05-8387. Medicare Program; Proposed Hospice Wage Index for Fiscal Year 2006  

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    AGENCY:

    Centers for Medicare & Medicaid Services (CMS), HHS.

    ACTION:

    Proposed rule.

    SUMMARY:

    This proposed rule would set forth the hospice wage index for fiscal year 2006 and identifies the revised labor market and metropolitan statistical areas. This proposed rule would also codify provisions of sections 408 and 946 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

    DATES:

    To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on June 28, 2005.

    ADDRESSES:

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    FOR FURTHER INFORMATION CONTACT:

    Terri Deutsch, (410) 786-9462.

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    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-1286-P and the specific “issue identifier” that precedes the section on which you choose to comment.

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    I. Background

    A. General

    1. Hospice Care

    Hospice care is an approach to treatment that recognizes that the impending death of an individual warrants a change in the focus from curative care to palliative care for relief of pain and for symptom management. The goal of hospice care is to help terminally ill individuals continue life with minimal disruption to normal activities while remaining primarily in the home environment. A hospice uses an interdisciplinary approach to deliver medical, social, psychological, emotional, and spiritual services through use of a broad spectrum of professional and other caregivers, with the goal of making the individual as physically and emotionally comfortable as possible. Counseling services and inpatient respite services are available to the family of the hospice patient. Hospice programs consider both the patient and the family as a unit of care.

    Section 1861(dd) of the Social Security Act (the Act) provides for coverage of hospice care for terminally ill Medicare beneficiaries who elect to receive care from a participating hospice. Section 1824(i) of the Act provides payment for Medicare-participating hospices.

    2. Medicare Payment for Hospice Care

    Our regulations at 42 CFR part 418 establish eligibility requirements, payment standards and procedures, define covered services, and delineate the conditions a hospice must meet to be approved for participation in the Medicare program. Part 418 subpart G provides for payment in one of four prospectively-determined rate categories (routine home care, continuous home care, inpatient respite care, and general inpatient care) to hospices based on each day a qualified Medicare beneficiary is under a hospice election.

    B. Hospice Wage Index

    The hospice wage index is used to adjust payment rates for hospice agencies under the Medicare program to reflect local differences in area wage levels. The original hospice wage index was based on the 1981 Bureau of Labor Statistics hospital data and had not been updated since 1983. In 1994, because of disparity in wages from one geographical location to another, a committee was formulated to negotiate a wage index methodology that could be accepted by the industry and the government. This committee, functioning under a process established by the Negotiated Rulemaking Act of 1990, was comprised of national hospice associations; rural, urban, large, and small hospices; multisite hospices; consumer groups; and a government representative. On April 13, 1995, the Hospice Wage Index Negotiated Start Printed Page 22395Rulemaking Committee signed an agreement for the methodology to be used for updating the hospice wage index.

    1. Updates to the Hospice Wage Index

    In the August 8, 1997 Federal Register (62 FR 42860), we published a final rule implementing a new methodology for calculating the hospice wage index based on the recommendations of the negotiated rulemaking committee. The committee statement was included in the appendix of that final rule (62 FR 42883). The provisions of the final rule specified that the revised hospice wage index was to be— (1) calculated using the most current available hospital wage data; and (2) phased in over a 3-year transition period. For the first year of the transition period, October 1, 1997 through September 30, 1998, a blended index was calculated by adding two-thirds of the 1983 index value for an area to one-third of the revised wage index value for that area. During the second year of the transition period, October 1, 1998 through September 30, 1999, the calculation was similar, except that the blend was one-third of the 1983 index value and two-thirds of the revised wage index value for that area. The revised wage index was fully implemented during the third year of the transition period, October 1, 1999 through September 30, 2000.

    The annual update to the hospice wage index is published in the Federal Register and is based on the most current available hospital wage data, as well as any changes by the Office of Management and Budget (OMB) to the definitions of Metropolitan Statistical Areas (MSAs). Raw wage index values (inpatient hospital pre-floor and pre-reclassified wage index values) (as described in the August 8, 1997 hospice wage index final rule (62 FR 42860)) are subject to either a budget neutrality adjustment or application of the wage index floor. Raw wage index values of 0.8 or greater are adjusted by the budget neutrality adjustment factor. Budget neutrality means that, in a given year, estimated aggregate payments for Medicare hospice services using the updated wage index values will equal estimated payments that would have been made for these services if the 1983 wage index values had remained in effect. To achieve this budget neutrality, the raw wage index is multiplied by a budget neutrality adjustment factor. The budget neutrality adjustment factor is computed and applied annually. The budget neutrality adjustment factor is calculated by comparing what we would have paid using current rates and the 1983 wage index to what would be paid using current rates and new wage index.

    Raw wage index values below 0.8 are adjusted by the greater of: (1) The hospice budget neutrality adjustment factor; or (2) the hospice wage index floor (a 15 percent increase) subject to a maximum wage index value of 0.8.

    C. Hospice Provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003

    On December 8, 2003, the Congress enacted the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (Pub. L. 108-173). This legislation provided for the following provisions affecting hospice services:

    • Section 408, Recognition of Attending Nurse Practitioners as Attending Physicians to Serve Hospice Patients.
    • Section 512, Coverage of Hospice Consultation Services.
    • Section 946, Authorizing Use of Arrangements to Provide Core Hospice Services in Certain Circumstances.

    Section 408 of the MMA amended sections 1861(dd)(3)(B) and 1814(a)(7) of the Act to add nurse practitioners (NPs) to the definition of an attending physician for beneficiaries who have elected the hospice benefit. In other words, if a beneficiary's primary care provider before the determination of the terminal illness and election of the hospice benefit is an NP, the NP can remain as the attending physician, if the beneficiary chooses, after a hospice election. If the beneficiary does not have an attending physician or NP at the time of the terminal diagnosis, the beneficiary may choose to designate either a physician or an NP as his or her attending physician when electing the hospice benefit. Section 408 of the MMA was implemented through an administrative issuance (Change Request (CR) 3226, Transmittals 22 and 304, September 24, 2004).

    Section 512 of the MMA provides for a one-time evaluation and consultation to Medicare beneficiaries who have been determined to have a 6-month prognosis if the disease runs its normal course, and who require the expertise of the medical director or physician employed by a hospice in order to be able to make end-of-life decisions. This provision was implemented in the CY 2005 Physician Fee Schedule final rule published in the November 15, 2004 Federal Register (69 FR 66335) and is incorporated in our regulations at § 418.205 and § 418.304(d).

    Section 946(a) of the MMA allows a hospice program “in extraordinary, exigent, or other non-routine circumstances, such as unanticipated period of high patient loads, staffing shortages due to illness or other events, or temporary travel of a patient outside a hospice program's service area, * * * “ to enter into arrangements with another hospice program to provide services to beneficiaries. Section 946(b) of the MMA provides that “in the case of hospice care provided by a hospice program under arrangement under section 1861(dd)(5)(D) made by another hospice program, the hospice program that made the arrangements shall bill and be paid for the hospice care.” In section II.B.2 of this proposed rule, we discuss our proposal to revise the regulations to implement payment for hospice services made under arrangements. We will address the implementation of section 946(a) of the MMA in a future rulemaking document.

    II. Provisions of the Proposed Rule

    A. Hospice Wage Index for FY 2006

    1. Revised OMB Definition for Geographical Statistical Areas

    As required by § 418.306(c), each hospice's labor market is established using the MSA definitions issued by OMB. In the September 4, 1996 hospice wage index proposed rule (61 FR 46579), we explained that the MSA definitions were issued by OMB on December 28, 1992, based on the 1990 census, and updated by OMB based on the decennial census. In accordance with our regulations, changes to the MSA definitions are announced in a Federal Register notice.

    In the August 27, 2004 Federal Register (69 FR 52710), we published a notice with respect to the hospice wage index for FY 2005. In that notice, we acknowledged that on June 6, 2003, OMB issued OMB Bulletin No. 03-04 announcing revised definitions for MSAs, new definitions for Micropolitan Statistical Areas and Combined Statistical Areas, and guidance on using the statistical definitions. (A copy of the Bulletin may be obtained at the following Internet address: http://www.whitehouse.gov/​omb/​bulletins/​b03-04.html.) In addition, we noted that we would not address the new OMB definitions because the wage data used to calculate the FY 2005 hospice wage index (FY 2004 hospital wage data) did not reflect revisions based on the new definitions. We indicated that the new OMB definitions would be addressed in the FY 2006 wage index update.

    a. Background

    In general, OMB defines an urban area as a Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA). A rural area is defined Start Printed Page 22396as any area outside of the urban area. Any area not included in an MSA is considered to be nonurban and receives the statewide rural rate.

    Under the hospital inpatient prospective payment system (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 under sections 1886(d)(8) and (d)(10) of the Act. In accordance with our regulations for hospice payment, we also use MSAs to define labor market areas, but the application differs from IPPS. Section 1814(i)(2)(D) of the Act requires Medicare to pay for hospice services based on the geographic location where the service is furnished. The wage index value used is based upon the location of the beneficiary's home for routine home care and continuous home care and the location of the hospice agency for general inpatient and respite care.

    In this proposed rule, we will address the new OMB definitions and their application to the hospice wage index. Since our regulations require the use of the IPPS wage data as the basis for determining the hospice wage index, we are providing the following summary of the revised geographical statistical areas adopted in the FY 2005 IPPS final rule. (For a more detailed discussion of the changes in the hospital wage index based on the new OMB definitions see the FY 2005 IPPS proposed and final rules published May 18, 2004 (69 FR 28196) and August 11, 2004 (69 FR 48916).)

    b. Current Labor Market Areas Based on MSAs

    As discussed in the FY 2005 IPPS final rule, “the [hospital] wage index is calculated and assigned to hospitals on the basis of the labor market area in which the hospital is located.” In addition, the IPPS final rule (69 FR 49026) defined hospital labor markets as follows:

    We currently define hospital labor market areas based on the definitions of Metropolitan Statistical Areas (MSAs), Primary MSAs (PMSAs), and New England County Metropolitan Areas (NECMAs) issued by OMB. OMB also designates Consolidated MSAs (CMSAs). A CMSA is a metropolitan area with a population of one million or more, comprising two or more PMSAs (identified by their separate economic and social character). For purposes of the hospital 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, hospitals are assigned to either an MSA, PMSA, or NECMA based on whether the county in which the hospital is located is part of that area. For purposes of the IPPS wage index, we combine all of the counties in a State outside a designated MSA, PMSA, or NECMA together to calculate a statewide rural wage index.

    c. Core-Based Statistical Areas

    In the December 27, 2000 Federal Register (65 FR 82228 through 82238), OMB announced its new standards and in that notice, OMB defined 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: MSAs and Micropolitan Statistical Areas (65 FR 82235).

    According to OMB, MSAs are based on urbanized areas of 50,000 or more population, and Micropolitan Statistical Areas (referred to in further 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 CBSA (either MSA 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.”

    In its June 6, 2003 bulletin, OMB announced the new CBSAs, comprised of MSAs and the new Micropolitan Areas based on Census 2000 data. The new CBSA designations recognize 49 new (urban) MSAs and 565 new Micropolitan Areas, and revised the composition of many of the existing (urban) MSAs. There are 1,090 counties in MSAs under these new CBSA designations compared with 848 counties in the previous MSAs. Of these 1,090 counties, 737 are in the same MSA as they were before the changes, 65 are in different MSAs, 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.

    d. Revised Labor Market Areas

    As discussed in the FY 2005 IPPS final rule (69 FR 49027), alternatives to the use of MSAs for the purpose of establishing labor market areas for the Medicare wage index were examined. In the May 27, 1994, IPPS proposed rule (59 FR 27724), the latest research concerning possible future refinements to the labor market areas was presented. Public comments received on the May 27, 1994 proposed rule were described in the June 2, 1995 proposed rule (60 FR 29219). In that rule, it was noted that there was no consensus among commenters on the choice for new labor market areas. Consequently, MSAs have continued to be used to define labor market areas for purposes of the wage index by many Medicare payment systems as noted in previous discussion.

    (1) New England County Metropolitan Areas

    NECMAs are currently used to define labor markets 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 CBSA definition, “OMB has defined the MSAs and Micropolitan Areas in New England on the basis of counties. OMB also established New England City and Town Areas, which are similar to the previous New England MSAs.” Therefore, to maintain consistency in the definition of labor market areas between New England and the rest of the country, IPPS decided to use the New England MSAs under the new CBSA definition.

    (2) 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 lines. For the hospital wage index the PMSAs are used rather than CMSA to define labor market areas “because they comprise a smaller geographic area with potentially varying labor costs due to different local economies.”

    (3) Micropolitan Areas

    The IPPS final rule noted the following regarding the use of Micropolitan Areas to define labor markets (69 FR 49029):

    One of the major issues with respect to the new definitions is whether to use Micropolitan Areas to define labor market areas for the purpose of the IPPS wage index. Because the new Micropolitan Areas are essentially a third area definition made up mostly of currently rural areas, but also some or all of current MSAs, how these areas are treated will have significant impacts on the calculation and application of the wage index. Treating Micropolitan Areas as separate and distinct labor market areas would affect both the wage indexes of the hospitals in the Micropolitan Areas and the Start Printed Page 22397hospitals in the labor market areas where those hospitals are currently located (both positively and negatively).

    Because we currently use MSAs to define urban labor market areas and we 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 complicates this terminology because these areas include so many hospitals that are currently included in the statewide rural labor market areas. In order to facilitate the discussion below, we use the term “rural” hospitals to describe hospitals in counties that are not assigned to either an MSA or a Micropolitan Area. This should not be taken to indicate that hospitals in Micropolitan Areas are no longer “rural” hospitals. In fact, we proposed that hospitals in Micropolitan Areas are included in the statewide rural labor market areas, for the reasons outlined below.

    2. Annual Update to the Hospice Wage Index

    (If you choose to comment on issues in this section, please include the caption “Annual Update to the Hospice Wage Index” at the beginning of your comments)

    a. Background

    Section 418.306(c) requires that we issue annually in the Federal Register, hospice wage index based on our most current available hospital wage data, including any changes to the definitions of MSAs.

    Section 4441(a) of the Balanced Budget Act of 1997 (BBA) amended section 1814(i)(1)(C)(ii) of the Act to establish updates to hospice rates for FYs 1998 through 2002. Hospice rates were to be updated by a factor equal to the hospital market basket index, minus 1 percentage point. However, neither the BBA nor subsequent legislation specified the hospital market basket adjustment to be used to compute payment for FY 2006. Therefore, payment rates for FY 2006 will be updated according to section 1814(i)(1)(C)(ii)(VII) of the Act, which specifies that the update to the payment rates after FY 2002 will be the hospital market basket percentage increase for the fiscal year. This rate update is implemented via administrative issuance to be published July 2005 to provide adequate time to implement system change requirements and is not part of this proposed rule.

    The hospice wage index presented in this proposed rule would be effective October 1, 2005 through September 30, 2006. We note that we are not proposing any modifications to the hospice wage index methodology. In accordance with the our regulations and the agreement signed with other members of the Hospice Wage Index Negotiated Rulemaking Committee, we will continue to use the most current hospital data available to adjust for area wage differences. For this proposed rule, the FY 2005 hospital wage index was the most current hospital wage data available when the FY 2006 wage index values were calculated. We continue to use the pre-reclassified and prefloor hospital area wage index data. Payment rates for each of the four levels of care (routine home care, continuous home care, respite care, and general inpatient care) are adjusted annually based upon the hospital market basket for that year and are promulgated administratively to allow for sufficient time for system changes and provider notification. Due to the need to ensure appropriate time for implementing changes, we have not incorporated these payment rates into this proposed rule.

    The payment rates are divided into the labor and nonlabor portions. The appropriate wage index value is applied to the labor portion of the hospice rate based on the geographic area in which the beneficiary resides when receiving routine home care or continuous home care. The appropriate wage index value is applied to the labor portion of the hospice rate based on the geographic area of the hospice agency for beneficiaries receiving general inpatient or respite level of care.

    We use the previous fiscal year's hospital wage index data to calculate the hospice wage index values. For FY 2006 proposed hospice wage index, we use the FY 2005 hospital prefloor and pre-reclassified hospital wage data. This means that the hospital wage data used for the hospice wage index is not adjusted to take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886 (D)(10) of the Act. All wage index values for FY 2006 would be adjusted by either by the proposed FY 2006 budget neutrality adjustment factor, 1.063479, or the wage index floor adjustment. This means, that for wage index values 0.8 or greater, the value is multiplied by the budget neutrality adjustment factor. For wage index values that are below 0.8, either the budget neutrality adjustment factor or the wage index floor, not to exceed 0.8, is applied. In other words, the floor adjustment is the greater of the raw wage index value multiplied by the proposed budget neutrality adjustment factor (1.063479 for FY 2006) or the raw wage index value for that area is multiplied by 15 percent subject to a maximum value of 0.8. Budget neutrality means that, in a given year, estimated aggregate payments for Medicare hospice services using the updated wage index will equal estimated payments that would have been made for the same services if the wage index adopted for hospices in 1983 had remained in effect. (For a detailed discussion of the methodology used to compute the hospice wage index see the September 4, 1996 proposed rule (61 FR 46579) and the August 8, 1997 final rule (62 FR 42860)). The proposed FY 2006 hospice wage indexes for urban and rural areas are listed in Tables A and B of the Addendum.

    b. Implementation of the Revised Labor Market Designations

    (If you choose to comment on issues in this section, please include the caption “Implementation of Revised Labor Market Designations” at the beginning of your comments)

    For the hospice payment system, § 418.306(c) requires that the hospice wage index be “based on the most current available CMS hospital wage index, including any changes to the definitions of Metropolitan Statistical Areas.” We continue to believe MSAs are a reasonable and appropriate proxy for developing geographic areas for purposes of adjusting for wage differences in hospice. We also note that MSAs are used to define labor market areas for purposes of the wage index for many of the other Medicare payment systems (for example, long term care hospital (LTCH) prospective payment system (PPS), inpatient rehabilitation facility (IRF) PPS, home health agency (HHA) PPS, skilled nursing facility (SNF) PPS, Outpatient PPS and inpatient psychiatric facility (IPF) PPS.

    First, historically, Medicare prospective payment systems have used metropolitan area (MA) definitions developed by OMB. For example, in adopting the MSA designation for the IPPS area labor adjustment, the Secretary stated:

    [i]n administering a national payment system, we must have a national classification system built on clear, objective standards. Otherwise the program becomes increasingly difficult to administer because the distinction between rural and urban hospitals is blurred. We believe that the MSA system is the only one that currently meets the requirements for use as a classification system in a national payment program. The MSA classification system is a statistical standard developed for use by Federal agencies in the production, analysis, and publication of data on metropolitan areas. The standards have been developed with the aim of producing definitions that will be consistent as possible for all MSAs nationwide.” (49 FR 27426).

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    In addition, in numerous instances, the Congress has recognized that the areas developed by OMB may be used for differentiating among geographic areas for Medicare payment purposes. For example, in the IPPS statutory section, section 1886(d)(2)(D) of the Act, the Congress defines an “urban area” as “an area within a Metropolitan Statistical Area (as defined by the Office of Management and Budget) or within such similar area as the Secretary has recognized.” Similarly, in the sections of the statute governing the guidelines to be used by the Medicare Geographic Classification Review Board for purposes of reclassification, sections 1886(d)(10)(A) and (D)(i)(II) of the Act, the Congress directed the Secretary to create guidelines for “determining whether the county in which the hospital is located should be treated as being part of a particular [MSA].” Thus, the Congress has accepted and ratified the use of MSAs as an inherently rational manner of dividing up labor-market areas for purposes of Medicare payments.

    The process used by OMB to develop the MSAs creates geographic areas that are based upon characteristics we believe also generally reflect the characteristics of unified labor market areas. For example, the CBSAs reflect 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. OMB reviews its MA definitions preceding each decennial census to reflect recent population changes, and the CBSAs are based on the Census 2000 data. Finally, in the context of the inpatient prospective payment system, we have reviewed alternative methods for determining geographic areas for purposes of the wage index, and in each case, have determined to remain with the OMB designations rather than replace these designations with alternatives.

    As stated previously, § 418.306(c) requires the hospice wage index to reflect changes to the definitions of MSA. Therefore, we are proposing to adopt the revised labor market area designations based on OMB's CBSA designations.

    For the proposed FY 2006 hospice wage index, we would adopt the CBSA designations as finalized in the FY 2005 IPPS. We believe that OMB's CBSA designations, based on Census 2000 data reflect the most recent available geographic classifications (MA definitions). We are not proposing to change at this time, the methodology derived as a result of the negotiated rulemaking committee. We believe that there are factors which require evaluation to determine if the hospice methodology supports the cost of providing hospice services and if the methodology requires modification.

    As discussed in the IPPS final rule (69 FR 49032), when the IPPS adopted the revised labor market areas based on OMB's new CBSA designations on October 1, 2004, IPPS established a transition to the new designations to mitigate the resulting adverse impact on certain hospitals. Section 1814(i)(1)(A) of the Act requires hospice payment to be based on “costs which are reasonable and related to the cost of providing hospice care or which are based on such other tests of reasonableness the Secretary may prescribe in regulations * * *.” Our regulations at § 418.306(c) require us to issue annually in the Federal Register “ a hospice wage index based on the most current available CMS hospital data wage data, including any changes to the definitions of Metropolitan Statistical Areas.” This language would not seem to permit us to establish a transition to the new CBSA designations. In addition, unlike IPPS and other payment systems where each entity uses a single MSA (CBSA), hospice agencies may use various wage indices to compute their payments based upon the location of the beneficiary for routine and continuous home care or the MSA (CBSA) for the location of the agency for respite and general inpatient care. The methodology for applying the hospice floor (15 percent) to wage index values below 0.8 is used to leverage areas where there are significantly low wage index values. Moreover, we do not believe that in the aggregate, hospice agencies would be impacted negatively by the new CBSA designations. The existing methodology of computing the hospice wage index, the annual calculation of the hospice payment rates based upon the market basket index, and the variability of CBSAs that may be attributed to different hospice agencies are sufficient to mitigate adverse effects on individual hospice agencies. While we understand that there are CBSAs that decrease based upon the new definitions, there are those that are positively affected. For example, many counties that have been included in the rural definitions under the MSA designations are now designated as urban areas under the CBSA will generally receive an increase in their wage index. We believe that adjustments made to CBSAs because of negative impact would necessitate adjustment to CBSAs that are positively impacted. Variability and changes in wage indices both positively and negatively have occurred under the MSA designations and occur as a result of geographic differences. As a result, we propose to adopt the CBSA definitions and resulting wage indices without transitions. The impact of the CBSA designations is discussed in section V of this proposed rule.

    In adopting the CBSA designations, we identified that there were no IPPS hospitals and thus no hospital wage index data on which to base the calculation of the FY 2006 hospice wage index for rural Massachusetts. Because there is no reasonable proxy for more recent rural data within Massachusetts, we are proposing to use the prefloor, preclassified hospital wage index data for FY 2005 and apply the FY 2006 proposed budget neutrality factor of 1.063479. In the event that future rural areas do not have hospital wage index data to derive a hospice wage index, we propose to use a comparable methodology to derive a wage index. Similarly, if there urban areas without hospital wage index data, we propose to use all of the urban areas within the State as a reasonable proxy. We are soliciting comment on these approaches to calculating the wage index value for areas without hospital wage data for FY 2006 and subsequent years.

    To facilitate an understanding of the policies related to the proposed changes in the hospice wage index discussed in section II.A of this proposed rule, we are providing the following tables in the Addendum to this proposed rule:

    • Table A—Proposed Hospice Wage Index for Urban Areas by CBSA.
    • Table B—Proposed Hospice Wage Index for Rural Areas by CBSA.
    • Table C—Comparison of Hospice Wage Index for Urban Areas by MSA and CBSA. This table lists the counties by MSA designation and the wage index if we had retained the use of MSAs. It also presents the CBSA designation for these counties and the corresponding wage index using the CBSA designations. The MSA designations include those counties that were classified as rural and indicated the State rural MSA code and the corresponding CBSA for these counties which under the CBSA designation are now urban. We note that some counties that are classified as rural under the MSA designation would become rural under the new CBSA designation and vice versa.
    • Table D—Comparison of the Hospice Wage Index for Rural Areas by MSA and CBSA. This table compares Start Printed Page 22399the State rural MSA designations and their corresponding wage indices to the CBSA designations and their respective wage indices.
    • Table E—Rural Counties Converting to Urban Counties by State. This table presents the rural counties that under the CBSA designations convert to urban counties. The list includes the county name, State county code, MSA designation, MSA name, CBSA name, and CBSA designation. Please note that these conversions are based on the OMB designations.
    • Table F—Crosswalk of Counties by State from MSA to CBSA. This table crosswalks all counties in each State from MSA to CBSA and includes the State, State county code, MSA designation, MSA name, CBSA designation, and CBSA name. These tables will assist providers in identifying their location and their catchment area(s) by their previous designations and their CBSA designation as well as the wage indices for those areas based upon the previous MSA designations as well as the CBSA designations.

    3. Labeling Error in the Hospice Wage Index

    We have discovered an error in the labeling of the wage index tables that we have been publishing in the annual hospice wage index update. That labeling error is the listing of Stanly County, North Carolina as one of the areas under MSA 1520 when, in fact, we consider Stanly County, NC to be a rural area in North Carolina. Stanly County wage data have always been correctly treated as rural in the actual creation of the hospice wage index values, and it has only been the listing of Stanly County under MSA 1520 that was in error. Consequently, we are correcting our labeling error from past notices for the hospice and have removed Stanly County from the list of areas that fall under the MSA 1520 wage index. Since this is strictly a ministerial correction that does not affect the actual computation of the wage index values, hospice providers in and beneficiaries who reside in Stanly County and receive routine home and continuous home care in Stanly County will continue to fall under, and use, the wage index for rural North Carolina.

    B. Proposed Changes To Implement Hospice-Related Provisions of the MMA

    (If you choose to comment on issues in this section, please include the caption “MMA Provisions” at the beginning of your comments)

    In section I.C of this proposed rule, we note that section 408 of the MMA was effective upon enactment and initially implemented through administrative issuances. This proposed rule would incorporate the provisions in regulation.

    1. Coverage of Nurse Practitioner as Attending Physician in Hospice (Section 408 of the MMA)

    Section 408 of the MMA amended sections 1861(dd)(3)(B) and 1814(a)(7) of the Act to add nurse practitioners (NPs) to the definition of an attending physician, for beneficiaries who have elected the hospice benefit. In other words, if a beneficiary's primary care provider is an NP, before the determination of the terminal illness and election of the hospice benefit, the NP can remain as the attending physician, if chosen by the beneficiary. If the beneficiary does not have an attending physician or NP, the beneficiary must be provided with an option of either a physician or an NP (if available and if allowed by State law) to serve as the attending physician. An NP is defined as a registered nurse who performs such services as he or she is legally authorized to perform (in the State in which the services are performed) in accordance with State law (or State regulatory mechanism provided by State law) and who meets the training, education, and experience requirements as the Secretary may prescribe.

    As discussed in Change Request 3226 (Transmittals 22 and 304, September 24, 2004), beginning December 8, 2003, Medicare pays for medically reasonable and necessary services provided by NPs to Medicare beneficiaries who have elected the hospice benefit and who have selected a nurse practitioner as their attending physician. Nurse practitioners are paid 85 percent of the fee schedule amount for their services as attending physicians. Services for the terminal and related conditions provided by an NP—

    • Serving as the attending physician that are medical in nature must be reasonable and necessary and must be services that, in the absence of an NP, would be performed by a physician; and
    • May not be separately billed if the—

    ++ Services would not be reasonable and necessary if provided by an attending physician;

    ++ NP is not the patient's attending physician; or

    ++ Services would be performed by a registered or licensed nurse in the absence of a physician or nurse practitioner.

    Since NPs are not physicians, as defined in 1861(r)(1) of the Act, they may not act as medical directors or physicians of the hospice or certify the beneficiary's terminal illness and hospices may not contract for their attending physician services as described in 1861(dd)(2)(B)(i)(III) of the Act. All of these provisions apply to NPs without regard to whether they are hospice employees.

    We are proposing to revise § 418.3, 418.22(c)(1)(ii), and § 418.304 to implement the provisions of section 408 of the MMA.

    2. Payment for Authorizing Use of Arrangements To Provide Hospice Service Under Certain Circumstances (Section 946 of the MMA)

    Section 946(a) of the MMA amended section 1861(dd)(5) of the Act by adding the following: “(D) In extraordinary, exigent, or other non-routine circumstances, such as unanticipated periods of high patient loads, staffing shortages due to illness or other events, or temporary travel of a patient outside a hospice program's service area, a hospice program may enter into arrangements with another hospice program for the provision by that other program of services described in paragraph (2)(A)(ii)(I).” Section 946(a) of the MMA is discussed in this proposed rule to assist the reader in understanding how hospices will be reimbursed for these types of arrangements. We will issue more specific regulations regarding section 946(a) of the MMA in future rulemaking.

    Section 946(b) of the MMA amended section 1814(i) of the Act to add the following: “(5) In the case of hospice care provided by a hospice program under arrangements under section 1861(dd)(5)(D) made by another hospice program, the hospice program that made the arrangements shall bill and be paid for the hospice care.” This means that the hospice that establishes the contractual arrangement with the hospice that will be providing services to the beneficiary, continues to bill for and receive payment during the hospice election.

    Section 4442 of the BBA amended section 1814(i)(2) of the Act, effective for services furnished on or after October 1, 1997, to require hospice agencies to submit claims for payment for hospice services furnished in an individual's home on the basis of the geographic location at which the service is furnished. Therefore, the methodology for applying the wage index to the labor portion of the payment rates remains the same. This means that the wage index for routine and continuous home care would reflect the place where the service is provided, Start Printed Page 22400which may be outside of the hospice program's service area during periods of temporary travel. We do not propose in this rule to define “temporary travel” since this would depend upon individual needs and abilities determined by the interdisciplinary group, the beneficiary, and his or her family. The wage index for general inpatient care would reflect the MSA for the hospice agency that retains management responsibility. Payment will continue to be made to the hospice agency for which the beneficiary has made the election. We are proposing to revise § 418.302(d) to implement this provision.

    III. Collection of Information Requirements

    Under the Paperwork Reduction Act of 1995, we are required to provide 30-day notice in the Federal Register and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues:

    • The need for the information collection and its usefulness in carrying out the proper functions of our agency.
    • The accuracy of our estimate of the information collection burden.
    • The quality, utility, and clarity of the information to be collected.
    • Recommendations to minimize the information collection burden on the affected public, including automated collection techniques.

    Section 418.22(c)(1) requires for the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from the individual's attending physician, if the individual has an attending physician, that meets the definition of physician specified in § 410.20 of this subchapter.

    While this requirement is subject to the PRA it is currently approved by OMB under control number 0938-0302, “ICRs in Hospice Care Regulation and Supporting Regulations”, with a current expiration date of September 30, 2006.

    IV. Response to Comments

    Because of the large number of public comments we normally receive on Federal Register documents, 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 preamble, and, when we proceed with a subsequent document, we will respond to the comments in the preamble to that document.

    V. Regulatory Impact Analysis

    (If you choose to comment on issues in this section, please include the caption “Impact Analysis” at the beginning of your comments)

    A. Overall Impact

    We have examined the impacts 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 Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132. We estimated the impact on hospices, as a result of the proposed changes to the FY 2006 hospice wage index. As discussed previously, the methodology for computing the wage index was determined through a negotiated rulemaking committee and implemented in the August 8, 1997 final rule (62 FR 42860). This proposed rule updates the hospice wage index in accordance with our regulation and that methodology, incorporating the adoption of the CBSA designations used in the hospital wage index data. Table I reflects the proposed hospice wage index impact using the CBSA designations. Table II indicates the proposed wage index impact using the hospice wage indices under the MSA designations as well as the CBSA designations.

    In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside an MSA and has fewer than 100 beds. We have determined that this proposed rule would not have a significant impact on the operations of a substantial number of small rural hospitals.

    Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies assess anticipated costs and benefits before issuing any rule that may result in expenditure in any 1 year by State, local, and tribal governments, in the aggregate, or by the private sector, of $110 million or more. This proposed rule would have no substantial effect on State, local, or tribal governments or on the private sector.

    Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. We have reviewed this proposed rule under the threshold criteria of Executive Order 13132, Federalism, and have determined that it would not have an impact on the rights, roles, and responsibilities of State, local, or tribal governments.

    In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the Office of Management and Budget.

    1. Hospice Size

    The impact of hospice wage index changes have been analyzed according to type of hospice, geographic location, type of ownership, hospice base, and hospice size. Hospice size was determined by the number of routine home care days (RHC). Since routine home care days account for over 70 percent of the services provided by a hospice, we used RHC days as a proxy for the size of the hospice agency. In the past, we had, designated the size by four categories: (1) 0 to 1,754 RHC days representing small agencies; (2) 1,754 to 4,373 RHC days or (3) 4,373 to 9,681 RHC days representing medium-sized agencies; and (4) 9,681 RHC days or more representing large agencies.

    To determine the statistical distribution of RHC days, based upon the total number of hospice agencies and their respective RHC days using FY 2003 claims processed through March 2004, were used. In determining the statistical distribution, we deleted data for four hospice agencies with RHC days that greatly exceeded the total number of RHC days of other agencies. However, these data have been included in the impact analysis since we recognize that the skewness existed in the “large” agency size distribution using four size categories and does not change with the use of three size categories.

    Based upon this analysis, we are using only three size designations to present the impact analyses. We believe that these three designations better describe the size of the hospice. The three categories are: Small agencies having 0 to 3,499 RHC days; medium agencies having 3,500 to 19,999 RHC days; and large agencies having 20,000 or more RHC days.

    2. Impact on Hospices

    Our discussions for this proposed rule will focus on the impact of adopting the Start Printed Page 22401CBSA designations. Table I indicates the impact of using the proposed CBSA designations. Table II provides a comparison between impact using the MSA and CBSA designations. As discussed above, we use the latest claims file available to us to develop the impact table when we issue the annual yearly wage index update. For the purposes of this proposed rule, we used the 2003 claims that were processed through June 2004 since this was the latest file available. Thus the projections or anticipated payments indicated in Table I do not represent the expenditures that we anticipate for FY 2006. We anticipate that the final rule will more accurately project payment for FY 2006. For the purposes of this proposed rule, we compared estimated payments using the FY 1983 hospice wage index to estimated payments using the FY 2006 wage index and determined the proposed hospice wage index to be budget neutral. Budget neutrality means that, in a given year, estimated aggregate payments for Medicare hospice services using the proposed FY 2006 wage index would equal estimated aggregate payments that would have been made for the same services if the 1983 wage index had remained in effect. Budget neutrality to 1983 does not imply that estimated payments would not increase since the budget neutrality applies only to the wage index portion and not the total payment rate, which accommodates inflation.

    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). We have determined that this proposed rule is not an economically significant rule under this Executive Order.

    The RFA requires agencies to analyze options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and government agencies. Most hospices and most other providers and suppliers are 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 at 65 FR 69432, that sets forth size standards for health care industries). For purposes of the RFA, most hospices are small entities. As indicated in Table I below, there are 2,435 hospices. Approximately 70 percent of Medicare certified hospices are identified as voluntary, government, or other agencies and, therefore, are considered small entities. Because the National Hospice and Palliative Care Organization estimates that approximately 79 percent of hospice patients are Medicare beneficiaries, we have not considered other sources of revenue in this analysis. Furthermore, the wage index methodology was previously determined by consensus, through a negotiated rulemaking committee that included representatives of national hospice associations; rural, urban, large, and small hospices; multisite hospices; and consumer groups. Based on all of the options considered, the committee agreed on the methodology described in the committee statement, and it was adopted into regulation in the August 8, 1997 final rule. In developing the process for updating the wage index in the 1997 final rule, we considered the impact of this methodology on small entities and attempted to mitigate any potential negative effects.

    As stated previously, the following discussions are limited to demonstrating trends rather than projected dollars if the subsequent final rule to this proposed rule were implemented for FY 2006. We used the CBSA designations and wage indices as well as the data from FY 2003 claims processed through June 2004 in developing the impact analysis. We will recalculate the impacts for the final rule using the FY 2004 claims file. We will discuss the estimated payments for FY 2006 at that time. Since the impact tables are intended to reflect the implementation of the CBSA in contrast with the current MSA designations, the introduction of the wage indices is the only variable used in the computation. It is important to note that the payment rates used reflect the FY 2005 rates. The FY 2006 payment rates will be adjusted to reflect the full FY 2006 hospital market basket, as required by section 1814(i)(1)(C) (ii)(VII) of the Act. As previously noted, we publish these rates through administrative issuances. As discussed in section II.A.1.a. of this proposed rule, hospice agencies may various wage indices to compute their payments based on the geographic location of the beneficiary for routine and continuous home care or the MSA (CBSA) or the location of the hospice agency for respite and general inpatient care. Therefore, we analyze the impact on hospices using the following parameters: geographic location; hospice size; type of ownership; and hospice base).

    Our analysis demonstrates that, under this proposed rule, rural hospices would experience an increase in payment that is greater than that of urban hospices. Rural hospices are anticipated to experience a modest increase of 0.8 percent and urban hospices a slight decrease of 0.2 percent. However, the impact overall is anticipated to remain unchanged if the CBSA designations are adopted. This flat trend is also evident when contrasting the findings with projections using the MSA designations. However, the projections using the MSA designations remain flat for urban areas and decrease slightly by 0.1 percent for rural areas.

    Of the urban hospices, we anticipate that most of the regions would experience decreases ranging from a 1.4 for the urban New England region to 0.1 decrease for the South Atlantic. A slight increase is anticipated for the West North Central, West South Central, and Pacific urban regions of 0.1, 0.2, and 0.1, respectively. In contrast, the rural regions are expected to receive an increase for all regions ranging from a substantial increase of 21.7 percent for rural Puerto Rico to a 1 percent increase for East North Central. We believe that that aberration for Puerto Rico can be attributed to the increase in the hospital wage indices in the region as well as the large number of rural counties under the MSA designations in Puerto Rico that have been designated as urban counties under the CBSA designations. Rural New England and West North Central regions are expected to remain flat. Only one rural region, the Mid-Atlantic, is anticipated to experience a decrease of 1.5 percent. The anticipated increase for the rural regions using the MSA designations is in contrast, more modest with increases ranging from 0.1 to 0.3 and decreases anticipated for the rural South Atlantic, East North Central, East South Central, and Middle Atlantic of 0.2, 0.3, 0.6, and 0.7, respectively.

    As discussed previously, we have designated three hospice sizes based on routine home care days. Under the Medicare hospice benefit, hospices can provide four different levels of care days. The majority of the days provided by a hospice are routine home care days. Therefore, the number of routine home care days can be used as a proxy for the size of the hospice, that is, the more days of care provided, the larger the hospice. Using routine home care days as a proxy for size, our analysis indicates that the impact of the wage index update on small hospices (those Start Printed Page 22402that provide up to 3,499 days of routine home care) will experience a 0.1 percent increase in both the CBSA and MSA projections. The impact remains virtually the same for both the CBSA and MSA designations for all three sizes. As indicated above, a 0.1 percent increase is anticipated for small agencies and remains unchanged for large agencies. There is a scant decrease of 0.1 percent for medium sized agencies (with 3,500 to 19,999 RHC days) using the CBSA designations while it remains unchanged for MSA designations. The lack of variability by agency size indicates that this proposed rule would have no impact on a small number of small entities. Rural Puerto Rico with 6 hospice agencies and 184,000 routine care days, representing the smallest number of hospices and second lowest routine home care days in the rural region, is anticipated to experience a substantial increase of 21.7 percent while rural South Atlantic with 138 hospices and 1,394,000 routine home care days, which represents the highest number of routine home days, will have an increase of 0.6 percent. The rural Mid-Atlantic region with 39 hospices and 280,000 routine home care days is anticipated to decrease by 1.5 percent. Rural New England with 27 hospices representing the second lowest number of agencies with 112,000 routine home care days, and representing the lowest number of rural days, is anticipated to remain unchanged.

    Urban Puerto Rico region with 30 hospice agencies with 428,000 routine home care days, representing the lowest number of urban agencies and routine home care days, is anticipated to experience a decrease of 0.5 percent using the CBSA designations in contrast to a 0.2 percent increase using the MSA designation. Urban East North Central with 244 hospice agencies representing the largest number of urban hospice agencies with 5,275,000 routine home care days is anticipated to experience a decrease of 0.3 percent using the CBSA designation and would remain unchanged using the MSA designation. Urban West South Central with the largest number of routine home care days of 5,765,000 is anticipated to experience a 0.2 percent increase using the CBSA designations and 0.4 percent increase using the MSA designations. Based upon these comparisons, the urban regions would expect a slightly larger increase in payment using the MSA designations while the rural areas are anticipated to experience a substantially larger increase using the CBSA designations. However, as indicated above, in the aggregate, hospice agencies overall are anticipated to remain unchanged using either the CBSA or MSA designations.

    By type of ownership, proprietary hospice agencies are anticipated to increase by 0.2 percent while voluntary agencies with the largest number of agencies and routine home care days of 1,309 and 23,696,000, respectively, are anticipated to decrease by 0.2 percent and government by 0.3. Since we are unable to determine the ownership type for the unknown category, we are unable to determine the impact of the anticipated decrease of 1.1 percent. By MSA designation, in contrast, voluntary and proprietary hospice agencies are anticipated to remain unchanged with government agencies anticipated to decrease by 0.1 percent.

    Freestanding hospice agencies with the largest number of agencies of 1,188 and routine home care days of 29,277,000 are anticipated to remain unchanged when using MSA as well as CBSA designations. Home health-based hospice agencies are anticipated to remain unchanged with the MSA designations but are anticipated to increase by 0.2 percent with CBSA designation. Hospital-based hospice agencies are anticipated to decrease slightly with both MSA and CBSA designations at 0.1 and 0.3 respectively. SNF-based hospice agencies with the lowest number of agencies and routine home care days of 15 and 174,000, respectively, are also anticipated to experience a decrease with both MSA and CBSA designations of 0.6 and 0.9, respectively.

    As discussed above, the overall impact for hospice agencies remain unchanged using the CBSA designations with a slight decrease in urban and an increase in rural hospice agencies. While there are more decreases in urban hospice agencies, there is overall increase in the rural agencies. Hospice size remains virtually unchanged when comparing MSA to CBSA designations. Type of ownership and hospice base appear similar between the two designations. As a result, there is no compelling reason to maintain the use of the MSA designations as opposed to the CBSA designations based upon overall hospice agency impact.

    3. Anticipated Effects

    We have compared estimated payments using the FY 1983 hospice wage index to estimated payments using the proposed FY 2006 wage index and determined the current hospice wage index to be budget neutral. This impact analysis compares hospice payments using the FY 2005 hospice wage index to the estimated payments using the proposed FY 2006 wage index. The data used in developing the quantitative analysis for this proposed rule were obtained from the June 2004 update of the national claims history file of all FY 2003 claims processed through June 2004. We deleted bills from hospices that have since closed. As discussed above, for the purposes of this proposed rule, this file is adequate to demonstrate the impact of using the MSA and proposed CBSA designations and is not intended to project the anticipated expenditures for FY 2006. We will be using an updated file for the final rule which will more accurately indicate the expected expenditures for FY 2006.

    Table I demonstrates the results of our analysis. In column 2 of Table I, we indicate the number of routine home care days that were included in our analysis, although the analysis was performed on all types of hospice care. Column 3 indicates payments that were made using the FY 2005 wage index. Column 4 is based on claims (for hospices in business during that time period) and estimates payments (with the caveat as discussed above) to be made to hospices using proposed CBSA designations and FY 2006 wage index. The final column, which compares columns 3 and 4, shows the percent change in estimated hospice payments made based on the category of the hospice.

    Table I categorizes hospices by various geographic and provider characteristics. The first row displays the results of the impact analysis for all Medicare-certified hospices. The second and third rows of the table categorize hospices according to their geographic location (urban and rural). Our analysis indicted that there are 1,494 hospices located in urban areas and 941 hospices located in rural areas. The next two groupings in the table indicate the number of hospices by census region, also broken down by urban and rural hospices. The sixth grouping shows the impact on hospices based on the size of the hospice's program. We determined that the majority of hospice payments are made at the routine home care rate. Therefore, we based the size of each individual hospice's program on the number of routine home care days provided in 2004. The next grouping shows the impact on hospices by type of ownership. The final grouping shows the impact on hospices defined by whether they are provider-based or freestanding.

    Table II demonstrates the estimated payments using the CBSA and MSA designations. The groupings as well as columns 1 and 2 are the same as in Start Printed Page 22403Table I. Columns 3 and 4 represent the estimated payments using the CBSA and MSA designations, respectively. Column 5 represents the percentage change in the estimated payments using CBSA designations compared with the estimated payments using the MSA designations.

    Our analysis shows that the majority of hospices are in urban areas and provide the vast majority of routine home care days. However, rural hospices are anticipated to receive a larger percent increase in payment of 0.8 percent in contrast to a decrease of 0.2 percent for urban hospices if CBSA designations were used in the proposed FY 2006 wage index. However, overall, there is no anticipated change using the CBSA designations.

    Since the impact tables are intended to reflect the implementation of the CBSA as opposed to the current MSA designations, the introduction of the wage indices is the only variable used in the computation. It is important to note that the payment rates used reflect the FY2005 rates. The FY 2006 payment rates would be adjusted to reflect the full FY 2006 hospital market basket, as required by section 1814(i)(1)(C)(ii)(VII) of the Act. We publish these rates through administrative issuances.

    Table I.—Impact of Hospice Wage Index Changes Based on Use of CBSA Designations

    Number of hospices (1)Number of routine home care days in thousands (2)Payments using FY 2005 wage index in thousands (3)Estimated payments using FY 2006 wage index in thousands (CBSA designations) (4)Percent change in hospice payments (CBSA designations) (5)
    By Geographic Location:
    All Hospices2,43543,2326,086,7266,084,1940.0
    Urban Hospices1,49435,8775,225,2405,215,515−0.2
    Rural Hospices9417,355861,486868,6800.8
    By Region—Urban:
    New England931,051179,129176,671−1.4
    Middle Atlantic1733,573551,587549,856−0.3
    South Atlantic2097,4421,164,7581,163,315−0.1
    East North Central2445,275765,379762,940−0.3
    East South Central1092,644346,632345,627−0.3
    West North Central1092,442316,698316,9380.1
    West South Central2285,765740,895742,5690.2
    Mountain1072,821439,997437,091−0.7
    Pacific1924,436683,956684,4760.1
    Puerto Rico3042836,20836,031−0.5
    By Region—Rural:
    New England2711214,83514,8320.0
    Middle Atlantic3928029,00028,572−1.5
    South Atlantic1381,394170,695171,7520.6
    East North Central142940113,436113,5410.1
    East South Central1141,571179,805180,4340.3
    West North Central184889105,953105,9950.0
    West South Central1261,096119,455121,5271.7
    Mountain10653465,69665,8720.3
    Pacific5935547,51247,7720.5
    Puerto Rico618415,09818,38121.7
    Routine Home Care Days:
    0-3499 DAYS (Small)629997125,214125,3300.1
    3500-19,999 DAYS (Medium)1,19211,6231,531,0601,529,182−0.1
    20,000+ DAYS (Large)61430,6124,430,4524,429,6830.0
    Type Of Ownership:
    Voluntary1,30923,6963,417,5063,411,195−0.2
    Proprietary84017,8432,444,3692,449,6660.2
    Government185874116,914116,593−0.3
    Unknown101819107,937106,741−1.1
    Hospice Base:
    Freestanding1,18829,2774,137,9794,136,4040.0
    Home Health Agency6237,8021,107,7071,110,1340.2
    Hospital5505,470751,268749,156−0.3
    Skilled Nursing Facility1517428,53628,273−0.9
    Unknown5950961,23760,227−1.6
    Note: For purposes of comparing the proposed CBSA designations with the current MSA designations, hospice listings are based on the MSA designations.
    FY 2005 payment rates were used for estimated payments for FY 2006. FY 2006 payment rates will be adjusted to reflect the full hospital market basket.
    Start Printed Page 22404

    Table II.—Comparison of Impact of the Hospice Wage Index Using CBSA and MSA Designations

    Number of hospices (1)Number of routine home care days (in thousands) (2)Estimated Payments using FY 2006 wage index and CBSA designations (in thousands) (4)Estimated payments using FY 2006 wage index and MSA designations (in thousands) (6)Percent change in hospice payments (CBSA vs. MSA designations) (7)
    By Geographic Location:
    All Hospices2,43543,2326,084,1946,086,3140.0
    Urban Hospices1,49435,8775,215,5155,224,948−0.2
    Rural Hospices9417,355868,680860,3661.0
    By Region—Urban:
    New England931,051176,671178,262−0.9
    Middle Atlantic1733,573549,856548,9150.2
    South Atlantic2097,4421,163,3151,165,203−0.2
    East North Central2445,275762,940765,293−0.3
    East South Central1092,644345,627346,797−0.3
    West North Central1092,442316,938317,338−0.1
    West South Central2285,765742,569744,193−0.2
    Mountain1072,821437,091437,836−0.2
    Pacific1924,436684,476684,819−0.1
    Puerto Rico3042836,03136,292−0.7
    By Region—Rural:
    New England2711214,83214,846−0.1
    Middle Atlantic3928028,57228,811−0.8
    South Atlantic1381,394171,752170,4290.8
    East North Central142940113,541113,1510.3
    East South Central1141,571180,434178,7430.9
    West North Central184889105,995106,186−0.2
    West South Central1261,096121,527119,7061.5
    Mountain10653465,87265,6950.3
    Pacific5935547,77247,6610.2
    Puerto Rico618418,38115,14017.6
    Routine Home Care Days:
    0-3499 DAYS (Small)629997125,330125,398−0.1
    3500-19,999 DAYS (Medium)1,19211,6231,529,1821,531,330−0.1
    20,000+ DAYS (Large)61430,6124,429,6834,428,5860.0
    Type of Ownership
    Voluntary1,30923,6963,411,1953,415,970−0.1
    Proprietary84017,8432,449,6662,445,1170.2
    Government185874116,593116,753−0.1
    Unknown101819106,741107,476−0.7
    Hospice Base:
    Freestanding1,18829,2774,136,4044,137,6890.0
    Home Health Agency6237,8021,110,1341,108,2100.2
    Hospital5505,470749,156750,172−0.1
    Skilled Nursing Facility1517428,27328,351−0.3
    Unknown5950960,22760,892−1.1
    Note: For purposes of comparing the proposed CBSA designations with the current MSA designations, hospice listings are based on the MSA designations.
    FY 2005 payment rates were used for estimated payments for FY 2006. FY 2006 payment rates will be adjusted to reflect the full hospital market basket.
    Start List of Subjects

    List of Subjects for 42 CFR Part 418

    • Health facilities
    • Hospice care
    • Medicare
    • Reporting and recordkeeping requirements
    End List of Subjects

    For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services would amend 42 CFR part 418 as set forth below:

    Start Part

    PART 418—HOSPICE CARE

    1. The authority citation for part 418 continues to read as follows:

    Start Authority

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

    End Authority

    2. Section 418.3 is amended by revising the definition of Attending physician to read as follows:

    Definitions.
    * * * * *

    Attending physician means a—(1)(i) Doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he or she performs an action; or

    (ii) Nurse practitioner who meets the training, education, and experience requirements as the Secretary may prescribe; and

    (2) Is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care.

    * * * * *

    3. Section 418.22 is amended by—

    A. Republishing the heading of paragraph (c) and paragraph (c)(1).

    B. Revising paragraph (c)(1)(ii).

    The republication and revisions read as follows:

    Certification of terminal illness.
    * * * * *
    Start Printed Page 22405

    (c) Sources of certification. (1) For the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from—

    (i) * * *

    (ii) The individual's attending physician, if the individual has an attending physician. The attending physician must meet the definition of physician specified in § 410.20 of this subchapter.

    * * * * *

    4. Section 418.302 is amended by revising paragraph (d) to read as follows:

    Payment procedures for hospice care.
    * * * * *

    (d)(1) The intermediary reimburses the hospice its appropriate payment amount for each day for which an eligible Medicare beneficiary is under the hospice's care.

    (2) Effective December 8, 2003, if a hospice makes arrangements with another hospice to provide services under the circumstances specified in section 1861(dd)(5)(D) of the Act, the intermediary reimburses the hospice for which the beneficiary has made an election as described in paragraph (d)(1) of this section.

    * * * * *

    5. Section 418.304 is amended by—

    A. Revising the section heading.

    B. Revising the introductory text of paragraph (a).

    C. Adding a new paragraph (e).

    The revisions and additions read as follows:

    Payment for physician and nurse practitioner services.

    (a) The following services performed by hospice physicians and nurse practitioners are included in the rates described in § 418.302:

    * * * * *

    (e)(1) Effective December 8, 2003, Medicare pays for attending physician services provided by nurse practitioners to Medicare beneficiaries who have elected the hospice benefit and who have selected a nurse practitioner as their attending physician. This applies to nurse practitioners without regard to whether they are hospice employees.

    (2) Nurse practitioners may bill and receive payment for services only if the—

    (i) Nurse practitioner is the beneficiary's attending physician as defined in § 418.3;

    (ii) Services are medically reasonable and necessary; and

    (iii) Services are performed by a physician in the absence of the nurse practitioner; and

    (iv) Services are not related to the certification of terminal illness specified in § 418.22.

    (3) Payment for nurse practitioner services are made at 85 percent of the physician fee schedule amount.

    (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare—Hospital Insurance; and Program No. 93.774, Medicare—Supplementary Medical Insurance Program)

    Start Signature

    Dated: April 7, 2005.

    Mark B. McClellan,

    Administrator, Centers for Medicare & Medicaid Services.

    Approved: April 15, 2005.

    Michael O. Leavitt,

    Secretary.

    End Signature

    Addendum

    Table A.—Hospice Wage index for Urban Areas by CBSA

    CBSA code numberUrban area (Constituent counties or county equivalents) 1Wage index 2
    10180Abilene, TX0.8348
    Callahan County, TX
    Jones County, TX
    Taylor County, TX
    10380Aguadilla-Isabela-San Sebastian, PR0.4922
    Aguada Municipio, PR
    Aguadilla Municipio, PR
    Anasco Municipio, PR
    Isabela Municipio, PR
    Lares Municipio, PR
    Moca Muncipio, PR
    Rincón Municipio, PR
    San Sebastián Municipio, PR
    10420Akron, OH0.9630
    Portage County, OH
    Summit County, OH
    10500Albany, GA1.1981
    Baker County, GA
    Dougherty County, GA
    Lee County, GA
    Terrell County, GA
    Worth County, GA
    10580Albany-Schenectady-Troy, NY0.9199
    Albany County, NY
    Rensselaer County, NY
    Saratoga County, NY
    Schenectady County, NY
    Schoharie County, NY
    10740Albuquerque, NM1.1151
    Bernalillo County, NM
    Sandoval County, NM
    Torrance County, NM
    Valencia County, NM
    10780Alexandria, LA0.8690
    Grant Parrish
    Start Printed Page 22406
    Rapides Parish, LA
    10900Allentown-Bethlehem-Easton, PA-NJ1.0104
    Warren County, NJ
    Carbon County, PA
    Lehigh County, PA
    Northampton County, PA
    11020Altoona, PA0.8999
    Blair County, PA
    11100Amarillo, TX0.9761
    Armstrong County, TX
    Carson County, TX
    Potter County, TX
    Randall County, TX
    11180Ames, IA1.0081
    Story County, IA
    11260Anchorage, AK1.2937
    Anchorage Municipality, AK
    Matanuska-Susitna Borough, AK
    11300Anderson, IN0.9266
    Madison County, IN
    11340Anderson, SC0.9220
    Anderson County, SC
    11460Ann Arbor, MI1.1722
    Washtenaw County, MI
    11500Anniston-Oxford, AL0.8381
    Calhoun County, AL
    11540Appleton, WI0.9711
    Calumet County, WI
    Outagamie County, WI
    11700Asheville, NC0.9774
    Buncombe County, NC
    Haywood County, NC
    Henderson County, NC
    Madison County, NC
    12020Athens-Clarke County, GA1.0850
    Clarke County, GA
    Madison County, GA
    Oconee County, GA
    Oglethorpe County, GA
    12060Atlanta-Sandy Springs-Marietta, GA1.0604
    Barrow County, GA
    Bartow County, GA
    Butts County
    Carroll County, GA
    Cherokee County, GA
    Clayton County, GA
    Cobb County, GA
    Coweta County, GA
    Dawson County, GA
    DeKalb County, GA
    Douglas County, GA
    Fayette County, GA
    Forsyth County, GA
    Fulton County, GA
    Gwinnett County, GA
    Haralson County, GA
    Heard County, GA
    Henry County, GA
    Jasper County, GA
    Lamar County, GA
    Meriwether County, GA
    Newton County, GA
    Paulding County, GA
    Pickens County, GA
    Pike County, GA
    Rockdale County, GA
    Spalding County, GA
    Walton County, GA
    12100Atlantic City, NJ1.1625
    Atlantic County, NJ
    Start Printed Page 22407
    12220Auburn-Opelika, AL0.8736
    Lee County, AL
    12260Augusta-Richmond County, GA-SC0.9735
    Burke County, GA
    Columbia County, GA
    McDuffie County, GA
    Richmond County, GA
    Aiken County, SC
    Edgefield County, SC
    12420Austin-Round Rock, TX1.0204
    Bastrop County, TX
    Caldwell County, TX
    Hays County, TX
    Travis County, TX
    Williamson County, TX
    12540Bakersfield, CA1.0673
    Kern County, CA
    12580Baltimore-Towson, MD1.0536
    Anne Arundel County, MD
    Baltimore City, MD
    Baltimore County, MD
    Carroll County, MD
    Harford County, MD
    Howard County, MD
    Queen Anne's County, MD
    12620Bangor, ME1.0587
    Penobscot County, ME
    12700Barnstable Town, MA1.3118
    Barnstable County, MA
    12940Baton Rouge, LA0.8847
    Ascension Parish, LA
    East Baton Rouge Parish, LA
    East Feliciana Parish, LA
    Iberville Parish, LA
    Livingston Parish, LA
    Pointe Coupee Parish, LA
    St. Helena Parish, LA
    West Baton Rouge Parish, LA
    West Feliciana Parish, LA
    12980Battle Creek, MI0.9961
    Calhoun County, MI
    13020Bay City, MI1.0182
    Bay County, MI
    13140Beaumont-Port Arthur, TX0.9163
    Hardin County, TX
    Jefferson County, TX
    Orange County, TX
    13380Bellingham, WA1.2381
    Whatcom County, WA
    13460Bend, OR1.1276
    Deschutes County, OR
    13644Bethesda-Frederick-Gaithersburg, MD1.1651
    Frederick County, MD
    Montgomery County, MD
    13740Billings, MT0.9530
    Carbon County, MT
    Yellowstone County, MT
    13780Binghamton, NY0.8983
    Broome County, NY
    Tioga County, NY
    13820Birmingham-Hoover, AL0.9738
    Bibb County, AL
    Blount County, AL
    Chilton County, AL
    Jefferson County, AL
    St. Clair County, AL
    Shelby County, AL
    13900Bismarck, ND0.8000
    Burleigh County, ND
    Morton County, ND
    Start Printed Page 22408
    13980Blacksburg-Christiansburg-Radford, VA0.8456
    Giles County, VA
    Montgomery County, VA
    Pulaski County, VA
    Radford City, VA
    14020Bloomington, IN0.9132
    Greene County, IN
    Monroe County, IN
    Owen County, IN
    14060Bloomington-Normal, IL0.9689
    McLean County, IL
    14260Boise City, ID0.9946
    Ada County, ID
    Boise County, ID
    Canyon County, ID
    Gem County, ID
    Owyhee, County, ID
    14484Boston-Quincy, MA1.2518
    Norfolk County, MA
    Plymouth County, MA
    Suffolk County, MA
    14500Boulder, CO1.0684
    Boulder County, CO
    14540Bowling Green, KY0.8657
    Edmonson County, KY
    Warren County, KY
    14740Bremerton-Silverdale, WA1.1288
    Kitsap County, WA
    14860Bridgeport-Stamford-Norwalk, CT1.3650
    Fairfield County, CT
    15180Brownsville-Harlingen, TX1.0768
    Cameron County, TX
    15260Brunswick, GA1.2690
    Brantley County, GA
    Glynn County, GA
    McIntosh County, GA
    15380Buffalo-Niagara Falls, NY0.9932
    Erie County, NY
    Niagara County, NY
    15500Burlington, NC0.9536
    Alamance County, NC
    15540Burlington-South Burlington, VT0.9914
    Chittenden County, VT
    Franklin County, VT
    Grand Isle County, VT
    15764Cambridge-Newton-Framingham, MA1.1899
    Middlesex County, MA
    15804Camden, NJ1.1353
    Burlington County, NJ
    Camden County, NJ
    Gloucester County, NJ
    15940Canton-Massillon, OH0.9460
    Carroll County, OH
    Stark County, OH
    15980Cape Coral-Fort Myers, FL0.9966
    Lee County, FL
    16180Carson City, NV1.1009
    Carson City, NV
    16220Casper, WY0.9830
    Natrona County, WY
    16300Cedar Rapids, IA0.9545
    Benton County, IA
    Jones County, IA
    Linn County, IA
    16580Champaign-Urbana, IL1.0132
    Champaign County, IL
    Ford County, IL
    Piatt County, IL
    16620Charleston, WV0.9439
    Boone County, WV
    Start Printed Page 22409
    Clay County, WV
    Kanawha County, WV
    Lincoln County, WV
    Putnam County, WV
    16700Charleston-North Charleston, SC1.0018
    Berkeley County, SC
    Charleston County, SC
    Dorchester County, SC
    16740Charlotte-Gastonia-Concord, NC-SC1.0361
    Anson County, NC
    Cabarrus County, NC
    Gaston County, NC
    Mecklenburg County, NC
    Union County, NC
    York County, SC
    16820Charlottesville, VA1.0947
    Albemarle County, VA
    Fluvanna County, VA
    Greene County, VA
    Nelson County, VA
    Charlottesville City, VA
    16860Chattanooga, TN-GA0.9791
    Catoosa County, GA
    Dade County, GA
    Walker County, GA
    Hamilton County, TN
    Marion County, TN
    Sequatchie County, TN
    16940Cheyenne, WY0.9550
    Laramie County, WY
    16974Chicago-Naperville-Joliet, IL1.1558
    Cook County, IL
    DeKalb County, IL
    Du Page County, IL
    Grundy County, IL
    Kane County, IL
    Kendall County, IL
    McHenry County, IL
    Will County, IL
    17020Chico-Paradise, CA1.1211
    Butte County, CA
    17140Cincinnati-Middletown, OH-KY-IN1.0120
    Dearborn County, IN
    Franklin County, IN
    Ohio County, IN
    Boone County, KY
    Bracken County, KY
    Campbell County, KY
    Gallatin County , KY
    Grant County, KY
    Kenton County, KY
    Pendleton County, KY
    Brown County, OH
    Butler County, OH
    Clermont County, OH
    Hamilton County, OH
    Warren County, OH
    17300Clarksville, TN-KY0.8531
    Christian County, KY
    Trigg County, KY
    Montgomery County, TN
    Stewart County, TN
    17420Cleveland, TN0.8342
    Bradley County, TN
    Polk County, TN
    17460Cleveland-Elyria-Mentor, OH1.0263
    Cuyahoga County, OH
    Geauga County, OH
    Lake County, OH
    Lorain County, OH
    Start Printed Page 22410
    Medina County, OH
    17660Coeur d'Alene, ID0.9932
    Kootenai County, ID
    17780College Station-Bryan, TX0.9830
    Brazos County, TX
    Burleson County, TX
    Robertson County, TX
    17820Colorado Springs, CO1.0414
    El Paso County, CO
    Teller County, CO
    17860Columbia, MO0.8929
    Boone County, MO
    Howard County, MO
    17900Columbia, SC0.9988
    Calhoun County, SC
    Fairfield County, SC
    Kershaw County, SC
    Lexington County, SC
    Richland County, SC
    Saluda County, SC
    17980Columbus, GA-AL0.9242
    Russell County, AL
    Chattahoochee County, GA
    Harris County, GA
    Marion County, GA
    Muscogee County, GA
    18020Columbus, IN0.9984
    Bartholomew County, IN
    18140Columbus, OH1.0355
    Delaware County, OH
    Fairfield County, OH
    Franklin County, OH
    Licking County, OH
    Madison County, OH
    Morrow County, OH
    Pickaway County, OH
    Union County, OH
    18580Corpus Christi, TX0.9196
    Aransas, TX
    Nueces County, TX
    San Patricio County, TX
    18700Corvallis, Oregon1.1214
    Benton County, OR
    19060Cumberland, MD-WV0.9212
    Allegany County, MD
    Mineral County, WV
    19124Dallas-Plano-Irving TX1.0713
    Collin County, TX
    Dallas County, TX
    Delta County, TX
    Denton County, TX
    Ellis County, TX
    Hunt County, TX
    Kaufman County, TX
    Rockwall County, TX
    19140Dalton, GA1.0165
    Murray County, GA
    Whitfield County, GA
    19180Danville, IL0.8925
    Vermilion, County, IL
    19260Danville, VA0.9192
    Danville City, VA
    Pittsylvania County, VA
    19340Davenport-Moline-Rock Island, IA-IL0.9330
    Henry County, IL
    Mercer County, IL
    Rock Island County, IL
    Scott County, IA
    19380Dayton, OH0.9894
    Greene County, OH
    Start Printed Page 22411
    Miami County, OH
    Montgomery County, OH
    Preble County, OH
    19460Decatur, AL0.9459
    Lawrence County, AL
    Morgan County, AL
    19500Decatur, IL0.8638
    Macon County, IL
    19660Deltona-Daytona Beach-Ormond Beach, FL0.9463
    Volusia County, FL
    19740Denver-Aurora, CO1.1596
    Adams County, CO
    Arapahoe County, CO
    Broomfield County, CO
    Clear Creek County, CO
    Denver County, CO
    Douglas County, CO
    Elbert County, CO
    Jefferson County, CO
    Park County, CO
    19780Des Moines, IA0.9854
    Dallas County, IA
    Guthrie County, IA
    Madison County, IA
    Polk County, IA
    Warren County, IA
    19804Detroit-Livonia-Dearborn, MI1.1006
    Wayne County, MI
    20020Dothan, AL0.8015
    Geneva County, AL
    Henry County, AL
    Houston County, AL
    20100Dover, DE1.0449
    Kent County, DE
    20220Dubuque, IA0.9303
    Dubuque County, IA
    20260Duluth, MN-WI1.0996
    Carlton County, MN
    St. Louis County, MN
    Douglas County, WI
    20500Durham, NC1.1021
    Chatham County, NC
    Durham County, NC
    Orange County, NC
    Person County, NC
    20740Eau Claire, WI0.9719
    Chippewa County, WI
    Eau Claire County, WI
    20764Edison, NJ1.1843
    Middlesex County, NJ
    Monmouth County, NJ
    Ocean County, NJ
    Somerset County, NJ
    20940El Centro, CA0.9418
    Imperial County, CA
    21060Elizabethtown, KY0.9235
    Hardin County, KY
    Larue County, KY
    21140Elkhart-Goshen, IN0.9867
    Elkhart County, IN
    21300Elmira, NY0.8981
    Chemung County, NY
    21340El Paso, TX0.9764
    El Paso County, TX
    21500Erie, PA0.9251
    Erie County, PA
    21604Essex County, MA1.1339
    Essex County, MA
    21660Eugene-Springfield, OR1.1635
    Lane County, OR
    Start Printed Page 22412
    21780Evansville, IN-KY0.8903
    Gibson County, IN
    Posey County, IN
    Vanderburgh County, IN
    Warrick County, IN
    Henderson County, KY
    Webster County, KY
    21820Fairbanks, AK1.1854
    Fairbanks North Star Borough, AK
    21940Fajardo, PR0.4530
    Ceiba Municipio, PR
    Fajardo Municipio, PR
    Luquillo Municipio, PR
    22020Fargo, ND-MN0.9693
    Clay County, MN
    Cass County, ND
    22140Farmington, NM0.8560
    San Juan County, NM
    22180Fayetteville, NC0.9957
    Cumberland County, NC
    Hoke County, NC
    22220Fayetteville-Springdale-Rogers, AR-MO0.9184
    Benton County, AR
    Madison County, AR
    Washington County, AR
    McDonald County, MO
    22380Flagstaff, AZ1.1472
    Coconino County, AZ
    22420Flint, MI1.1888
    Genesee County, MI
    22500Florence, SC0.9394
    Darlington County, SC
    Florence County, SC
    22520Florence-Muscle Shoals, AL0.8383
    Colbert County, AL
    Lauderdale County, AL
    22540Fond du Lac, WI1.0525
    Fond du Lac County, WI
    22660Fort Collins-Loveland, CO1.0867
    Larimer County, CO
    22744Ft. Lauderdale-Pompano Beach-Deerfield Beach, FL1.0810
    Broward County, FL
    22900Fort Smith, AR-OK0.8809
    Crawford County, AR
    Franklin County, AR
    Sebastian County, AR
    Le Flore County, OK
    Sequoyah County, OK
    23020Fort Walton Beach-Crestview-Destin, FL0.9344
    Okaloosa County, FL
    23060Fort Wayne, IN1.0430
    Allen County, IN
    Wells County, IN
    Whitley County, IN
    23104Forth Worth-Arlington, TX1.0073
    Johnson County, TX
    Parker County, TX
    Tarrant County, TX
    Wise County, TX
    23420Fresno, CA1.1205
    Fresno County, CA
    23460Gadsden, AL0.8560
    Etowah County, AL
    23540Gainesville, FL1.0059
    Alachua County, FL
    Gilchrist County, FL
    23580Gainesville, GA1.0164
    Hall County, GA
    23844Gary, IN0.9901
    Jasper County, IN
    Start Printed Page 22413
    Lake County, IN
    Newton County, IN
    Porter County, IN
    24020Glens Falls, NY0.9004
    Warren County, NY
    Washington County, NY
    24140Goldsboro, NC0.9335
    Wayne County, NC
    24220Grand Forks, ND-MN0.9668
    Grand Forks County, ND
    Polk County, MN
    24300Grand Junction, CO1.0528
    Mesa County, CO
    24340Grand Rapids-Wyoming, MI1.0018
    Barry County, MI
    Ionia County, MI
    Kent County, MI
    Newaygo County, MI
    24500Great Falls, MT0.9369
    Cascade County, MT
    24540Greeley, CO1.0043
    Weld County, CO
    24580Green Bay, WI1.0199
    Brown County, WI
    Kewaunee County, WI
    Oconto County, WI
    24660Greensboro-High Point, NC0.9773
    Guilford County, NC
    Randolph County, NC
    Rockingham County, NC
    24780Greenville, NC0.9766
    Green County, NC
    Pitt County, NC
    24860Greenville, SC1.0164
    Greenville County, SC
    Laurens County, SC
    Pickens County, SC
    25020Guayama, PR0.4606
    Arroyo Municipio, PR
    Guayama Municipio, PR
    Patillas Municipio, PR
    25060Gulfport-Biloxi, MS0.9518
    Hancock County, MS
    Harrison County, MS
    Stone County, MS
    25180Hagerstown-Martinsburg, MD-WV1.0332
    Washington County, MD
    Berkeley County, WV
    Morgan County, WV
    25260Hanford-Corcoran, CA0.9886
    Kings County, CA
    25420Harrisburg—Carlisle, PA0.9953
    Cumberland County, PA
    Dauphin County, PA
    Perry County, PA
    25500Harrisonburg, VA0.9864
    Rockingham County, VA
    Harrisonburg City, VA
    25540Hartford-West Hartford-East Hartford, CT1.1756
    Hartford County, CT
    Middlesex County, CT
    Tolland County, CT
    25620Hattiesburg, MS0.8000
    Forrest County, MS
    Lamar County, MS
    Perry County, MS
    25860Hickory-Morganton-Lenoir, NC1.0105
    Alexander County, NC
    Burke County, NC
    Caldwell County, NC
    Start Printed Page 22414
    Catawba County, NC
    25980Hinesville-Fort Stewart, GA0.8205
    Liberty County, GA
    Long County, GA
    26100Holland-Grand Haven, MI0.9984
    Ottawa County, MI
    26180Honolulu, HI1.1712
    Honolulu County, HI
    26300Hot Springs, AR0.9836
    Garland County, AR
    26380Houma-Bayou Cane-Thibodaux, LA0.8211
    Lafourche Parish, LA
    Terrebonne Parish, LA
    26420Houston-Baytown-Sugar Land, TX1.0606
    Austin County, TX
    Brazoria County, TX
    Chambers County, TX
    Fort Bend County, TX
    Galveston County, TX
    Harris County, TX
    Liberty County, TX
    Montgomery County, TX
    San Jacinto County, TX
    Waller County, TX
    26580Huntington-Ashland, WV-KY-OH1.0171
    Boyd County, KY
    Greenup County, KY
    Lawrence County, OH
    Cabell County, WV
    Wayne County, WV
    26620Huntsville, AL0.9413
    Limestone County, AL
    Madison County, AL
    26820Idaho Falls, ID0.9634
    Bonneville County, ID
    Jefferson County, ID
    26900Indianapolis, IN1.0755
    Boone County, IN
    Brown County, IN
    Hamilton County, IN
    Hancock County, IN
    Hendricks County, IN
    Johnson County, IN
    Marion County, IN
    Morgan County, IN
    Putnam County, IN
    Shelby County, IN
    26980Iowa City, IA1.0267
    Johnson County, IA
    Washington County, IA
    27060Ithaca, NY1.0198
    Tompkins County, NY
    27100Jackson, MI0.9727
    Jackson County, MI
    27140Jackson, MS0.8817
    Copiah County, MS
    Hinds County, MS
    Madison County, MS
    Rankin County, MS
    Simpson County, MS
    27180Jackson, TN0.9465
    Chester County, TN
    Madison County, TN
    27260Jacksonville, FL1.0142
    Baker County, FL
    Clay County, FL
    Duval County, FL
    Nassau County, FL
    St. Johns County, FL
    27340Jacksonville, NC0.8934
    Start Printed Page 22415
    Onslow County, NC
    27500Janesville, WI1.0191
    Rock County, WI
    27620Jefferson City, MO0.8867
    Callaway County, MO
    Cole County, MO
    Moniteau County, MO
    Osage County, MO
    27740Johnson City, TN0.8663
    Carter County, TN
    Unicoi County, TN
    Washington County, TN
    27780Johnstown, PA0.8912
    Cambria County, PA
    27860Jonesboro, AR0.8661
    Craighead County, AR
    Poinsett County, AR
    27900Joplin, MO0.9275
    Jasper County, MO
    Newton County, MO
    28020Kalamazoo-Portage, MI1.1354
    Kalamazoo County, MI
    Van Buren County, MI
    28100Kankakee-Bradley, IL1.1276
    Kankakee County, IL
    28140Kansas City, KS-MO1.0240
    Franklin County, KS
    Johnson County, KS
    Leavenworth County, KS
    Linn County, KS
    Miami County, KS
    Wyandotte County, KS
    Bates County, MO
    Caldwell County, MO
    Cass County, MO
    Clay County, MO
    Clinton County, MO
    Jackson County, MO
    Lafayette County, MO
    Platte County, MO
    Ray County, MO
    28420Kennewick-Richland-Pasco, WA1.1188
    Benton County, WA
    Franklin County, WA
    28660Killeen-Temple-Fort Hood, TX0.9829
    Bell County, TX
    Coryell County, TX
    Lampasas County, TX
    28700Kingsport-Bristol, TN-VA0.8763
    Hawkins County, TN
    Sullivan County, TN
    Bristol City, VA
    Scott County, VA
    Washington County, VA
    28740Kingston, NY0.9571
    Ulster County, NY
    28940Knoxville, TN0.9091
    Anderson County, TN
    Blount County, TN
    Knox County, TN
    Loudon County, TN
    Union County, TN
    29020Kokomo, IN0.9556
    Howard County, IN
    Tipton County, IN
    29100La Crosse, WI-MN0.9879
    Houston County, MN
    La Crosse County, WI
    29140Lafayette, IN0.9643
    Benton County, IN
    Start Printed Page 22416
    Carroll County, IN
    Tippecanoe, IN
    29180Lafayette, LA0.8833
    Lafayette County, LA
    St. Martin County, LA
    29340Lake Charles, LA0.8439
    Calcasieu Parish, LA
    Cameron Parish
    29404Lake County-Kenosha County, IL-WI1.0998
    Lake County, IL
    Kenosha County, WI
    29460Lakeland, FL0.9497
    Polk County, FL
    29540Lancaster, PA1.0510
    Lancaster County, PA
    29620Lansing-East Lansing, MI1.0271
    Clinton County, MI
    Eaton County, MI
    Ingham County, MI
    29700Laredo, TX0.9302
    Webb County, TX
    29740Las Cruces, NM0.9342
    Dona Ana County, NM
    29820Las Vegas-Paradise, NV1.2100
    Clarke County, NV
    29940Lawrence, KS0.9193
    Douglas County, KS
    30020Lawton, OK0.8733
    Comanche County, OK
    30140Lebanon, PA0.9114
    Lebanon County, PA
    30300Lewiston, ID-WA0.9905
    Nez Perce County, ID
    Asotin County, WA
    30340Lewiston-Auburn, ME1.0169
    Androscoggin County, ME
    30460Lexington-Fayette, KY0.9953
    Bourbon County, KY
    Clark County, KY
    Fayette County, KY
    Jessamine County, KY
    Scott County, KY
    Woodford County, KY
    30620Lima, OH0.9922
    Allen County, OH
    30700Lincoln, NE1.0856
    Lancaster County, NE
    30780Little Rock-North Little Rock, AR0.9386
    Faulkner County, AR
    Grant County, AR
    Lonoke County, AR
    Perry County, AR
    Pulaski County, AR
    Saline County, AR
    30860Logan, UT-ID0.9671
    Franklin County, ID
    Cache County, UT
    30980Longview, TX0.9360
    Gregg County, TX
    Rusk County, TX
    Upshur County, TX
    31020Longview, WA1.0873
    Cowlitz County, WA
    31084Los Angeles-Long Beach-Glendale-Santa Ana, CA1.2477
    Los Angeles County, CA
    31140Louisville, KY-IN0.9701
    Clark County, IN
    Floyd County, IN
    Harrison County, IN
    Washington County, IN
    Start Printed Page 22417
    Bullitt County, KY
    Henry County, KY
    Jefferson County, KY
    Meade County, KY
    Nelson County, KY
    Oldham County, KY
    Shelby County, KY
    Spencer County, KY
    Trimble County, KY
    31180Lubbock, TX0.9334
    Crosby County, TX
    Lubbock County, TX
    31340Lynchburg, VA0.9589
    Amherst County, VA
    Appomattox County, VA
    Bedford County, VA
    Campbell County, VA
    Bedford City, VA
    Lynchburg City, VA
    31420Macon, GA1.0515
    Bibb County, GA
    Crawford County, GA
    Jones County, GA
    Monroe County, GA
    Twiggs County, GA
    31460Madera, CA0.9062
    Madera County, CA
    31540Madison, WI1.0960
    Columbia County, WI
    Dane County, WI
    Iowa County, WI
    31700Manchester-Nashua, NH1.1318
    Hillsborough County, NI
    31900Mansfield, OH0.9772
    Richland County, OH
    32420Mayagũez, PR0.5167
    Hormigueros Municipio, PR
    Mayagũez, PR
    32580McAllen-Edinburg-Pharr, TX0.9148
    Hidalgo County, TX
    32780Medford, OR1.1203
    Jackson County, OR
    32820Memphis, TN-AR-MS0.9802
    Crittenden County, AR
    DeSoto County, MS
    Marshall County, MS
    Tate County, MS
    Tunica, County, MS
    Fayette County, TN
    Shelby County, TN
    Tipton County, TN
    32900Merced, CA1.1246
    Merced County, CA
    33124Miami-Miami Beach-Kendall, FL1.0497
    Miami-Dade County, FL
    33140Michigan City-La Porte, IN0.9924
    La Porte County, IN
    33260Midland TX0.9980
    Midland County, TX
    33340Milwaukee-Waukesha-West Allis, WI1.0716
    Milwaukee County, WI
    Ozaukee County, WI
    Washington County, WI
    Waukesha County, WI
    33460Minneapolis-St. Paul-Bloomington, MN-WI1.1768
    Anoka County, MN
    Carver County, MN
    Chisago County, MN
    Dakota County, MN
    Hennepin County, MN
    Start Printed Page 22418
    Isanti County, MN
    Ramsey County, MN
    Scott County, MN
    Sherburne County, MN
    Washington County, MN
    Wright County, MN
    Pierce County, WI
    St. Croix County, WI
    33540Missoula, MT1.0229
    Missoula County, MT
    33660Mobile, AL0.8503
    Mobile County, AL
    33700Modesto, CA1.2726
    Stanislaus County, CA
    33740Monroe, LA0.8405
    Ouachita Parish, LA
    Union Parish, LA
    33780Monroe, MI1.0109
    Monroe County, MI
    33860Montgomery, AL0.8827
    Autauga County, AL
    Elmore County, AL
    Lowndes County, AL
    Montgomery County, AL
    34060Morgantown, WV0.9284
    Monongalia County, WV
    Preston County, WV
    34100Morristown, TN0.8285
    Grainger County, TN
    Hamblen County, TN
    Jefferson County, TN
    34580Mount Vernon-Anacortes, WA1.1247
    Skagit County, WA
    34620Muncie, IN0.9125
    Delaware County, IN
    34740Muskegon-Norton Shores, MI1.0359
    Muskegon County, MI
    34820Myrtle Beach-Conway-North Myrtle Beach, SC0.9595
    Horry County, SC
    34900Napa, CA1.3326
    Napa County, CA
    34940Naples-Marco Island, FL1.1228
    Collier County, FL
    34980Nashville-Davidson-Murfreesboro, TN1.0726
    Cannon County, TN
    Cheatham County, TN
    Davidson County, TN
    Dickson County, TN
    Hickman County, TN
    Macon County, TN
    Robertson County, TN
    Rutherford County, TN
    Sumner County, TN
    Trousdale County, TN
    Williamson County, TN
    Wilson County, TN
    35004Nassau-Suffolk, NY1.3726
    Nassau County, NY
    Suffolk County, NY
    35084Newark-Union, NJ-PA1.2429
    Essex County, NJ
    Hunterdon County, NJ
    Morris County, NJ
    Sussex County, NJ
    Union County, NJ
    Pike County, PA
    35300New Haven-Milford, CT1.2556
    New Haven County, CT
    35380New Orleans-Metairie-Kenner, LA0.9681
    Jefferson Parish, LA
    Start Printed Page 22419
    Orleans Parish, LA
    Plaquemines Parish, LA
    St. Bernard Parish, LA
    St. Charles Parish, LA
    St. John The Baptist Parish, LA
    St. Tammany Parish, LA
    35644New York-Wayne-White Plains, NY-NJ1.4156
    Bergen County, NJ
    Hudson County, NJ
    Passaic County, NJ
    Bronx County, NY
    Kings County, NY
    New York County, NY
    Putnam County, NY
    Queens County, NY
    Richmond County, NY
    Rockland County, NY
    Westchester County, NY
    35660Niles-Benton Harbor, MI0.9409
    Berrien County, MI
    35980Norwich-New London Ct1.2332
    New London County, CT
    36084Oakland-Fremont-Hayward, CA1.6186
    Alameda County, CA
    Contra Costa County, CA
    36100Ocala, FL0.9734
    Marion County, FL
    36140Ocean City, NJ1.1496
    Cape May County, NJ
    36220Odessa, TX1.0420
    Ector County, TX
    36260Ogden-Clearfield, UT0.9801
    Davis County, UT
    Morgan County, UT
    Weber County, UT
    36420Oklahoma City, OK0.9552
    Canadian County, OK
    Cleveland County, OK
    Grady County, OK
    Lincoln County, OK
    Logan County, OK
    McClain County, OK
    Oklahoma County, OK
    36500Olympia, WA1.1705
    Thurston County, WA
    36540Omaha-Council Bluffs, NE-IA1.0373
    Harrison County, IA
    Mills County, IA
    Pottawattamie County, IA
    Cass County, NE
    Douglas County, NE
    Sarpy County, NE
    Saunders County, NE
    Washington County, NE
    36740Orlando, FL1.0360
    Lake County, FL
    Orange County, FL
    Osceola County, FL
    Seminole County, FL
    36780Oshkosh-Neenah, WI0.9677
    Winnebago County, WI
    36980Owensboro, KY0.8969
    Daviess County, KY
    Hancock County, KY
    McLean County, KY
    37100Oxnard-Thousand Oaks-Ventura, CA1.1810
    Ventura County, CA
    37340Palm Bay-Melbourne-Titusville, FL1.0244
    Brevard County, FL
    37460Panama City-Lynn Haven, FL0.8640
    Start Printed Page 22420
    Bay County, FL
    37620Parkersburg-Marietta, WV-OH0.8814
    Washington County, OH
    Pleasants County, WV
    Wirt County, WV
    Wood County, WV
    37700Pascagoula, MS0.8480
    George County, MS
    Jackson County, MS
    37860Pensacola-Ferry Pass-Brent, FL0.8833
    Escambia County, FL
    Santa Rosa County, FL
    37900Peoria, IL0.9450
    Marshall County, IL
    Peoria County, IL
    Stark County, IL
    Tazewell County, IL
    Woodford County, IL
    37964Philadelphia, PA1.1555
    Bucks County, PA
    Chester County, PA
    Delaware County, PA
    Montgomery County, PA
    Philadelphia County, PA
    38060Phoenix-Mesa-Scottsdale, AZ1.0616
    Maricopa County, AZ
    Pinal County, AZ
    38220Pine Bluff, AR0.9224
    Cleveland County, AR
    Jefferson County, AR
    Lincoln County, AR
    38300Pittsburgh, PA0.9291
    Allegheny County, PA
    Armstrong County, PA
    Beaver County, PA
    Butler County, PA
    Fayette County, PA
    Washington County, PA
    Westmoreland County, PA
    38340Pittsfield, MA1.1102
    Berkshire County, MA
    38540Pocatello, ID1.0210
    Bannock County, ID
    Power County, ID
    38660Ponce, PR0.5757
    Juana Diaz Municipio, PR
    Ponce Municipio, PR
    Villalba Municipio, PR
    38860Portland-South Portland-Biddeford, ME1.0754
    Cumberland County, ME
    Sagadahoc County, ME
    York County, ME
    38900Portland-Vancouver-Beaverton, OR-WA1.2127
    Clackamas County, OR
    Columbia County, OR
    Multnomah County, OR
    Washington County, OR
    Yamhill County, OR
    Clark County, WA
    Skamania County, WA
    38940Port St. Lucie-Fort Pierce, FL1.0684
    Martin County, FL
    St. Lucie County, FL
    39100Poughkeepsie-Newburgh-Middletown, NY1.2084
    Duchess County, NY
    Orange County, NY
    39140Prescott, AZ1.0520
    Yavapai County, AZ
    39300Providence-New Bedford-Fall River, RI-MA1.1623
    Bristol County, MA
    Start Printed Page 22421
    Bristol County, RI
    Kent County, RI
    Newport County, RI
    Providence County, RI
    Washington County, RI
    39340Provo-Orem, UT1.0197
    Juab County, UT
    Utah County, UT
    39380Pueblo, CO0.9308
    Pueblo County, CO
    39460Punta Gorda, FL1.0040
    Charlotte County, FL
    39540Racine, WI0.9619
    Racine County, WI
    39580Raleigh-Cary, NC1.0695
    Franklin County, NC
    Johnston County, NC
    Wake County, NC
    39660Rapid City, SD0.9478
    Meade County, SD
    Pennington County, SD
    39740Reading, PA0.9800
    Berks County, PA
    39820Redding, CA1.2586
    Shasta County, CA
    39900Reno-Sparks, NV1.1120
    Storey County, NV
    Washoe County, NV
    40060Richmond, VA0.9994
    Amelia County, VA
    Caroline County, VA
    Charles City County, VA
    Chesterfield County, VA
    Cumberland County, VA
    Dinwiddie County, VA
    Goochland County, VA
    Hanover County, VA
    Henrico County, VA
    King and Queen County, VA
    King William County, VA
    Louisa County, VA
    New Kent County, VA
    Powhatan County, VA
    Prince George County, VA
    Sussex County, VA
    Colonial Heights City, VA
    Hopewell City, VA
    Petersburg City, VA
    Richmond City, VA
    40140Riverside-San Bernardino-Ontario, CA1.1666
    Riverside County, CA
    San Bernardino County, CA
    40220Roanoke, VA0.8949
    Botetourt County, VA
    Craig County, VA
    Franklin County, VA
    Roanoke County, VA
    Roanoke City, VA
    Salem City, VA
    40340Rochester, MN1.2234
    Dodge County, MN
    Olmsted County, MN
    Wabasha County, MN
    40380Rochester, NY0.9870
    Livingston County, NY
    Monroe County, NY
    Ontario County, NY
    Orleans County, NY
    Wayne County, NY
    40420Rockford, IL1.0237
    Start Printed Page 22422
    Boone County, IL
    Winnebago County, IL
    40484Rockingham County, NH1.0870
    Rockingham County, NH
    Stafford County, NH
    40580Rocky Mount, NC0.9569
    Edgecombe County, NC
    Nash County, NC
    40660Rome, Georgia0.9442
    Floyd County, GA
    40900Sacramento-Arden-Arcade-Roseville, CA1.2443
    El Dorado County, CA
    Placer County, CA
    Sacramento County, CA
    Yolo County, CA
    40980Saginaw-Saginaw Township North, MI1.0437
    Saginaw County, MI
    41060St. Cloud, MN1.0863
    Benton County, MN
    Stearns County, MN
    41100St. George, UT1.0058
    Washington County, UT
    41140St. Joseph, MO-KS1.0649
    Doniphan County, KS
    Andrew County, MO
    Buchanan County, MO
    DeKalb County, MO
    41180St. Louis, MO-IL0.9652
    Bond County, IL
    Calhoun County, IL
    Clinton County, IL
    Jersey County, IL
    Macoupin County, IL
    Madison County, IL
    Monroe County, IL
    St. Clair County, IL
    Crawford County, MO
    Franklin County, MO
    Jefferson County, MO
    Lincoln County, MO
    St. Charles County, MO
    St. Louis County, MO
    St. Louis City, MO
    Warren County, MO
    Washington County, MO
    41420Salem, OR1.1226
    Marion County, OR
    Polk County, OR
    41500Salinas, CA1.4700
    Monterey County, CA
    41540Salisbury, MD0.9702
    Somerset County, MD
    Wicomico County, MD
    41620Salt Lake City, UT1.0168
    Salt Lake County, UT
    Summit County, UT
    Tooele County, UT
    41660San Angelo, TX0.8685
    Irion County, TX
    Tom Green County, TX
    41700San Antonio, TX0.9575
    Atascosa County, TX
    Bandera County, TX
    Bexar County, TX
    Comal County, TX
    Guadalupe County, TX
    Kendall County, TX
    Medina County, TX
    Wilson County, TX
    41740San Diego-Carlsbad-San Marcos, CA1.1982
    Start Printed Page 22423
    San Diego County, CA
    41780Sandusky, OH0.9589
    Erie County, OH
    41884San Francisco-San Mateo-Redwood City, CA1.5646
    Marin County, CA
    San Francisco County, CA
    San Mateo County, CA
    41900San Germán-Cabo Rojo, PR0.6026
    Cabo Rojo Municipio, PR
    Lajas Municipio, PR
    Sabana Grande Municipio, PR
    San Germán-Cabo Rojo Municipio, PR
    41940San Jose-Sunnyvale-Santa Clara, CA1.5657
    San Benito County, CA
    Santa Clara County, CA
    41980San Juan-Caguas-Guaynabo, PR0.5342
    Aguas Buenas Municipio, PR
    Aibonito Municipio, PR
    Arecibo Municipio, PR
    Barceloneta Municipio, PR
    Barranquitas Municipio, PR
    Bayamón Municipio, PR
    Caguas Municipio, PR
    Camuy Municipio, PR
    Canóvanas Municipio, PR
    Carolina Municipio, PR
    Catano Municipio, PR
    Cayey, Municipio PR
    Ciales Municipio, PR
    Cidra Municipio, PR
    Comerio Municipio, PR
    Corozal Municipio, PR
    Dorado Municipio, PR
    Florida Municipio, PR
    Guaynabo Municipio, PR
    Gurabo Municipiobo, PR
    Hatillo Municipio, PR
    Humacao Municipio, PR
    Juncos Municipio, PR
    Las Piedras Municipio, PR
    Loiza Municipio, PR
    Manatí Municipio, PR
    Maunabo Municipio, PR
    Morovis Municipio, PR
    Naguabo Municipio, PR
    Naranjito Municipio, PR
    Orocovis Municipio, PR
    Quebradillas Municipio, PR
    Rio Grande Municipio, PR
    San Juan Municipio, PR
    San Lorenzo Municipio, PR
    Toa Alta Municipio, PR
    Toa Baja Municipio, PR
    Trujillo Alto Municipio, PR
    Vega Alta Municipio, PR
    Vega Baja Municipio, PR
    Yabucoa Municipio, PR
    42020San Luis Obispo-Paso Robles, CA1.1824
    San Luis Obispo County, CA
    42044Santa Ana-Anaheim-Irvine, CA1.2348
    Orange County, CA
    42060Santa Barbara-Santa Maria-Goleta, CA1.1455
    Santa Barbara County, CA
    42100Santa Cruz-Watsonville, CA1.5717
    Santa Cruz County, CA
    42140Santa Fe, NM1.1601
    Santa Fe County, NM
    42220Santa Rosa-Petaluma, CA1.3784
    Sonoma County, CA
    42260Sarasota-Bradenton-Venice, FL1.0240
    Start Printed Page 22424
    Manatee County, FL
    Sarasota County, FL
    42340Savannah, GA1.0061
    Bryan County, GA
    Chatham County, GA
    Effingham County, GA
    42540Scranton—Wilkes-Barre, PA0.9085
    Lackawanna County, PA
    Luzerne County, PA
    Wyoming County, PA
    42644Seattle-Bellevue-Everett, WA1.2222
    King County, WA
    Snohomish County, WA
    43100Sheboygan, WI0.9516
    Sheboygan County, WI
    43300Sherman-Denison, TX1.0227
    Grayson County, TX
    43340Shreveport-Bossier City, LA0.9712
    Bossier Parish, LA
    Caddo Parish, LA
    De Soto Parish, LA
    43580Sioux City, IA-NE-SD0.9646
    Woodbury County, IA
    Dakota County, NE
    Dixon County, NE
    Union County, SD
    43620Sioux Falls, SD1.0040
    Lincoln County, SD
    McCook County, SD
    Minnehaha County, SD
    Turner County, SD
    43780South Bend-Mishawaka, IN-MI1.0047
    St. Joseph County, IN
    Cass County, MI
    43900Spartanburg, SC1.0123
    Spartanburg, SC
    44060Spokane, WA1.1337
    Spokane County, WA
    44100Springfield, IL0.9293
    Menard County, IL
    Sangamon County, IL
    44140Springfield, MA1.0822
    Franklin County, MA
    Hampden County, MA
    Hampshire County, MA
    44180Springfield, MO0.9100
    Christian County, MO
    Dallas County, MO
    Greene County, MO
    Polk County, MO
    Webster County, MO
    44220Springfield, OH0.9303
    Clark County, OH
    44300State College, PA0.8998
    Centre County, PA
    44700Stockton, CA1.1235
    San Joaquin County, CA
    44940Sumter, SC0.9061
    Sumter County, SC
    45060Syracuse, NY1.0069
    Madison County, NY
    Onondaga County, NY
    Oswego County, NY
    45104Tacoma, WA1.1781
    Pierce County, WA
    45220Tallahassee, FL0.9204
    Gadsden County, FL
    Jefferson County, FL
    Leon County, FL
    Wakulla County, FL
    Start Printed Page 22425
    45300Tampa-St. Petersburg-Clearwater, FL0.9597
    Hernando County, FL
    Hillsborough County, FL
    Pasco County, FL
    Pinellas County, FL
    45460Terre Haute, IN0.9058
    Clay County, IN
    Sullivan County, IN
    Vermillion County, IN
    Vigo County, IN
    45500Texarkana, AR-Texarkana, TX0.8947
    Miller County, AR
    Bowie County, TX
    45780Toledo, OH1.0129
    Fulton County, OH
    Lucas County, OH
    Ottawa County, OH
    Wood County, OH
    45820Topeka, KS0.9469
    Jackson County, KS
    Jefferson County, KS
    Osage County, KS
    Shawnee County, KS
    Wabaunsee County, KS
    45940Trenton-Ewing, NJ1.0928
    Mercer County, NJ
    46060Tucson, AZ0.9493
    Pima County, AZ
    46140Tulsa, OK0.9242
    Creek County, OK
    Okmulgee County, OK
    Osage County, OK
    Pawnee County, OK
    Rogers County, OK
    Tulsa County, OK
    Wagoner County, OK
    46220Tuscaloosa, AL0.8865
    Greene County, AL
    Hale County, AL
    Tuscaloosa County, AL
    46340Tyler, TX1.0105
    Smith County, TX
    46540Utica-Rome, NY0.8822
    Herkimer County, NY
    Oneida County, NY
    46660Valdosta, GA0.8870
    Brooks County, GA
    Echols County, GA
    Lanier County, GA
    Lowndes County, GA
    46700Vallejo-Fairfield, CA1.5185
    Solano County, CA
    46940Vero Beach, FL1.0079
    Indian River County, FL
    47020Victoria, TX0.9008
    Calhoun County, TX
    Goliad County, TX
    Victoria County, TX
    47220Vineland-Millville-Bridgeton, NJ1.1244
    Cumberland County, NJ
    47260Virginia Beach-Norfolk-Newport News, VA-NC0.9459
    Currituck County, NC
    Gloucester County, VA
    Isle of Wight County, VA
    James City County, VA
    Mathews County, VA
    Surry County, VA
    York County, VA
    Chesapeake City, VA
    Hampton City, VA
    Start Printed Page 22426
    Newport News City, VA
    Norfolk City, VA
    Poquoson City, VA
    Portsmouth City, VA
    Suffolk City, VA
    Virginia Beach City, VA
    Williamsburg City, VA
    47300Visalia-Tulare-Porterville, CA1.0608
    Tulare County, CA
    47380Waco, TX0.8663
    McLennan County, TX
    47580Warner Robins, GA0.9028
    Houston County, GA
    47644Warren-Farmington Hills-Troy, MI1.0754
    Lapeer County, MI
    Livingston County, MI
    Macomb County, MI
    Oakland County, MI
    St. Clair County, MI
    47894Washington-Arlington-Alexandria, DC-VA1.1723
    District of Columbia, DC
    Calvert County, MD
    Charles County, MD
    Prince George's County, MD
    Alexandria City, VA
    Arlington County, VA
    Clarke County, VA
    Fairfax City, VA
    Fairfax County, VA
    Falls Church City, VA
    Fauquier County, VA
    Fredericksburg City, VA
    Loudoun County, VA
    Manassas City, VA
    Manassas Park City, VA
    Prince William County, VA
    Spotsylvania County, VA
    Stafford County, VA
    Warren County, VA
    Jefferson County, WV
    47940Waterloo-Cedar Falls, IA0.9181
    Black Hawk County, IA
    Bremer County, IA
    Grundy County, IA
    48140Wausau, WI1.0177
    Marathon County, WI
    48260Weirton-Steubenville, WV-OH0.8806
    Jefferson County, OH
    Brooke County, WV
    Hancock County, WV
    48300Wenatchee, WA1.0025
    Chelan County, WA
    Douglas County, WA
    48424West Palm Beach-Boca Raton-Boynton Beach, FL1.1020
    Palm Beach County, FL
    48540Wheeling, WV-OH0.8000
    Belmont County, OH
    Marshall County, WV
    Ohio County, WV
    48620Wichita, KS1.0057
    Butler County, KS
    Harvey County, KS
    Sedgwick County, KS
    Sumner County, KS
    48660Wichita Falls, TX0.8861
    Archer County, TX
    Clay County, TX
    Wichita County, TX
    48700Williamsport, PA0.9024
    Lycoming County, PA
    Start Printed Page 22427
    48864Wilmington, DE-MD-NJ1.1750
    New Castle County, DE
    Cecil County, MD
    Salem County, NJ
    48900Wilmington, NC0.9823
    Brunswick County, NC
    New Hanover County, NC
    Pender County, NC
    49020Winchester, VA-WV1.1162
    Frederick County, VA
    Winchester City, VA
    Hampshire County, WV
    49180Winston-Salem, NC0.9998
    Davie County, NC
    Forsyth County, NC
    Stokes County, NC
    Yadkin County, NC
    49340Worcester, MA1.1694
    Worcester County, MA
    49420Yakima, WA1.0977
    Yakima County, WA
    49500Yauco, PR0.5167
    Guánica Municipio, PR
    Guayanilla Municipio, PR
    Penuelas Municipio, PR
    Yauco Municipio, PR
    49620York-Hanover, PA0.9731
    York County, PA
    49660Youngstown-Warren-Boardman, OH-PA0.9823
    Mahoning County, OH
    Trumbull County, OH
    Mercer County, PA
    49700Yuba City, CA1.1021
    Sutter County, CA
    Yuba County, CA
    49740Yuma, AZ0.9434
    Yuma County, AZ
    1 This column lists each CBSA area name and each county or county equivalent, in the CBSA area. Counties not listed in this Table are considered to be rural areas. Wage Index values for these areas are found in Table B.
    2 Wage index values are based on FY 2000 hospital cost report data before reclassification. This wage index is further adjusted. Wage index values greater than 0.8 are subject to a budget neutrality adjustment calculated by multiplying the hospital wage index value for a given area by the proposed budget neutrality factor of 1.063479. Wage index values below 0.8 are adjusted to be the greater of a 15-percent increase, subject to a maximum wage index value of 0.8, or a budget neutrality adjustment calculated by multiplying the hospital wage index value for a given area by the budget neutrality factor. We have completed all of these adjustments and included them in the wage index values reflected in this table.

    Table B.—Hospice Wage Index for Rural Areas by CBSA

    CBSA code numberNonurban areaWage index 3
    01Alabama0.8112
    02Alaska1.2492
    03Arizona0.9503
    04Arkansas0.8000
    05California1.1192
    06Colorado0.9963
    07Connecticut1.2673
    08Delaware1.0106
    10Florida0.9118
    11Georgia0.8224
    12Hawaii1.1190
    13Idaho0.8749
    14Illinois0.8868
    15Indiana0.9202
    16Iowa0.9013
    17Kansas0.8592
    18Kentucky0.8247
    19Louisiana0.8000
    20Maine0.9613
    21Maryland0.9805
    22Massachusetts 51.0865
    23Michigan0.9344
    24Minnesota0.9922
    25Mississippi0.8120
    26Missouri0.8255
    27Montana0.9253
    28Nebraska0.9609
    29Nevada0.9869
    30New Hampshire1.0571
    31New Jersey 4
    32New Mexico0.9231
    33New York0.8668
    34North Carolina0.9107
    35North Dakota0.8235
    36Ohio0.9245
    37Oklahoma0.8174
    38Oregon1.0543
    39Pennsylvania0.8838
    40Puerto Rico0.8000
    41Rhode Island 4
    42South Carolina0.9234
    43South Dakota0.8931
    44Tennessee0.8369
    45Texas0.8472
    46Utah0.8813
    47Vermont0.9970
    48Virgin Islands0.8000
    49Virginia0.8560
    50Washington1.0967
    51West Virginia0.8364
    52Wisconsin1.0095
    53Wyoming0.9765
    Start Printed Page 22428
    65Guam1.0221
    3 Wage index values are based on FY 2000 hospital cost report data before reclassification. This wage index is further adjusted. Wage index values greater than 0.8 are subject to a budget neutrality adjustment calculated by multiplying the hospital wage index value for a given area by the proposed budget neutrality factor of 1.063479. Wage index values below 0.8 are adjusted to be the greater of a 15-percent increase, subject to a maximum wage index value of 0.8, or a budget neutrality adjustment calculated by multiplying the hospital wage index value for a given area by the budget neutrality factor. We have completed all of these adjustments and included them in the wage index values reflected in this table.
    4 All counties within the State are classified as urban. Massachusetts has areas designated as rural, however, no short-term, acute care hospitals are located in the area(s) for FY 2006. Because more recent data is not available for those areas, we are using last year's wage index value.
    5Based on CBSA designations Massachusetts has areas designated as rural. However, no IPPS hospitals are located in those rural area(s) for FY 2006. Because more recent data is not available for those areas, we are using the FY 2005 prefloor, preclassified hospital wage index value, for rural Massachusetts multiplied by the proposed FY 2006 budget neutrality factor of 1.063479.

    Table C.—Hospice Wage Index for Urban Areas by MSA and CBSA

    MSA code numberWage index 2MSA urban area designations (Constituent counties or county equivalents) 1CBSA code numberWage index 2
    00400.8525Abilene, TX101800.8348
    Taylor, TX
    00600.4938Aguadilla, PR103800.4922
    Aguada, PR
    Aguadilla, PR
    Moca, PR
    00800.9638Akron, OH104200.9630
    Portage, OH
    Summit, OH
    01201.1992Albany, GA105001.1981
    Dougherty, GA
    Lee, GA
    01600.9122Albany-Schenectady-Troy, NY105800.9199
    Albany, NY
    Rensselaer, NY
    Saratoga, NY
    Schenectady, NY
    Schoharie, NY
    01600.9122Albany-Schenectady-Troy, NY105800.9199
    Montgomery, NYRural0.8668
    02001.1161Albuquerque, NM107401.1151
    Bernalillo, NM
    Sandoval, NM
    Valencia, NM
    02200.8697Alexandria, LA107800.8690
    Rapides, LA
    02401.0150Allentown-Bethlehem-Easton, PA109001.0104
    Carbon, PA
    Lehigh, PA
    Northampton, PA
    02800.9007Altoona, PA110200.8999
    Blair, PA
    03200.9769Amarillo, TX111000.9761
    Potter, TX
    Randall, TX
    03801.2889Anchorage, AK112601.2937
    Anchorage, AK
    04401.1513Ann Arbor, MI
    Lenawee, MIRural0.9344
    Livingston, MI476441.0754
    04401.1513Ann Arbor, MI114601.1722
    Washtenaw, MI
    04500.8389Anniston, AL115000.8381
    Calhoun, AL
    04600.9702Oshkosh-Neenah, WI367800.9677
    Start Printed Page 22429
    Winnebago, WI
    04600.9702Appleton, WI115400.9711
    Calumet, WI
    Outagamie, WI
    04700.4321Arecibo, PR419800.5342
    Arecibo, PR
    Camuy, PR
    Hatillo, PR
    04801.0113Asheville, NC117000.9774
    Buncombe, NC
    Madison, NC
    05001.0859Athens, GA120201.0850
    Clarke, GA
    Madison, GA
    Oconee, GA
    05201.0613Atlanta, GA120601.0604
    Barrow, GA
    Bartow, GA
    Carroll, GA
    Cherokee, GA
    Clayton, GA
    Cobb, GA
    Coweta, GA
    DeKalb, GA
    Douglas, GA
    Fayette, GA
    Forsyth, GA
    Fulton, GA
    Gwinnett, GA
    Henry, GA
    Newton, GA
    Paulding, GA
    Pickens, GA
    Rockdale, GA
    Spalding, GA
    Walton, GA
    05601.1610Cape May, NJ361401.1496
    Cape May, NJ
    05601.1610Atlantic, NJ121001.1625
    Atlantic, NJ
    05800.8744Aubrn-Opelika, AL122200.8736
    Lee, AL
    06000.9801Augusta-Aiken, GA-SC122600.9735
    Columbia, GA
    McDuffie, GA
    Richmond, GA
    Aiken, SC
    Edgefield, SC
    06401.0213Austin-San Marcos, TX124201.0204
    Bastrop, TX
    Caldwell, TX
    Hays, TX
    Travis, TX
    Williamson, TX
    06801.0683Bakersfield, CA125401.0673
    Kern, CA
    07201.0545Baltimore, MD125801.0536
    Anne Arundel, MD
    Baltimore, MD
    Baltimore City, MD
    Carroll, MD
    Harford, MD
    Howard, MD
    Queen Anne's, MD
    07331.0596Bangor, ME126201.0587
    Penobscot, ME
    07431.3130Barnstable-Yarmouth, MA127001.3118
    Barnstable, MA
    07600.8892Baton Rouge, LA129400.8847
    Ascension, LA
    Start Printed Page 22430
    East Baton Rouge, LA
    Livingston, LA
    West Baton Rouge, LA
    08400.9171Beaumont-Port Arthur, TX131400.9163
    Hardin, TX
    Jefferson, TX
    Orange, TX
    08601.2392Bellingham, WA133801.2381
    Whatcom, WA
    08700.9417Benton Harbor, MI356600.9409
    Berrien, MI
    08751.2738Bergen-Passaic, NJ356441.4156
    Bergen, NJ
    Passaic, NJ
    08800.9538Billings, MT137400.9530
    Yellowstone, MT
    09200.9206Biloxi-Gulfport, MS250600.9518
    Hancock, MS
    Harrison, MS
    09200.9206Pascagoula, MS377000.8480
    Jackson, MS
    09600.8991Binghamton, NY137800.8983
    Broome, NY
    Tioga, NY
    10000.9791Birmingham, AL138200.9738
    Blount, AL
    Jefferson, AL
    St. Clair, AL
    Shelby, AL
    10100.8000Bismarck, ND139000.8000
    Burleigh, ND
    Morton, ND
    10200.9140Bloomington, IN140200.9132
    Monroe, IN
    10400.9698Bloomington-Normal, IL140600.9689
    McLean, IL
    10800.9955Boise City, ID142600.9946
    Ada, ID
    Canyon, ID
    11231.2017Boston, MA144841.2518
    Norfolk, MA
    Plymouth, MA
    Suffolk, MA
    11231.2017Worcester-Lawrence-Lowell-Brockton, MA-NH
    Bristol, MA
    Essex, MA393001.1623
    Middlesex, MA216041.1339
    Worcester, MA157641.1899
    Hillsborough, NH493401.1694
    Merrimack, NH317001.1318
    Rockingham, NH317001.1318
    Strafford, NH317001.1318
    404841.0870
    11251.0693Boulder, CO145001.0684
    Boulder, CO
    11251.0693Longmont, CO145001.0684
    Boulder, CO
    11450.9073Brazoria, TX264201.0606
    Brazoria, TX
    11501.1298Bremerton, WA147401.1288
    Kitsap, WA
    12401.0777Brownsville-Harlingeno, TX151801.0768
    Cameron, TX
    12401.0777San Benito, TX151801.0768
    Cameron, TX
    12600.9839Bryan-College Station, TX177800.9830
    Brazos, TX
    12800.9941Buffalo-Niagara Falls, NY153800.9932
    Erie, NY
    Niagara, NY
    Start Printed Page 22431
    13030.9923Burlington, VT155400.9914
    Chittenden, VT
    Franklin, VT
    Grand Isle, VT
    13100.4670Caguas, PR419800.5342
    Caguas, PR
    Cayey, PR
    Cidra, PR
    Gurabo, PR
    San Lorenzo, PR
    13200.9468Canton-Massillon, OH159400.9460
    Carroll, OH
    Stark, OH
    13500.9839Casper, WY162200.9830
    Natrona, WY
    13600.9553Cedar Rapids, IA163000.9545
    Linn, IA
    14001.0141Champaign-Urbana, IL165801.0132
    Champaign, IL
    14401.0027Charleston-North Charleston, SC167001.0018
    Berkeley, SC
    Charleston, SC
    Dorchester, SC
    14800.9448Charleston, WV166200.9439
    Kanawha, WV
    Putnam, WV
    15201.0337Charlotte-Gastonia-Rock Hill, NC-SC
    Cabarrus, NC
    Gaston, NC167401.0361
    Mecklenburg, NC
    Union, NC
    York, SC
    15201.0337Charlotte-Gastonia-Rock Hill, NC-SC
    Lincoln, NC
    Rowan, NC340.9107
    15401.0957Charlottesville, VA168201.0947
    Albemarle, VA
    Charlottesville City, VA
    Fluvanna, VA
    Greene, VA
    15600.9800Chattanooga, TN-GA168600.9791
    Catoosa, GA
    Dade, GA
    Walker, GA
    Hamilton, TN
    Marion, TN
    15800.9559Cheyenne, WY169400.9550
    Laramie, WY
    16001.1550Chicago, IL169741.1558
    Cook, IL
    DeKalb, IL
    Du Page, IL
    Grundy, IL
    Kane, IL
    Kendall, IL
    McHenry, IL
    Will, IL
    16001.1550Chicago, IL294041.0998
    Lake, IL
    16201.1221Chico-Paradise, CA170201.1211
    Butte, CA
    16401.0213Cincinnati, OH-KY-IN171401.0120
    Brown, OH
    Clermont, OH
    Hamilton, OH
    Warren, OH
    Boone, KY
    Campbell, KY
    Gallatin, KY
    Grant, KY
    Start Printed Page 22432
    Kenton, KY
    Pendleton, KY
    Dearborn, IN
    Ohio, IN
    16600.8539Clarksville, TN-KY173000.8531
    Christian, KY
    Montgomery, TN
    Hopkinsville
    16801.0246Cleveland-Elyria, OH174601.0263
    Cuyahoga, OH
    Geauga, OH
    Lake, OH
    Lorain, OH
    Medina, OH
    16801.0246Elyria, OH360.9245
    Ashtabula, OH
    17201.0423Colorado Springs, CO178201.0414
    El Paso, CO
    17400.8937Columbia, MO178600.8929
    Boone, MO
    17601.0059Columbia, SC179000.9988
    Lexington, SC
    Richland, SC
    18000.9250Columbus, GA-AL179800.9242
    Chattahochee, GA
    Harris, GA
    Muscogee, GA
    Russell, AL
    18401.0381Columbus, OH181401.0355
    Delaware, OH
    Fairfield, OH
    Franklin, OH
    Licking, OH
    Madison, OH
    Pickaway, OH
    18800.9204Corpus Christi, TX185800.9196
    Nueces, TX
    San Patricio, TX
    18901.1224Corvallis, Oregon187001.1214
    Benton, OR
    19000.9220Cumberland, MD-WV190600.9212
    Allegany, MD
    Mineral, WV
    19201.0702Dallas, TX191241.0713
    Collin, TX
    Dallas, TX
    Denton, TX
    Ellis, TX
    Hunt, TX
    Kaufman, TX
    Rockwall, TX
    19201.0702Dallas, TX
    Henderson, TX450.8472
    19500.9200Danville, VA192600.9192
    Danville City, VA
    Pittsylvania, VA
    19600.9338Davenport-Moline-Rock Island, IA-IL193400.9330
    Scott, IA
    Henry, IL
    Rock Island, IL
    20000.9826Dayton, OH193800.9894
    Greene, OH
    Miami, OH
    Montgomery, OH
    20000.9826Dayton-Springfield, OH442200.9303
    Clark, OH
    20200.9473Daytona Beach, FL
    Flagler, FL100.9118
    Volusia, FL196600.9463
    20300.9467Decatur, AL194600.9459
    Start Printed Page 22433
    Lawrence, AL
    Morgan, AL
    20400.8645Decatur, IL195000.8638
    Macon, IL
    20801.1607Denver, CO197401.1596
    Adams, CO
    Arapahoe, CO
    Denver, CO
    Douglas, CO
    Jefferson, CO
    21200.9863Des Moines, IA197800.9854
    Dallas, IA
    Polk, IA
    Warren, IA
    21601.0886Detroit, MI198041.1006
    Wayne, MI
    21601.0886Detroit, MI476441.0754
    Lapeer, MI
    Macomb, MI
    Oakland, MI
    St. Clair, MI
    21601.0886Detroit, MI337801.0109
    Monroe, MI
    21800.8085Dothan, AL200200.8015
    Houston, AL
    21800.8085Dothan, AL200200.8015
    Dale, AL
    21901.0458Dover, DE201001.0449
    Kent, DE
    22000.9312Dubuque, IA202200.9303
    Dubuque, IA
    22401.1023Dulut, MN-WI202601.0996
    St. Louis, MN
    Douglas, WI
    22401.1023Superior, MN-WI202601.0996
    St. Louis, MN
    Douglas, WI
    22811.2408Dutchess County, NY391001.2084
    Dutchess, NY
    22900.9728Eau Claire, WI207400.9719
    Chippewa, WI
    Eau Claire, WI
    23200.9773El Paso, TX213400.9764
    El Paso, TX
    23300.9876Elkhart-Goshen, IN211400.9867
    Elkhart, IN
    23350.8989Elmira, NY213000.8981
    Chemung, NY
    23400.9581Enid, OK370.8174
    Garfield, OK
    23600.9260Erie, PA215000.9251
    Erie, PA
    24001.1645Eugene-Springfield, OR216601.1634
    Lane, OR
    24400.8936Evansville, IN-KY217800.8903
    Posey, IN
    Vanderburgh, IN
    Warrick, IN
    Henderson, KY
    24400.8936Henderson, IN-KY217800.8903
    Posey, IN
    Vanderburgh, IN
    Warrick, IN
    Henderson, KY
    25200.9701Fargo, ND-MN220200.9693
    Clay, MN
    Cass, ND
    25200.9701Moorhead, ND-MN220200.9693
    Clay, MN
    Cass, ND
    Start Printed Page 22434
    25600.9966Fayetteville, NC221800.9957
    Cumberland, NC
    25800.9192Fayetteville-Springdale-Rogers, AR222200.9184
    Benton, AR
    Washington, AR
    26201.1295Flagstaff, AZ223801.1472
    Coconino, AZ
    26201.1295Flagstaff, UT
    Kane, UT460.8813
    26401.1898Flint, MI224201.1888
    Genesee, MI
    26500.8391Florence, AL225200.8383
    Colbert, AL
    Lauderdale, AL
    26550.9537Florence, SC225000.9394
    Florence, SC
    26701.0876Fort Collins-Loveland, CO226601.0867
    Larimer, CO
    26801.0820Ft. Lauderdale, FL227441.0810
    Broward, FL
    27000.9975Fort Myers-Cape Coral, FL159800.9966
    Lee, FL
    27101.0693Fort Pierce-Port St. Lucie, FL389401.0684
    Martin, FL
    St. Lucie, FL
    27200.8838Fort Smith, AR-OK229000.8809
    Crawford, AR
    Sebastian, AR
    Sequoyah, OK
    27500.9352Fort Walton Beach, FL230200.9344
    Okaloosa, FL
    27601.0364Allen, IN230601.0430
    Wells, IN
    Whitley, IN
    27601.0364Fort Wayne, IN150.9202
    Adams, IN
    De Kalb, IN
    Huntington, IN
    28001.0133Forth Worth-Arlington, TX231041.0073
    Johnson, TX
    Parker, TX
    Tarrant, TX
    28001.0133Hood, TX450.8472
    28401.1078Fresno, CA234201.1205
    Fresno, CA
    28401.1078Madera, CA314600.9062
    28800.8568Gadsden, AL234600.8560
    Etowah, AL
    29001.0068Gainesville, FL235401.0059
    Alachua, FL
    29201.0009Galveston-Texas City, TX264201.0606
    Galveston, TX
    29600.9944Gary, IN238440.9901
    Lake, IN
    Porter, IN
    29750.9013Glens Falls, NY240200.9004
    Warren, NY
    Washington, NY
    29800.9344Goldsboro, NC241400.9335
    Wayne, NC
    29850.9677Grand Forks, ND-MN242200.9668
    Grand Forks, ND
    Polk, MN
    29951.0538Grand Junction, CO243001.0528
    Mesa, CO
    30001.0132Grand Rapids-Muskegon-Holland, MI
    Allegan, MI
    Kent, MI230.9344
    Muskegon, MI243401.0018
    Ottawa, MI347401.0359
    Start Printed Page 22435
    261000.9984
    30400.9378Great Falls, MT245000.9369
    Cascade, MT
    30601.0053Greeley, CO245401.0043
    Weld, CO
    30801.0204Green Bay, WI245801.0199
    Brown, WI
    31200.9912Greensboro-Winston-Salem-High Point, NC
    Alamance, NC
    Davidson, NC155000.9536
    Davie, NC340.9107
    Forsyth, NC491800.9998
    Guilford, NC491800.9998
    Randolph, NC246600.9773
    Stokes, NC246600.9773
    Yadkin, NC491800.9998
    491800.9998
    31500.9775Greenville, NC247800.9766
    Pitt, NC
    31601.0006Greenville-Spartanburg-Anderson, SC
    Anderson, SC
    Cherokee, SC113400.9220
    Greenville, SC420.9234
    Pickens, SC248601.0164
    Spartanburg, SC248601.0164
    439001.0123
    31801.0580Hagerstown, MD251801.0332
    Washington, MD
    32000.9650Hamilton-Middletown, OH171401.0120
    Butler, OH
    32400.9884Harrisburg-Carlisle, PA254200.9953
    Cumberland, PA
    Dauphin, PA
    Perry, PA
    32400.9884Lebanon, PA301400.9114
    Lebanon, PA
    32831.1766Hartford, CT255401.1756
    Hartford, CT
    Litchfield, CT
    Middlesex, CT
    Tolland, CT
    32850.8000Hattiesburg, MS256200.8000
    Forrest, MS
    Lamar, MS
    32901.0114Hickory-Morganton-Lenoir, NC258601.0105
    Alexander, NC
    Burke, NC
    Caldwell, NC
    Catawba, NC
    33201.1723Honolulu, HI261801.1712
    Honolulu, HI
    33500.8219Houma, LA263800.8211
    Lafourche, LA
    Terrebonne, LA
    33601.0769Houston, TX264201.0606
    Chambers, TX
    Fort Bend, TX
    Harris, TX
    Liberty, TX
    Montgomery, TX
    Waller, TX
    34001.0180Huntington-Ashland, WV-KY-OH265801.0171
    Boyd, KY
    Greenup, KY
    Lawrence, OH
    Cabell, WV
    Wayne, WV
    34001.0180Carter, KY180.8247
    34400.9421Huntsville, AL266200.9413
    Limestone, AL
    Start Printed Page 22436
    Madison, AL
    34801.0686Indianapolis, IN269001.0755
    Boone, IN
    Hamilton, IN
    Hancock, IN
    Hendricks, IN
    Johnson, IN
    Marion, IN
    Morgan, IN
    Shelby, IN
    34801.0686Indianapolis, IN113000.9266
    Madison, IN
    35001.0276Iowa City, IA269801.0267
    Johnson, IA
    35200.9735Jackson, MI271000.9727
    Jackson, MI
    35600.8948Jackson, MS271400.8817
    Hinds, MS
    Madison, MS
    Rankin, MS
    35800.9473Jackson, TN271800.9465
    Madison, TN
    Chester, TN
    36001.0163Jacksonville, FL272601.0142
    Clay, FL
    Duval, FL
    Nassau, FL
    St. Johns, FL
    36050.8942Jacksonville, NC273400.8934
    Onslow, NC
    36100.8078Jamestown, NY330.8668
    Chautauqua, NY
    36201.0200Janesville-Beloit, WI275001.0191
    Rock, WI
    36401.1627Jersey City, NJ356441.4156
    Hudson, NJ
    36600.8730Johnson City-Kingsport-Bristol, TN-VA349801.0726
    Carter, TN
    36600.8730Kingsport-Bristol, TN-VA287000.8763
    Hawkins, TN
    Sullivan, TN
    Bristol City, VA
    Scott, VA
    Washington, VA
    36600.8730Johnson City, TN277400.8663
    Unicoi, TN
    Washington, TN
    36800.8494Johnstown, PA
    Cambria, PA277800.8912
    Somerset, PA390.8838
    37000.8669Jonesboro, AR
    Craighead, AR278600.8661
    37100.9283Joplin, MO279000.9275
    Jasper, MO
    Newton, MO
    37201.1017Kalamazoo-Battlecreek, MI
    Calhoun, MI129800.9961
    Kalamazoo, MI280201.1354
    Van Buren, MI280201.1354
    37401.1286Kankakee, IL281001.1276
    Kankakee, IL
    37601.0262Kansas City, KS-MO281401.0240
    Johnson, KS
    Leavenworth, KS
    Miami, KS
    Wyandotte, KS
    Cass, MO
    Clay, MO
    Clinton, MO
    Jackson, MO
    Start Printed Page 22437
    Lafayette, MO
    Platte, MO
    Ray, MO
    38001.0402Kenosha, WI294041.0998
    Kenosha, WI
    38100.9838Killeen-Temple, TX286600.9829
    Bell, TX
    Coryell, TX
    38400.9056Knoxville, TN289400.9091
    Anderson, TN
    Blount, TN
    Knox, TN
    Loudon, TN
    Union, TN
    38400.9056Sevier, TN440.8369
    38500.9565Kokomo, IN290200.9556
    Howard, IN
    Tipton, IN
    38700.9888La Crosse, WI-MN291000.9879
    Houston, MN
    La Crosse, WI
    38800.8627Lafayette, LA190.8000
    Acadia, LA
    St. Landry, LA
    38800.8627Lafayette, LA291800.8833
    Lafayette, LA
    St. Martin, LA
    39200.9651Lafayette, IN
    Clinton, IN150.9202
    Tippecanoe, IN291400.9643
    39600.8486Lake Charles, LA293400.8439
    Calcasieu, LA
    39800.9505Lakeland-Winter Haven, FL294600.9497
    Polk, FL
    40001.0520Lancaster, PA295401.0510
    Lancaster, PA
    40401.0280Lansing-East Lansing, MI296201.0271
    Clinton, MI
    Eaton, MI
    Ingham, MI
    40800.9311Laredo, TX297000.9302
    Webb, TX
    41000.9350Las Cruces, NM297400.9342
    Dona Ana, NM
    41201.1838Las Vegas, NV-AZ
    Mohave, AZ030.9503
    Clarke, NV298201.2100
    Nye, NV290.9869
    41500.9201Lawrence, KS299400.9193
    Douglas, KS
    42000.8741Lawton, OK300200.8733
    Comanche, OK
    42431.0178Lewiston-Auburn, ME303401.0169
    Androscoggin, ME
    42800.9813Lexington, KY304600.9953
    Bourbon, KY
    Clark, KY
    Fayette, KY
    Jessamine, KY
    Scott, KY
    Woodford, KY
    42800.9813Madison, KY180.8247
    43200.9855Lima, OH
    Allen, OH306200.9922
    Auglaize, OH360.9245
    43601.0866Lincoln, NE307001.0856
    Lancaster, NE
    44000.9395Little Rock-North Little Rock, AR307800.9386
    Faulkner, AR
    Lonoke, AR
    Start Printed Page 22438
    Pulaski, AR
    Saline, AR
    44200.9302Longview-Marshall, TX309800.9360
    Gregg, TX
    Upshur, TX
    44200.9302Harrison, TX450.9245
    44801.2488Los Angeles-Long Beach, CA1.2477
    Los Angeles, CA31084
    45200.9752Louisville, KY-IN311400.9701
    Clark, IN
    Floyd, IN
    Harrison, IN
    Bullitt, KY
    Jefferson, KY
    Oldham, KY
    45200.9752Louisville, KY-IN193400.9330
    Scott, IN
    46000.9343Lubbock, TX311800.9334
    Lubbock, TX
    46400.9598Lynchburg, VA313400.9589
    Amherst, VA
    Bedford, VA
    Bedford City, VA
    Campbell, VA
    Lynchburg City, VA
    46801.0214Macon, GA314201.0515
    Bibb, GA
    Jones, GA
    Twiggs, GA
    46801.0214Macon, GA
    Houston, GA475800.9028
    Peach, GA110.8224
    47201.1065Madison, WI315401.0960
    Dane, WI
    48000.9692Mansfield, OH
    Crawford, OH360.9245
    Richland, OH319000.9772
    48400.5484Mayaguez, PR419000.6026
    Anasco, PR
    Cabo Rojo, PR
    Sabana Grande, PR
    San German, PR
    48400.5484Mayaguez, PR324200.5167
    Hormigueros, PR
    Mayaguez, PR
    48800.9156McAllen-Edinburg-Mission, TX325800.9148
    Hidalgo, TX
    48901.1213Medford-Ashland, OR327801.1203
    Jackson, OR
    49001.0254Melbourne-Titusville-Palm Bay, FL373401.0244
    Brevard, Fl
    49200.9829Memphis, TN-AR-MS328200.9802
    Crittenden, AR
    DeSoto, MS
    Fayette, TN
    Shelby, TN
    Tipton, TN
    49401.1256Merced, CA329001.1246
    Merced, CA
    50001.0506Miami, FL331241.0497
    Dade, FL
    50151.2092Hunterdon, NJ350841.2429
    Hunterdon, NJ
    50151.2092Middlesex-Somerset, NJ207641.1843
    Middlesex, NJ
    Somerset, NJ
    50801.0725Milwaukee-Waukesha, WI333401.0716
    Milwaukee, WI
    Ozaukee, WI
    Washington, WI
    Start Printed Page 22439
    Waukesha, WI
    51201.1779Minneapolis-St. Paul, MN-WI334601.1768
    Anoka, MN
    Carver, MN
    Chisago, MN
    Dakota, MN
    Hennepin, MN
    Isanti, MN
    Ramsey, MN
    Scott, MN
    Sherbune, MN
    Washington, MN
    Wright, MN
    Pierce, WI
    St. Croix, WI
    51401.0238Missoula, MT335401.0229
    Missoula, MT
    51600.8443Mobile, AL
    Baldwin, AL010.8112
    Mobile, AL336600.8503
    51701.2737Modesto, CA337001.2726
    Stanislaus, CA
    51901.1590Monmouth-Ocean, NJ207641.1843
    Monmouth, NJ
    Ocean, NJ
    52000.8423Monroe, LA337400.8405
    Ouachita, LA
    52400.8835Montgomery, AL338600.8827
    Autauga, AL
    Elmore, AL
    Montgomery, AL
    52800.9133Muncie, IN346200.9125
    Delaware, IN
    53300.9603Myrtle Beach, SC348200.9595
    Horry, SC
    53451.1238Naples, FL349401.1228
    Collier, FL
    53601.0759Nashville, TN349801.0726
    Cheatham, TN
    Davidson, TN
    Dickson, TN
    Robertson, TN
    Rutherford TN
    Sumner, TN
    Williamson, TN
    Wilson, TN
    53801.3739Nassau-Suffolk, NY350041.3726
    Nassau, NY
    Suffolk, NY
    54831.3044New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT
    Fairfield, CT
    New Haven, CT148601.3650
    353001.2556
    55231.2343New London-Norwich, CT359801.2332
    New London, CT
    55600.9690New Orleans, LA353800.9681
    Jefferson, LA
    Orleans, LA
    Plaquemines, LA
    St. Bernard, LA
    St. Charles, LA
    St. John The Baptist, LA
    St. Tammany, LA
    55600.9690St. James, LA190.8000
    56001.4461New York, NY356441.4156
    Bronx, NY
    Kings, NY
    New York, NY
    Putnam, NY
    Queens, NY
    Start Printed Page 22440
    Richmond, NY
    Rockland, NY
    Westchester, NY
    56401.2374Newark, NJ350841.2429
    Essex, NJ
    Morris, NJ
    Sussex, NJ
    Union, NJ
    56401.2374Newark, NJ109001.0104
    Warren, NJ
    56601.1890Newburgh, NY-PA
    Orange, NY391001.2084
    Pike, PA350841.2429
    57200.9467Norfolk-Virginia Beach-Newport News, VA-NC472600.9459
    Currituck, NC
    Chesapeake City, VA
    Gloucester, VA
    Hampton City, VA
    James City, VA
    Isle of Wight, VA
    Mathews, VA
    Newport News City, VA
    Norfolk City, VA
    Poquoson City, VA
    Portsmouth City, VA
    Suffolk City, VA
    Virginia Beach City VA
    Williamsburg City, VA
    York, VA
    57751.6201Oakland, CA360841.6186
    Alameda, CA
    Contra Costa, CA
    57900.9743Ocala, FL361000.9734
    Marion, FL
    58001.0253Odessa-Midland, TX
    Ector, TX362201.0420
    Midland, TX332600.9980
    58800.9544Oklahoma City, OK364200.9552
    Canadian, OK
    Cleveland, OK
    Logan, OK
    McClain, OK
    Oklahoma, OK
    58800.9544Pottawatomie, OK370.8174
    59101.1715Olympia, WA365001.1705
    Thurston, WA
    59201.0382Omaha, NE-IA365401.0373
    Pottawattamie, IA
    Cass, NE
    Douglas, NE
    Sarpy, NE
    Washington, NE
    59451.2359Orange County, CA420441.2348
    Orange, CA
    59601.0370Orlando, FL367401.0360
    Lake, FL
    Orange, FL
    Osceola, FL
    Seminole, FL
    59900.8977Owensboro, KY369800.8969
    Daviess, KY
    60150.8647Panama City, FL374600.8640
    Bay, FL
    60200.8822Parkersburg-Marietta, WV-OH376200.8814
    Washington, OH
    Wood, WV
    60800.8841Pensacola, FL378600.8833
    Escambia, FL
    Santa Rosa, FL
    61200.9459Peoria-Pekin, IL379000.9450
    Start Printed Page 22441
    Peoria, IL
    Tazewell, IL
    Woodford, IL
    61601.1521Philadelphia, NJ158041.1353
    Burlington, NJ
    Camden, NJ
    Gloucester, NJ
    Salem, NJ
    61601.1521Philadelphia, PA379641.1555
    Bucks, PA
    Chester, PA
    Delaware, PA
    Montgomery, PA
    Philadelphia, PA
    62001.0625Phoenix-Mesa, AZ380601.0616
    Maricopa, AZ
    Pinal, AZ
    62400.9232Pine Bluff, AR382200.9224
    Jefferson, AR
    62800.9320Pittsburgh, PA383000.9291
    Allegheny, PA
    Beaver, PA
    Butler, PA
    Fayette, PA
    Washington, PA
    Westmoreland, PA
    63231.1112Pittsfield, MA383401.1102
    Berkshire, MA
    63401.0220Pocatello, ID385401.0210
    Bannock, ID
    63600.5697Ponce, PR495000.5167
    Guayanilla, PR
    Juana Diaz, PR
    Penuelas, PR
    Yauco, PR
    63600.5697Ponce, PR386600.5757
    Ponce, PR
    Villalba, PR
    64031.0764Portland, ME388601.0754
    Cumberland, ME
    Sagadahoc, ME
    York, ME
    64401.2138Portland-Vancouver, OR-WA389001.2127
    Clackamas, OR
    Columbia, OR
    Multnomah, OR
    Washington, OR
    Yamhill, OR
    Clark, WA
    64831.1774Providence-Warwick-Pawtucket, RI393001.1623
    Bristol, RI
    Kent, RI
    Newport, RI
    Providence, RI
    Washington, RI
    65201.0232Provo-Orem, UT393401.0197
    Utah, UT
    65600.9316Pueblo, CO393800.9308
    Pueblo, CO
    65801.0049Punta Gorda, FL394601.0040
    Charlotte, FL
    66000.9628Racine, WI395400.9619
    Racine, WI
    66401.0919Durham-Chapel Hill, NC205001.1021
    Chatham, NC
    Durham, NC
    Orange, NC
    66401.0919Raleigh, NC395801.0695
    Franklin, NC
    Johnston, NC
    Start Printed Page 22442
    Wake, NC
    66600.9486Rapid City, SD396600.9478
    Pennington, SD
    66800.9809Reading, PA397400.9800
    Berks, PA
    66901.2598Redding, CA398201.2586
    Shasta, CA
    67201.1130Reno, NV399001.1120
    Washoe, NV
    67401.1198Richland-Kennewick-Pasco, WA Benton, WA284201.1188
    Franklin, WA
    67601.0002Richmond-Petersburg, VA400600.9994
    Charles City County, VA
    Chesterfield, VA
    Colonial Heights City, VA
    Dinwiddie, VA
    Goochland, VA
    Hanover, VA
    Henrico, VA
    Hopewell City, VA
    New Kent, VA
    Petersburg City, VA
    Powhatan, VA
    Prince George, VA
    Richmond City, VA
    67801.1677Riverside-San Bernardino, CA401401.1666
    Riverside, CA
    San Bernardino, CA
    68000.8971Roanoke, VA402200.8949
    Botetourt, VA
    Roanoke, VA
    Roanoke City, VA
    Salem City, VA
    68201.2245Rochester, MN403401.2234
    Olmsted, MN
    68400.9789Rochester, NY403800.9870
    Livingston, NY
    Monroe, NY
    Ontario, NY
    Orleans, NY
    Wayne, NY
    68400.9789Genesee, NY330.8668
    68801.0246Rockford, IL404201.0237
    Boone, IL
    Winnebago, IL
    68801.0246Ogle, IL140.8868
    68950.9578Rocky Mount, NC405800.9569
    Edgecombe, NC
    Nash, NC
    69201.2611Sacramento, CA409001.2443
    El Dorado, CA
    Placer, CA
    Sacramento, CA
    69601.0321Saginaw-Bay City-Midland, MI
    Bay, MI
    Midland, MI130201.0182
    Saginaw, MI230.9344
    409801.0437
    69801.0873St. Cloud, MN410601.0863
    Benton, MN
    Stearns, MN
    70001.0658St. Joseph, MO411401.0649
    Andrew, MO
    Buchanan, MO
    70400.9666St. Louis, MO-IL411800.9652
    Franklin, MO
    Jefferson, MO
    Lincoln, MO
    St. Charles, MO
    St. Louis, MO
    Start Printed Page 22443
    St. Louis City, MO
    Warren, MO
    Clinton, IL
    Jersey, IL
    Madison, IL
    Monroe, IL
    St. Clair, IL
    70801.1236Salem, OR414201.1226
    Marion, OR
    Polk, OR
    71201.4714Salinas, CA
    Monterey, CA415001.4700
    71601.0098Ogden, UT362600.9801
    Davis, UT
    Weber, UT
    71601.0098Salt Lake City, UT416201.0168
    Salt Lake, UT
    72000.8693San Angelo, TX416600.8685
    Tom Green, TX
    72400.9604San Antonio, TX417000.9575
    Bexar, TX
    Comal, TX
    Guadalupe, TX
    Wilson, TX
    73201.1993San Diego, CA417401.1982
    San Diego, CA
    73601.5660San Francisco, CA418841.5646
    Marin, CA
    San Francisco, CA
    San Mateo, CA
    74001.5694San Jose, CA419401.5657
    Santa Clara, CA
    74400.5522San Juan-Bayamon, PR419800.5342
    Aguas Buenas, PR
    Barceloneta, PR
    Bayamon, PR
    Canovanas, PR
    Carolina, PR
    Catano, PR
    Comerio, PR
    Corozal, PR
    Dorado, PR
    Florida, PR
    Guaynabo, PR
    Humacao, PR
    Juncos, PR
    Los Piedras, PR
    Loiza, PR
    Manati, PR
    Morovis, PR
    Naguabo, PR
    Naranjito, PR
    Rio Grande, PR
    San Juan, PR
    Toa Alta, PR
    Toa Baja, PR
    Trujillo Alto, PR
    Vega Alta, PR
    Vega Baja, PR
    Yabucoa, PR
    74400.5522San Juan-Bayamon, PR219400.4530
    Ceiba, PR
    Fajardo, PR
    Luguillo, PR
    74601.1834San Luis Obispo-Atascadero-Paso Robles, CA420201.1824
    San Luis Obispo, CA
    74801.1465Santa Barbara-Santa Maria-Lompoc, CA420601.1455
    Santa Barbara, CA
    74851.5731Santa Cruz-Watsonville, CA421001.5717
    Santa Cruz, CA
    Start Printed Page 22444
    74901.1272Santa Fe, NM
    Los Alamos, NM320.9231
    Santa Fe, NM421401.1601
    75001.3796Santa Rosa, CA422201.3784
    Sonoma, CA
    75101.0249Sarasota-Bradenton, FL422601.0240
    Manatee, FL
    Sarasota, FL
    75201.0070Savannah, GA423401.0061
    Bryan, GA
    Chatham, GA
    Effingham, GA
    75600.9071Scranton—Wilkes-Barre—Hazleton, PA425400.9085
    Lackawanna, PA
    Luzerne, PA
    Wyoming, PA
    75600.9071Columbia, PA390.8838
    76001.2219Seattle-Bellevue-Everett, WA426441.2222
    King, WA
    Snohomish, WA
    76001.2219Island, WA501.0967
    76100.8389Sharon, PA496600.9823
    Mercer, PA
    76200.9525Sheboygan, WI431000.9516
    Sheboygan, WI
    76401.0237Sherman-Denison, TX433001.0227
    Grayson, TX
    76800.9698Shreveport-Bossier City, LA433400.9712
    Bossier, LA
    Caddo, LA
    76800.9698Webster, LA190.8000
    77200.9680Sioux City, IA-NE435800.9646
    Woodbury, IA
    Dakota, NE
    77601.0049Sioux Falls, SD436201.0040
    Lincoln, SD
    Minnehaha, SD
    78001.0056South Bend, IN437801.0047
    St. Joseph, IN
    78401.1347Spokane, WA440601.1337
    Spokane, WA
    78800.9301Springfield, IL441000.9293
    Menard, IL
    Sangamon, IL
    79200.9151Springfield, MO441800.9100
    Christian, MO
    Greene, MO
    Webster, MO
    80031.0828Springfield, MA441401.0822
    Hampden, MA
    Hampshire, MA
    80500.9006State College, PA443000.8998
    Centre, PA
    80800.8814Steubenville-Weirton, OH-WV482600.8806
    Brooke, WV
    Hancock, WV
    Jefferson, OH
    81201.1245Stockton-Lodi, CA447001.1235
    San Joaquin, CA
    81400.9069Sumter, SC449400.9061
    Sumter, SC
    81600.9999Syracuse, NY450601.0069
    Madison, NY
    Onondaga, NY
    Oswego, NY
    81600.9999Cayuga, NY330.8668
    82001.1792Tacoma, WA451041.1781
    Pierce, WA
    82400.9213Tallahassee, FL452200.9204
    Gadsden, FL
    Start Printed Page 22445
    Leon, FL
    82800.9605Tampa-St. Petersburg-Clearwater, FL453000.9597
    Hernando, FL
    Hillsborough, FL
    Pasco, FL
    Pinellas, FL
    83200.9135Terre Haute, IN454600.9058
    Clay, IN
    Vermillion, IN
    Vigo, IN
    83600.8955Texarkana, AR-Texarkana, TX455000.8947
    Miller, AR
    Bowie, TX
    84001.0138Toledo, OH457801.0129
    Fulton, OH
    Lucas, OH
    Wood, OH
    84400.9478Topeka, KS458200.9469
    Shawnee, KS
    84801.0938Trenton, NJ459401.0928
    Mercer, NJ
    85200.9501Tucson, AZ460600.9493
    Pima, AZ
    85600.9291Tulsa, OK461400.9242
    Creek, OK
    Osage, OK
    Rogers, OK
    Tulsa, OK
    Wagoner, OK
    86000.8984Tuscaloosa, AL462200.8865
    Tuscaloosa, AL
    86401.0114Tyler, TX463401.0105
    Smith, TX
    86800.8829Utica-Rome, NY465400.8822
    Herkimer, NY
    Oneida, NY
    87201.4388Vallejo-Fairfield-Napa, CA
    Napa, CA349001.3326
    Solano, CA467001.5185
    87351.1821Ventura, CA371001.1810
    Ventura, CA
    87500.9015Victoria, TX470200.9008
    Victoria, TX
    87601.1254Vineland-Millville-Bridgeton, NJ472201.1244
    Cumberland, NJ
    87801.0591Visalia-Tulare-Porterville, CA473001.0608
    Tulare, CA
    88000.8671Waco, TX473800.8663
    McLennan, TX
    88401.1678Washington, DC-MD-VA-WV478941.1723
    District of Columbia, DC
    Calvert, MD
    Charles, MD
    Prince Georges, MD
    Alexandria City, VA
    Arlington, VA
    Clarke, VA
    Fairfax, VA
    Fairfax City, VA
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    Loudoun, VA
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    Prince William, VA
    Spotsylvania, VA
    Stafford, VA
    Warren, VA
    Jefferson, WV
    Start Printed Page 22446
    88401.1678Washington, DC-MD-VA-WV136441.1651
    Frederick, MD
    Montgomery, MD
    88401.1678Culpeper, VA490.8560
    King George, VA
    88401.1678Washington, DC-MD-VA-WV251801.0332
    Berkeley, WV
    89200.9189Waterloo-Cedar Falls, IA479400.9181
    Black Hawk, IA
    89401.0187Wausau, WI481401.0177
    Marathon, WI
    89601.1030West Palm Beach-Boca Raton, FL484241.1020
    Palm Beach, FL
    90000.8000Wheeling, WV-OH485400.8000
    Belmont, OH
    Marshall, WV
    Ohio, WV
    90401.0097Wichita, KS486201.0057
    Butler, KS
    Harvey, KS
    Sedgwick, KS
    90800.8936Wichita Falls, TX486600.8861
    Archer, TX
    Wichita, TX
    91400.9032Williamsport, PA487000.9024
    Lycoming, PA
    91601.1838Wilmington-Newark, DE-MD488641.1750
    New Castle, DE
    Cecil, MD
    92000.9832Wilmington, NC489000.9823
    Brunswick, NC
    New Hanover, NC
    92601.0987Yakima, WA494201.0977
    Yakima, WA
    92700.9982Yolo, CA409001.2443
    Yolo, CA
    92800.9740York, PA496200.9731
    York, PA
    93201.0130Youngstown-Warren, OH496600.9823
    Mahoning, OH
    Trumbull, OH
    93201.0130Columbiana, OH360.9245
    93401.1031Yuba City, CA497001.1021
    Sutter, CA
    Yuba, CA
    93600.9443Yuma, AZ497400.9434
    Yuma, AZ
    010.8129Bibb, AL138200.9738
    Chilton, AL
    Walker, AL
    010.8129Geneva, AL200200.8015
    Henry, AL
    010.8129Greene, AL462200.8865
    Hale, AL
    010.8129Lowndes, AL338600.8827
    021.2387Fairbanks North Star AK218201.1854
    Matanuska-Susitna, AK112601.2937
    030.9729Yavapai, AZ391401.0520
    040.8199Cleveland, AR382200.9224
    Franklin, AR229000.8809
    Garland, AR263000.9836
    Grant, AR307800.9386
    Lincoln, AR382200.9224
    Madison, AR222200.9184
    Perry, AR307800.9386
    Poinsett, AR278600.8661
    051.0960Imperial, CA209400.9418
    Kings, CA252600.9886
    San Benito, CA419401.5657
    060.9972Clear, Creek, CO197401.1596
    Start Printed Page 22447
    Elbert, CO
    Gilpin, CO
    Park, CO
    060.9972Teller, CO178201.0414
    100.9283Baker, FL272601.0142
    Gilchrist, FL235401.0059
    Indian River, FL469401.0079
    100.9283Jefferson, FL452200.9204
    Wakulla, FL
    110.8778Brooks, GA466600.8870
    Echols, GA
    Lanier, GA
    Lowndes, GA
    110.8778Hall, GA235801.0164
    Marion, GA179800.9242
    Oglethorpe, GA120201.0850
    110.8778Long, GA259800.8205
    Liberty, GA
    110.8778Murray, GA191401.0165
    Whitfield, GA
    110.8778Baker, GA105001.1981
    Terrell, GA
    Worth, GA
    110.8778Crawford, GA314201.0515
    Monroe, GA
    110.8778Brantley, GA152601.2690
    Glynn, GA
    MCIntosh, GA
    110.8778Butts, GA120601.0604
    Dawson, GA
    Haralson, GA
    Heard, GA
    Jasper, GA
    Lamar, GA
    Meriwether, GA
    Pike, GA
    110.8778Burke, GA122600.9735
    Floyd, GA0.9442
    40660
    130.9395Boise, ID142600.9946
    Gem, ID
    Owyhee, ID
    130.9395Bonneville, ID268200.9634
    Jefferson, ID
    130.9395Franklin, ID308600.9671
    Kootenai, ID176600.9932
    Nez Perce, ID303000.9905
    Power, ID385401.0210
    140.8877Bond, IL411800.9652
    Calhoun, IL
    Macoupin, IL
    140.8877Ford, IL165801.0132
    Platt
    140.8877Marshall, IL379000.9450
    Stark, IL37900
    140.8877Mercer193400.9330
    Vermilion, IL191800.8925
    150.9299Bartholomew, IN180200.9984
    Franklin, IN171401.0120
    Gibson, IN217800.8903
    La Porte, IN331400.9924
    Sullivan, IN454600.9058
    Washington, IN311400.9701
    150.9299Brown, IN269001.0755
    Putnam, IN
    150.9299Benton, IN291400.9643
    Carroll, IN
    150.9299Greene, IN140200.9132
    Owen, IN
    150.9299Jasper, IN238440.9901
    Start Printed Page 22448
    Newton, IN
    160.9101Benton, IA163000.9545
    Jones, IA
    160.9101Bremer, IA479400.9181
    Grundy, IA
    160.9101Guthrie, IA197800.9854
    Madison, IA
    160.9101Harrison, IA365401.0373
    Mills, IA
    160.9101Story, IA111801.0081
    Washington, IA269801.0267
    170.8608Doniphan, KS411401.0649
    Sumner, KS486201.0057
    170.8608Franklin, KS281401.0240
    Linn, KS
    170.8608Jackson, KS458200.9469
    Jefferson, KS
    Osage, KS
    Wabaunsee, KS
    180.8349Bracken, KY171401.0120
    Trigg, KY173000.8531
    Webster, KY217800.8903
    180.8349Edmonson, KY145400.8657
    Warren, KY
    180.8349Hancock, KY369800.8969
    Mc Lean, KY
    180.8349Hardin, KY210600.9235
    Larue, KY
    180.8349Henry, KY311400.9701
    Meade, KY
    Nelson, KY
    Shelby, KY
    Spencer, KY
    Trimble, KY
    190.8000Cameron, LA293400.8439
    DE Soto, LA433400.9712
    Grant, LA107800.8690
    Union, LA337400.8405
    190.8000East Feliciana, LA129400.8847
    Iberville, LA
    Pointe Coupee, LA
    St. Helena, LA
    West Feliciana, LA
    210.9770Somerset, MD415400.9702
    Wicomico
    221.0874Franklin, MA441401.0822
    230.9303Barry, MI243401.0018
    Ionia, MI
    Newaygo, MI
    230.9303Cass, MI437801.0047
    240.9941Carlton, MN202601.0996
    240.9941Dodge, MN403401.2234
    Wabasha, MN
    250.8072Copiah, MS271400.8817
    Simpson, MS
    250.8072George, MS377000.8480
    Perry, MS256200.8000
    Stone, MS250600.9518
    250.8072Marshall, MS328200.9802
    Tate, MS
    Tunica, MS
    260.8333Bates, MO281401.0240
    Caldwell, MO
    260.8333Callaway, MO276200.8867
    Cole, MO
    Moniteau, MO
    Osage, MO
    260.8333Crawford, Mo411800.9652
    Washington, MO
    260.8333Dallas, MO441800.9100
    Start Printed Page 22449
    Polk, MO
    260.8333DeKalb, MO411401.0649
    Howard, MO178600.8929
    McDonald, MO222200.9184
    270.9262Carbon, MT137400.9530
    280.9617Dixon, NE435800.9646
    Saunders, NE365401.0373
    Seward, NE307001.0856
    291.0466Storey, NV399001.1120
    Carson City, NV161801.1009
    320.9079San Juan, NM221400.8560
    Torrance, NM107401.1151
    330.8944Tompkins, NY270601.0198
    Ulster, NY287400.9571
    340.9048Anson, NC167401.0361
    Greene, NC247800.9766
    Hoke, NC221800.9957
    Pender, NC489000.9823
    Person, NC205001.1021
    Rockingham, NC246600.9773
    340.9048Haywood, NC117000.9774
    Henderson, NC
    360.9323Erie, OH417800.9589
    Ottawa, OH457801.0129
    Preble, OH193800.9894
    360.9323Morrow, OH181401.0355
    Union, OH
    370.8023Grady, OK364200.9552
    Lincoln, OK
    370.8023Le Flore, OK229000.8809
    370.8023Okmulgee, OK461400.9242
    Pawnee, OK
    381.0697Deschutes, OR134601.1276
    390.8886Armstrong, PA383000.9291
    400.4654Albonito, PR419800.5342
    Barranquitas, PR
    Ciales, PR
    Maunabo, PR
    Orocovis, PR
    Quebradillas, PR
    400.4654Arroyo, PR250200.4606
    Guayama, PR
    Patillas, PR
    400.4654Guanica, PR495000.5167
    Lajas, PR419000.6026
    400.4654Isabela, PR103800.4922
    Lares, PR
    Rincon, PR
    San Sebastian, PR
    420.9197Calhoun, SC179000.9988
    Fairfield, SC
    Kershaw, SC
    Saluda, SC
    420.9197Darlington, SC225000.9394
    Laurens, SC248601.0164
    430.8934Mc Cook, SD436201.0040
    Turner, SD
    430.8934Meade, SD396600.9478
    Union, SD435800.9646
    440.8383Bradley, TN174200.8342
    Polk, TN1.0726
    440.8383Cannon, TN349801.0726
    Hickman, TN
    Macon, TN
    Smith, TN
    Trousdale, TN
    440.8383Grainger, TN341000.8285
    Hamblen, TN
    Jefferson, TN
    440.8383Sequatchie, TN168600.9791
    Start Printed Page 22450
    Stewart, TN173000.8531
    450.8420Aransas, TX185800.9196
    Calhoun, TX470200.9008
    Clay, TX486600.8861
    Crosby, TX311800.9334
    Delta, TX191241.0713
    Goliad, TX470200.9008
    Irion, TX416600.8685
    Lampasas, TX286600.9829
    Rusk, TX309800.9360
    Wise, TX231041.0073
    450.8420Armstrong, TX111000.9761
    Carson, TX
    450.8420Callahan, TX101800.8348
    Jones, TX
    450.8420Atascosa, TX417000.9575
    Bandera, TX
    Kendall, TX
    Medina, TX
    450.8420Austin, TX264201.0606
    San Jacinto, TX
    450.8420Burleson, TX177800.9830
    Robertson, TX
    460.9413Cache, UT308600.9671
    Juab, UT393401.0197
    Morgan, UT362600.9801
    Washington, UT411001.0058
    460.9413Summit, UT416201.0168
    Tooele, UT
    490.9025Amelia, VA400600.9994
    Caroline, VA
    Cumberland, VA
    King and Queen, VA
    King William, VA
    Louisa, VA
    Sussex, VA
    490.9025Appomattox, VA313400.9589
    Nelson, VA168201.0947
    Surry, VA472600.9459
    490.9025Craig, VA402200.8949
    Franklin, VA
    490.9025Frederick, VA490201.1162
    Winchester City, VA
    490.9025Giles, VA139800.8456
    Montgomery, VA
    Pulaski, VA
    Radford City, VA
    490.9025Rockingham, VA255000.9864
    Harrisonburg City, VA
    501.0721Asotin, WA303000.9905
    Cowlitz, WA310201.0873
    Skagit, WA345801.1247
    Skamania, WA389001.2127
    501.0721Chelan, WA483001.0025
    Douglas, WA
    510.8604Boone, WV166200.9439
    Clay, WV
    Lincoln, WV
    510.8604Hampshire, WV490201.1162
    Morgan, WV251801.0332
    510.8604Monongalia, WV340600.9284
    Preston, WV
    510.8604Pleasants, WV376200.8814
    Wirt, WV
    521.0110Columbia, WI315401.0960
    Iowa, WI
    521.0110Fund Du Lac225401.0525
    521.0110Kewaunee, WI245801.0199
    Start Printed Page 22451
    Oconto, WI
    1 This column lists each MSA area name and each county or county equivalent, in the MSA area. Counties not listed in this Table are considered to be rural areas. Wage Index values for these areas are found in Table D.
    2 Wage index values are based on FY 2000 hospital cost report data before reclassification. This wage index is further adjusted. Wage index values greater than 0.8 are subject to a budget neutrality adjustment calculated by multiplying the hospital wage index value for a given area by a budget neutrality factor of 1.064435 for wage indices based on MSA designations and 1.063479 for wage indices based on CBSA designations. Wage index values below 0.8 are adjusted to be the greater of a 15-percent increase, subject to a maximum wage index value of 0.8, or a budget neutrality adjustment calculated by multiplying the hospital wage index value for a given area by the budget neutrality factor. We have completed all of these adjustments and included them in the wage index values reflected in this table.

    Table D.—Comparison Wage Index for Rural Areas by MSA and CBSA

    MSA code numberWage index 3 MSA designationNonurban areaCBSA code numberWage index 3 CBSA designation
    99010.8129Alabama010.8112
    99021.2387Alaska021.2492
    99030.9729Arizona030.9503
    99040.8199Arkansas040.8000
    99051.0960California051.1192
    99060.9972Colorado060.9963
    99071.2685Connecticut071.2673
    99081.0115Delaware081.0106
    99100.9283Florida100.9118
    99110.8778Georgia110.8224
    99121.1200Hawaii121.1190
    99130.9395Idaho130.8749
    99140.8877Illinois140.8868
    99150.9299Indiana150.9202
    99160.9101Iowa160.9013
    99170.8608Kansas170.8592
    99180.8349Kentucky180.8247
    99190.8000Louisiana190.8000
    99200.9621Maine300.9613
    99210.9770Maryland210.9805
    99221.0874Massachusetts 5221.0865
    99230.9303Michigan230.9344
    99240.9941Minnesota240.9922
    99250.8072Mississippi250.8120
    99260.8333Missouri260.8255
    99270.9262Montana270.9253
    99280.9617Nebraska280.9609
    9929TBDNevada290.9869
    99301.0580New Hampshire301.0571
    9931New Jersey 4
    99320.9079New Mexico320.9231
    99330.8944New York330.8668
    99340.9048North Carolina340.9107
    99350.8242North Dakota350.8235
    99360.9323Ohio360.9245
    99370.8023Oklahoma370.8174
    99381.0697Oregon381.0543
    99390.8886Pennsylvania390.8838
    99400.4654Puerto Rico400.8000
    9941Rhode Island 4
    99420.9197South Carolina420.9234
    99430.8934South Dakota430.8931
    99440.8383Tennessee440.8369
    99450.8420Texas450.8472
    99460.9413Utah460.8813
    99470.9979Vermont470.9970
    99480.8000Virgin Islands480.8000
    99490.9025Virginia490.8560
    99501.0721Washington501.0967
    99510.8604West Virginia510.8364
    99521.0110Wisconsin521.0095
    99530.9774Wyoming530.9765
    Start Printed Page 22452
    99651.0230Guam541.0221
    3 Wage index values are based on FY 2000 hospital cost report data before reclassification. This wage index is further adjusted. Wage index values greater than 0.8 are subject to a budget neutrality adjustment calculated by multiplying the hospital wage index value for a given area by a proposed budget neutrality factor of 1.064435 for wage indices based on MSA designations and 1.063479 for wage indices based on CBSA designations. Wage index values below 0.8 are adjusted to be the greater of a 15-percent increase, subject to a maximum wage index value of 0.8, or a budget neutrality adjustment calculated by multiplying the hospital wage index value for a given area by the budget neutrality factor. We have completed all of these adjustments and included them in the wage index values reflected in this table.
    4 All counties within the State are classified as urban.
    5Based on CBSA designations Massachusetts has areas designated as rural. However, no IPPS hospitals are located in those rural area(s) for FY 2006. Because more recent data is not available for those areas, we are using the FY 2005 prefloor, preclassified hospital wage index value, for rural Massachusetts multiplied by the proposed FY 2006 budget neutrality factor of 1.063479.

    Table E.—Rural Counties Converting to Urban Counties by State

    County nameState county codeMSA codeMSA nameCBSA codeCBSA name
    BIBB0103001ALABAMA13820Birmingham-Hoover, AL
    CHILTON0110001ALABAMA13820Birmingham-Hoover, AL
    GENEVA0130001ALABAMA20020Dothan, AL
    GREENE0131001ALABAMA46220Tuscaloosa, AL
    HALE0132001ALABAMA46220Tuscaloosa, AL
    HENRY0133001ALABAMA20020Dothan, AL
    LOWNDES0142001ALABAMA33860Montgomery, AL
    WALKER0163001ALABAMA13820Birmingham-Hoover, AL
    FAIRBANKS NORTH STAR0209002ALASKA21820Fairbanks, AK
    MATANUSKA-SUSITNA0217002ALASKA11260Anchorage, AK
    YAVAPAI0312003ARIZONA39140Prescott, AZ
    CLEVELAND0412004ARKANSAS38220Pine Bluff, AR
    FRANKLIN0423004ARKANSAS22900Fort Smith, AR-OK
    GARLAND0425004ARKANSAS26300Hot Springs, AR
    GRANT0426004ARKANSAS30780Little Rock-North Little Rock, AR
    LINCOLN0439004ARKANSAS38220Pine Bluff, AR
    MADISON0443004ARKANSAS2220Fayetteville-Springdale-Rogers, AR-MO
    PERRY0452004ARKANSAS30780Little Rock-North Little Rock, AR
    POINSETT0455004ARKANSAS27860Jonesboro, AR
    IMPERIAL0512005CALIFORNIA20940El Centro, CA
    KINGS0515005CALIFORNIA25260Hanford-Corcoran, CA
    SAN BENITO0545005CALIFORNIA41940San Jose-Sunnyvale-Santa Clara, CA
    CLEAR CREEK0609006COLORADO19740Denver-Aurora, CO
    ELBERT0619006COLORADO19740Denver-Aurora, CO
    GILPIN0623006COLORADO19740Denver-Aurora, CO
    PARK0646006COLORADO19740Denver-Aurora, CO
    TELLER0659006COLORADO17820Colorado Springs, CO
    BAKER1001010FLORIDA27260Jacksonville, FL
    GILCHRIST1020010FLORIDA23540Gainesville, FL
    INDIAN RIVER1030010FLORIDA46940Vero Beach, FL
    JEFFERSON1032010FLORIDA45220Tallahassee, FL
    WAKULLA1064010FLORIDA45220Tallahassee, FL
    BAKER1102011GEORGIA10500Albany, GA
    BRANTLEY1111011GEORGIA15260Brunswick, GA
    BROOKS1112011GEORGIA46660Valdosta, GA
    BURKE1115011GEORGIA12260Augusta-Richmond County, GA-SC
    BUTTS1116011GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
    CRAWFORD1133011GEORGIA31420Macon, GA
    DAWSON1135011GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
    ECHOLS1142011GEORGIA46660Valdosta, GA
    FLOYD1146011GEORGIA40660Rome, GA
    GLYNN1149011GEORGIA15260Brunswick, GA
    HALL1155011GEORGIA23580Gainesville, GA
    HARALSON1157011GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
    HEARD1159011GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
    Start Printed Page 22453
    JASPER1161111GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
    LAMAR1165111GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
    LANIER1165211GEORGIA46660Valdosta, GA
    LIBERTY1168011GEORGIA25980Hinesville-Fort Stewart, GA
    LONG1169111GEORGIA25980Hinesville-Fort Stewart, GA
    LOWNDES1170011GEORGIA46660Valdosta, GA
    MC INTOSH1170311GEORGIA15260Brunswick, GA
    MARION1173011GEORGIA17980Columbus, GA-AL
    MERIWETHER1174011GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
    MONROE1176011GEORGIA31420Macon, GA
    MURRAY1177211GEORGIA19140Dalton, GA
    OGLETHORPE1180111GEORGIA12020Athens-Clarke County, GA
    PIKE1182111GEORGIA12060Atlanta-Sandy Springs-Marietta, GA
    TERRELL1188511GEORGIA10500Albany, GA
    WHITFIELD1197011GEORGIA19140Dalton, GA
    WORTH1198011GEORGIA10500Albany, GA
    BOISE1307013IDAHO14260Boise City-Nampa, ID
    BONNEVILLE1309013IDAHO26820Idaho Falls, ID
    FRANKLIN1320013IDAHO30860Logan, UT-ID
    GEM1322013IDAHO14260Boise City-Nampa, ID
    JEFFERSON1325013IDAHO26820Idaho Falls, ID
    KOOTENAI1327013IDAHO17660Coeur d'Alene, ID
    NEZ PERCE1334013IDAHO30300Lewiston, ID-WA
    OWYHEE1336013IDAHO14260Boise City-Nampa, ID
    POWER1338013IDAHO38540Pocatello, ID
    BOND1402014ILLINOIS41180St. Louis, MO-IL
    CALHOUN1406014ILLINOIS41180St. Louis, MO-IL
    FORD1435014ILLINOIS16580Champaign-Urbana, IL
    MACOUPIN1467014ILLINOIS41180St. Louis, MO-IL
    MARSHALL1470014ILLINOIS37900Peoria, IL
    MERCER1474014ILLINOIS19340Davenport-Moline-Rock Island, IA-IL
    PIATT1482014ILLINOIS16580Champaign-Urbana, IL
    STARK1496014ILLINOIS37900Peoria, IL
    VERMILION1498214ILLINOIS19180Danville, IL
    BARTHOLOMEW1502015INDIANA18020Columbus, IN
    BENTON1503015INDIANA29140Lafayette, IN
    BROWN1506015INDIANA26900Indianapolis, IN
    CARROLL1507015INDIANA29140Lafayette, IN
    FRANKLIN1523015INDIANA17140Cincinnati-Middletown, OH-KY-IN
    GIBSON1525015INDIANA21780Evansville, IN-KY
    GREENE1527015INDIANA14020Bloomington, IN
    JASPER1536015INDIANA23844Gary, IN
    LA PORTE1545015INDIANA33140Michigan City-La Porte, IN
    NEWTON1555015INDIANA23844Gary, IN
    OWEN1559015INDIANA14020Bloomington, IN
    PUTNAM1566015INDIANA26900Indianapolis, IN
    SULLIVAN1576015INDIANA45460Terre Haute, IN
    WASHINGTON1587015INDIANA31140Louisville, KY-IN
    BENTON1605016IOWA16300Cedar Rapids, IA
    BREMER1608016IOWA47940Waterloo-Cedar Falls, IA
    GRUNDY1637016IOWA47940Waterloo-Cedar Falls, IA
    GUTHRIE1638016IOWA19780Des Moines, IA
    HARRISON1642016IOWA36540Omaha-Council Bluffs, NE-IA
    JONES1652016IOWA16300Cedar Rapids, IA
    MADISON1660016IOWA19780Des Moines, IA
    MILLS1664016IOWA36540Omaha-Council Bluffs, NE-IA
    STORY1684016IOWA11180Ames, IA
    WASHINGTON1691016IOWA26980Iowa City, IA
    DONIPHAN1721017KANSAS41140St. Joseph, MO-KS
    FRANKLIN1729017KANSAS28140Kansas City, MO-KS
    JACKSON1742017KANSAS45820Topeka, KS
    JEFFERSON1743017KANSAS45820Topeka, KS
    LINN1753017KANSAS28140Kansas City, MO-KS
    OSAGE1769017KANSAS45820Topeka, KS
    SUMNER1795017KANSAS48620Wichita, KS
    Start Printed Page 22454
    WABAUNSEE1798017KANSAS45820Topeka, KS
    BRACKEN1811018KENTUCKY17140Cincinnati-Middletown, OH-KY-IN
    EDMONSON1829118KENTUCKY14540Bowling Green, KY
    HANCOCK1845018KENTUCKY36980Owensboro, KY
    HARDIN1846018KENTUCKY21060Elizabethtown, KY
    HENRY1851018KENTUCKY31140Louisville, KY-IN
    LARUE1861018KENTUCKY21060Elizabethtown, KY
    MC LEAN1874018KENTUCKY36980Owensboro, KY
    MEADE1880118KENTUCKY31140Louisville, KY-IN
    NELSON1889018KENTUCKY31140Louisville, KY-IN
    SHELBY1897818KENTUCKY31140Louisville, KY-IN
    SPENCER1898018KENTUCKY31140Louisville, KY-IN
    TRIGG1898318KENTUCKY17300Clarksville, TN-KY
    TRIMBLE1898418KENTUCKY31140Louisville, KY-IN
    WARREN1898618KENTUCKY14540Bowling Green, KY
    WEBSTER1898918KENTUCKY21780Evansville, IN-KY
    CAMERON1911019LOUISIANA29340Lake Charles, LA
    DE SOTO1915019LOUISIANA43340Shreveport-Bossier City, LA
    EAST FELICIANA1918019LOUISIANA12940Baton Rouge, LA
    GRANT1921019LOUISIANA10780Alexandria, LA
    IBERVILLE1923019LOUISIANA12940Baton Rouge, LA
    POINTE COUPEE1938019LOUISIANA12940Baton Rouge, LA
    ST. HELENA1945019LOUISIANA12940Baton Rouge, LA
    UNION1955019LOUISIANA33740Monroe, LA
    WEST FELICIANA1962019LOUISIANA12940Baton Rouge, LA
    SOMERSET2119021MARYLAND41540Salisbury, MD
    WICOMICO2122021MARYLAND41540Salisbury, MD
    FRANKLIN2206022MASSACHUSETTS44140Springfield, MA
    BARRY2307023MICHIGAN24340Grand Rapids-Wyoming, MI
    CASS2313023MICHIGAN43780South Bend-Mishawaka, IN-MI
    IONIA2333023MICHIGAN24340Grand Rapids-Wyoming, MI
    NEWAYGO2361023MICHIGAN24340Grand Rapids-Wyoming, MI
    CARLTON2408024MINNESOTA20260Duluth, MN-WI
    DODGE2419024MINNESOTA40340Rochester, MN
    WABASHA2478024MINNESOTA40340Rochester, MN
    COPIAH2514025MISSISSIPPI27140Jackson, MS
    GEORGE2519025MISSISSIPPI37700Pascagoula, MS
    MARSHALL2546025MISSISSIPPI32820Memphis, TN-MS-AR
    PERRY2555025MISSISSIPPI25620Hattiesburg, MS
    SIMPSON2563025MISSISSIPPI27140Jackson, MS
    STONE2565025MISSISSIPPI25060Gulfport-Biloxi, MS
    TATE2568025MISSISSIPPI32820Memphis, TN-MS-AR
    TUNICA2571025MISSISSIPPI32820Memphis, TN-MS-AR
    BATES2606026MISSOURI28140Kansas City, MO-KS
    CALDWELL2612026MISSOURI28140Kansas City, MO-KS
    CALLAWAY2613026MISSOURI27620Jefferson City, MO
    COLE2625026MISSOURI27620Jefferson City, MO
    CRAWFORD2627026MISSOURI41180St. Louis, MO-IL
    DALLAS2629026MISSOURI44180Springfield, MO
    DE KALB2631026MISSOURI41140St. Joseph, MO-KS
    HOWARD2644026MISSOURI17860Columbia, MO
    MC DONALD2659026MISSOURI22220Fayetteville-Springdale-Rogers, AR-MO
    MONITEAU2667026MISSOURI27620Jefferson City, MO
    OSAGE2675026MISSOURI27620Jefferson City, MO
    POLK2682126MISSOURI44180Springfield, MO
    WASHINGTON2699226MISSOURI41180St. Louis, MO-IL
    CARBON2704027MONTANA13740Billings, MT
    DIXON2825028NEBRASKA43580Sioux City, IA-NE-SD
    SAUNDERS2877028NEBRASKA36540Omaha-Council Bluffs, NE-IA
    SEWARD2879028NEBRASKA30700Lincoln, NE
    STOREY2914029NEVADA39900Reno-Sparks, NV
    CARSON CITY2912029NEVADA16180Carson City, NV
    SAN JUAN3222032NEW MEXICO22140Farmington, NM
    TORRANCE3228032NEW MEXICO10740Albuquerque, NM
    TOMPKINS3373033NEW YORK27060Ithaca, NY
    ULSTER3374033NEW YORK28740Kingston, NY
    ANSON3403034NORTH CAROLINA16740Charlotte-Gastonia-Concord, NC-SC
    GREENE3439034NORTH CAROLINA24780Greenville, NC
    Start Printed Page 22455
    HAYWOOD3443034NORTH CAROLINA11700Asheville, NC
    HENDERSON3444034NORTH CAROLINA11700Asheville, NC
    HOKE3446034NORTH CAROLINA22180Fayetteville, NC
    PENDER3470034NORTH CAROLINA48900Wilmington, NC
    PERSON3472034NORTH CAROLINA20500Durham, NC
    ROCKINGHAM3478034NORTH CAROLINA24660Greensboro-High Point, NC
    ERIE3622036OHIO41780Sandusky, OH
    MORROW3660036OHIO18140Columbus, OH
    OTTAWA3663036OHIO45780Toledo, OH
    PREBLE3669036OHIO19380Dayton, OH
    UNION3681036OHIO18140Columbus, OH
    GRADY3725037OKLAHOMA36420Oklahoma City, OK
    LE FLORE3739037OKLAHOMA22900Fort Smith, AR-OK
    LINCOLN3740037OKLAHOMA36420Oklahoma City, OK
    OKMULGEE3755037OKLAHOMA46140Tulsa, OK
    PAWNEE3758037OKLAHOMA46140Tulsa, OK
    DESCHUTES3808038OREGON13460Bend, OR
    ARMSTRONG3907039PENNSYLVANIA38300Pittsburgh, PA
    CALHOUN4208042SOUTH CAROLINA17900Columbia, SC
    DARLINGTON4215042SOUTH CAROLINA22500Florence, SC
    FAIRFIELD4219042SOUTH CAROLINA17900Columbia, SC
    KERSHAW4227042SOUTH CAROLINA17900Columbia, SC
    LAURENS4229042SOUTH CAROLINA24860Greenville, SC
    SALUDA4240042SOUTH CAROLINA17900Columbia, SC
    MC COOK4343043SOUTH DAKOTA43620Sioux Falls, SD
    MEADE4346043SOUTH DAKOTA39660Rapid City, SD
    TURNER4362043SOUTH DAKOTA43620Sioux Falls, SD
    UNION4363043SOUTH DAKOTA43580Sioux City, IA-NE-SD
    BRADLEY4405044TENNESSEE17420Cleveland, TN
    CANNON4407044TENNESSEE34980Nashville-Davidson—Murfreesboro, TN
    GRAINGER4428044TENNESSEE34100Morristown, TN
    HAMBLEN4431044TENNESSEE34100Morristown, TN
    HICKMAN4440044TENNESSEE34980Nashville-Davidson—Murfreesboro, TN
    JEFFERSON4444044TENNESSEE34100Morristown, TN
    MACON4455044TENNESSEE34980Nashville-Davidson—Murfreesboro, TN
    POLK4469044TENNESSEE17420Cleveland, TN
    SEQUATCHIE4476044TENNESSEE16860Chattanooga, TN-GA
    SMITH4479044TENNESSEE34980Nashville-Davidson—Murfreesboro, TN
    STEWART4480044TENNESSEE17300Clarksville, TN-KY
    TROUSDALE4484044TENNESSEE34980Nashville-Davidson—Murfreesboro, TN
    ARANSAS4503045TEXAS18580Corpus Christi, TX
    ARMSTRONG4505045TEXAS11100Amarillo, TX
    ATASCOSA4506045TEXAS41700San Antonio, TX
    AUSTIN4507045TEXAS26420Houston-Baytown-Sugar Land, TX
    BANDERA4509045TEXAS41700San Antonio, TX
    BURLESON4522145TEXAS17780College Station-Bryan, TX
    CALHOUN4522445TEXAS47020Victoria, TX
    CALLAHAN4523045TEXAS10180Abilene, TX
    CARSON4525145TEXAS11100Amarillo, TX
    CLAY4529145TEXAS48660Wichita Falls, TX
    CROSBY4536245TEXAS31180Lubbock, TX
    DELTA4540045TEXAS19124Dallas-Plano-Irving, TX
    GOLIAD4556145TEXAS47020Victoria, TX
    IRION4567245TEXAS41660San Angelo, TX
    JONES4572145TEXAS10180Abilene, TX
    KENDALL4573145TEXAS41700San Antonio, TX
    LAMPASAS4575245TEXAS28660Killeen-Temple-Fort Hood, TX
    MEDINA4579245TEXAS41700San Antonio, TX
    ROBERTSON4587845TEXAS17780College Station-Bryan, TX
    RUSK4588145TEXAS30980Longview, TX
    SAN JACINTO4588445TEXAS26420Houston-Baytown-Sugar Land, TX
    WISE4597345TEXAS23104Fort Worth-Arlington, TX
    CACHE4602046UTAH30860Logan, UT-ID
    JUAB4611046UTAH39340Provo-Orem, UT
    MORGAN4614046UTAH36260Ogden-Clearfield, UT
    Start Printed Page 22456
    SUMMIT4621046UTAH41620Salt Lake City, UT
    TOOELE4622046UTAH41620Salt Lake City, UT
    WASHINGTON4626046UTAH41100St. George, UT
    AMELIA4903049VIRGINIA40060Richmond, VA
    APPOMATTOX4905049VIRGINIA31340Lynchburg, VA
    CAROLINE4916049VIRGINIA40060Richmond, VA
    CRAIG4922049VIRGINIA40220Roanoke, VA
    CUMBERLAND4924049VIRGINIA40060Richmond, VA
    FRANKLIN4933049VIRGINIA40220Roanoke, VA
    FREDERICK4934049VIRGINIA49020Winchester, VA-WV
    GILES4935049VIRGINIA13980Blacksburg-Christiansburg-Radford, VA
    KING AND QUEEN4948049VIRGINIA40060Richmond, VA
    KING WILLIAM4950049VIRGINIA40060Richmond, VA
    LOUISA4954049VIRGINIA40060Richmond, VA
    MONTGOMERY4960049VIRGINIA13980Blacksburg-Christiansburg-Radford, VA
    NELSON4962049VIRGINIA16820Charlottesville, VA
    PULASKI4977049VIRGINIA13980Blacksburg-Christiansburg-Radford, VA
    ROCKINGHAM4982049VIRGINIA25500Harrisonburg, VA
    SURRY4990049VIRGINIA47260Virginia Beach-Norfolk-Newport News, VA
    SUSSEX4991049VIRGINIA40060Richmond, VA
    HARRISONBURG CITY4942149VIRGINIA25500Harrisonburg, VA
    RADFORD CITY4977149VIRGINIA13980Blacksburg-Christiansburg-Radford, VA
    WINCHESTER CITY4996249VIRGINIA49020Winchester, VA-WV
    ASOTIN5001050WASHINGTON30300Lewiston, ID-WA
    CHELAN5003050WASHINGTON48300Wenatchee, WA
    COWLITZ5007050WASHINGTON31020Longview, WA
    DOUGLAS5008050WASHINGTON48300Wenatchee, WA
    SKAGIT5028050WASHINGTON34580Mount Vernon-Anacortes, WA a
    SKAMANIA5029050WASHINGTON38900Portland-Vancouver-Beaverton, OR-WA
    BOONE5102051WEST VIRGINIA16620Charleston, WV
    CLAY5107051WEST VIRGINIA16620Charleston, WV
    HAMPSHIRE5113051WEST VIRGINIA49020Winchester, VA-WV
    LINCOLN5121051WEST VIRGINIA16620Charleston, WV
    MONONGALIA5130051WEST VIRGINIA34060Morgantown, WV
    MORGAN5132051WEST VIRGINIA25180Hagerstown-Martinsburg, MD-WV
    PLEASANTS5136051WEST VIRGINIA37620Parkersburg-Marietta, WV-OH
    PRESTON5138051WEST VIRGINIA34060Morgantown, WV
    WIRT5152051WEST VIRGINIA37620Parkersburg-Marietta, WV-OH
    COLUMBIA5210052WISCONSIN31540Madison, WI
    FOND DU LAC5219052WISCONSIN22540Fond du Lac, WI
    IOWA5224052WISCONSIN31540Madison, WI
    KEWAUNEE5230052WISCONSIN24580Green Bay, WI
    OCONTO5241052WISCONSIN24580Green Bay, WI
    AIBONITO4005040PUERTO RICO41980San Juan-Caguas-Guaynabo, PR
    ARROYO4008040PUERTO RICO25020Guayama, PR
    BARRANQUITAS4010040PUERTO RICO41980San Juan-Caguas-Guaynabo, PR
    CIALES4019040PUERTO RICO41980San Juan-Caguas-Guaynabo, PR
    GUANICA4027040PUERTO RICO49500Yauco, PR
    GUAYAMA4028040PUERTO RICO25020Guayama, PR
    ISABELA4035040PUERTO RICO10380Aguadilla-Isabela-San Sebastian, PR
    LAJAS4039040PUERTO RICO41900San German-Cabo Rojo, PR
    LARES4040040PUERTO RICO10380Aguadilla-Isabela-San Sebastian, PR
    MAUNABO4047040PUERTO RICO41980San Juan-Caguas-Guaynabo, PR
    OROCOVIS4053040PUERTO RICO41980San Juan-Caguas-Guaynabo, PR
    PATILLAS4054040PUERTO RICO25020Guayama, PR
    QUEBRADILLAS4057040PUERTO RICO41980San Juan-Caguas-Guaynabo, PR
    RINCON4058040PUERTO RICO10380Aguadilla-Isabela-San Sebastian, PR
    SAN SEBASTIAN4066040PUERTO RICO10380Aguadilla-Isabela-San Sebastian, PR
    Start Printed Page 22457

    Table F.—Crosswalk of Counties by State From MSA to CBSA

    County nameStateState county codeMSA codeMSA nameCBSA codeCBSA name
    AUTAUGAAL010005240MONTGOMERY, AL33860Montgomery, AL
    BALDWINAL010105160MOBILE, AL*
    BARBOURAL0102001ALABAMA*
    BIBBAL0103001ALABAMA13820Birmingham-Hoover, AL
    BLOUNTAL010401000BIRMINGHAM, AL13820Birmingham-Hoover, AL
    BULLOCKAL0105001ALABAMA*
    BUTLERAL0106001ALABAMA*
    CALHOUNAL010700450ANNISTON, AL11500Anniston-Oxford, AL
    CHAMBERSAL0108001ALABAMA*
    CHEROKEEAL0109001ALABAMA
    CHILTONAL0110001ALABAMA13820Birmingham-Hoover, AL
    CHOCTAWAL0111001ALABAMA*
    CLARKEAL0112001ALABAMA*
    CLAYAL0113001ALABAMA*
    CLEBURNEAL0114001ALABAMA*
    COFFEEAL0115001ALABAMA*
    COLBERTAL011602650FLORENCE, AL22520Florence-Muscle Shoals, AL
    CONECUHAL0117001ALABAMA*
    COOSAAL0118001ALABAMA*
    COVINGTONAL0119001ALABAMA*
    CRENSHAWAL0120001ALABAMA*
    CULLMANAL0121001ALABAMA*
    DALEAL012202180DOTHAN, AL*
    DALLASAL0123001ALABAMA*
    DE KALBAL0124001ALABAMA*
    ELMOREAL012505240MONTGOMERY, AL33860Montgomery, AL
    ESCAMBIAAL0126001ALABAMA*
    ETOWAHAL012702880GADSDEN, AL23460Gadsden, AL
    FAYETTEAL0128001ALABAMA*
    FRANKLINAL0129001ALABAMA*
    GENEVAAL0130001ALABAMA20020Dothan, AL
    GREENEAL0131001ALABAMA46220Tuscaloosa, AL
    HALEAL0132001ALABAMA46220Tuscaloosa, AL
    HENRYAL0133001ALABAMA20020Dothan, AL
    HOUSTONAL013402180DOTHAN, AL20020Dothan, AL
    JACKSONAL0135001ALABAMA*
    JEFFERSONAL013601000BIRMINGHAM, AL13820Birmingham-Hoover, AL
    LAMARAL0137001ALABAMA*
    LAUDERDALEAL013802650FLORENCE, AL22520Florence-Muscle Shoals, AL
    LAWRENCEAL013902030DECATUR, AL19460Decatur, AL
    LEEAL014000580AUBURN-OPELIKA, AL12220Auburn-Opelika, AL
    LIMESTONEAL014103440HUNTSVILLE, AL26620Huntsville, AL
    LOWNDESAL0142001ALABAMA33860Montgomery, AL
    MACONAL0143001ALABAMA*
    MADISONAL014403440HUNTSVILLE, AL26620Huntsville, AL
    MARENGOAL0145001ALABAMA*
    MARIONAL0146001ALABAMA*
    MARSHALLAL0147001ALABAMA*
    MOBILEAL014805160MOBILE, AL33660Mobile, AL
    MONROEAL0149001ALABAMA*
    MONTGOMERYAL015005240MONTGOMERY, AL33860Montgomery, AL
    MORGANAL015102030DECATUR, AL19460Decatur, AL
    PERRYAL0152001ALABAMA*
    PICKENSAL0153001ALABAMA*
    PIKEAL0154001ALABAMA*
    RANDOLPHAL0155001ALABAMA
    RUSSELLAL015601800COLUMBUS, GA-AL17980Columbus, GA-AL
    ST. CLAIRAL015701000BIRMINGHAM, AL13820Birmingham-Hoover, AL
    SHELBYAL015801000BIRMINGHAM, AL13820Birmingham-Hoover, AL
    SUMTERAL0159001ALABAMA*
    TALLADEGAAL0160001ALABAMA*
    TALLAPOOSAAL0161001ALABAMA*
    TUSCALOOSAAL016208600TUSCALOOSA, AL46220Tuscaloosa, AL
    WALKERAL0163001ALABAMA13820Birmingham-Hoover, AL
    WASHINGTONAL0164001ALABAMA*
    WILCOXAL0165001ALABAMA*
    WINSTONAL0166001ALABAMA*
    STATEWIDEAL0199901ALABAMA*
    ALEUTIANS EASTAK0201302ALASKA*
    ALEUTIANS WESTAK0201602ALASKA*
    Start Printed Page 22458
    ANCHORAGEAK020200380ANCHORAGE,AK11260Anchorage, AK
    ANGOONAK0203002ALASKA*
    BARROW-NORTH SLOPEAK0204002ALASKA*
    BETHELAK0205002ALASKA*
    BRISTOL BAY BOROUGHAK0206002ALASKA*
    DENALIAK0206802ALASKA*
    DILLINGHAMAK0207002ALASKA*
    CORDOVA-MCCARTHYAK0208002ALASKA*
    FAIRBANKS NORTH STARAK0209002ALASKA21820Fairbanks, AK
    HAINESAK0210002ALASKA*
    JUNEAUAK0211002ALASKA*
    KENAI-COOK INLETAK0212002ALASKA*
    KENAI PENINSULAAK0212202ALASKA*
    KETCHIKAN GATEWAYAK0213002ALASKA*
    KOBUKAK0214002ALASKA*
    KODIAK ISLAND BOROUGHAK0215002ALASKA*
    KSUKOKWINAK0216002ALASKA*
    LAKE AND PENINSULAAK0216402ALASKA*
    MATANUSKA-SUSITNAAK0217002ALASKA11260Anchorage, AK
    NOMEAK0218002ALASKA*
    NORTH SLOPE BOROUHAK0218502ALASKA*
    NORTHWEST ARTIC BOROUGHAK0218802ALASKA*
    OUTER KETCHIKANAK0219002ALASKA*
    PR.OF WALESAK0220002ALASKA*
    PR.OF WALES-OUT.KETCHIKANAK0220102ALASKA*
    SEWARDAK0221002ALASKA*
    SITKA BOROUGHAK0222002ALASKA*
    SKAGWAY-YAKUTATAK0223002ALASKA*
    SKAGWAY-YAKUTAT-ANGOONAK0223102ALASKA*
    SKAGWAY-HOONAH-ANGOONAK0223202ALASKA*
    SOUTHEAST FAIRBANKSAK0224002ALASKA*
    UPPER YUKONAK0225002ALASKA*
    VALDEZ-CHITNA-WHITTIERAK0226002ALASKA*
    VALDEZ-CORDOVAAK0226102ALASKA*
    WADE HAMPTONAK0227002ALASKA*
    WRANGELL-PETERSBURGAK0228002ALASKA*
    YAKUTAT BOROUGHAK0228202ALASKA*
    YUKON-KOYUKUKAK0229002ALASKA*
    STATEWIDEAK0299902ALASKA*
    APACHEAZ0300003ARIZONA*
    COCHISEAZ0301003ARIZONA*
    COCONINOAZ030202620FLAGSTAFF, ARIZONA-UTAH22380Flagstaff, AZ
    GILAAZ0303003ARIZONA*
    GRAHAMAZ0304003ARIZONA*
    GREENLEEAZ0305003ARIZONA*
    LAPAZAZ0305503ARIZONA*
    MARICOPAAZ030606200PHOENIX-MESA, AZ38060Phoenix-Mesa-Scottsdale, AZ
    MOHAVEAZ030704120LAS VEGAS, NV-AZ*
    NAVAJOAZ0308003ARIZONA*
    PIMAAZ030908520TUCSON, AZ46060Tucson, AZ
    PINALAZ031006200PHOENIX-MESA, AZ38060Phoenix-Mesa-Scottsdale, AZ
    SANTA CRUZAZ0311003ARIZONA*
    YAVAPAIAZ0312003ARIZONA39140Prescott, AZ
    YUMAAZ031309360YUMA, AZ49740Yuma, AZ
    STATEWIDEAZ0399903ARIZONA*
    ARKANSASAR0400004ARKANSAS*
    ASHLEYAR0401004ARKANSAS*
    BAXTERAR0402004ARKANSAS*
    BENTONAR040302580FAYETTEVILLE-SPRINGDALE-ROGERS, AR22220Fayetteville-Springdale-Rogers, AR-MO
    BOONEAR0404004ARKANSAS*
    BRADLEYAR0405004ARKANSAS*
    CALHOUNAR0406004ARKANSAS*
    CARROLLAR0407004ARKANSAS*
    CHICOTAR0408004ARKANSAS*
    CLARKAR0409004ARKANSAS*
    Start Printed Page 22459
    CLAYAR0410004ARKANSAS*
    CLEBURNEAR0411004ARKANSAS*
    CLEVELANDAR0412004ARKANSAS38220Pine Bluff, AR
    COLUMBIAAR0413004ARKANSAS*
    CONWAYAR0414004ARKANSAS*
    CRAIGHEADAR041503700JONESBORO, AR27860Jonesboro, AR
    CRAWFORDAR041602720FORT SMITH, AR-OK22900Fort Smith, AR-OK
    CRITTENDENAR041704920MEMPHIS, TN-AR-MS32820Memphis, TN-MS-AR
    CROSSAR0418004ARKANSAS*
    DALLASAR0419004ARKANSAS*
    DESHAAR0420004ARKANSAS*
    DREWAR0421004ARKANSAS*
    FAULKNERAR042204400LITTLE ROCK-NORTH LITTLE ROCK, AR30780Little Rock-North Little Rock, AR
    FRANKLINAR0423004ARKANSAS22900Fort Smith, AR-OK
    FULTONAR0424004ARKANSAS
    GARLANDAR0425004ARKANSAS26300Hot Springs, AR
    GRANTAR0426004ARKANSAS30780Little Rock-North Little Rock, AR
    GREENEAR0427004ARKANSAS*
    HEMPSTEADAR0428004ARKANSAS*
    HOT SPRINGAR0429004ARKANSAS*
    HOWARDAR0430004ARKANSAS*
    INDEPENDENCEAR0431004ARKANSAS*
    IZARDAR0432004ARKANSAS*
    JACKSONAR0433004ARKANSAS*
    JEFFERSONAR043406240PINE BLUFF, AR38220Pine Bluff, AR
    JOHNSONAR0435004ARKANSAS*
    LAFAYETTEAR0436004ARKANSAS*
    LAWRENCEAR0437004ARKANSAS*
    LEEAR0438004ARKANSAS*
    LINCOLNAR0439004ARKANSAS38220Pine Bluff, AR
    LITTLE RIVERAR0440004ARKANSAS*
    LOGANAR0441004ARKANSAS*
    LONOKEAR044204400LITTLE ROCK-NORTH LITTLE ROCK, AR30780Little Rock-North Little Rock, AR
    MADISONAR0443004ARKANSAS22220Fayetteville-Springdale-Rogers, AR-MO
    MARIONAR0444004ARKANSAS*
    MILLERAR044508360TEXARKANA, TX-TEXARKANA, AR45500Texarkana, TX-Texarkana, AR
    MISSISSIPPIAR0446004ARKANSAS*
    MONROEAR0447004ARKANSAS*
    MONTGOMERYAR0448004ARKANSAS*
    NEVADAAR0449004ARKANSAS*
    NEWTONAR0450004ARKANSAS*
    OUACHITAAR0451004ARKANSAS*
    PERRYAR0452004ARKANSAS30780Little Rock-North Little Rock, AR
    PHILLIPSAR0453004ARKANSAS*
    PIKEAR0454004ARKANSAS*
    POINSETTAR0455004ARKANSAS27860Jonesboro, AR
    POLKAR0456004ARKANSAS*
    POPEAR0457004ARKANSAS*
    PRAIRIEAR0458004ARKANSAS*
    PULASKIAR045904400LITTLE ROCK-NORTH LITTLE ROCK, AR30780Little Rock-North Little Rock, AR
    RANDOLPHAR0460004ARKANSAS*
    ST. FRANCISAR0461004ARKANSAS*
    SALINEAR046204400LITTLE ROCK-NORTH LITTLE ROCK, AR30780Little Rock-North Little Rock, AR
    SCOTTAR0463004ARKANSAS*
    SEARCYAR0464004ARKANSAS*
    SEBASTIANAR046502720FORT SMITH, AR-OK22900Fort Smith, AR-OK
    SEVIERAR0466004ARKANSAS*
    SHARPAR0467004ARKANSAS*
    STONEAR0468004ARKANSAS*
    UNIONAR0469004ARKANSAS*
    VAN BURENAR0470004ARKANSAS*
    WASHINGTONAR047102580FAYETTEVILLE-SPRINGDALE-ROGERS, AR22220Fayetteville-Springdale-Rogers, AR-MO
    Start Printed Page 22460
    WHITEAR0472004ARKANSAS*
    WOODRUFFAR0473004ARKANSAS*
    YELLAR0474004ARKANSAS*
    STATEWIDEAR0499904ARKANSAS*
    ALAMEDACA050005775OAKLAND, CA36084Oakland-Fremont-Hayward, CA
    ALPINECA0501005CALIFORNIA*
    AMADORCA0502005CALIFORNIA*
    BUTTECA050301620CHICO-PARADISE, CA17020Chico, CA
    CALAVERASCA0504005CALIFORNIA*
    COLUSACA0505005CALIFORNIA*
    CONTRA COSTACA050605775OAKLAND, CA36084Oakland-Fremont-Hayward, CA
    DEL NORTECA0507005CALIFORNIA*
    EL DORADOCA050806920SACRAMENTO, CA40900Sacramento-Arden-Arcade-Roseville, CA
    FRESNOCA050902840FRESNO, CA23420Fresno, CA
    GLENNCA0510005CALIFORNIA*
    HUMBOLDTCA0511005CALIFORNIA*
    IMPERIALCA0512005CALIFORNIA20940El Centro, CA
    INYOCA0513005CALIFORNIA*
    KERNCA051400680BAKERSFIELD, CA12540Bakersfield, CA
    KINGSCA0515005CALIFORNIA25260Hanford-Corcoran, CA
    LAKECA0516005CALIFORNIA*
    LASSENCA0517005CALIFORNIA*
    LOS ANGELESCA052004480LOS ANGELES-LONG BEACH, CA31084Los Angeles-Long Beach-Santa Ana, CA
    LOS ANGELESCA052104480LOS ANGELES-LONG BEACH, CA31084Los Angeles-Long Beach-Santa Ana, CA
    MADERACA053002840FRESNO, CA31460Madera, CA
    MARINCA053107360SAN FRANCISCO, CA41884San Francisco-San Mateo-Redwood City, CA
    MARIPOSACA0532005CALIFORNIA*
    MENDOCINOCA0533005CALIFORNIA*
    MERCEDCA053404940MERCED, CA32900Merced, CA
    MODOCCA0535005CALIFORNIA*
    MONOCA0536005CALIFORNIA*
    MONTEREYCA053707120SALINAS, CA41500Salinas, CA
    NAPACA053808720VALLEJO-FAIRFIELD-NAPA, CA34900Napa, CA
    NEVADACA0539005CALIFORNIA*
    ORANGECA054005945ORANGE COUNTY, CA42044Santa Ana-Anaheim-Irvine, CA
    PLACERCA054106920SACRAMENTO, CA40900Sacramento—Arden-Arcade—Roseville, CA
    PLUMASCA0542005CALIFORNIA*
    RIVERSIDECA054306780RIVERSIDE-SAN BERNARDINO, CA40140Riverside-San Bernardino-Ontario, CA
    SACRAMENTOCA054406920SACRAMENTO, CA40900Sacramento—Arden-Arcade—Roseville, CA
    SAN BENITOCA0545005CALIFORNIA41940San Jose-Sunnyvale-Santa Clara, CA
    SAN BERNARDINOCA054606780RIVERSIDE-SAN BERNARDINO, CA40140Riverside-San Bernardino-Ontario, CA
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    Start Printed Page 22488
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    Start Printed Page 22489
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    Start Printed Page 22494
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    Start Printed Page 22495
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    Start Printed Page 22496
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    Start Printed Page 22497
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    Start Printed Page 22501
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    Start Printed Page 22502
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    Start Printed Page 22503
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    Start Printed Page 22504
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    Start Printed Page 22505
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    Start Printed Page 22506
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    Start Printed Page 22507
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    Start Printed Page 22508
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    Start Printed Page 22509
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    *Rural designation.
    End Part End Supplemental Information

    [FR Doc. 05-8387 Filed 4-22-05; 2:58 pm]

    BILLING CODE 4120-03-P

Document Information

Published:
04/29/2005
Department:
Centers for Medicare & Medicaid Services
Entry Type:
Proposed Rule
Action:
Proposed rule.
Document Number:
05-8387
Dates:
To be assured consideration, comments must be received at one of
Pages:
22393-22510 (118 pages)
Docket Numbers:
CMS-1286-P
RINs:
0938-AN89
Topics:
Health facilities, Hospice care, Medicare, Reporting and recordkeeping requirements
PDF File:
05-8387.pdf
CFR: (4)
42 CFR 418.3
42 CFR 418.22
42 CFR 418.302
42 CFR 418.304