[Federal Register Volume 61, Number 171 (Tuesday, September 3, 1996)]
[Notices]
[Pages 46466-46478]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-22376]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[BPD-842-NC]
RIN 0938-AH70
Medicare Program; Schedule of Prospectively Determined Payment
Rates for Skilled Nursing Facility Inpatient Routine Service Costs
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Final notice with comment period.
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SUMMARY: This final notice with comment period sets forth the schedule
of payment rates for low Medicare volume skilled nursing facilities for
prospective payments for routine service costs for Federal fiscal year
1997 (cost reporting periods beginning on or after October 1, 1996 and
before October 1, 1997). Section 1888(d) of the Social Security Act
requires the Secretary to establish and publish the prospectively
determined payment rates 90 days prior to the beginning of the affected
Federal fiscal year.
DATES: Effective date: The schedule of payment rates is effective for
cost reporting periods beginning on or after October 1, 1996.
Comment date: Written comments will be considered if we receive
them at the appropriate address, as provided below, no later than 5:00
p.m. on November 4, 1996.
ADDRESSES: Mail written comments (an original and three copies) to the
following address: Health Care Financing Administration, Department of
Health and Human Services, Attention: BPD-842-NC, P.O. Box 7517,
Baltimore, MD 21244-0517.
If you prefer, you may deliver your written comments (an original
and three copies) to one of the following addresses: Room 309-G, Hubert
H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC
20201, or C5-09-26, 7500 Security Boulevard, Baltimore, MD 21244-1850.
Comments may also be submitted electronically to the following e-
mail address: [email protected]. E-mail comments must include the
full name and address of the sender and must be submitted to the
referenced address in order to be considered. All comments must be
incorporated in the e-mail message because we may not be able to access
attachments. Electronically submitted comments will be available for
public inspection at the Independence Avenue address, below.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In
[[Page 46467]]
commenting, please refer to file code BPD-842-NC. Comments received
timely will be available for public inspection as they are received,
generally beginning approximately 3 weeks after publication of a
document, in Room 309-G of the Department's offices at 200 Independence
Avenue, SW, Washington, DC, on Monday through Friday of each week from
8:30 a.m. to 5 p.m. (phone: (202) 690-7890).
Copies: To order copies of the Federal Register containing this
document, send your request to: New Orders, Superintendent of
Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date
of the issue requested and enclose a check or money order payable to
the Superintendent of Documents, or enclose your Visa or Master Card
number and expiration date. Credit card orders can also be placed by
calling the order desk at (202) 512-1800 or by faxing to (202) 512-
2250. The cost for each copy is $8.00. As an alternative, you can view
and photocopy the Federal Register document at most libraries
designated as Federal Depository Libraries and at many other public and
academic libraries throughout the country that receive the Federal
Register.
FOR FURTHER INFORMATION CONTACT: Joseph Menning (410) 786-4594.
SUPPLEMENTARY INFORMATION:
I. Background
Section 1888 of the Social Security Act (the Act) sets forth the
statutory requirements concerning Medicare payments to skilled nursing
facilities (SNFs) for their routine service costs for services
furnished to Medicare beneficiaries. Most SNFs are paid on a reasonable
cost basis up to a schedule of routine service per diem cost limits
established in accordance with the general reasonable cost provisions
of section 1861(v)(1) of the Act and the specific SNF payment
provisions of section 1888 of the Act. However, under the provision at
section 1888(d) of the Act, for cost reporting periods beginning on or
after October 1, 1986, a SNF with fewer than 1,500 Medicare covered
days in a given cost reporting period may choose to receive payment
based on a prospectively determined payment rate in the subsequent cost
reporting period. The prospectively determined payment rates for low
Medicare volume SNFs are established on a per diem basis and include
payment for the cost of furnishing general inpatient routine services
and capital-related costs associated with routine services.
The per diem amounts may not exceed the limit on routine service
costs set forth in section 1888(a) of the Act with respect to the
facility, adjusted to take into account average capital-related costs
with respect to the type and location of the facility. The limit used
for this purpose is the applicable routine service cost limit in effect
when the provider elects to be paid under the prospectively determined
payment rates.
For SNFs located in an urban area, the prospectively determined
payment amount is equal to 105 percent of the mean of the per diem
reasonable routine service and routine capital-related costs of
services for SNFs in urban areas within the same census region. The
mean per diem is determined without regard to the limitations of
section 1888(a) of the Act and is adjusted for different area wage
levels.
For SNFs located in a rural area, the prospectively determined
payment amount is equal to 105 percent of the mean of the per diem
reasonable routine service and routine capital-related costs of covered
services for SNFs in rural areas within the same census region. The
mean per diem is determined without regard to the limitations of
section 1888(a) of the Act and is adjusted for different area wage
levels.
Prior to the enactment of the Omnibus Budget Reconciliation Act of
1993 (OBRA 1993; Public Law 103-66), we published guidelines specifying
the methodology and data used and the actual prospectively determined
payment rates annually in the Medicare Provider Reimbursement Manual
(HCFA Pub. 15-1). The general requirements for the rates were included
under sections 2820 and 2821 of the manual and the actual rates, the
most recent effective for Federal fiscal year 1993, were in section
2828 of the manual.
Section 13503(b) of OBRA 1993 prohibited changes to the Federal
fiscal year 1993 prospectively determined payment rates paid under
section 1888(d) of the Act for services furnished during cost reporting
periods beginning in Federal fiscal year 1994 and in Federal fiscal
year 1995, except as may be necessary to take into account the
amendments made by section 13503(c). Section 13503(c) of OBRA 1993
amended sections 1861(v)(1)(B) and 1878(f)(2) of the Act by eliminating
return on owner's equity for services furnished on or after October 1,
1993.
On July 21, 1995, we published in the Federal Register a final rule
(60 FR 37590) that codified in the Code of Federal Regulations the
statutory requirements for the optional prospectively determined
payment system for low Medicare volume SNFs and the guidelines on the
methodology and data used that were in the Provider Reimbursement
Manual. These implementing regulations, effective on August 21, 1995,
appear at 42 CFR 413.1, 413.24 and 413.300 through 413.321.
Under the provisions of Sec. 413.312(a)(1), to calculate the
prospectively determined payment rates, we use the SNF cost data that
were used to develop the applicable SNF inpatient routine service cost
limits, a wage index to adjust for area wage differences, and the most
recent projections of increases in the costs from the SNF market basket
(inflation factors). Section 413.312(a)(2) provides that we will
announce in the Federal Register the wage index and the annual
percentage increases in the market basket used in the calculation of
the rates. In addition, Sec. 413.320 provides that at least 90 days
before the beginning of a Federal fiscal year to which revised
prospectively determined payment rates are to be applied, HCFA will
publish a notice in the Federal Register establishing the rates for
routine services and explaining the basis on which the rates are
calculated.
This notice announces the schedule of payment rates for prospective
payments for routine service costs in Federal fiscal year 1997 (cost
reporting periods beginning on or after October 1, 1996 and before
October 1, 1997) for low Medicare volume SNFs that elect this method of
payment. This notice represents the first schedule of prospectively
determined payment rates published in a Federal Register notice after
the effective date of the July 1995 implementing regulations. In
addition, this notice includes the inflation factors to update the
routine service cost limits applicable for Federal fiscal year 1997,
which are necessary to compute a SNF's prospectively determined payment
rate.
II. Update of the Schedule of Prospectively Determined Payment Rates
As mentioned earlier, the statute provided that both the SNF
routine service cost limits and the prospectively determined payment
rates be frozen at the Federal fiscal year 1993 amounts for cost
reporting periods beginning in Federal fiscal year 1994 and in Federal
fiscal year 1995. As a result of these rates and limits remaining at
the Federal fiscal year 1993 levels, the Medicare program experienced a
savings in Medicare trust funds. We had anticipated that, because of
these prior years' savings, we would have legislative support to
preserve these program savings for Federal fiscal year 1996 and later.
We expected to do this
[[Page 46468]]
by trending the Federal fiscal year 1993 limits and rates to cost
reporting periods beginning in Federal fiscal year 1996, except that
the inflation factors for Federal fiscal year 1994 and Federal fiscal
year 1995 would not be included. However, such legislation has not been
enacted. Therefore, in the interim for Federal fiscal year 1996, we
provided the Medicare intermediaries with updated Federal fiscal year
1996 limits and rates by trending the Federal fiscal 1993 data to
Federal fiscal 1996 by using the projected inflation factors and the
methodology described in the October 7, 1992 Federal Register notice
(57 FR 46177) that announced the Federal fiscal year 1993 limits
(including the inflation factors for Federal fiscal years 1994 and
1995).
In addition, in May 1996, we provided all Medicare intermediaries
with revisions to the Federal fiscal year 1993 cost limits and
prospectively determined payment rates that reflected corrections to
the projected inflation factors used in the October 7, 1992 notice. (An
explanation of the circumstances under which HCFA corrects projected
inflation factors is in the October 7, 1992 notice (57 FR 46179 through
46180).) These revised Federal fiscal year 1993 limits and rates were
also used to compute updated limits and rates for cost reporting
periods beginning in Federal fiscal year 1996. However, these revisions
did not affect prospectively determined payment rates issued before the
May 1996 notification to the intermediaries.
In developing the prospectively determined payment rates effective
with this notice, we are using the basic methodology and cost report
data specified in Sec. 413.312 of the regulations (and described in
section 2828 of the Provider Reimbursement Manual). We will continue to
use the same wage indexes and the same urban and rural designations
used to compute the Federal fiscal year 1993 cost limits and
prospectively determined rates, as specified in the October 7, 1992
Federal Register notice and described in section 2828 of the Provider
Reimbursement Manual, respectively. In addition, we will continue to
provide a per diem add-on to the prospectively determined payment rates
to account for costs incurred by SNFs in complying with the nursing
home reform provisions specified in section 1819 of the Act (enacted by
OBRA 1987), including the costs of conducting nurse aide training and
competency evaluations, and for costs associated with the Occupational
Safety and Health Administration (OSHA) universal precaution
requirements.
Tables I and II under section IV. of this notice contain the
Federal fiscal year 1997 prospectively determined payment rates. Table
III under section IV. of this notice contains the Federal fiscal year
1997 routine service cost limits. Table IV under section IV. of this
notice contains the monthly inflation factors to be applied to full 12
month cost reporting periods beginning in Federal fiscal year 1997.
III. Methodology for Determining Prospectively Determined Per Diem
Payment Rates
The schedule of rates set forth in Tables I and II under section
IV. of this notice applies to all SNFs that qualify and request to
receive the optional prospective payment rate for routine services
under the provisions of subpart I of part 413. Under Sec. 413.314(d), a
SNF's prospective payment rate, excluding capital-related costs, cannot
exceed its actual routine service cost limit (without regard to
exceptions, exemptions, or retroactive adjustments) in effect at the
time of the election to be paid a prospectively determined payment
rate. The prospectively determined payment rate is in place of payment
that would otherwise be made for routine service costs and associated
capital-related costs under section 1861(v) of the Act. There are no
retroactive adjustments to these rates and under Sec. 413.308(c), an
SNF may not revoke its request to be paid under this provision after it
has received the initial determination of eligibility from the
intermediary and the cost reporting period has begun.
A. Data
The actual cost data used to develop the prospectively determined
payment rates for cost reporting periods beginning in FY 1993 were
obtained from settled freestanding SNF Medicare cost reports for
periods ending on or after June 30, 1989, and through May 31, 1990.
Comparable data for hospital-based SNFs were obtained from settled
Medicare cost reports for periods ending on or after October 31, 1988,
and through September 30, 1989. We are continuing to use the same cost
report data to develop the prospectively determined payment rates in
this notice.
B. Use of the Most Recent Available Inflation Factors
We are continuing to use the SNF input price market basket index
(inflation factor) to adjust the cost report data to the initial cost
reporting period to which the prospectively determined payment rates
apply. The inflation factors are comprised of a ``market basket'' of
the most commonly used categories of SNF routine service expenses. The
categories used are based primarily on those used in the National
Center for Health Statistics in its National Nursing Home Surveys. The
categories are weighted according to the estimated proportion of SNF
routine service cost attributable to each category. The Appendix to
this notice specifies the weights used in each category.
We are adjusting the cost report data described above using the
most recent available inflation factors shown below. These inflation
factors are similar to those used in the May 1996 notification to the
intermediaries described in section II. of this notice. These inflation
factors, representing the annual percentage increases in the market
basket over the previous year, are:
1988................................................................5.1
1989................................................................6.6
1990................................................................6.3
1991................................................................4.4
1992................................................................3.8
1993................................................................3.7
1994................................................................3.4
1995................................................................2.9
1996................................................................2.9
1997................................................................3.2
1998................................................................3.4
If a facility has a cost reporting period beginning in a month
after October 1, 1996, the intermediary increases the adjusted routine
operating portion of the rate that otherwise apply to the SNF by the
factor from Table IV of this notice that corresponds to the month and
year in which the cost reporting period begins. Each factor represents
the compounded monthly increase derived from the annual increase in the
market basket index and is used to account for inflation in costs that
occur after the date on which the prospective payment rates are
effective.
If a facility uses a cost reporting period that is not 12 months in
duration, a special adjustment factor will be calculated. This is
necessary because market basket increases are computed to the midpoint
of a cost reporting period and the adjustment factors in Table IV of
this notice are based on an assumed 12-month cost reporting period. For
cost reporting periods of other than 12 months, the calculation is done
for the midpoint of the specific cost reporting period. The SNF's
intermediary obtains this adjustment factor from HCFA central office.
C. Use of Wage Index to Adjust Labor-Related Cost
We are continuing to use the hospital industry wage index to
account for area
[[Page 46469]]
wage differences. We are continuing to apply the wage index to five
categories of labor-related costs: wages, employee benefits, health
service costs, business service costs, and other miscellaneous costs.
The portion of labor-related costs remains at the level of 83.1
percent. In addition, the same wage index values and urban/rural
designations, as shown in Tables V and VI of this notice, are to be
applied to the labor-related portion of the prospectively determined
payment rates in this notice. (These are the same wage index values and
urban/rural designations shown in the October 7, 1992 cost limit notice
and section 2828 of the Provider Reimbursement Manual.)
D. Use of Classification System
We will retain the classification system based on grouping SNFs by
census regions and by urban or rural area designation within the
region. As required by sections 1888(d)(3) and 1886(d)(2)(D) of the
Act, the term ``region'' means one of the nine census divisions,
comprising the fifty States and the District of Columbia, established
by the Bureau of Census for statistical and reporting purposes. The
term ``urban area'' means an area within a Metropolitan Statistical
Area (MSA) (as defined by the Office of Management and Budget (OMB),
with exceptions for certain New England County Metropolitan Areas
(NECMAs), as described in a notice published in the Federal Register on
April 1, 1991 (56 FR 13319)). The term ``rural area'' means an area
outside of an MSA.
E. Use of OBRA 1987 and OSHA Per Diem Add-on
Section 1861(v)(1)(E) of the Act provides for payment for costs
incurred by SNFs in complying with the nursing home reform provisions
specified in section 1819 of the Act, including the costs of conducting
nurse aide training and competency evaluations (referred to as the OBRA
1987 nursing home reform). Since the cost report data used in this
notice does not account for the costs of implementing the OBRA 1987
nursing home reform provisions, we will continue to provide a per diem
add-on for these costs. In addition, we will continue to provide a per
diem add-on for the costs associated with the Occupational Safety and
Health Administration (OSHA) universal precaution requirements. A
detailed description of the derivation of the per diem add-on is
contained in section 2828 of the Provider Reimbursement Manual. The
amount of the OBRA/OSHA per diem add-on to determine prospectively
determined payment rates for cost reporting periods beginning in
Federal fiscal year 1997 is $2.06. (For cost limit purposes, the per
diem add-on is $2.20 for Federal fiscal year 1997.)
F. Comparison of Provider's Prospective Payment Rate with Provider's
Cost Limit
Below is an example of the calculation of the prospectively
determined payment rate for a provider including the comparison of the
adjusted routine operating portion of the rate with the applicable
routine operating cost limit applicable to the specific provider. The
capital-related component of the rate is added to the lower of the
SNF's specific cost limit or its adjusted routine operating portion of
the rate to arrive at the provider's actual prospectively determined
payment rate.
Example: In this case, the adjusted cost limit is less than the
adjusted routine operating portion of the rate for a freestanding SNF
located in Providence, Rhode Island (MSA Region 1), with a cost
reporting period beginning January 1, 1997. Therefore, the
prospectively determined payment rate for this SNF is the adjusted cost
limit plus the capital-related component of the rate ($126.12).
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Labor- Non-labor Capital-
related related related
component component component
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Limit (From Table III)................................................... $88.45 $18.99 ...........
Rate (From Table I)...................................................... $116.46 $22.21 $10.00
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Calculation of Prospective Payment Rate
----------------------------------------------------------------------------------------------------------------
Limit Rate Rate source
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Labor-Related Component............................. $88.45 $116.46 (Table I).
Wage Index.......................................... x 1.0630 x 1.0630 (Table V).
Adjusted Labor Component............................ $94.02 $123.80 --
Non-Labor Component................................. $18.99 22.21 (Table I).
OBRA/OSHA Per Diem Add-on........................... +$2.20 +$2.06 (Sec III.E).
Adjusted Limit/Rate................................. $115.21 $148.07 --
Cost Reporting Year Adjustment Factor............... x 1.00796 x 1.00796 (Table IV).
Applicable Limit and Operating Rate Portion......... $116.12 $149.25 --
Capital-Related Component........................... +10.00 -- (Table I).
Prospectively Determined Payment Rate............... $126.12 -- --
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Table I.--Prospective Rates--MSA Locations, Effective for Cost Reporting Periods Beginning in FY 1997
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Labor- Nonlabor- Capital-
Region \1\ related related related
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1. New England (CT, ME, MA, NH, RI, VT).................................. $116.46 $22.21 $10.00
2. Middle Atlantic (PA, NJ, NY).......................................... 112.33 20.30 9.79
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)................... 100.69 16.19 9.81
4. East North Central (IL, IN, MI, OH, WI)............................... 95.68 15.90 9.18
5. East South Central (AL, KY, MS, TN)................................... 96.25 14.16 7.32
6. West North Central (IA, KS, MN, MO, NB, ND, SD)....................... 102.64 17.05 10.23
7. West South Central (AR, LA, OK, TX)................................... 89.81 14.03 10.06
[[Page 46470]]
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............................. 106.86 18.25 13.04
9. Pacific (AK, CA, HI, OR, WA).......................................... 97.24 19.93 8.40
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\1\ There are 16 MSAs that have counties in two or more regions. For each of these MSAs, the region in which a
majority of the SNFs are located determines the regional rate that is paid as shown below. This is the same
methodology as that used to implement the requirements of section 1886(d)(2)(D) of the Act as they apply to
the hospital prospective payment.
The MSAs are as follows:
------------------------------------------------------------------------
MSA Region
------------------------------------------------------------------------
Chattanooga, TN-GA............................................ 5
Cincinnati, OH-KY-IN.......................................... 4
Columbus, GA-AL............................................... 3
Davenport-Rock Island-Moline, IA-IL........................... 4
Duluth-Superior, MN-WI........................................ 6
Evansville-Henderson, IN-KY................................... 4
Huntington-Ashland, WV-KY-OH.................................. 3
Johnson City-Kingsport-Bristol, TN-VA......................... 5
Louisville, KY-IN............................................. 5
Memphis, TN-AR-MS............................................. 5
Minneapolis-St. Paul, MN-WI................................... 6
Parkersburg-Marietta, WV-OH................................... 3
St. Louis, MO-IL.............................................. 6
Steubenville-Weirton, OH-WV................................... 4
Wheeling, WV-OH............................................... 3
Wilmington-Newark, DE-NJ-MD................................... 3
------------------------------------------------------------------------
Table II.--Prospective Rates--Non-MSA Locations Effective for Cost Reporting Periods Beginning in FY 1997
----------------------------------------------------------------------------------------------------------------
Labor- Nonlabor- Capital-
Region related related related
----------------------------------------------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).................................. $125.72 $20.96 $10.58
2. Middle Atlantic (PA, NJ, NY).......................................... 117.44 16.86 7.94
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)................... 111.02 15.09 9.19
4. East North Central (IL, IN, MI, OH, WI)............................... 104.72 14.62 8.28
5. East South Central (AL, KY, MS, TN)................................... 105.49 13.28 6.77
6. West North Central (IA, KS, MN, MO, NB, ND, SD)....................... 108.01 14.37 6.66
7. West South Central (AR, LA, OK, TX)................................... 102.51 13.03 9.22
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............................. 107.03 15.69 8.36
9. Pacific (AK, CA, HI, OR, WA).......................................... 119.77 20.11 10.16
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Table III.--Routine Service Cost Limits in Effect for Cost Reporting Periods Beginning in Federal Fiscal Year
1997
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Labor- Non-labor-
Provider type/location related related OBRA/OSHA
component component add-ons
----------------------------------------------------------------------------------------------------------------
Freestanding: ........... ........... $2.20
MSA.................................................................. $88.45 $18.99
Non-MSA.............................................................. 89.81 15.16
Hospital based: ........... ........... 2.20
MSA limit............................................................ 124.76 26.45
Non-MSA limit........................................................ 114.31 19.01
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[[Page 46471]]
Table IV.--Cost Reporting Year Adjustment Factors \1\ Effective for Cost
Reporting Periods Beginning in FY 1997
------------------------------------------------------------------------
The
If an SNF cost reporting period begins: adjustment
factor is:
------------------------------------------------------------------------
November 1, 1996............................................ 1.00268
December 1, 1996............................................ 1.00528
January 1, 1997............................................. 1.00796
February 1, 1997............................................ 1.01083
March 1, 1997............................................... 1.01343
April 1, 1997............................................... 1.01631
May 1, 1997................................................. 1.01910
June 1, 1997................................................ 1.02200
July 1, 1997................................................ 1.02481
August 1, 1997.............................................. 1.02773
September 1, 1997........................................... 1.03066
------------------------------------------------------------------------
\1\ Based on compounded actual market basket inflation rates of 3.70
percent for 1993, 3.40 percent for 1994 and projected rates of 2.90
percent for 1995, 2.90 percent for 1996, 3.20 percent for 1997, and
3.40 percent for 1998.
Table V--Wage Index for Urban Areas
------------------------------------------------------------------------
Wage
Urban area (constituent counties or county equivalents) index
------------------------------------------------------------------------
Abilene TX................................................... 0.9220
Taylor, TX
Aguadilla, PR................................................ 0.4568
Aguada, PR
Aguadilla, PR
Isabella, PR
Moca, PR
Akron, OH.................................................... 0.9493
Portage, OH
Summit, OH
Albany, GA................................................... 0.8050
Dougherty, GA
Lee, GA
Albany-Schenectady-Troy, NY.................................. 0.8922
Albany, NY
Greene, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Albuquerque, NM.............................................. 1.0123
Bernalillo, NM
Alexandria, LA............................................... 0.8275
Rapides, LA
Allentown-Bethlehem, PA-NJ................................... 0.9857
Warren, NJ
Carbon, PA
Lehigh, PA
Northampton, PA
Altoona, PA.................................................. 0.9238
Blair, PA
Amarillo, TX................................................. 0.8739
Potter, TX
Randall, TX
Anaheim-Santa Ana, CA........................................ 1.2130
Orange, CA
Anchorage, AK................................................ 1.4176
Anchorage, AK
Anderson, IN................................................. 0.9583
Madison, IN
Anderson, SC................................................. 0.7258
Anderson, SC
Ann Arbor, MI................................................ 1.1384
Washtenaw, MI
Anniston, AL................................................. 0.7931
Calhoun, AL
Appleton-Oshkosh-Neenah, WI.................................. 0.9179
Calumet, WI
Outagamie, WI
Winnebago, WI
Arecibo, PR.................................................. 0.3953
Arecibo, PR
Camuy, PR
Hatillo, PR
Quebradillas, PR
Asheville, NC................................................ 0.8739
Buncombe, NC
Athens, GA................................................... 0.8209
Clarke, GA
Jackson, GA
Madison, GA
Oconee, GA
Atlanta, GA.................................................. 0.9596
Barrow, GA
Butts, GA
Cherokee, GA
Clayton, GA
Cobb, GA
Coweta, GA
De Kalb, GA
Douglas, GA
Fayette, GA
Forsyth, GA
Fulton, GA
Gwinnett, GA
Henry, GA
Newton, GA
Paulding, GA
Rockdale, GA
Spalding, GA
Walton, GA
Atlantic City, NJ............................................ 1.0507
Atlantic City , NJ
Cape May, NJ
Augusta, GA-SC............................................... 0.9401
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Aurora-Elgin, IL............................................. 0.9665
Kane, IL
Kendall, IL
Austin, TX................................................... 0.9599
Hays, TX
Travis, TX
Williamson, TX
Bakersfield, CA.............................................. 1.0868
Kern, CA
Baltimore, MD................................................ 1.0156
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Annes, MD
Bangor, ME................................................... 0.9064
Penobscot, ME
Baton Rouge, LA.............................................. 0.9089
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
Battle Creek, MI............................................. 0.9465
Calhoun, MI
Beaumont-Port Arthur, TX..................................... 0.9604
Hardin, TX
Jefferson, TX
Orange, TX
Beaver County, PA............................................ 1.0165
Beaver, PA
Bellingham, WA............................................... 1.0497
Whatcom, WA
Benton Harbor, MI............................................ 0.8406
Berrien, MI
Bergen-Passaic, NJ........................................... 1.0295
Bergen, NJ
Passaic, NJ
Billings, MT................................................. 0.9325
Yellowstone, MT
Biloxi-Gulfport, MS.......................................... 0.8062
Hancock, MS
Harrison, MS
Binghamton, NY............................................... 0.9260
Broome, NY
Tioga, NY
Birmingham, AL............................................... 0.8769
Blount, AL
Jefferson, AL
Saint Clair, AL
Shelby, AL
Walker, AL
Bismarck, ND................................................. 0.8812
Burleigh, ND
Morton, ND
Bloomington, IN.............................................. 0.8639
Monroe, IN
Bloomington-Normal, IL....................................... 0.8658
McLean, IL
Boise City, ID............................................... 0.9757
Ada, ID
Boston-Lawrence-Salem-Lowell-Brockton, MA.................... 1.1809
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Boulder-Longmont, CO......................................... 1.0149
Boulder, CO
Bradenton, FL................................................ 0.9262
Manatee, FL
Brazoria, TX................................................. 0.9314
Brazoria, TX
Bremerton, WA................................................ 0.9535
Kitsap, WA
Bridgeport-Stamford-Norwalk-Danbury.......................... 1.2032
Fairfield, CT
Brownsville-Harlingen, TX.................................... 0.8601
Cameron, TX
Bryan-College Station, TX.................................... 0.9489
Brazos, TX
Buffalo, NY.................................................. 0.8908
Erie, NY
Burlington, NC............................................... 0.7986
Alamance, NC
Burlington, VT............................................... 0.9358
[[Page 46472]]
Chittenden, VT
Grand Isle, VT
Caguas, PR................................................... 0.4479
Caguas, PR
Gurabo, PR
San Lorenz, PR
Aguas Buenas, PR
Cayey, PR
Cidra, PR
Canton, OH................................................... 0.8811
Carroll, OH
Stark, OH
Casper, WY................................................... 0.8891
Natrona, WY
Cedar Rapids, IA............................................. 0.8907
Linn, IA
Champaign-Urbana-Rantoul, IL................................. 0.8745
Champaign, IL
Charleston, SC............................................... 0.8331
Berkeley, SC
Charleston, SC
Dorchester, SC
Charleston, WV............................................... 0.9692
Kanawha, WV
Putnam, WV
Charlotte-Gastonia-Rock Hill, NC-SC.......................... 0.9486
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Union, NC
York, SC
Charlottesville, VA.......................................... 0.9615
Albermarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
Chattanooga, TN-GA........................................... 0.9198
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
Sequatchie, TN
Cheyenne, WY................................................. 0.7908
Laramie, WY
Chicago, IL.................................................. 1.0518
Cook, IL
Du Page, IL
McHenry, IL
Chico, CA.................................................... 1.0981
Butte, CA
Cincinnati, OH-KY-IN......................................... 0.9821
Dearborn, IN
Boone, KY
Campbell, KY
Kenton, KY
Clermont, OH
Hamilton, OH
Warren, OH
Clarksville-Hopkinsville, TN-KY.............................. 0.7319
Christian, KY
Montgomery, TN
Cleveland, OH................................................ 1.0739
Cuyahoga, OH
Geauga, OH
Lake, OH
Medina, OH
Colorado Springs, CO......................................... 0.9816
El Paso, CO
Columbia, MO................................................. 0.9506
Boone, MO
Columbia, SC................................................. 0.8940
Lexington, SC
Richland, SC
Columbus, GA-AL.............................................. 0.7482
Russell, AL
Chattanoochee, GA
Muscogee, GA
Columbus, OH................................................. 0.9673
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
Union, OH
Corpus Christi, TX........................................... 0.8594
Nueces, TX
San Patricio, TX
Cumberland, MD-WV............................................ 0.8188
Allegany, MD
Mineral, WV
Dallas, TX................................................... 0.9638
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Kaufman, TX
Rockwall, TX
Danville, VA................................................. 0.7506
Danville City, VA
Pittsylvania, VA
Davenport-Rock Island-Moline, IA-IL.......................... 0.8471
Scott, IA
Henry, IL
Rock Island, IL
Dayton-Springfield, OH....................................... 0.9664
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
Daytona Beach, FL............................................ 0.8943
Volusia, FL
Decatur, AL.................................................. 0.7487
Lawrence, AL
Morgan, AL
Decatur, IL.................................................. 0.8286
Macon, IL
Denver, CO................................................... 1.0758
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
Des Moines, IA............................................... 0.9171
Dallas, IA
Polk, IA
Warren, IA
Detroit, MI.................................................. 1.0824
Lapeer, MI
Livingston, MI
Macomb, MI
Monroe, MI
Oakland, MI
Saint Clair, MI
Wayne, MI
Dothan, AL................................................... 0.7555
Dale, AL
Houston, AL
Dubuque, IA.................................................. 0.8374
Dubuque, IA
Duluth, MN-WI................................................ 0.9517
St. Louis, MN
Douglas, WI
Eau Claire, WI............................................... 0.8478
Chippewa, WI
Eau Claire, WI
El Paso, TX.................................................. 0.8714
El Paso, TX
Elkhart-Goshen, IN........................................... 0.8949
Elkhart, IN
Elmira, NY................................................... 0.8810
Chemung, NY
Enid, OK..................................................... 0.8912
Garfield, OK
Erie, PA..................................................... 0.9155
Erie, PA
Eugene-Springfield, OR....................................... 1.0164
Lane, OR
Evansville, IN-KY............................................ 0.9276
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
Fargo-Moorhead, ND-MN........................................ 0.9707
Clay, MN
Cass, ND
Fayetteville, NC............................................. 0.8296
Cumberland, NC
Fayetteville-Springdale, AR.................................. 0.7990
Washington, AR
Flint, MI.................................................... 1.1544
Genesee, MI
Florence, AL................................................. 0.7679
Colbert, AL
Lauderdale, AL
Florence, SC................................................. 0.8429
Florence, SC
Fort Collins-Loveland, CO.................................... 1.0238
Larimor, CO
Ft Lauderdale-Hollywood-Pompano Beach, FL.................... 1.0356
Broward, FL
Fort Myers-Cape Coral, FL.................................... 0.9799
Lee, FL
Fort Pierce, FL.............................................. 1.1041
Martin, FL
St. Lucie, FL
Fort Smith, AR-OK............................................ 0.7931
Crawford, AR
Sebastian, AR
Sequoyah, OK
Fort Walton Beach, FL........................................ 0.8916
Okaloosa, FL
Fort Wayne, IN............................................... 0.8901
Allen, IN
De Kalb, IN
Whitley, IN
Forth Worth-Arlington, TX.................................... 0.9747
[[Page 46473]]
Johnson, TX
Parker, TX
Tarrant, TX
Fresno, CA................................................... 1.0737
Fresno, CA
Gadsden, AL.................................................. 0.8199
Etowah, AL
Gainesville, FL.............................................. 0.8798
Alachua, FL
Bradford, FL
Galveston-Texas City, TX..................................... 0.9431
Galveston, TX
Gary-Hammond, IN............................................. 0.9866
Lake, IN
Porter, IN
Glens Falls, NY.............................................. 0.9231
Warren, NY
Washington, NY
Grand Forks, ND.............................................. 0.9577
Grand Forks, ND
Grand Rapids, MI............................................. 0.9883
Kent, MI
Ottawa, MI
Great Falls, MT.............................................. 0.9992
Cascade, MT
Greeley, CO.................................................. 0.9358
Weld, CO
Green Bay, WI................................................ 0.9585
Brown, WI
Greensboro-Winston-Salem-High Point, NC...................... 0.9165
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
Greenville-Spartanburg, SC................................... 0.8923
Greenville, SC
Pickens, SC
Spartanburg, SC
Hagerstown, MD............................................... 0.9157
Washington, MD
Hamilton-Middletown, OH...................................... 0.9384
Butler, OH
Harrisburg-Lebanon-Carlisle, PA.............................. 0.9919
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
Hartford-Middletown-New Britain-Bristol, CT.................. 1.1916
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
Hickory, NC.................................................. 0.8741
Alexander, NC
Burke, NC
Catawba, NC
Honolulu, HI................................................. 1.1580
Honolulu, HI
Houma-Thibodaux, LA.......................................... 0.7344
Lafourche, LA
Terrebonne, LA
Houston, TX.................................................. 0.9935
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
Huntington-Ashland, WV-KY-OH................................. 0.9438
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
Huntsville, AL............................................... 0.8835
Madison, AL
Indianapolis, IN............................................. 0.9663
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Marion, IN
Morgan, IN
Shelby, IN
Iowa City, IA................................................ 0.9528
Johnson, IA
Jackson, MI.................................................. 0.9664
Jackson, MI
Jackson, MS.................................................. 0.7733
Hinds, MS
Madison, MS
Rankin, MS
Jackson, TN.................................................. 0.7910
Madison, TN
Jacksonville, FL............................................. 0.9051
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
Jacksonville, NC............................................. 0.7154
Onslow, NC
Jamestown-Dunkirk, NY........................................ 0.7735
Chautaqua, NY
Janesville-Beloit, WI........................................ 0.8466
Rock, WI
Jersey City, NJ.............................................. 1.0526
Hudson, NJ
Johnson City-Kingsport-Bristol, TN-VA........................ 0.8668
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
Johnstown, PA................................................ 0.9067
Cambria, PA
Somerset, PA
Joliet, IL................................................... 1.0278
Grundy, IL
Will, IL
Joplin, MO................................................... 0.7957
Jasper, MO
Newton, MO
Kalamazoo, MI................................................ 1.1709
Kalamazoo, MI
Kankakee, IL................................................. 0.8489
Kankakee, IL
Kansas City, KS-MO........................................... 0.9588
Johnson, KS
Leavenworth, KS
Miami, KS
Wyandotte, KS
Cass, MO
Clay, MO
Jackson, MO
Lafayette, MO
Platte, MO
Ray, MO
Kenosha, WI.................................................. 0.8855
Kenosha, WI
Killeen-Temple, TX........................................... 1.1295
Bell, TX
Coryell, TX
Knoxville, TN................................................ 0.8693
Anderson, TN
Blount, TN
Grainger, TN
Jefferson, TN
Knox, TN
Sevier, TN
Union, TN
Kokomo, IN................................................... 0.9435
Howard, IN
Tipton, IN
LaCrosse, WI................................................. 0.8956
LaCrosse, WI
Lafayette, LA................................................ 0.8227
Lafayette, LA
St. Martin, LA
Lafayette, IN................................................ 0.8432
Tippecanoe, IN
Lake Charles, LA............................................. 0.8374
Calcasieu, LA
Lake County, IL.............................................. 0.9994
Lake, IL
Lakeland-Winter Haven, FL.................................... 0.8171
Polk, FL
Lancaster, PA................................................ 0.9258
Lancaster, PA
Lansing-East Lansing, MI..................................... 1.0222
Clinton, MI
Eaton, MI
Ingham, MI
Laredo, TX................................................... 0.7278
Webb, TX
Las Cruces, NM............................................... 0.7909
Dona Ana, NM
Las Vegas, NV................................................ 1.0631
Clark, NV
Lawrence, KS................................................. 0.8937
Douglas, KS
Lawton, OK................................................... 0.8388
Comanche, OK
Lewiston-Auburn, ME.......................................... 0.9057
Androscoggin, ME
Lexington-Fayette, KY........................................ 0.8446
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Scott, KY
Woodford, KY
Lima, OH..................................................... 0.8062
Allen, OH
Auglaize, OH
Lincoln, NE.................................................. 0.8956
Lancaster, NE
Little Rock-North Little Rock, AR............................ 0.8420
[[Page 46474]]
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
Longview-Marshall, TX........................................ 0.8691
Gregg, TX
Harrison, TX
Lorain-Elyria, OH............................................ 0.8969
Lorain, OH
Los Angeles-Long Beach, CA................................... 1.2354
Los Angeles, CA
Louisville, KY-IN............................................ 0.9092
Clark, IN
Floyd, IN
Harrison, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
Shelby, KY
Lubbock, TX.................................................. 0.8790
Lubbock, TX
Lynchburg, VA................................................ 0.8544
Amherst, VA
Campbell, VA
Lynchburg City, VA
Macon-Warner Robins, GA...................................... 0.8804
Bibb, GA
Huston, GA
Jones, GA
Peach, GA
Madison, WI.................................................. 1.0311
Dane, WI
Manchester-Nashua, NH........................................ 1.0261
Hillsborough, NH
Merrimack, NH
Mansfield, OH................................................ 0.8392
Richland, OH
Mayaguez, PR................................................. 0.4771
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
San German, PR
McAllen-Edinburg-Mission, TX................................. 0.7715
Hidalgo, TX
Medford, OR.................................................. 1.0045
Jackson, OR
Melbourne-Titusville Fl...................................... 0.9199
Brevard, Fl
Memphis, TN-AR-MS............................................ 0.9060
Crittenden, AR
De Soto, MS
Shelby, TN
Tipton, TN
Merced, CA................................................... 1.0312
Merced, CA
Miami-Hialeah, FL............................................ 1.0188
Dade, FL
Middlesex-Somerset-Hunterdon, NJ............................. 1.0401
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
Midland, TX.................................................. 1.0377
Midland, TX
Milwaukee, WI................................................ 0.9719
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
Minneapolis-St Paul, MN-WI................................... 1.0818
Anoka, MN
Carver, MN
Chisago, MN
Dakota, MN
Hennepin, MN
Isanti, MN
Ramsey, MN
Scott, MN
Washington, MN
Wright, MN
St. Croix, WI
Mobile, AL................................................... 0.8319
Baldwin, AL
Mobile, AL
Modesto, CA.................................................. 1.1577
Stanislaus, CA
Monmouth-Ocean, NJ........................................... 0.9900
Monmouth, NJ
Ocean, NJ
Monroe, LA................................................... 0.7864
Ouachita, LA
Montgomery, AL............................................... 0.7738
Autauga, AL
Elmore, AL
Montgomery, AL
Muncie, IN................................................... 0.8068
Delaware, IN
Muskegon, MI................................................. 0.9568
Muskegon, MI
Naples, FL................................................... 1.0324
Collier, FL
Nashville, TN................................................ 0.9397
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
Nassau-Suffolk, NY........................................... 1.2938
Nassau, NY
Suffolk, NY
New Bedford-Fall River-Attleboro, MA......................... 1.0002
Bristol, MA
New Haven Waterbury-Meriden, CT.............................. 1.2095
New Haven, CT
New London, London-Norwich................................... 1.1571
New London, CT
New Orleans, LA.............................................. 0.8908
Jefferson, LA
Orleans, LA
St. Bernard, LA
St. Charles, LA
St. John The Baptist, LA
St. Tammany, LA
New York, NY................................................. 1.3460
Bronx, NY
Kings, NY
New York City, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
Newark, NJ................................................... 1.1232
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Niagara Falls, NY............................................ 0.8382
Niagara, NY
Norfolk-Virginia Beach-Newport News, VA...................... 0.8515
Chesapeake City, VA
Gloucester, VA
Hampton City, VA
James City Co., VA
Newport News City, VA
Norfolk City, VA
Poquoson, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City, VA
Williamsburg City, VA
York, VA
Oakland, CA.................................................. 1.4283
Alameda, CA
Contra Costa, CA
Ocala, FL.................................................... 0.8614
Marion, FL
Odessa, TX................................................... 1.0817
Ector, TX
Oklahoma City, OK............................................ 0.9145
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
Olympia, WA.................................................. 1.1002
Thurston, WA
Omaha, NE-IA................................................. 0.8989
Pottawattamie, IA
Douglas, NE
Sarpy, NE
Washington, NE
Orange, County, NY........................................... 0.9653
Orange, NY
Orlando, FL.................................................. 0.9621
Orange, FL
Osceola, FL
Seminole, FL
Owensboro, KY................................................ 0.8114
Daviess, KY
Oxnard-Ventura, CA........................................... 1.2309
Ventura, CA
Panama City, FL.............................................. 0.8632
Bay, FL
Parkersburg-Marietta, WV-OH.................................. 0.8540
Washington, OH
Wood, WV
Pascagoula, MS............................................... 0.8755
Jackson, MS
Pensacola, FL................................................ 0.8623
[[Page 46475]]
Escambia, FL
Santa Rosa, FL
Peoria, IL................................................... 0.8710
Peoria, IL
Tazewell, IL
Woodford, IL
Philadelphia, PA-NJ.......................................... 1.0952
Burlington, NJ
Camden, NJ
Gloucester, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
Phoenix, AZ.................................................. 1.0429
Maricopa, AZ
Pine Bluff, AR............................................... 0.7872
Jefferson, AR
Pittsburgh, PA............................................... 1.0127
Allegheny, PA
Fayette, PA
Washington, PA
Westmoreland, PA .........
Pittsfield, MA............................................... 1.0782
Berkshire, MA
Ponce, PR.................................................... 0.4601
Juana Diaz, PR
Ponce, PR
Portland, ME................................................. 0.9292
Cumberland, ME
Sagadahoc, ME
York, ME
Portland, OR................................................. 1.1576
Clackamas, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Portsmouth-Dover-Rochester, NH............................... 1.0080
Rockingham, NH
Strafford, NH
Poughkeepsie, NY............................................. 1.0447
Dutchess, NY
Providence-Pawtucket-Woonsocket, RI.......................... 1.0630
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
Provo-Orem, UT............................................... 1.0230
Utah, UT
Pueblo, CO................................................... 0.8722
Pueblo, CO
Racine, WI................................................... 0.8849
Racine, WI
Raleigh-Durham, NC........................................... 0.9465
Durham, NC
Franklin, NC
Orange, NC
Wake, NC
Rapid City, SD............................................... 0.8400
Pennington, SD
Reading, PA.................................................. 0.8814
Berks, PA
Redding, CA.................................................. 1.0549
Shasta, CA
Reno, NV..................................................... 1.1618
Washoe, NV
Richland-Kennewick, WA....................................... 0.9402
Benton, WA
Franklin, WA
Richmond-Petersburg, VA...................................... 0.9417
Charles City Co., VA
Chesterfield, VA
Colonial Heights City, VA
Dinwiddie, VA
Goochland, VA
Hanover, VA
Henrico, VA
Hopewell City, VA
New Kent, VA
Petersburg City, VA
Powhatan, VA
Prince George, VA
Richmond City, VA
Riverside-San Bernardino, CA................................. 1.1160
Riverside, CA
San Bernardino, CA
Roanoke, VA.................................................. 0.8284
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
Rochester, MN................................................ 1.1030
Olmsted, MN
Rochester, NY................................................ 0.9710
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
Rockford, IL................................................. 0.9283
Boone, IL
Winnebago, IL
Sacramento, CA............................................... 1.2232
Eldorado, CA
Placer, CA
Sacramento, CA
Yolo, CA
Saginaw-Bay City-Midland, MI................................. 1.0451
Bay, MI
Midland, MI
Saginaw, MI
St. Cloud, MN................................................ 0.9420
Benton, MN
Sherburne, MN
Stearns, MN
St. Joseph, MO............................................... 0.9414
Buchanan, MO
St. Louis, MO-IL............................................. 0.9388
Clinton, IL
Jersey, IL
Madison, IL
Monroe, IL
St. Clair, IL
Franklin, MO
Jefferson, MO
St. Charles, MO
St. Louis, MO
St. Louis City, MO
Sullivan City, MO
Salem, OR.................................................... 1.0445
Marion, OR
Polk, OR
Salinas-Seaside-Monterey, CA................................. 1.3041
Monterey, CA
Salt Lake City-Ogden, UT..................................... 0.9932
Davis, UT
Salt Lake, UT
Weber, UT
San Angelo, TX............................................... 0.8139
Tom Green, TX
San Antonio, TX.............................................. 0.8452
Bexar, TX
Comal, TX
Guadalupe, TX
San Diego, CA................................................ 1.1934
San Diego, CA
San Francisco, CA............................................ 1.4539
Marin, CA
San Francisco, CA
San Mateo, CA
San Jose, CA................................................. 1.4900
Santa Clara, CA
San Juan, PR................................................. 0.4987
Barcelona, PR
Bayoman, PR
Canovanas, PR
Carolina, PR
Catano, PR
Corozal, PR
Dorado, PR
Fajardo, PR
Florida, PR
Guaynabo, PR
Humacao, PR
Juncos, PR
Los Piedras, PR
Loiza, PR
Luguillo, PR
Manati, PR
Naranjito, PR
Rio Grande, PR
San Juan, PR
Toa Alta, PR
Toa Baja, PR
Trojillo Alto, PR
Vega Alta, PR
Vega Baja, PR
Santa Barbara-Santa Maria-Lompoc, CA......................... 1.1768
Santa Barbara, CA
Santa Cruz, CA............................................... 1.2784
Santa Cruz, CA
Santa Fe, NM................................................. 0.9139
Los Alamos, NM
Santa Fe, NM
Santa Rosa-Petaluma, CA...................................... 1.2957
Sonoma, CA
Sarasota, FL................................................. 0.9781
Sarasota, FL
Savannah, GA................................................. 0.8327
Chatham, GA
Effingham, GA
Scranton, Wilkes Barre, PA................................... 0.8952
Columbia, PA
Lackawanna, PA
Luzerne, PA
Monroe, PA
Wyoming, PA
Seattle, WA.................................................. 1.0871
King, WA
Snohomish, WA
Sharon, PA................................................... 0.9061
Mercer, PA
Sheboygan, WI................................................ 0.8872
[[Page 46476]]
Sheboygan, WI
Sherman-Denison, TX.......................................... 0.9089
Grayson, TX
Shreveport, LA............................................... 0.9299
Bossier, LA
Caddo, LA
Sioux City, IA-NE............................................ 0.8504
Woodbury, IA
Dakota, NE
Sioux Falls, SD.............................................. 0.8833
Minnehaha, SD
South Bend-Mishawaka, IN..................................... 1.0067
St. Joseph, IN
Spokane, WA.................................................. 1.0691
Spokane, WA
Springfield, IL.............................................. 0.9295
Menard, IL
Sangamon, IL
Springfield, MO.............................................. 0.8082
Christian, MO
Greene, MO
Springfield, MA.............................................. 1.0316
Hampden, MA
Hampshire, MA
State College, PA............................................ 0.9901
Centre, PA
Steubenville-Weirton, OH-WV.................................. 0.8712
Jefferson, OH
Brooke, WV
Hancock, WV
Stockton, CA................................................. 1.1612
San Joaquin, CA
Syracuse, NY................................................. 0.9917
Madison, NY
Onondaga, NY
Oswego, NY
Tacoma, WA................................................... 1.0317
Pierce, WA
Tallahassee, FL.............................................. 0.9220
Gadsden, FL
Leon, FL
Tampa-St. Petersburg-Clearwater, FL.......................... 0.9188
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
Terre Haute, IN.............................................. 0.8758
Clay, IN
Vigo, IN
Texarkana, TX-AR............................................. 0.7892
Miller, AR
Bowie, TX
Toledo, OH................................................... 1.0097
Fulton, OH
Lucas, OH
Wood, OH
Topeka, KS................................................... 0.9302
Shawnee, KS
Trenton, NJ.................................................. 1.0038
Mercer, NJ
Tucson, AZ................................................... 0.9591
Pima, AZ
Tulsa, OK.................................................... 0.8532
Creeks, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
Tuscaloosa, AL............................................... 0.8521
Tuscaloosa, AL
Tyler, TX.................................................... 0.9838
Smith, TX
Utica-Rome, NY............................................... 0.8512
Herkimer, NY
Oneida, NY
Vallejo-Fairfield-Napa, CA................................... 1.3203
Napa, CA
Solano, CA
Vancouver, WA................................................ 1.0798
Clark, WA
Victoria, TX................................................. 0.8994
Victoria, TX
Vineland-Millville-Bridgeton, NJ............................. 0.9760
Cumberland, NJ
Visalia-Tulare-Porterville, CA............................... 1.0392
Tulare, CA
Waco, TX..................................................... 0.7814
McLennan, TX
Washington, DC-MD-VA......................................... 1.0941
District of Columbia, DC
Calvert, MD
Charles, MD
Frederick, MD
Montgomery, MD
Prince Georges, MD
Alexandria City, VA
Arlington, VA
Fairfax, VA
Fairfax City, VA
Falls Church City, VA
Loudoun, VA
Manassas City, VA
Manassas Park City, VA
Prince William, VA
Stafford, VA
Waterloo-Cedar Falls, IA..................................... 0.8642
Black Hawk, IA
Bremer, IA
Wausau, WI................................................... 0.9748
Marathon, WI
West Palm Beach-Boca Raton-Delray Beach, FL.................. 1.0135
Palm Beach, FL
Wheeling, WV-OH.............................................. 0.8067
Belmont, OH
Marshall, WV
Ohio, WV
Wichita, KS.................................................. 0.9809
Butler, KS
Harvey, KS
Sedgwick, KS
Wichita Falls, TX............................................ 0.8172
Wichita, TX
Williamsport, PA............................................. 0.8864
Lycoming, PA
Wilmington, DE-NJ-MD......................................... 1.0869
New Castle, DE
Cecil, MD
Salem, NJ
Wilmington, NC............................................... 0.8712
New Hanover, NC
Worcester-Fitchburg-Leominster, MA........................... 1.0826
Worcester, MA
Yakima, WA................................................... 1.0111
Yakima, WA
York, PA..................................................... 0.9021
Adams, PA
York, PA
Youngstown-Warren, OH........................................ 0.9866
Mahoning, OH
Trumbull, OH
Yuba City, CA................................................ 1.0167
Sutter, CA
Yuba, CA
Yuma, AZ..................................................... 0.8885
Yuma, AZ
------------------------------------------------------------------------
Table VI.--Wage Index for Rural Areas
------------------------------------------------------------------------
Wage
Non-urban areas index
------------------------------------------------------------------------
ALABAMA...................................................... 0.7121
ALASKA....................................................... 1.3426
ARIZONA...................................................... 0.8747
ARKANSAS..................................................... 0.6966
CALIFORNIA................................................... 1.0142
COLORADO..................................................... 0.8415
CONNECTICUT.................................................. 1.1905
DELAWARE..................................................... 0.8572
FLORIDA...................................................... 0.8730
GEORGIA...................................................... 0.7767
HAWAII....................................................... 0.9618
IDAHO........................................................ 0.8953
ILLINOIS..................................................... 0.7700
INDIANA...................................................... 0.7806
IOWA......................................................... 0.7532
KANSAS....................................................... 0.7446
KENTUCKY..................................................... 0.7793
LOUISIANA.................................................... 0.7384
MAINE........................................................ 0.8328
MARYLAND..................................................... 0.8061
MASSACHUSETTS................................................ 1.1654
MICHIGAN..................................................... 0.8826
MINNESOTA.................................................... 0.8309
MISSISSIPPI.................................................. 0.6957
MISSOURI..................................................... 0.7249
MONTANA...................................................... 0.8255
NEBRASKA..................................................... 0.6995
NEVADA....................................................... 0.9702
NEW HAMPSHIRE................................................ 0.9547
NEW JERSEY................................................... (\1\)
NEW MEXICO................................................... 0.8318
NEW YORK..................................................... 0.8402
NORTH CAROLINA............................................... 0.7936
NORTH DAKOTA................................................. 0.7719
OHIO......................................................... 0.8453
OKLAHOMA..................................................... 0.7400
OREGON....................................................... 0.9607
PENNSYLVANIA................................................. 0.8613
PUERTO RICO.................................................. \2\ 0.433
3
RHODE ISLAND................................................. (\1\)
SOUTH CAROLINA............................................... 0.7650
SOUTH DAKOTA................................................. 0.7168
TENNESSEE.................................................... 0.7340
TEXAS........................................................ 0.7591
UTAH......................................................... 0.8983
VERMONT...................................................... 0.9035
VIRGINIA..................................................... 0.7815
VIRGIN ISLANDS............................................... \2\ 0.573
4
WASHINGTON................................................... 0.9635
WEST VIRGINIA................................................ 0.8488
WISCONSIN.................................................... 0.8447
[[Page 46477]]
WYOMING...................................................... 0.8457
------------------------------------------------------------------------
\1\ All counties within State are classified urban.
\2\ Approximate value for area.
V. Impact Statement
For notices such as this, we generally prepare a regulatory
flexibility analysis that is consistent with the Regulatory Flexibility
Act (RFA) (5 U.S.C. 601 through 612) unless we certify that a notice
will not have a significant economic impact on a substantial number of
small entities. For purposes of the RFA, all SNFs are considered to be
small entities. Individuals and States are not included in the
definition of a small entity.
The purpose of the July 21, 1995 final rule was to allow SNFs that
provide fewer than 1,500 days of care to Medicare beneficiaries in a
cost reporting period to have the option of receiving prospectively
determined payment rates in the following cost reporting period. In our
analysis of the impact of the July 21 final rule (60 FR 37593), we
noted that Medicare payments to SNFs constitute only about 5.3 percent
of total SNF revenues and indicated that the rule would have only a
small impact on those revenues. We estimate that the prospectively
determined payment rates contained in this notice will result in a cost
to the Medicare program of $10 to $20 million for FY 1997. These costs
represent the difference between estimated aggregate payments to SNFs
that elect to be paid under the prospectively determined payment rates
and estimated aggregate payments to the same SNFs if paid on a
reasonable cost basis under the routine SNF cost limits. Thus, we
continue to believe that this optional payment system will have a
positive impact on small entities, while easing their cost reporting
burden.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a final notice such as this may have a
significant impact on the operations of a substantial number of small
rural hospitals. Such an analysis must conform to the provisions of
section 604 of the RFA. For purposes of section 1102(b) of the Act, we
define a small rural hospital as a hospital that is located outside of
a Metropolitan Statistical Area and has fewer than 50 beds.
We are not preparing analyses for either the RFA or section 1102(b)
of the Act because we have determined, and we certify, that this final
notice will not have a significant economic impact on a substantial
number of small entities or a significant impact on the operations of a
substantial number of small rural hospitals.
In accordance with the provisions of Executive Order 12866, this
final notice was reviewed by the Office of Management and Budget.
Under the provisions of Public Law 104-121, we have determined that
this notice is not a major rule.
VI. Other Required Information
A. Collection of Information Requirements
This final notice with comment period does not impose information
collection and recordkeeping requirements. Consequently, it need not be
reviewed by the Office of Management and Budget under the authority of
the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.).
B. Waiver of Proposed Notice and 30-Day Delay in the Effective Date
In adopting notices such as this, we ordinarily publish a proposed
notice in the Federal Register with a 60-day period for public comment
as required under section 1871(b)(1) of the Act. We also normally
provide a delay of 30 days in the effective date for documents such as
this. However, we may waive these procedures if we find good cause that
prior notice and comment or a delay in the effective date are
impracticable, unnecessary, or contrary to the public interest.
As discussed in section II of this notice, we have used the same
basic methodology to develop this schedule of rates that was used in
setting the rates published in section 2828 of the Provider
Reimbursement Manual for cost reporting periods beginning in Federal
fiscal year 1993. As discussed above, section 13503(b) of OBRA 1993
delayed the update to the schedule of prospectively determined payment
rates until Federal fiscal year 1996. However, the delay in passing the
proposed Federal fiscal year 1996 budget legislation, which contained
provisions affecting the Federal fiscal year 1996 and Federal fiscal
year 1997 prospectively determined payment rates, resulted in a delay
in publishing updated Federal fiscal year 1996 rates. Regardless of
that delay and in conformance with the clear direction of section
1888(d) of the Act and Sec. 413.320, this notice announces the update
to the schedule of prospectively determined payment rates for SNF
inpatient service costs for cost reporting periods beginning in Federal
fiscal year 1997. However, given the publishing time constraints
mandated in Sec. 413.320, it would not have been possible to publish a
proposed notice and still implement the updated prospectively
determined payment rates set forth in this notice. To do so would have
been impractical, unnecessary, and contrary to the public interest.
Therefore, we find good cause to waive publication of a proposed notice
and the 30-day delay in the effective date of this notice with comment
period. However, we are providing a 60-day period for public comment,
as indicated at the beginning of this notice.
C. Response to Comments
Because of the large number of items of correspondence we normally
receive on Federal Register documents published for comment, we are not
able to acknowledge or respond to them individually. We will consider
all comments we receive by the date and time specified in the DATES
section of this notice, and, if we proceed with a subsequent document,
we will respond to the comments in that document.
Appendix.--Derivation of ``Market Basket'' Index for SNF Routine Service Costs
----------------------------------------------------------------------------------------------------------------
Relative
Category of costs \1\ Price variable used \2\
importance
---------------------------------------1993---------------------------------------------------------------------
Payroll Expense.................. 64.0 Percentage changes in average hourly earnings of employees in
nursing and personal care facility. (SIC 805) Source: U.S.
Dept. of Labor, Bureau of Labor Statistics, Employment and
Earnings (monthly). Table C-2.
[[Page 46478]]
Employee Benefits................ 7.8 Supplements to wages and salaries per worker in nonagricultural
establishments. For supplements to wages. Source: U.S. Dept. of
Commerce, Bureau of Economic Analysis, Survey of Current
Business. Table 1.11.
For total employment. Source: U.S. Dept. of Labor, Bureau of
Labor Statistics, Employment and Earnings (monthly). Table B-4.
Food............................. 7.6 Processed foods and feeds component of producer price index.
Source: U.S. Dept. of Labor, Bureau of Labor Statistics,
Monthly Labor Review, Table 23.
Food and beverage component of Consumer Price Index, all urban.
Source: U.S. Dept. of Labor, Bureau of Labor Statistics,
Monthly Labor Review, Table 22.
Other business services.......... 5.1 Services component of Consumer Price Index, all urban. Source:
U.S. Dept. of Labor, Bureau of Labor Statistics, Monthly Labor
Review, Table 23.
Fuel and other utilities......... 4.0 A. Implicit price deflator-consumption of fuel oil and coal
(derived from fuel oil component of Consumer Price Index).
Source: U.S. Dept. of Commerce, Bureau of Economic Analysis,
Survey of Current Business (monthly), Table 7.11.
B. Implicit price deflator-consumer of electricity (derived from
electricity component of Consumer Price Index). Source: U.S.
Dept. of Commerce, Bureau of Economic Analysis.
C. Implicit price deflator for natural gas (derived from utility
(piped) gas component of Consumer Price Index). Source: Same as
electricity above.
D. Water and sewage maintenance component of the Consumer Price
Index. Source: U.S. Dept. of Labor, Bureau of Labor Statistics,
Monthly Labor Review, Table 23.
Supplies......................... 3.1 All Item Consumer Price Index, all urban. Source: U.S. Dept. of
Labor, Bureau of Labor Statistics, Monthly Labor Review, Table
23.
Drugs............................ 2.2 Pharmaceutical preparations, ethical component of producer price
index. Source: U.S. Dept. of Labor, Bureau of Labor Statistics,
Producer Prices and Price Indexes (monthly), Table 6.
Health services.................. 1.6 Physician services component of Consumer Price Index for all
urban consumers. Source: U.S. Dept. of Labor, Bureau of Labor
Statistics, Monthly Labor Review, Table 23.
Miscellaneous.................... 4.6 All Item Consumer Price Index, all urban. Source: U.S. Dept. of
Labor, Bureau of Labor Statistics, Monthly Labor Review, Table
23.
----------------------------------------------------------------------------------------------------------------
\1\ The basic weights for all major categories of skilled nursing home costs were obtained from the DHEW-
National Center for Health Statistics (NCHS) National Nursing Home Surveys (NNHS) for 1972 and 1976 for home
certified for participation in the Medicare program. See Nursing Home Costs 1972, United States: National
Nursing Home Survey, August 1973-April 1974, DHEW, NCHS: National Nursing Home Survey: 1977 Summary for the
United States, Vital and Health Statistics, Series 13, Number 43.
A Laspeyres price index was constructed using 1977 weights and price variables indicated in this table. In
calendar year 1977 each ``price'' variable has an index of 100.0. The relative routine service cost weights
change each period in accordance with price changes for each price variable. Cost categories with relatively
higher ``price'' increases get relatively higher cost weights and vice versa.
\2\ Forecasted by DRI/McGraw Hill, Health Care Costs, First Quarter, 1992, 1750 K St., NW, Washington D.C.
20006.
Authority: Secs. 1102, 1814(b), 1861(v)(1), 1866(a), 1871, and
1888 of the Social Security Act (42 U.S.C. 1302, 1395f(b),
1395x(v)(1), 1395cc(a), 1395hh, and 1395yy); sec. 13503(b) and (c)
of Pub. L. 103-66 (42 U.S.C. 1395x(v)(1)(B) and 1395yy (note)) and
42 CFR 413.1, 413.24, and 413.300 through 413.321).
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance)
Dated: July 1, 1996.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
Dated: August 2, 1996.
Donna E. Shalala,
Secretary.
[FR Doc. 96-22376 Filed 8-30-96; 8:45 am]
BILLING CODE 4120-01-P