............ Ionia County, 23 Rural........... 0.8824 24340 Urban........... 0.9390
Michigan.
23340............ Iosco County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23350............ Iron County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23360............ Isabella County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23370............ Jackson County, 3520 Urban........... 0.9304 27100 Urban........... 0.9304
Michigan.
23380............ Kalamazoo County, 3720 Urban........... 1.0143 28020 Urban........... 1.0381
Michigan.
23390............ Kalkaska County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23400............ Kent County, 3000 Urban........... 0.9445 24340 Urban........... 0.9390
Michigan.
23410............ Keweenaw County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23420............ Lake County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23430............ Lapeer County, 2160 Urban........... 1.0147 47644 Urban........... 0.9871
Michigan.
23440............ Leelanau County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23450............ Lenawee County, 0440 Urban........... 1.0707 99923 Rural........... 0.8895
Michigan.
23460............ Livingston County, 0440 Urban........... 1.0707 47644 Urban........... 0.9871
Michigan.
23470............ Luce County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23480............ Mackinac County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23490............ Macomb County, 2160 Urban........... 1.0147 47644 Urban........... 0.9871
Michigan.
23500............ Manistee County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23510............ Marquette County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23520............ Mason County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23530............ Mecosta County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23540............ Menominee County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23550............ Midland County, 6960 Urban........... 0.9241 99923 Rural........... 0.8895
Michigan.
23560............ Missaukee County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23570............ Monroe County, 2160 Urban........... 1.0147 33780 Urban........... 0.9468
Michigan.
23580............ Montcalm County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23590............ Montmorency County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23600............ Muskegon County, 3000 Urban........... 0.9445 34740 Urban........... 0.9664
Michigan.
23610............ Newaygo County, 23 Rural........... 0.8824 24340 Urban........... 0.9390
Michigan.
23620............ Oakland County, 2160 Urban........... 1.0147 47644 Urban........... 0.9871
Michigan.
23630............ Oceana County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23640............ Ogemaw County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23650............ Ontonagon County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23660............ Osceola County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23670............ Oscoda County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23680............ Otsego County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23690............ Ottawa County, 3000 Urban........... 0.9445 26100 Urban........... 0.9055
Michigan.
23700............ Presque Isle 23 Rural........... 0.8824 99923 Rural........... 0.8895
County, Michigan.
23710............ Roscommon County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23720............ Saginaw County, 6960 Urban........... 0.9241 40980 Urban........... 0.9088
Michigan.
23730............ St Clair County, 2160 Urban........... 1.0147 47644 Urban........... 0.9871
Michigan.
23740............ St Joseph County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23750............ Sanilac County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23760............ Schoolcraft County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23770............ Shiawassee County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23780............ Tuscola County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
23790............ Van Buren County, 3720 Urban........... 1.0143 28020 Urban........... 1.0381
Michigan.
23800............ Washtenaw County, 0440 Urban........... 1.0707 11460 Urban........... 1.0859
Michigan.
23810............ Wayne County, 2160 Urban........... 1.0147 19804 Urban........... 1.0424
Michigan.
[[Page 3675]]
23830............ Wexford County, 23 Rural........... 0.8824 99923 Rural........... 0.8895
Michigan.
24000............ Aitkin County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24010............ Anoka County, 5120 Urban........... 1.1075 33460 Urban........... 1.1075
Minnesota.
24020............ Becker County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24030............ Beltrami County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24040............ Benton County, 6980 Urban........... 0.9965 41060 Urban........... 0.9965
Minnesota.
24050............ Big Stone County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24060............ Blue Earth County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24070............ Brown County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24080............ Carlton County, 24 Rural........... 0.9132 20260 Urban........... 1.0213
Minnesota.
24090............ Carver County, 5120 Urban........... 1.1075 33460 Urban........... 1.1075
Minnesota.
24100............ Cass County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24110............ Chippewa County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24120............ Chisago County, 5120 Urban........... 1.1075 33460 Urban........... 1.1075
Minnesota.
24130............ Clay County, 2520 Urban........... 0.8486 22020 Urban........... 0.8486
Minnesota.
24140............ Clearwater County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24150............ Cook County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24160............ Cottonwood County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24170............ Crow Wing County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24180............ Dakota County, 5120 Urban........... 1.1075 33460 Urban........... 1.1075
Minnesota.
24190............ Dodge County, 24 Rural........... 0.9132 40340 Urban........... 1.1131
Minnesota.
24200............ Douglas County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24210............ Faribault County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24220............ Fillmore County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24230............ Freeborn County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24240............ Goodhue County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24250............ Grant County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24260............ Hennepin County, 5120 Urban........... 1.1075 33460 Urban........... 1.1075
Minnesota.
24270............ Houston County, 3870 Urban........... 0.9564 29100 Urban........... 0.9564
Minnesota.
24280............ Hubbard County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24290............ Isanti County, 5120 Urban........... 1.1075 33460 Urban........... 1.1075
Minnesota.
24300............ Itasca County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24310............ Jackson County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24320............ Kanabec County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24330............ Kandiyohi County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24340............ Kittson County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24350............ Koochiching County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24360............ Lac Qui Parle 24 Rural........... 0.9132 99924 Rural........... 0.9132
County, Minnesota.
24370............ Lake County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24380............ Lake Of Woods 24 Rural........... 0.9132 99924 Rural........... 0.9132
County, Minnesota.
24390............ Le Sueur County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24400............ Lincoln County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24410............ Lyon County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24420............ Mc Leod County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24430............ Mahnomen County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24440............ Marshall County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24450............ Martin County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24460............ Meeker County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24470............ Mille Lacs County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24480............ Morrison County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24490............ Mower County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24500............ Murray County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24510............ Nicollet County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24520............ Nobles County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24530............ Norman County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24540............ Olmsted County, 6820 Urban........... 1.1131 40340 Urban........... 1.1131
Minnesota.
24550............ Otter Tail County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24560............ Pennington County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24570............ Pine County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24580............ Pipestone County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24590............ Polk County, 2985 Urban........... 0.7901 24220 Urban........... 0.7901
Minnesota.
24600............ Pope County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24610............ Ramsey County, 5120 Urban........... 1.1075 33460 Urban........... 1.1075
Minnesota.
24620............ Red Lake County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24630............ Redwood County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24640............ Renville County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24650............ Rice County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24660............ Rock County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24670............ Roseau County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24680............ St Louis County, 2240 Urban........... 1.0213 20260 Urban........... 1.0213
Minnesota.
24690............ Scott County, 5120 Urban........... 1.1075 33460 Urban........... 1.1075
Minnesota.
[[Page 3676]]
24700............ Sherburne County, 5120 Urban........... 1.1075 33460 Urban........... 1.1075
Minnesota.
24710............ Sibley County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24720............ Stearns County, 6980 Urban........... 0.9965 41060 Urban........... 0.9965
Minnesota.
24730............ Steele County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24740............ Stevens County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24750............ Swift County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24760............ Todd County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24770............ Traverse County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24780............ Wabasha County, 24 Rural........... 0.9132 40340 Urban........... 1.1131
Minnesota.
24790............ Wadena County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24800............ Waseca County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24810............ Washington County, 5120 Urban........... 1.1075 33460 Urban........... 1.1075
Minnesota.
24820............ Watonwan County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24830............ Wilkin County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24840............ Winona County, 24 Rural........... 0.9132 99924 Rural........... 0.9132
Minnesota.
24850............ Wright County, 5120 Urban........... 1.1075 33460 Urban........... 1.1075
Minnesota.
24860............ Yellow Medicine 24 Rural........... 0.9132 99924 Rural........... 0.9132
County, Minnesota.
25000............ Adams County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25010............ Alcorn County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25020............ Amite County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25030............ Attala County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25040............ Benton County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25050............ Bolivar County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25060............ Calhoun County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25070............ Carroll County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25080............ Chickasaw County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25090............ Choctaw County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25100............ Claiborne County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25110............ Clarke County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25120............ Clay County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25130............ Coahoma County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25140............ Copiah County, 25 Rural........... 0.7634 27140 Urban........... 0.8311
Mississippi.
25150............ Covington County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25160............ Desoto County, 4920 Urban........... 0.9416 32820 Urban........... 0.9397
Mississippi.
25170............ Forrest County, 3285 Urban........... 0.7601 25620 Urban........... 0.7601
Mississippi.
25180............ Franklin County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25190............ George County, 25 Rural........... 0.7634 37700 Urban........... 0.8156
Mississippi.
25200............ Greene County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25210............ Grenada County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25220............ Hancock County, 0920 Urban........... 0.8706 25060 Urban........... 0.8929
Mississippi.
25230............ Harrison County, 0920 Urban........... 0.8706 25060 Urban........... 0.8929
Mississippi.
25240............ Hinds County, 3560 Urban........... 0.8382 27140 Urban........... 0.8311
Mississippi.
25250............ Holmes County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25260............ Humphreys County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25270............ Issaquena County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25280............ Itawamba County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25290............ Jackson County, 0920 Urban........... 0.8706 37700 Urban........... 0.8156
Mississippi.
25300............ Jasper County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25310............ Jefferson County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25320............ Jefferson Davis 25 Rural........... 0.7634 99925 Rural........... 0.7674
County,
Mississippi.
25330............ Jones County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25340............ Kemper County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25350............ Lafayette County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25360............ Lamar County, 3285 Urban........... 0.7601 25620 Urban........... 0.7601
Mississippi.
25370............ Lauderdale County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25380............ Lawrence County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25390............ Leake County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25400............ Lee County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25410............ Leflore County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25420............ Lincoln County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25430............ Lowndes County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25440............ Madison County, 3560 Urban........... 0.8382 27140 Urban........... 0.8311
Mississippi.
25450............ Marion County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25460............ Marshall County, 25 Rural........... 0.7634 32820 Urban........... 0.9397
Mississippi.
25470............ Monroe County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25480............ Montgomery County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25490............ Neshoba County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25500............ Newton County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25510............ Noxubee County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25520............ Oktibbeha County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25530............ Panola County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
[[Page 3677]]
25540............ Pearl River County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25550............ Perry County, 25 Rural........... 0.7634 25620 Urban........... 0.7601
Mississippi.
25560............ Pike County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25570............ Pontotoc County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25580............ Prentiss County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25590............ Quitman County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25600............ Rankin County, 3560 Urban........... 0.8382 27140 Urban........... 0.8311
Mississippi.
25610............ Scott County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25620............ Sharkey County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25630............ Simpson County, 25 Rural........... 0.7634 27140 Urban........... 0.8311
Mississippi.
25640............ Smith County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25650............ Stone County, 25 Rural........... 0.7634 25060 Urban........... 0.8929
Mississippi.
25660............ Sunflower County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25670............ Tallahatchie 25 Rural........... 0.7634 99925 Rural........... 0.7674
County,
Mississippi.
25680............ Tate County, 25 Rural........... 0.7634 32820 Urban........... 0.9397
Mississippi.
25690............ Tippah County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25700............ Tishomingo County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25710............ Tunica County, 25 Rural........... 0.7634 32820 Urban........... 0.9397
Mississippi.
25720............ Union County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25730............ Walthall County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25740............ Warren County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25750............ Washington County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25760............ Wayne County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25770............ Webster County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25780............ Wilkinson County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25790............ Winston County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25800............ Yalobusha County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
25810............ Yazoo County, 25 Rural........... 0.7634 99925 Rural........... 0.7674
Mississippi.
26000............ Adair County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26010............ Andrew County, 7000 Urban........... 0.9519 41140 Urban........... 0.9519
Missouri.
26020............ Atchison County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26030............ Audrain County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26040............ Barry County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26050............ Barton County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26060............ Bates County, 26 Rural........... 0.7959 28140 Urban........... 0.9476
Missouri.
26070............ Benton County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26080............ Bollinger County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26090............ Boone County, 1740 Urban........... 0.8345 17860 Urban........... 0.8345
Missouri.
26100............ Buchanan County, 7000 Urban........... 0.9519 41140 Urban........... 0.9519
Missouri.
26110............ Butler County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26120............ Caldwell County, 26 Rural........... 0.7959 28140 Urban........... 0.9476
Missouri.
26130............ Callaway County, 26 Rural........... 0.7959 27620 Urban........... 0.8387
Missouri.
26140............ Camden County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26150............ Cape Girardeau 26 Rural........... 0.7959 99926 Rural........... 0.7900
County, Missouri.
26160............ Carroll County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26170............ Carter County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26180............ Cass County, 3760 Urban........... 0.9490 28140 Urban........... 0.9476
Missouri.
26190............ Cedar County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26200............ Chariton County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26210............ Christian County, 7920 Urban........... 0.8250 44180 Urban........... 0.8237
Missouri.
26220............ Clark County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26230............ Clay County, 3760 Urban........... 0.9490 28140 Urban........... 0.9476
Missouri.
26240............ Clinton County, 3760 Urban........... 0.9490 28140 Urban........... 0.9476
Missouri.
26250............ Cole County, 26 Rural........... 0.7959 27620 Urban........... 0.8387
Missouri.
26260............ Cooper County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26270............ Crawford County, 26 Rural........... 0.7959 41180 Urban........... 0.8954
Missouri.
26280............ Dade County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26290............ Dallas County, 26 Rural........... 0.7959 44180 Urban........... 0.8237
Missouri.
26300............ Daviess County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26310............ De Kalb County, 26 Rural........... 0.7959 41140 Urban........... 0.9519
Missouri.
26320............ Dent County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26330............ Douglas County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26340............ Dunklin County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26350............ Franklin County, 7040 Urban........... 0.8962 41180 Urban........... 0.8954
Missouri.
26360............ Gasconade County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26370............ Gentry County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26380............ Greene County, 7920 Urban........... 0.8250 44180 Urban........... 0.8237
Missouri.
26390............ Grundy County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26400............ Harrison County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26410............ Henry County, 26 Rural........... 0.7959 99926 Rural........... 0.7900
Missouri.
26411............ Hickory County,