[Federal Register Volume 62, Number 126 (Tuesday, July 1, 1997)]
[Notices]
[Pages 35608-35634]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-17235]
[[Page 35607]]
_______________________________________________________________________
Part V
Department of Health and Human Services
_______________________________________________________________________
Health Care Financing Administration
_______________________________________________________________________
Medicare Program; Schedule of Limits on Home Health Agency Costs Per
Visit for Cost Reporting Periods Beginning on or After July 1, 1997;
Notice
Federal Register / Vol. 62, No. 126 / Tuesday, July 1, 1997 /
Notices
[[Page 35608]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[BPD-889-NC]
RIN 0938-AH88
Medicare Program; Schedule of Limits on Home Health Agency Costs
Per Visit for Cost Reporting Periods Beginning on or After July 1, 1997
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Notice with comment Period.
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SUMMARY: This notice sets forth a revised schedule of limits on home
health agency costs that may be paid under the Medicare program for
cost reporting periods beginning on or after July 1, 1997. These limits
replace the per visit limits that were set forth in our July 1, 1996
notice with comment period (61 FR 34344). This notice also responds to
comments on the July 1, 1996 notice.
DATES: Effective Date: The schedule of limits is effective for cost
reporting periods beginning on or after July 1, 1997.
Comment Period: Written comments will be considered if we receive
them at the appropriate address, as provided below, no later than 5
p.m. on September 2, 1997.
ADDRESSES: Mail written comments (one original and three copies) to the
following address: Health Care Financing Administration, Department of
Health and Human Services, Attention: BPD-889-NC, P.O. Box 7517,
Baltimore, Maryland 21207-0517.
If you prefer, you may deliver your written comments (one original
and three copies) to one of the following addresses:
Room 309-G, Hubert H. Humphrey Building, 00 Independence Avenue, SW,
Washington, D.C. 20201, or
Room C5-09-26, Central Building 7500 Security Boulevard Baltimore,
Maryland 21244-1850.
Comments may also be submitted electronically to the following e-
mail address: [email protected] E-mail comments must include the
full name and address of the sender and must be submitted to the
referenced address in order to be considered. All comments must be
incorporated in the e-mail message because we may not be able to access
attachments. Electronically submitted comments will be available for
public inspection at the Independence Avenue address below.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code BPD-889-NC. Comments received timely will be available for
public inspection as they are received, generally beginning
approximately 3 weeks after publication of a document, in Room 309-G of
the Department's offices at 200 Independence Avenue, SW, Washington,
DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m.
(Phone: (202) 690-7890).
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FOR FURTHER INFORMATION CONTACT: Michael Bussacca, (410) 786-4602.
SUPPLEMENTARY INFORMATION:
I. Background
Section 1861(v)(1)(A) of the Social Security Act (the Act)
authorizes the Secretary to establish limits on allowable costs
incurred by a provider of services that may be paid under the Medicare
program, based on estimates of the costs necessary in the efficient
delivery of needed health services. Under this authority, we have
maintained limits on home health agency (HHA) per-visit costs since
1979. The limits may be applied to direct or indirect overall costs or
to the costs incurred for specific items or services furnished by the
provider. Implementing regulations are located at 42 CFR 413.30.
Additional statutory provisions specifically governing the limits
applicable to HHAs are contained at section 1861(v)(1)(L) of the Act.
Section 1861(v)(1)(L)(i) of the Act specifies that the cost limits are
not to exceed 112 percent of the mean of the labor-related and nonlabor
per-visit costs for freestanding HHAs. Section 1861(v)(1)(L)(iii) of
the Act requires that the Secretary establish HHA cost limits on an
annual basis for cost reporting periods beginning on or after July 1 of
each year (except for cost reporting periods beginning on or after July
1, 1994, and before July 1, 1996). In establishing these limits, the
Act directs the Secretary to use the applicable hospital wage index, as
discussed below.
On July 1, 1996, we published in the Federal Register (61 FR 34344)
a notice with comment period that set forth a revised schedule of
limits on HHA costs that may be paid under the Medicare program for
cost reporting periods beginning on or after July 1, 1996. These limits
replaced the per-visit limits that were set forth in our February 14,
1995 notice with comment period (60 FR 8389). The July 1, 1996 limits
were computed using the actual cost-per-visit data from cost reporting
periods ending on or after June 30, 1991, and settled by October 1,
1995, and were adjusted by later estimates in the ``market basket''
index to reflect changes in the prices of goods and services furnished
by HHAs.
This notice with comment period sets forth revised cost limits for
cost reporting periods beginning on or after July 1, 1997. As required
by section 1861(v)(1)(L)(iii) of the Act, we are using the area wage
index applicable under section 1886(d)(3)(E) of the Act determined
using the survey of the most recent available wages and wage-related
costs of hospitals located in the geographic area in which the HHA is
located. For purposes of this notice, the HHA wage index is based on
the most recent hospital wage index, that is, the hospital wage index
effective for hospital discharges on or after October 1, 1996, which
uses Federal fiscal year (FY) 1993 wage data. As the statute also
specifies, in applying the hospital wage index to HHAs, no adjustments
are to be made to account for hospital reclassifications under section
1886(d)(8)(B) of the Act, decisions of the Medicare Geographic
Classification Review Board (MGCRB) under section
[[Page 35609]]
1886(d)(10) of the Act, or decisions by the Secretary.
II. Analysis of and Response to Public Comments
We received 28 items of timely correspondence on the July 1, 1996
notice with comment period. A summary of these comments and our
responses are discussed below.
Comment: One commenter suggested that an HHA based in a hospital
that has been redesignated by the MGCRB should be allowed to use the
same wage index as that used by the parent hospital.
Response: Section 1861(v)(1)(L)(iii) of the Social Security Act
requires us to use the wage index used for hospitals under the
inpatient hospital prospective payment system (PPS) using the survey of
the most recent available wages and wage-related costs of hospitals
located in the geographic area in which the HHA is located, determined
without regard to whether the hospitals have been reclassified to a new
geographic area. Given this explicit statutory requirement, the wage
index value for an area cannot reflect any redesignations by the MGCRB.
Comment: A number of commenters raised concerns regarding the
budget neutrality factor of 0.91, included in the July 1, 1996 notice
and its effect on the July 1, 1996 schedule of limits. They indicated
that the decrease in the budget neutrality factor, from 1.067, for the
limits effective July 1, 1993, to 0.91 for the cost limits effective
July 1, 1996, failed to account for industry growth and growing labor
costs. Commenters also expressed concern that this decrease would
create a reduction in cost limits that could threaten the quality of
services HHAs can affordably provide, especially in rural areas.
Response: Subsequent to the publication of the July 1, 1996
schedule of limits, we identified several errors in the data that were
used to calculate the budget neutrality factor of 0.91 in the July 1,
1996 notice. In order to ensure the accuracy of the factor, we
conducted an exhaustive review of all the data used in the calculation
of the 1996 limits. Based on corrected data, we have revised the budget
neutrality factor to be 1.078. Our fiscal intermediaries have been
directed, in Program Memorandum A-96-11, November 1996, to use this
revised factor in limits calculations for all cost reporting periods
beginning on or after July 1, 1996. Since the previous factor, in the
limits effective July 1, 1993, had a value of 1.067, the revised budget
neutrality factor of 1.078 had no substantial effect on the July 1,
1996 schedule of limits applied to any agency.
Comment: One commenter suggested that the limits take into account
the special circumstances of rural home health agencies.
Response: The July 1, 1996 limits were based on the latest
available settled cost reports. In calculating the limits, we
determined the average cost per visit for urban and rural agencies
separately. Therefore, the limits applied to rural HHAs are based on
the actual operating and cost experience of rural agencies, and are
reflective of the circumstances unique to an agency operating in a
rural area.
Comment: One commenter recommended that the wage index used in the
July 1, 1996 schedule of limits be that used in the hospital
prospective payment system that was effective on October 1, 1996.
Response: Section 1861(v)(1)(L)(iii) of the Act requires us to use
the area wage index applicable under section 1886(d)(3)(E) of the Act
determined using the survey of the most recent available wages and
wage-related costs of hospitals located in the geographic area in which
the HHA is located. Accordingly, in our July 1, 1996 notice, the HHA
wage index was based on the most recent hospital wage index at that
time, which was the index effective for hospital discharges on or after
October 1, 1995.
Comment: One commenter suggested that we include in our Federal
Register notices and the public use data file more details and
information on the methodology and data used in calculating the limits.
Response: In each of the Federal Register notices we have published
since 1979, we have striven to provide all of the information necessary
for the public to understand the reason and basis for our policies. At
the same time, we try to avoid dense and highly technical discussions
that would be of interest to few readers and that might be found to be
confusing or perceived as obfuscatory. We are always open to
suggestions on the adequacy of the information provided in the notices.
In response to the commenter, in this 1997 notice, we are providing
additional information on the assumptions used in computing the budget
neutrality adjustment. We will attempt to include more technical
details in future notices. We are also amenable to including additional
data items in the public use data file, and will expand this file as
requested.
Comment: Commenters wanted assurance that the effect of an increase
in the minimum wage had been considered when the forecast of the HHA
market basket was made for the July 1, 1996 schedule of limits.
Response: Public Law 104-188 signed on August 20, 1996, raised the
minimum wage of $4.25 per hour by $0.50 per hour in October 1996 to
$4.75 per hour, and an additional $0.40 per hour in September 1997 to
$5.15 per hour. The HHA input price index is a national, not a
regional, measure of price changes in a ``market basket'' reflecting
the inputs used by HHAs in providing covered home health services. The
forecast used for the HHA market basket in the July 1, 1996 notice did
reflect anticipated increases in the minimum wage, although the timing
and magnitude of the changes were different than those of the actual
legislated increases, enacted after the July 1, 1996 notice. There are
two areas where minimum wage increases can impact on the HHA market
basket. Each of these areas is discussed in detail below.
One area where an increase in the minimum wage can have an impact
on the HHA input price index is the annual percent increase of that
index. The impact of a minimum wage increase is reflected in the HHA
input price index as a ``one-time'' increase in the growth rate that is
distributed over time in a lagged manner. The increase is distributed
over time because of the two-step increase in the minimum wage, the use
of four-quarter moving-average percent changes, and the delayed
response by some firms to increased wages of employees that are
currently slightly above the new minimum. The minimum wage increase is
reflected in: (1) The price proxies for compensation of workers in the
HHA input price index, which are the five Employment Cost Indexes (ECI)
for each of the occupational categories; and (2) the noncompensation
price proxies as secondary impacts where labor is used in an earlier
stage of processing.
DRI/McGraw-Hill, under contract with HCFA to forecast the HHA
index, includes increases in the minimum wage in its macroeconomic
forecast assumptions. The increase in the minimum wage is incorporated
in the DRI models used to establish the economy-wide profile, as well
as the profile for individual occupations and sectors, for wages,
salaries, benefits, and noncompensation price inflation used in the HHA
input price index. While the inclusion of the minimum wage increases
directly affects the wage price proxy (five ECIs for the occupational
groupings) in the HHA input price index, it also indirectly affects the
growth of other nonlabor cost input
[[Page 35610]]
proxies in a lesser manner through a stages-of-processing methodology.
The first quarter 1996 DRI/McGraw-Hill forecast was used to
determine the HHA input price increases in the July 1, 1996 notice. In
its first quarter 1996 forecast, DRI anticipated minimum wage increases
in 1997 and 1998, and included its expectations in the model at that
time. When DRI made its first quarter 1996 forecast in March 1996, it
expected minimum wage increases of $0.45 per hour in April 1997 and an
additional $0.10 per hour in April 1998. These expectations contributed
to an increase in the HHA input price index growth rate between the
second quarter of 1997 and the second quarter of 1999. (The growth rate
is affected for nine quarters, in part because HCFA uses a four-quarter
moving-average percent change for price increases, meaning that an
increase in the minimum wage in the second quarter of 1998 will show up
in the calculation of the four-quarter moving-average percent change
for the second quarter of 1999.)
As mentioned above, the actual, legislated minimum wage increases
are $0.50 per hour in October 1996 and an additional $0.40 per hour in
September 1997. Because the July 1, 1996 notice was published before we
knew the exact amount of the minimum wage increase, the first quarter
1996 DRI forecast, the latest data available for use in that notice,
did not reflect the actual, legislated minimum wage increase. Beginning
with the second quarter 1996 DRI forecast, however, the legislated
minimum wage increase is reflected in all DRI forecasts. The HHA input
price index growth rate, based on the actual minimum wage increase,
will be impacted between the fourth quarter of 1996 and the fourth
quarter of 1998, instead of the period between the second quarter of
1997 and the second quarter of 1999 as anticipated in the first quarter
1996 DRI forecast. The forecasted impact will also be larger than was
anticipated in the first quarter 1996 forecast because the minimum wage
will increase $0.35 per hour more than was expected in early 1996.
To analyze the impact of the cumulative $0.90 per hour minimum wage
increase on the HHA input price index growth rate, we examined the
underlying wage distribution of the ECI occupational categories used in
the HHA compensation price proxies. We estimated the impact on those
workers in those occupational categories earning below or up to the
September 1997 national minimum wage of $5.15 an hour. An analysis of
the March 1995 Current Population Survey showed that roughly 10 percent
of workers in those occupational categories earned below $5.15. Those
workers earning just above this new minimum are also expected to be
affected by a modest ripple effect. DRI estimates the new minimum wage
will increase the growth rate in the HHA input price index by 0.25
percentage points between the fourth quarter of 1996 and the fourth
quarter of 1998.
We compared the first quarter 1996 DRI forecast used in the July 1,
1996 notice to the fourth quarter 1996 DRI forecast for the forecasted
FY 1996, FY 1997, and FY 1998 percent increases. The first quarter 1996
forecast was made based on DRI assumptions of how much and when the
minimum wage would increase, while the fourth quarter 1996 DRI forecast
was made after the August 1996 passage date of the minimum wage
legislation. Since the first of the two-step minimum wage increase did
not take place until October 1996, the FY 1996 percent increase in the
HHA market basket was not impacted by the increase in the minimum wage.
Our analysis showed that even though the full effect of the minimum
wage was not included in the July 1, 1996 notice, other negative
factors such as lower than expected benefits price increases and lower
than expected administrative and general expense price increases more
than offset the effect of the minimum wage increases. The FY 1997
increase is now being forecast by DRI to be lower than originally
expected in the first quarter of 1996 by 0.2 percentage points (3.1
percent vs 2.9 percent). The FY 1998 increase, however, is now being
forecast to increase roughly 0.1 percentage points faster than was
expected in the first quarter of 1996 (3.3 percent vs 3.2 percent). The
cumulative growth in the HHA market basket for FY 1997 and FY 1998 is
0.1 percentage points lower than was forecast in the July 1, 1996
notice.
The other area where a change in the minimum wage can impact the
HHA input price index is the cost category weights, although any impact
on percentage changes would be insignificant. Because the 1993 base
year for the HHA market basket is earlier than the October 1996 minimum
wage increase, this change is not represented in the cost category
weights. However, when HCFA updates the base year for the HHA index in
a future year, the minimum wage increase will be reflected in the wages
and salaries cost category weight.
Comment: Several commenters requested that we evaluate labor-
related share by provider or individual geographic area, not by
industry averages.
Response: The national industry share of labor-related costs is
used for adjusting area variations in compensation costs for the major
provider types, including PPS hospitals, skilled nursing facilities
(SNFs), and HHAs. The national average reflects a standard mix of
labor-related inputs relative to nonlabor inputs. Inefficient mixes of
inputs are not rewarded with higher payments. If the labor-related
share was somehow estimated at the individual provider level, it could
encourage individual providers to game the system to maximize payments.
Additionally, the required data to calculate or estimate labor-related
costs of the individual provider or in geographic areas are typically
not available. However, more data are available at the national level.
Comment: One commenter questioned why the HHA Input Price Index has
failed to address concerns that the home health industry has previously
submitted to HCFA , such as costs that change as a result of
modifications in hospital discharge practices or advancements in home
health technology.
Response: HCFA, by design, uses fixed weight or Laspeyres-type
indices to measure pure price increases for HHA services. A Laspeyres
index is used to measure the cost of a given market basket at different
points in time. The HHA Input Price Index answers the question of how
much more or less it would cost, at a later time, to purchase the same
mix of goods and services per HHA visit that was purchased in the base
period. Changes in costs as a result of modifications in hospital
discharge practices or advancements in home health technology are
appropriately handled in other ways in the HHA update framework. For
example, if discharge patterns change so that more high-skilled
physical therapist and registered nurse visits are needed relative to
HHA aide visits, this automatically is reflected in higher cost per
visit. Higher costs per visit within each of the various visit types
are reflected in the HHA Medicare cost report data and thus in payment
limit updates. If the effect of changing technology and changing
discharge practices is a change in the mix of goods and services, then
this is automatically taken into account when the weights are rebased.
When this occurs, the most recently available cost structure of the
industry, reflecting changes in technology, changed mix of goods and
services, etc., is reflected in the weights developed for the market
basket. Therefore, the cost limits methodology, which includes the
Input Price Index,
[[Page 35611]]
accounts for the changes in costs that were of concern to the
commenters.
Comment: One commenter questioned why HCFA uses data from outside
the home health care industry as a proxy for changes in home health
employees' compensation. In addition, one commenter pointed out that
HHAs also compete with employers in nonhealth industries, such as
retail and service industries.
Response: The HHA market basket wage and benefits labor categories
include: (1) Skilled nurses, therapists, and other professional and
technical workers; (2) managerial and supervisory workers; (3) clerical
workers; and (4) service workers. HHAs compete for these occupational
labor categories with employers both inside and outside the HHA care
sector. In the case of compensation for nurses and certain other health
care technicians and professionals, the hospital labor market may be
predominant. However, hospitals and HHAs also compete with other
industries to obtain certain skilled professional and technical staff
(for example, accountants and computer programmers). For professional
and technical workers (skilled nurses, therapists, and other
professional and technical workers), we believe that a price proxy that
reflects a blend of compensation variables internal and external to the
health sector is appropriate. The blend used is price proxies that are
equally weighted between ECI for civilian hospital workers and ECI for
economy-wide professional and technical workers. The PPS hospital
market basket has used this same blend of internal and external price
proxies for professional and technical workers since the 1980's.
Since HHAs compete primarily with employers outside the health care
sector for the other three occupational categories (managerial and
supervisory, clerical, and service workers), we use economy-wide
employment cost indices as price proxies for these three occupational
groups. The health care sector is included in economy-wide employment
cost indices. According to the Bureau of Labor Statistics Current
Employment Statistics Survey (establishment data), in March 1995 the
health care sector accounted for over 9 percent of employment in the
total nonfarm economy.
We ran a simulation using the compensation weights in the 1993-
based HHA Input Price Index to show the cumulative difference between
using the blend in the HHA Input Price Index of 50 percent ECI for
hospital workers, and 50 percent ECI for professional and technical
workers and using only the ECI for hospital workers (the internal
health sector component of the blend) over 10 years (fourth quarter of
1986 through the fourth quarter of 1996). The cumulative difference was
only 0.7 percentage points over 10 years. This amounts to an average
difference of less than 0.1 percentage point per year, indicating that
the blend, while technically more accurate, results in a rate of
increase that is almost identical to that measured by the nonblended
ECI.
Comment: One commenter questioned why data for hospital-based HHAs
were not included in the derivation of weights for the revised and
rebased market basket.
Response: Data for hospital-based HHAs were not used in the revised
and rebased HHA Input Price Index because Medicare cost reports for
hospital-based HHAs contain costs that, due to the stepdown of overhead
cost from the hospital, are not part of an efficient HHA cost
structure. In addition, the data for hospital-based HHAs were not as
detailed as the data for freestanding HHAs. We believe that an input
price index based on the cost structure of freestanding HHAs more
accurately represents the cost structure of the home health industry
than would a market basket based on the cost structure of both
freestanding and hospital-based HHAs. This same approach is used for
SNFs.
III. Updating the Wage Index on a Budget-Neutral Basis
Section 4207(d)(2) of the Omnibus Budget Reconciliation Act of 1990
(OBRA `90) (Public Law 101-508) requires that, in updating the wage
index, aggregate payments to HHAs will remain the same as they would
have been if the wage index had not been updated. Therefore, overall
payments to HHAs are not affected by changes in the wage index values.
To comply with the requirement of section 4207(d)(2) of OBRA `90
that updating the wage index be budget neutral, we determined that it
is necessary to apply a budget neutrality adjustment factor of 1.078 to
the labor-related portion of the July 1, 1997 cost limits. This
adjustment ensures that aggregate payments to HHAs are not affected by
the change to a wage index based on the hospital wage index published
on August 30, 1996 (61 FR 46166). The adjustment factor of 1.078 is the
same as the factor derived from the November 1996 calculations. When we
updated the data for the wage index, we did not find changes
significant enough to have an effect on the budget neutrality
adjustment factor.
To determine this factor, we analyzed both the data obtained from
the freestanding agencies used to determine the cost limits and the
settled cost report data covering the same time period for the
hospital-based agencies. For each agency in this database, we replaced
their current wage index with the one corresponding to the 1982
hospital wage index. Some Metropolitan Statistical Areas (MSAs) that
currently exist did not exist at the time this index was created and
therefore have no matching 1982 wage index. In the database we are
currently using, these unmatchable MSAs represented 2 percent of the
total visits. Since this percentage was small, we deleted these
agencies from the analysis. We then determined what Medicare program
payments would be using the 1982 wage index. Next, we determined
payments using the new wage index and adjusted the labor portion of the
payment by the factor necessary to match program payments if the 1982
wage index was used. (See the example in section VIII.A of this notice
regarding the adjustment of cost limits by the wage index and the
budget neutrality factor.)
IV. Update of Limits
The methodology used to develop the schedule of limits set forth in
this notice is the same as that used in setting the limits that were
effective July 1, 1996. We have updated the cost limits to reflect the
expected cost increases occurring between the cost reporting periods
for the data contained in the database and June 30, 1998.
A. Data Used
To develop the schedule of limits that is effective July 1, 1997,
we extracted actual cost per-visit data from settled Medicare cost
reports for periods ending on or after June 30, 1991, and settled by
October 1, 1995. The majority of the cost reports were from FY 1993. We
then adjusted the data using the latest available market basket indexes
to reflect expected cost increases occurring between the cost reporting
periods contained in our database and June 30, 1998.
Previous to the July 1, 1996 notice, HCFA used the market basket
index to adjust the cost report data to the midpoint (December 31) of
the first cost reporting period to which the limits applied (July 1).
The present limits adjust the data to the end of the first cost
reporting period to which the limits apply (June 30, 1998), a change
that will enable fiscal intermediaries to calculate the applicable
adjustment factors for HHAs with a cost reporting period of fewer than
12 months. Previously, the
[[Page 35612]]
intermediaries had to contact HCFA's central office for this
adjustment.
B. Wage Index
The wage index is used to adjust the labor-related portion of the
limits to reflect differing wage levels among areas. In setting this
schedule of limits, we used the FY 1997 hospital wage index, which is
based on 1993 hospital wage data.
Each HHA's labor market area is determined based on the definitions
of MSAs issued by the Office of Management and Budget (OMB). Section
1861(v)(1)(L) of the Act requires us to use the current hospital wage
index (that is, the FY 1997 hospital wage index, which was published in
the Federal Register on August 30, 1996 (61 FR 46256)) to establish the
HHA cost limits. Therefore, this schedule of limits reflects the MSA
definitions that are currently in effect under the hospital prospective
payment system.
We are continuing to incorporate exceptions to the MSA
classification system for certain New England counties that were
identified in the July 1, 1992 notice (57 FR 29410). These exceptions
have been recognized in setting hospital cost limits for cost reporting
periods beginning on and after July 1, 1979 (45 FR 41218), and were
authorized under section 601(g) of the Social Security Amendments of
1983 (Pubic Law 98-21). Section 601(g) of Public Law 98-21 requires
that any hospital in New England that was classified as being in an
urban area under the classification system in effect in 1979 will be
considered urban for the purposes of the hospital prospective payment
system. This provision is intended to ensure equitable treatment under
the hospital prospective payment system. Under this authority, the
following counties have been deemed to be urban areas for purposes of
payment under the inpatient hospital prospective payment system:
Litchfield County, CT in the Hartford, CT MSA.
York County, ME and Sagadahoc County, ME in the Portland,
ME MSA.
Merrimack County, NH in the Boston-Brockton-Nashua, MA-NH
MSA.
Newport County, RI in the Providence Fall-Warwick, RI MSA.
We are continuing to grant these urban exceptions for the purpose
of applying the HCFA hospital wage index to the HHA cost limits. These
exceptions result in the same New England County Metropolitan Area
(NECMA) definitions for hospitals, SNFs, and HHAs. In New England, MSAs
are defined on town boundaries rather than on county lines but exclude
parts of the four counties cited above that would be considered urban
under the MSA definition. Under this notice, those four counties are
urban under either definition, NECMA or MSA.
V. Provisions of the HHA Schedule of Limits
The schedule of limits set forth below was calculated using 112
percent of the mean per-visit costs of freestanding HHAs and is
adjusted by the latest estimates in the market basket index.
The schedule of limits effective for cost reporting periods
beginning on or after July 1, 1997, is based on the actual cost per-
visit data from settled Medicare cost reports for periods ending on or
after June 30, 1991, and settled by October 1, 1995, updated by the
market basket rate of increase and provides for the following:
A classification system based on whether an HHA is located
within an MSA, a NECMA, or a non-MSA area. (See Tables 4a and 4b in
section X. of this notice for the listing of MSAs, NECMAs, and rural
areas.)
The use of a single schedule of limits for hospital-based
and freestanding agencies. This single limit is based on the cost
experience of freestanding agencies.
The use of a market basket index, which was developed from
the price of goods and services purchased by HHAs to account for the
impact of changing wage and price levels on HHA costs.
The use of the current hospital wage index. The wage index
is used to adjust the labor-related portion of the limits. The employee
wage portion of the market basket index, including a proportionate
share of contract services (64.226 percent), and the employee benefits
portion (13.442 percent) are used to determine the labor component
(77.668 percent) of all HHA per-visit costs used to set the limits.
Separate treatment of the labor and nonlabor components of
per-visit costs. The separate components of costs are calculated by
obtaining actual HHA cost data for each agency for cost periods ending
on or after June 30, 1991 and settled before October 1, 1995, and
increasing those data by the actual and projected increases in the HHA
market basket index. We then separate each HHA's per-visit costs into
labor and nonlabor portions, and divide the labor portion by the wage
index value for the agency's location to control for the effect of
geographic variations in prevailing wage levels. Separate means are
computed for the labor and nonlabor components of per-visit costs. For
each comparison group, the resulting amounts are shown in Table 3 of
section IX. of this notice.
The application of a cost-of-living adjustment to the
nonlabor portion of the limit for HHAs located in Alaska, Hawaii,
Puerto Rico, and the U.S. Virgin Islands.
Limits that are determined for the per-visit cost of each
type of home health service: skilled nursing care, physical therapy,
speech pathology, occupational therapy, medical social services, and
home health aide.
Application of the limits in the aggregate after an HHA's
actual costs are adjusted. An HHA's actual costs are adjusted for
individual items of cost that are found to be excessive under Medicare
principles of provider payment and for costs that are not included in
the limitation amount. The limits are applied in the aggregate to the
cost remaining after these adjustments are made. Payment is limited to
the lower of the actual costs or the cost limits.
VI. Market Basket
The 1993-Based cost categories and weights are listed in Table 1
below.
Table 1.--1993-Based Cost Categories, Weights, and Price Proxies
----------------------------------------------------------------------------------------------------------------
1993-Based
Cost category market basket Price proxy
weight
----------------------------------------------------------------------------------------------------------------
Compensation, including allocated 77.668 ..........................................................
Contract Services' Labor.
Wages and Salaries, including 64.226 HHA Occupational Wage Index.
allocated Contract Services,
Labor.
Employee benefits, including 13.442 HHA Occupational Benefits Index.
allocated Contract Services'
Labor.
Operations & Maintenance........ 0.832 CPI-U Fuel & Other Utilities.
Administrative & General, including 9.569 ..........................................................
allocated Contract Services' Non-
Labor.
Telephone....................... 0.725 CPI-U Telephone.
[[Page 35613]]
Paper & Printing................ 0.529 CPI-U Household Paper, Paper Products & Stationery
Supplies.
Postage......................... 0.724 CPI-U Postage.
Other Administrative & General, 7.591 CPI-U Services.
including allocated Contract
Services Non-Labor.
Transportation...................... 3.405 CPI-U Private Transportation.
Capital-Related................. 3.204 ..........................................................
Insurance....................... 0.560 CPI-U Household Insurance.
Fixed Capital................... 1.764 CPI-U Owner's Equivalent Rent.
Movable Capital................. 0.880 PPI Machinery & Equipment.
Other Expenses, including 5.322 CPI-U All Items Less Food & Energy.
allocated Contract Services'
Non-Labor.
----------------
Total......................... 100.000
----------------------------------------------------------------------------------------------------------------
VII. Methodology for Determining Cost-Per-Visit Limits
A. Data
For this notice, the cost-per-visit limit values were determined by
extracting settled actual cost-per-visit data from Medicare cost
reports for cost reporting periods ending on or after June 30, 1991,
and settled before October 1, 1995. We then adjusted the data using the
latest available market basket factors to reflect expected cost
increases occurring between the cost reporting periods contained in our
database and June 30, 1998. The following adjustment factors were used
to compute the per-visit costs:
Table 2.--Factors for Inflating Database Dollars to June 30, 1998
------------------------------------------------------------------------
Inflation adjustment factors \1\
-------------------------------------------------------------------------
Fiscal year end 1992 1993 1994
------------------------------------------------------------------------
January 31....................... ........... 1.17097 1.13480
February 28...................... ........... 1.16778 1.13203
March 31......................... ........... 1.16457 1.12934
April 30......................... ........... 1.16135 1.12672
May 31........................... ........... 1.15816 1.12413
June 30.......................... 1.19400 1.15505 1.12152
July 31.......................... 1.19056 1.15202 1.11889
August 31........................ 1.18719 1.14906 1.11625
September 30..................... 1.18387 1.14614 1.11359
October 31....................... 1.18061 1.14327 1.11091
November 30...................... 1.17738 1.14043 1.10824
December 31...................... 1.17417 1.13761 1.10562
------------------------------------------------------------------------
B. Cost Reporting Periods Consisting of Fewer Than 12 Months
HHAs may have cost reporting periods that are fewer than 12 months
in duration. This may happen, for example, when a new provider enters
the Medicare program after its selected fiscal year has already begun,
or when a provider experiences a change of ownership before the end of
the cost reporting period. As explained in section IV. of this
preamble, the data used in calculating the cost limits were updated to
June 30, 1998. Therefore, the cost limits published in this notice are
for a 12-month cost reporting period beginning July 1, 1997 and ending
June 30, 1998. For 12-month cost reporting periods beginning after July
1, 1997 and before July 1, 1998, cost reporting year adjustment factors
are provided in Table 5. However, when a cost reporting period consists
of fewer than 12 months, adjustments must be made to the data that have
been developed for use with 12-month cost reporting periods. To promote
the efficient dissemination of cost limits to providers with cost
reporting periods of fewer than 12 months, we are publishing the
following examples and tables to enable intermediaries to calculate the
applicable adjustment factors.
Cost reporting periods of fewer than 12 months may not necessarily
begin on the first of the month or end on the last day of the month. In
order to simplify the process in calculating ``short period''
adjustment factors, if the short cost reporting period begins before
the sixteenth of the month, we will consider the period to have begun
on the first of that month. If the start period begins on or after the
sixteenth of the month, it will be considered to have begun at the
beginning of the next month. Also, if the short period ends before the
sixteenth of the month, we will consider the period to have ended at
the end of the preceding month; if the short period ends on or after
the sixteenth of the month, it will be considered to have ended at the
end of that month.
Examples:
1. After approval by its intermediary, an HHA changes its fiscal
year end from June 30 to December 31. Therefore, the HHA had a short
cost reporting period beginning on July 1, 1997 and ending on December
31, 1997. The cost limits that apply to this short period must be
adjusted as follows:
Step 1--From Table 6, sum the index levels for the months of July
1997 through December 1997: 6.81963.
Step 2--Divide the results from Step 1 by the number of months in
the short period.
6.819636=1.136605
[[Page 35614]]
Step 3--From Table 6, sum the index levels for the months in the
common period of July 1997 through June 1998.
13.75528
Step 4--Divide the results from Step 3 by the number of months in
the common period.
13.7552812=1.146273
Step 5--Divide the results from Step 2 by the results from Step 4.
This is the adjustment factor to be applied to the published limits
1.1366051.146273=.991566
Step 6--Apply the results from Step 5 to the published cost limits.
a. Urban Skilled Nursing Labor Portion.
$79.01 x .991566=$78.34
b. Urban Skilled Nursing Nonlabor Portion.
$22.28 x .991566=$22.09
2. A HHA with a fiscal year end of November 30, 1997 changes
ownership on September 21, 1998. The HHA is required to file a
terminated cost report for the period of December 1, 1997 to September
21, 1998. The cost limits that apply to this short period must be
adjusted as follows:
Step 1--From Table 6, sum the index level for the month of December
1997 through September 1998.
11.58995
Step 2--Divide the results from Step 1 by the number of months in
the short period.
11.5899510=158995
Step 3--From Table 6, sum the index levels for the months in the
common period of July 1997, through June 1998.
13.75528
Step 4--Divide the results from Step 3 by the number of months from
the common period.
13.7552812=1.146273
Step 5--Divide the results from Step 2 by the results from Step 4.
1.1589951.146273=1.011099
Step 6--Apply the results from Step 5 to the published cost limits.
a. Urban Skilled Nursing Labor Portion.
$79.01 x 1.01199=$79.89
b. Urban Skilled Nursing Non-Labor Portion.
$22.28 x 1.011099=$22.53
C. Standardization for Wage Levels
After adjustment by the market basket index, we divided each HHA's
per-visit costs into labor and nonlabor portions. The labor portion of
costs (77.668 percent as determined by the market basket) represents
the employee wage and benefit factor plus the contract services factor
from the market basket. We then divided the labor portion of per-visit
costs by the wage index applicable to the HHA's location to arrive at
an adjusted labor cost.
D. Adjustment for ``Outliers''
We transformed all per-visit cost data into their natural
logarithms and grouped them by type of service and MSA, NECMA, or non-
MSA location, in order to determine the mean cost and standard
deviation for each group. We then eliminated all ``outlier'' costs,
retaining only those per-visit costs within two standard deviations of
the mean in each service.
E. Basic Service Limit
We calculate a basic service limit equal to 112 percent of the mean
labor and nonlabor portions of the per-visit costs of freestanding HHAs
for each type of service. (See Table 3 in section IX.)
VIII. Computing the Adjusted Limit
A. Adjustment of Cost Limits by Wage Index
To arrive at the adjusted limit, which is to be applied to each
service furnished by an HHA, the HHA's intermediary first determines
the adjusted labor-related component by multiplying the labor-related
component of the limit by the appropriate wage index and by multiplying
the adjusted labor-related component by the special labor adjustment
for budget neutrality. (See example below and Tables 4a and 4b in
section X. of this notice.) The sum of the nonlabor component plus the
labor-related component is the adjusted limit applicable to an HHA.
Example--Calculation of Adjusted Occupational Therapy Limit for a
Freestanding HHA In Dallas, TX
------------------------------------------------------------------------
------------------------------------------------------------------------
Labor component (Table 3).................................. $85.97
Wage index value (Table 4a)................................ 0.9729
Labor portion.............................................. 83.64
Special labor adjustment for budget neutrality............. 1.078
Adjusted labor portion..................................... 90.16
Nonlabor component (Table 3)............................... 24.55
Adjusted occupational therapy limit........................ 114.71
------------------------------------------------------------------------
B. Adjustment for Reporting Year
If an HHA has a 12-month cost reporting period beginning on or
after August 1, 1997, the adjusted per-visit limit for each service is
again revised by an adjustment factor from Table 5 that corresponds to
the month and year in which the cost reporting period begins. Each
factor represents the compounded rate of monthly increase derived from
the projected annual increase in the market basket index, and is used
to account for inflation in costs that will occur after the date on
which the limits become effective.
For example, if the HHA in the example above had a cost reporting
period beginning January 1, 1998, its per-visit therapy limit would be
further adjusted as follows:
Computation of Revised Limit for Occupational Therapy
------------------------------------------------------------------------
------------------------------------------------------------------------
Adjusted per-visit limit.................................. $114.71
Adjustment factor from Table 5............................ 1.01588
Revised per-visit limit................................... 116.53
------------------------------------------------------------------------
In this example, the revised adjusted per-visit limit for
occupational therapy applicable to this HHA for the cost reporting
period beginning January 1, 1998, is $116.53 per visit.
If an HHA uses a cost reporting period that is not 12 months in
duration, a special calculation of the adjustment factor must be made.
This results from the fact that projections are computed to June 30,
1998. This calculation is done using the methodology described in
section VII.B.
IX. Schedule of Limits
The schedule of limits set forth below applies to cost reporting
periods beginning on or after July 1, 1997. The intermediaries will
compute the adjusted limits using the wage index published in Tables 4a
and 4b of section X. and will notify each HHA they service of its
applicable cost per-visit limit for each type of service. Each HHA's
aggregate limit cannot be determined prospectively, but depends on each
HHA's Medicare visits for each type of service for the cost reporting
periods subject to this notice.
The HHA costs that are subject to the limits include the cost of
medical supplies routinely furnished in conjunction with patient care.
Durable medical equipment, orthotics, prosthetics, and other medical
supplies directly identifiable as services to an individual patient are
excluded from the per-visit costs and are paid without regard to this
schedule of limits. (See Chapter IV of the Home Health Agency Manual
(HCFA Pub. 11).)
The intermediary will determine the limit for each HHA by
multiplying the number of Medicare visits for each type of service
furnished by the HHA, by the respective per-visit cost limit. The sum
of these amounts is compared to the HHA's total allowable cost.
[[Page 35615]]
Example: HHA X, a freestanding agency located in Richmond, VA,
furnished 5,000 covered skilled nursing visits, 2,000 physical therapy
visits, and 4,000 home health aide visits to Medicare beneficiaries
during its 12-month cost reporting period beginning July 1, 1997. The
aggregate cost limit for the HHA is calculated as follows:
Determining the Aggregate Cost Limit
----------------------------------------------------------------------------------------------------------------
Adjusted
Type of visit Visits Nonlabor labor Adjusted Aggregate
portion portion limit \1\ limit
----------------------------------------------------------------------------------------------------------------
Skilled nursing................................ 5,000 $22.28 $72.64 $100.59 $502,950
Physical therapy............................... 2,000 24.30 79.54 110.04 220,080
Home health aide............................... 4,000 10.88 35.25 48.88 195,520
----------------------------------------------------------------
Total Visits............................. 11,000 ........... ........... ........... ...........
Aggregate cost limit........................... ........... ........... ........... ........... 918,5501
----------------------------------------------------------------------------------------------------------------
\1\ Includes special labor adjustment of 1.078 for budget neutrality.
Before the limits are applied during settlement of the cost report,
the HHA's actual costs are reduced by the amount of individual items of
cost (for example, administrative compensation and contract services)
that are found to be excessive under the Medicare principles of
provider payment. That is, the intermediary reviews the various
reported costs, taking into account all the Medicare payment
principles; for example, the cost guidelines for physical therapy
furnished under arrangements (see 42 CFR 413.106) and the limitation on
costs that are substantially out of line with those comparable home
health agencies (see 42 CFR 413.9).
Table 3.--Per Visit Limits for Home Health Agencies
------------------------------------------------------------------------
Labor Nonlabor
Type of visit Limit portion portion \1\
------------------------------------------------------------------------
MSA (NECMA) location:
Skilled nursing care......... $101.20 $79.01 $22.28
Physical therapy............. 110.81 86.51 24.30
Speech pathology............. 111.60 86.96 24.64
Occupational therapy......... 110.52 85.97 24.55
Medical social services...... 146.39 114.01 32.38
Home health aide............. 49.22 38.34 10.88
Non-MSA location:
Skilled nursing care......... 113.07 92.35 20.72
Physical therapy............. 123.38 100.66 22.72
Speech pathology............. 134.19 109.22 24.97
Occupational therapy......... 133.22 108.26 24.96
Medical social services...... 189.57 154.33 35.24
Home health aide............. 49.03 40.03 9.00
------------------------------------------------------------------------
\1\ Nonlabor portion of limits for HHAs located in Alaska, Hawaii,
Puerto Rico, and the Virgin Islands are increased by multiplying them
by the following cost-of-living adjustment factors:
------------------------------------------------------------------------
Adjustment
Location factor
------------------------------------------------------------------------
Alaska..................................................... 1.250
Hawaii:
County of Honolulu..................................... 1.225
County of Hawaii....................................... 1.150
County of Kauai........................................ 1.200
County of Maui......................................... 1.225
County of Kalawao...................................... 1.225
Puerto Rico................................................ 1.100
Virgin Islands............................................. l.125
------------------------------------------------------------------------
X. Wage Indexes
Table 4a.--Wage Index for Urban Areas
------------------------------------------------------------------------
Urban area (Constituent
counties or county Wage index
equivalents)
------------------------------------------------------------------------
0040........................... Abilene, TX............ 0.8048
Taylor, TX
0060........................... Aguadilla, PR.......... 0.4237
Aguada, PR
Aguadilla, PR
Moca, PR
[[Page 35616]]
0080........................... Akron, OH.............. 0.9853
Portage, OH
Summit, OH
0120........................... Albany, GA............. 0.8597
Dougherty, GA
Lee, GA
0160........................... Albany-Schenectady- 0.8624
Troy, NY.
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200........................... Albuquerque, NM........ 0.9344
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220........................... Alexandria, LA......... 0.8119
Rapides, LA
0240........................... Allentown-Bethlehem- 0.9992
Easton, PA.
Carbon, PA
Lehigh, PA
Northampton, PA
0280........................... Altoona, PA............ 0.9510
Blair, PA
0320........................... Amarillo, TX........... 0.8730
Potter, TX
Randall, TX
0380........................... Anchorage, AK.......... 1.3224
Anchorage, AK
0440........................... Ann Arbor, MI.......... 1.1662
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450........................... Anniston, AL........... 0.8023
Calhoun, AL
0460........................... Appleton-Oshkosh- 0.8890
Neenah, WI.
Calumet, WI
Outagamie, WI
Winnebago, WI
0470........................... Arecibo, PR............ 0.4397
Arecibo, PR
Camuy, PR
Hatillo, PR
0480........................... Asheville, NC.......... 0.9334
Buncombe, NC
Madison, NC
0500........................... Athens, GA............. 0.9408
Clarke, GA
Madison, GA
Oconee, GA
0520........................... *Atlanta, GA........... 1.0033
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
[[Page 35617]]
0560........................... Atlantic City--Cape 1.1077
May, NJ.
Atlantic City, NJ
Cape May, NJ
0600........................... Augusta-Aiken, GA-SC... 0.8836
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640........................... Austin-San Marcos, TX.. 0.9254
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680........................... Bakersfield, CA........ 1.0189
Kern, CA
0720........................... *Baltimore, MD......... 0.9798
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Annes, MD
0733........................... Bangor, ME............. 0.9391
Penobscot, ME
0743........................... Barnstable-Yarmouth, MA 1.3651
Barnstable, MA
0760........................... Baton Rouge, LA........ 0.8433
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840........................... Beaumont-Port Arthur, 0.8576
TX.
Hardin, TX
Jefferson, TX
Orange, TX
0860........................... Bellingham, WA......... 1.1317
Whatcom, WA
0870........................... Benton Harbor, MI...... 0.8506
Berrien, MI
0875........................... *Bergen-Passaic, NJ.... 1.1785
Bergen, NJ
Passaic, NJ
0880........................... Billings, MT........... 0.9086
Yellowstone, MT
0920........................... Biloxi-Gulfport- 0.8554
Pascagoula, MS.
Hancock, MS
Harrison, MS
Jackson, MS
0960........................... Binghamton, NY......... 0.8822
Broome, NY
Tioga, NY
1000........................... Birmingham, AL......... 0.9036
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010........................... Bismarck, ND........... 0.7923
Burleigh, ND
Morton, ND
1020........................... Bloomington, IN........ 0.8652
Monroe, IN
1040........................... Bloomington-Normal, IL. 0.8990
McLean, IL
1080........................... Boise City, ID......... 0.9383
Ada, ID
Canyon, ID
1123........................... *Boston-Worcester 1.1613
Lawrence-Lowell-
Brockton, MA-NH.
Bristol, MA
Essex, MA
[[Page 35618]]
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
Strafford, NH
1125........................... Boulder-Longmont, CO... 0.9522
Boulder, CO
1145........................... Brazoria, TX........... 0.9201
Brazoria, TX
1150........................... Bremerton, WA.......... 1.0901
Kitsap, WA
1240........................... Brownsville-Harlingen- 0.8542
San Benito, TX.
Cameron, TX
1260........................... Bryan-College Station, 0.8851
TX.
Brazos, TX
1280........................... *Buffalo-Niagara Falls, 0.9107
NY.
Erie, NY
Niagara, NY
1303........................... Burlington, VT......... 1.0068
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310........................... Caguas, PR............. 0.4573
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320........................... Canton-Massillon, OH... 0.8648
Carroll, OH
Stark, OH
1350........................... Casper, WY............. 0.8821
Natrona, WY
1360........................... Cedar Rapids, IA....... 0.8458
Linn, IA
1400........................... Champaign-Urbana, IL... 0.9391
Champaign, IL
1440........................... Charleston-North 0.8963
Charleston, SC.
Berkeley, SC
Charleston, SC
Dorchester, SC
1480........................... Charleston, WV......... 0.9526
Kanawha, WV
Putnam, WV
1520........................... *Charlotte-Gastonia- 0.9620
Rock Hill, NC-SC.
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Union, NC
York, SC
1540........................... Charlottesville, VA.... 0.9155
Albemarle, VA
Charlottesville City,
VA
Fluvanna, VA
Greene, VA
1560........................... Chattanooga, TN-GA..... 0.8847
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580........................... Cheyenne, WY........... 0.7678
Laramie, WY
1600........................... *Chicago, IL........... 1.0760
Cook, IL
DeKalb, IL
[[Page 35619]]
DuPage, IL Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620........................... Chico-Paradise, CA..... 1.0417
Butte, CA
1640........................... *Cincinnati, OH-KY-IN.. 0.9570
Dearborn, IN
Ohio, IN
Boone, KY
Campbell, KY
Gallatin, KY
Grant, KY
Kenton, KY
Pendleton, KY
Brown, OH
Clermont, OH
Hamilton, OH
Warren, OH
1660........................... Clarksville- 0.7716
Hopkinsville, TN-KY.
Christian, KY
Montgomery, TN
1680........................... *Cleveland-Lorain- 0.9886
Elyria, OH.
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720........................... Colorado Springs, CO... 0.9341
El Paso, CO
1740........................... Columbia, MO........... 0.8899
Boone, MO
1760........................... Columbia, SC........... 0.9160
Lexington, SC
Richland, SC
1800........................... Columbus, GA-AL........ 0.7779
Russell, AL
Chattanoochee, GA
Harris, GA
Muscogee, GA
1840........................... *Columbus, OH.......... 0.9681
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880........................... Corpus Christi, TX..... 0.8881
Nueces, TX
San Patricio, TX
1900........................... Cumberland, MD-WV...... 0.8671
Allegany, MD
Mineral, WV
1920........................... *Dallas, TX............ 0.9729
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950........................... Danville, VA........... 0.8497
Danville City, VA
Pittsylvania, VA
1960........................... Davenport-Rock Island- 0.8388
Moline, IA-IL.
Scott, IA
Henry, IL
Rock Island, IL
[[Page 35620]]
2000........................... Dayton-Springfield, OH. 0.9559
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020........................... Daytona Beach, FL...... 0.8871
Flagler, FL
Volusia, FL
2030........................... Decatur, AL............ 0.8384
Lawrence, AL
Morgan, AL
2040........................... Decatur, IL............ 0.7848
Macon, IL
2080........................... *Denver, CO............ 1.0166
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120........................... Des Moines, IA......... 0.8815
Dallas, IA
Polk, IA
Warren, IA
2160........................... *Detroit, MI........... 1.0724
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180........................... Dothan, AL............. 0.7740
Dale, AL
Houston, AL
2190........................... Dover, DE.............. 0.8997
Kent, DE
2200........................... Dubuque, IA............ 0.8112
Dubuque, IA
2240........................... Duluth-Superior, MN-WI. 0.9416
St. Louis, MN
Douglas, WI
2281........................... Dutchess County, NY.... 1.0589
Dutchess, NY
2290........................... Eau Claire, WI......... 0.8678
Chippewa, WI
Eau Claire, WI
2320........................... El Paso, TX............ 0.9464
El Paso, TX
2330........................... Elkhart-Goshen, IN..... 0.8801
Elkhart, IN
2335........................... Elmira, NY............. 0.8417
Chemung, NY
2340........................... Enid, OK............... 0.7862
Garfield, OK
2360........................... Erie, PA............... 0.9159
Erie, PA
2400........................... Eugene-Springfield, OR. 1.1271
Lane, OR
2440........................... Evansville-Henderson, 0.8983
IN-KY.
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520........................... Fargo-Moorhead, ND-MN.. 0.9045
Clay, MN
Cass, ND
2560........................... Fayetteville, NC....... 0.9007
Cumberland, NC
2580........................... Fayetteville-Springdale- 0.7220
Rogers, AR.
Benton, AR
Washington, AR
2620........................... Flagstaff, AZ-UT....... 0.9019
Coconino, AZ
[[Page 35621]]
Kane, UT
2640........................... Flint, MI.............. 1.1248
Genesee, MI
2650........................... Florence, AL........... 0.7938
Colbert, AL
Lauderdale, AL
2655........................... Florence, SC........... 0.8594
Florence, SC
2670........................... Fort Collins-Loveland, 1.0562
CO.
Larimer, CO
2680........................... *Ft. Lauderdale, FL.... 1.0548
Broward, FL
2700........................... Fort Myers-Cape Coral, 0.9032
FL.
Lee, FL
2710........................... Fort Pierce-Port St. 1.0169
Lucie, FL.
Martin, FL
St. Lucie, FL
2720........................... Fort Smith, AR-OK...... 0.7864
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750........................... Fort Walton Beach, FL.. 0.9192
Okaloosa, FL
2760........................... Fort Wayne, IN......... 0.8800
Adams, IN
Allen, IN
DeKalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800........................... *Forth Worth-Arlington, 1.0153
TX.
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840........................... Fresno, CA............. 1.1183
Fresno, CA
Madera, CA
2880........................... Gadsden, AL............ 0.8881
Etowah, AL
2900........................... Gainesville, FL........ 0.9434
Alachua, FL
2920........................... Galveston-Texas City, 1.0997
TX.
Galveston, TX
2960........................... Gary, IN............... 0.9641
Lake, IN
Porter, IN
2975........................... Glens Falls, NY........ 0.8562
Warren, NY
Washington, NY
2980........................... Goldsboro, NC.......... 0.8393
Wayne, NC
2985........................... Grand Forks, ND-MN..... 0.9011
Polk, MN
Grand Forks, ND
2995........................... Grand Junction, CO..... 0.8336
Mesa, CO
3000........................... Grand Rapids-Muskegon- 1.0119
Holland, MI.
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040........................... Great Falls, MT........ 0.8681
Cascade, MT
3060........................... Greeley, CO............ 0.9690
Weld, CO
3080........................... Green Bay, WI.......... 0.9038
Brown, WI
3120........................... *Greensboro-Winston- 0.9332
Salem-High Point, NC.
Alamance, NC
Davidson, NC
Davie, NC
[[Page 35622]]
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150........................... Greenville, NC......... 0.9078
Pitt, NC
3160........................... Greenville-Spartanburg- 0.8927
Anderson, SC.
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180........................... Hagerstown, MD......... 0.9175
Washington, MD
3200........................... Hamilton-Middletown, OH 0.9490
Butler, OH
3240........................... Harrisburg-Lebanon- 1.0158
Carlisle, PA.
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283........................... *Hartford, CT.......... 1.2367
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285........................... Hattiesburg, MS........ 0.7252
Forrest, MS
Lamar, MS
3290........................... Hickory-Morganton- 0.8626
Lenoir, NC.
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320........................... Honolulu, HI........... 1.1461
Honolulu, HI
3350........................... Houma, LA.............. 0.7853
Lafourche, LA
Terrebonne, LA
3360........................... *Houston, TX........... 1.0000
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400........................... Huntington-Ashland, WV- 0.9174
KY-OH.
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440........................... Huntsville, AL......... 0.8206
Limestone, AL
Madison, AL
3480........................... *Indianapolis, IN...... 0.9903
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500........................... Iowa City, IA.......... 0.9361
Johnson, IA
3520........................... Jackson, MI............ 0.9045
Jackson, MI
3560........................... Jackson, MS............ 0.7884
[[Page 35623]]
Hinds, MS
Madison, MS
Rankin, MS
3580........................... Jackson, TN............ 0.8288
Madison, TN
Chester, TN
3600........................... Jacksonville, FL....... 0.9086
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605........................... Jacksonville, NC....... 0.7055
Onslow, NC
3610........................... Jamestown, NY.......... 0.7670
Chautaqua, NY
3620........................... Janesville-Beloit, WI.. 0.8645
Rock, WI
3640........................... Jersey City, NJ........ 1.1382
Hudson, NJ
3660........................... Johnson City-Kingsport- 0.8884
Bristol, TN-VA.
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680........................... Johnstown, PA.......... 0.8398
Cambria, PA
Somerset, PA
3700........................... Jonesboro, AR.......... 0.7220
Craighead, AR
3710........................... Joplin, MO............. 0.7638
Jasper, MO
Newton, MO
3720........................... Kalamazoo-Battlecreek, 1.0542
MI.
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740........................... Kankakee, IL........... 0.9115
Kankakee, IL
3760........................... *Kansas City, KS-MO.... 0.9478
Johnson, KS
Leavenworth, KS
Miami, KS
Wyandotte, KS
Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Lafayette, MO
Platte, MO
Ray, MO
3800........................... Kenosha, WI............ 0.9145
Kenosha, WI
3810........................... Killeen-Temple, TX..... 1.0392
Bell, TX
Coryell, TX
3840........................... Knoxville, TN.......... 0.8502
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850........................... Kokomo, IN............. 0.8590
Howard, IN
Tipton, IN
3870........................... La Crosse, WI-MN....... 0.8618
Houston, MN
La Crosse, WI
[[Page 35624]]
3880........................... Lafayette, LA.......... 0.8163
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920........................... Lafayette, IN.......... 0.8781
Clinton, IN
Tippecanoe, IN
3960........................... Lake Charles, LA....... 0.8034
Calcasieu, LA
3980........................... Lakeland-Winter Haven, 0.8774
FL.
Polk, FL
4000........................... Lancaster, PA.......... 0.9583
Lancaster, PA
4040........................... Lansing-East Lansing, 1.0010
MI.
Clinton, MI
Eaton, MI
Ingham, MI
4080........................... Laredo, TX............. 0.7073
Webb, TX
4100........................... Las Cruces, NM......... 0.8497
Dona Ana, NM
4120........................... *Las Vegas, NV-AZ...... 1.0870
Mohave, AZ
Clark, NV
Nye, NV
4150........................... Lawrence, KS........... 0.8597
Douglas, KS
4200........................... Lawton, OK............. 0.8365
Comanche, OK
4243........................... Lewiston-Auburn, ME.... 0.9410
Androscoggin, ME
4280........................... Lexington, KY.......... 0.8293
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320........................... Lima, OH............... 0.8732
Allen, OH
Auglaize, OH
4360........................... Lincoln, NE............ 0.9161
Lancaster, NE
4400........................... Little Rock-North 0.8597
Little Rock, AR.
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420........................... Longview-Marshall, TX.. 0.8645
Gregg, TX
Harrison, TX
Upshur, TX
4480*.......................... Los Angeles-Long Beach, 1.2343
CA.
Los Angeles, CA
4520........................... Louisville, KY-IN...... 0.9447
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600........................... Lubbock, TX............ 0.8510
Lubbock, TX
4640........................... Lynchburg, VA.......... 0.8052
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
[[Page 35625]]
4680........................... Macon, GA.............. 0.8824
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720........................... Madison, WI............ 1.0021
Dane, WI
4800........................... Mansfield, OH.......... 0.8524
Crawford, OH
Richland, OH
4840........................... Mayaguez, PR........... 0.4215
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880........................... McAllen-Edinburg- 0.8485
Mission, TX.
Hidalgo, TX
4890........................... Medford-Ashland, OR.... 1.0068
Jackson, OR
4900........................... Melbourne-Titusville- 0.9068
Palm Bay, FL.
Brevard, Fl
4920........................... *Memphis, TN-AR-MS..... 0.8166
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940........................... Merced, CA............. 1.0660
Merced, CA
5000........................... *Miami, FL............. 0.9938
Dade, FL
5015........................... *Middlesex-Somerset- 1.0883
Hunterdon, NJ.
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080........................... *Milwaukee-Waukesha, WI 0.9645
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
5120........................... *Minneapolis-St. Paul, 1.0777
MN-WI.
Anoka, MN
Carver, MN
Chisago, MN
Dakota, MN
Hennepin, MN
Isanti, MN
Ramsey, MN
Scott, MN
Sherburne, MN
Washington, MN
Wright, MN
Pierce, WI
St. Croix, WI
5160........................... Mobile, AL............. 0.7981
Baldwin, AL
Mobile, AL
5170........................... Modesto, CA............ 1.0600
Stanislaus, CA
5190........................... *Monmouth-Ocean, NJ.... 1.0833
Monmouth, NJ
Ocean, NJ
5200........................... Monroe, LA............. 0.8211
Ouachita, LA
5240........................... Montgomery, AL......... 0.7876
Autauga, AL
Elmore, AL
Montgomery, AL
5280........................... Muncie, IN............. 0.9714
[[Page 35626]]
Delaware, IN
5330........................... Myrtle Beach, SC....... 0.7790
Horry, SC
5345........................... Naples, FL............. 1.0199
Collier, FL
5360........................... *Nashville, TN......... 0.9081
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380........................... *Nassau-Suffolk, NY.... 1.3547
Nassau, NY
Suffolk, NY
5483........................... *New Haven-Bridgeport- 1.2704
Stamford-Danbury-
Waterbury, CT.
Fairfield, CT
New Haven, CT
5523........................... New London-Norwich, CT. 1.2262
New London, CT
5560........................... * New Orleans, LA...... 0.9294
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. James, LA
St. John Baptist, LA
St. Tammany, LA
5600........................... * New York, NY......... 1.4154
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640........................... * Newark, NJ........... 1.1762
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660........................... Newburgh, NY-PA........ 1.0803
Orange, NY
Pike, PA
5720........................... * Norfolk-Virginia 0.8348
Beach-Newport News, VA-
NC.
Currituck, NC
Chesapeake City, VA
Gloucester, VA
Hampton City, VA
Isle of Wight, VA
James City, VA
Mathews, VA
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City
VA
Williamsburg City, VA
York, VA
5775........................... * Oakland, CA.......... 1.4991
Alameda, CA
Contra Costa, CA
5790........................... Ocala, FL.............. 0.9105
Marion, FL
5800........................... Odessa-Midland, TX..... 0.8482
Ector, TX
[[Page 35627]]
Midland, TX
5880........................... * Oklahoma City, OK.... 0.8371
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910........................... Olympia, WA............ 1.0689
Thurston, WA
5920........................... Omaha, NE-IA........... 0.9480
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945........................... * Orange County, CA.... 1.1966
Orange, CA
5960........................... * Orlando, FL.......... 0.9470
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990........................... Owensboro, KY.......... 0.7575
Daviess, KY
6015........................... Panama City, FL........ 0.8061
Bay, FL
6020........................... Parkersburg-Marietta, 0.7877
WV-OH.
Washington, OH
Wood, WV
6080........................... Pensacola, FL.......... 0.8202
Escambia, FL
Santa Rosa, FL
6120........................... Peoria-Pekin, IL....... 0.8905
Peoria, IL
Tazewell, IL
Woodford, IL
6160........................... * Philadelphia, PA-NJ.. 1.1237
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200........................... * Phoenix-Mesa, AZ..... 0.9810
Maricopa, AZ
Pinal, AZ
6240........................... Pine Bluff, AR......... 0.7886
Jefferson, AR
6280........................... *Pittsburgh, PA........ 0.9701
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323........................... Pittsfield, MA......... 1.0552
Berkshire, MA
6340........................... Pocatelo, ID........... 0.8784
Bannock ID
6360........................... Ponce, PR.............. 0.4685
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403........................... Portland, ME........... 0.9619
Cumberland, ME
[[Page 35628]]
Sagadahoc, ME
York, ME
6440........................... *Portland-Vancouver, OR- 1.1235
WA.
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483........................... Providence-Warwick- 1.1092
Pawtucket, RI.
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
Statewide, RI
6520........................... Provo-Orem, UT......... 1.01116
Utah, UT
6560........................... Pueblo, CO............. 0.8284
Pueblo, CO
6580........................... Punta Gorda, FL........ 0.8999
Charlotte, FL
6600........................... Racine, WI............. 0.8835
Racine, WI
6640........................... Raleigh-Durham-Chapel 0.9728
Hill, NC.
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660........................... Rapid City, SD......... 0.8455
Pennington, SD
6680........................... Reading, PA............ 0.9445
Berks, PA
6690........................... Redding, CA............ 1.1605
Shasta, CA
6720........................... Reno, NV............... 1.1018
Washoe, NV
6740........................... Richland-Kennewick- 0.9970
Pasco, WA.
Benton, WA
Franklin, WA
6760........................... Richmond-Petersburg, VA 0.9194
Charles City County,
VA
Chesterfield, VA
Colonial Heights
City, VA
Dinwiddie, VA
Goochland, VA
Hanover, VA
Henrico, VA
Hopewell City, VA
New Kent, VA
Petersburg City, VA
Powhatan, VA
Prince George, VA
Richmond City, VA
6780........................... *Riverside-San 1.1379
Bernardino, CA.
Riverside, CA
San Bernardino, CA
6800........................... Roanoke, VA............ 0.8702
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820........................... Rochester, MN.......... 1.0428
Olmsted, MN
6840........................... *Rochester, NY......... 0.9649
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
[[Page 35629]]
Wayne, NY
6880........................... Rockford, IL........... 0.8994
Boone, IL
Ogle, IL
Winnebago, IL
6895........................... Rocky Mount, NC........ 0.8955
Edgecombe, NC
Nash, NC
6920........................... *Sacramento, CA........ 1.2351
El Dorado, CA
Placer, CA
Sacramento, CA
6960........................... Saginaw-Bay City- 0.9612
Midland, MI.
Bay, MI
Midland, MI
Saginaw, MI
6980........................... St. Cloud, MN.......... 0.9457
Benton, MN
Stearns, MN
7000........................... St. Joseph, MO......... 0.8551
Andrews, MO
Buchanan, MO
7040........................... *St. Louis, MO-IL...... 0.9022
Clinton, IL
Jersey, IL
Madison, IL
Monroe, IL
St. Clair, IL
Franklin, MO
Jefferson, MO
Lincoln, MO
St. Charles, MO
St. Louis, MO
St. Louis City, MO
Warren, MO
7080........................... Salem, OR.............. 0.9728
Marion, OR
Polk, OR
7120........................... Salinas, CA............ 1.3803
Monterey, CA
7160........................... *Salt Lake City-Ogden, 0.9677
UT.
Davis, UT
Salt Lake, UT
Weber, UT
7200........................... San Angelo, TX......... 0.7577
Tom Green, TX
7240........................... *San Antonio, TX....... 0.8390
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320........................... *San Diego, CA......... 1.2134
San Diego, CA
7360........................... *San Francisco, CA..... 1.4260
Marin, CA
San Francisco, CA
San Mateo, CA
7400........................... *San Jose, CA.......... 1.4519
Santa Clara, CA
7440........................... *San Juan-Bayamon, PR.. 0.4506
Aguas Buenas, PR
Barceloneta, PR
Bayamon, PR
Canovanas, PR
Carolina, PR
Catano, PR
Ceiba, PR
Comerio, PR
Corozal, PR
Dorado, PR
Fajardo, PR
Florida, PR
[[Page 35630]]
Guaynabo, PR
Humacao, PR
Juncos, PR
Los Piedras, PR
Loiza, PR
Luguillo, PR
Manati, PR
Morovis, PR
Naguabo, PR
Naranjito, PR
Rio Grande, PR
San Juan, PR
Toa Alta, PR
Toa Baja, PR
Trujillo Alto, PR
Vega Alta, PR
Vega Baja, PR
Yabucoa, PR
7460........................... San Luis Obispo- 1.1561
Atascadero-Paso
Robles, CA.
San Luis Obispo, CA
7480........................... Santa Barbara-Santa 1.1242
Maria-Lompoc, CA.
Santa Barbara, CA
7485........................... Santa Cruz-Watsonville, 1.3520
CA.
Santa Cruz, CA
7490........................... Santa Fe, NM........... 1.0823
Los Alamos, NM
Santa Fe, NM
7500........................... Santa Rosa, CA......... 1.2526
Sonoma, CA
7510........................... Sarasota-Bradenton, FL. 0.9789
Manatee, FL
Sarasota, FL
7520........................... Savannah, GA........... 0.9649
Bryan, GA
Chatham, GA
Effingham, GA
7560........................... Scranton-Wilkes-Barre- 0.8752
Hazleton, PA.
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600........................... *Seattle-Bellevue- 1.1384
Everett, WA.
Island, WA
King, WA
Snohomish, WA
7610........................... Sharon, PA............. 0.8885
Mercer, PA
7620........................... Sheboygan, WI.......... 0.7764
Sheboygan, WI
7640........................... Sherman-Denison, TX.... 0.8614
Grayson, TX
7680........................... Shreveport-Bossier 0.9359
City, LA.
Bossier, LA
Caddo, LA
Webster, LA
7720........................... Sioux City, IA-NE...... 0.8313
Woodbury, IA
Dakota, NE
7760........................... Sioux Falls, SD........ 0.8620
Lincoln, SD
Minnehaha, SD
7800........................... South Bend, IN......... 0.9934
St. Joseph, IN
7840........................... Spokane, WA............ 1.0524
Spokane, WA
7880........................... Springfield, IL........ 0.8671
Menard, IL
Sangamon, IL
7920........................... Springfield, MO........ 0.7823
Christian, MO
Greene, MO
Webster, MO
[[Page 35631]]
8003........................... Springfield, MA........ 1.0586
Hampden, MA
Hampshire, MA
8050........................... State College, PA...... 0.9538
Centre, PA
8080........................... Steubenville-Weirton, 0.8266
OH-WV.
Jefferson, OH
Brooke, WV
Hancock, WV
8120........................... Stockton-Lodi, CA...... 1.1330
San Joaquin, CA
8140........................... Sumter, SC............. 0.7699
Sumter, SC
8160........................... Syracuse, NY........... 0.9395
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200........................... Tacoma, WA............. 1.0860
Pierce, WA
8240........................... Tallahassee, FL........ 0.8313
Gadsden, FL
Leon, FL
8280........................... * Tampa-St. Petersburg- 0.9250
Clearwater, FL.
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320........................... Terre Haute, IN........ 0.8591
Clay, IN
Vermillion, IN
Vigo, IN
8360........................... Texarkana, AR- 0.8503
Texarkana, TX.
Miller, AR
Bowie, TX
8400........................... Toledo, OH............. 1.0361
Fulton, OH
Lucas, OH
Wood, OH
8440........................... Topeka, KS............. 1.0086
Shawnee, KS
8480........................... Trenton, NJ............ 1.0549
Mercer, NJ
8520........................... Tucson, AZ............. 0.9068
Pima, AZ
8560........................... Tulsa, OK.............. 0.8095
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600........................... Tuscaloosa, AL......... 0.7784
Tuscaloosa, AL
8640........................... Tyler, TX.............. 0.9996
Smith, TX
8680........................... Utica-Rome, NY......... 0.8413
Herkimer, NY
Oneida, NY
8720........................... Vallejo-Fairfield-Napa, 1.3947
CA.
Napa, CA
Solano, CA
8735........................... Ventura, CA............ 1.1454
Ventura, CA
8750........................... Victoria, TX........... 0.8393
Victoria, TX
8760........................... Vineland-Millville- 0.9993
Bridgeton, NJ.
Cumberland, NJ
8780........................... Visalia-Tulare- 1.0151
Porterville, CA.
Tulare, CA
8800........................... Waco, TX............... 0.7772
McLennan, TX
8840........................... *Washington, DC-MD-VA- 1.0823
WV.
[[Page 35632]]
District of Columbia,
DC
Calvert, MD
Charles, MD
Frederick, MD
Montgomery, MD
Prince Georges, MD
Alexandria City, VA
Arlington, VA
Clarke, VA
Culpepper, VA
Fairfax, VA
Fairfax City, VA
Falls Church City, VA
Fauquier, VA
Fredericksburg City,
VA
King George, VA
Loudoun, VA
Manassas City, VA
Manassas Park City,
VA
Prince William, VA
Spotsylvania, VA
Stafford, VA
Warren, VA
Berkeley, WV
Jefferson, WV
8920........................... Waterloo-Cedar Falls, 0.8705
IA.
Black Hawk, IA
8940........................... Wausau, WI............. 1.0323
Marathon, WI
8960........................... West Palm Beach-Boca 1.0202
Raton, FL.
Palm Beach, FL
9000........................... Wheeling, OH-WV........ 0.7563
Belmont, OH
Marshall, WV
Ohio, WV
9040........................... Wichita, KS............ 0.9369
Butler, KS
Harvey, KS
Sedgwick, KS
9080........................... Wichita Falls, TX...... 0.8041
Archer, TX
Wichita, TX
9140........................... Williamsport, PA....... 0.8467
Lycoming, PA
9160........................... Wilmington-Newark, DE- 1.1315
MD.
New Castle, DE
Cecil, MD
9200........................... Wilmington, NC......... 0.9046
New Hanover, NC
Brunswick, NC
9260........................... Yakima, WA............. 1.0026
Yakima, WA
9270........................... Yolo, CA............... 1.1444
Yolo, CA
9280........................... York, PA............... 0.9104
York, PA
9320........................... Youngstown-Warren, OH.. 0.9742
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340........................... Yuba City, CA.......... 1.0414
Sutter, CA
Yuba, CA
9360........................... Yuma, AZ............... 0.9497
Yuma, AZ
------------------------------------------------------------------------
* Large Urban Area.
[[Page 35633]]
Table 4b.--Wage Index for Rural Areas
------------------------------------------------------------------------
Nonurban area Wage index
------------------------------------------------------------------------
Alabama.................................................... 0.7122
Alaska..................................................... 1.2444
Arizona.................................................... 0.7928
Arkansas................................................... 0.6954
California................................................. 1.0002
Colorado................................................... 0.8092
Connecticut................................................ 1.2759
Delaware................................................... 0.9447
Florida.................................................... 0.8668
Georgia.................................................... 0.7653
Hawaii..................................................... 1.0245
Idaho...................................................... 0.8277
Illinois................................................... 0.7553
Indiana.................................................... 0.8124
Iowa....................................................... 0.7373
Kansas..................................................... 0.7107
Kentucky................................................... 0.7753
Louisiana.................................................. 0.7232
Maine...................................................... 0.8317
Maryland................................................... 0.8427
Massachusetts.............................................. 1.0070
Michigan................................................... 0.8830
Minnesota.................................................. 0.8144
Mississippi................................................ 0.6793
Missouri................................................... 0.7261
Montana.................................................... 0.8128
Nebraska................................................... 0.7214
Nevada..................................................... 0.8775
New Hampshire.............................................. 0.9745
New Jersey \1\.............................................
New Mexico................................................. 0.8000
New York................................................... 0.8558
North Carolina............................................. 0.7950
North Dakota............................................... 0.7358
Ohio....................................................... 0.8332
Oklahoma................................................... 0.6942
Oregon..................................................... 0.9664
Pennsylvania............................................... 0.8453
Puerto Rico................................................ 0.4026
Rhode Island \1\...........................................
South Carolina............................................. 0.7668
South Dakota............................................... 0.7063
Tennessee.................................................. 0.7341
Texas...................................................... 0.7462
Utah....................................................... 0.8848
Vermont.................................................... 0.8921
Virginia................................................... 0.7713
Washington................................................. 0.9933
West Virginia.............................................. 0.7904
Wisconsin.................................................. 0.8430
Wyoming.................................................... 0.8177
------------------------------------------------------------------------
\1\ All counties within the State are classified urban.
Table 5.--Cost Reporting Year Adjustment Factor \1\
------------------------------------------------------------------------
The
If the HHA cost reporting period begins adjustment
factor is
------------------------------------------------------------------------
August 1, 1997............................................. 1.00251
September 1, 1997.......................................... 1.00509
October 1, 1997............................................ 1.00771
November 1, 1997........................................... 1.01038
December 1, 1997........................................... 1.01311
January 1, 1998............................................ 1.01588
February 1,1998............................................ 1.01871
March 1, 1998.............................................. 1.02154
April 1, 1998.............................................. 1.02435
May 1, 1998................................................ 1.02714
June 1, 1998............................................... 1.02993
------------------------------------------------------------------------
\1\ Based on compounded projected market basket inflation rates.
These adjustment factors are subject to change based on later
estimates of cost increases.
If, for any reason, we do not publish a new schedule of limits to
be effective on July 1, 1998 or do not announce other changes in the
current schedule by that date, the current limits will continue in
effect. Intermediaries will be notified of the adjustment factors to be
applied until a new schedule of limits or other provision is issued.
Table 6.--Monthly Index Levels for Calculating Inflation Factors to Be
Applied to Home Health Agency Cost Limits
------------------------------------------------------------------------
Month Index level
------------------------------------------------------------------------
July 1997.................................................. 1.12866
August 1997................................................ 1.13200
September 1997............................................. 1.13499
October 1997............................................... 1.13799
November 1997.............................................. 1.14100
December 1997.............................................. 1.14499
January 1998............................................... 1.14899
February 1998.............................................. 1.15300
March 1998................................................. 1.15500
April 1998................................................. 1.15700
May 1998................................................... 1.15900
June 1998.................................................. 1.16266
July 1998.................................................. 1.16632
August 1998................................................ 1.17000
September 1998............................................. 1.17299
October 1998............................................... 1.17599
November 1998.............................................. 1.17900
December 1998.............................................. 1.18266
January 1999............................................... 1.18632
February 1999.............................................. 1.19000
March 1999................................................. 1.19233
April 1999................................................. 1.19466
May 1999................................................... 1.19700
------------------------------------------------------------------------
Source: DRI/McGraw-Hill HCC, 1st QTR 1996; @USSIM/TREND 25YR0296 @CISSIM/
CONTROL961.
XI. Regulatory Impact Statement
For notices such as this, we generally prepare an initial
regulatory flexibility analysis that is consistent with the Regulatory
Flexibility Act (RFA) (5 U.S.C. 601 through 612) unless we certify that
the notice will not have a significant economic impact on a substantial
number of small entities. For purposes of the RFA, all HHAs are treated
as small entities.
As discussed below, this notice has an impact of less than $5
million on aggregate Medicare expenditures and we have no evidence that
the economic impact on most HHAs will be significant. Moreover, this
notice is necessary to implement the provisions of section
1861(v)(1)(L) of the Act; thus no alternatives to the provisions set
forth in this notice are available. However, because this notice may
have some effect on a large number of providers, we are providing a
voluntary regulatory flexibility analysis.
This notice with comment period sets forth a revised schedule of
HHA cost limits for cost reporting periods beginning on or after July
1, 1997. The methodology used to develop the schedule of limits set
forth in this notice is the same as that used in setting the limits
effective July 1, l996. In accordance with section 1861(v)(1)(L)(I) of
the Act, we are continuing to set the limits not to exceed 112 percent
of the mean of the labor-related and nonlabor per-visit costs for
freestanding HHAs. As required by section 1861(v)(1)(L)(iii) of the
Act, we are using the most recent hospital wage index to calculate the
HHA cost limits, that is, the hospital wage index effective for
discharges on or after October 1, 1996, which is based on 1993 wage
survey data. The wage index is used to adjust the labor-related portion
of the limits to reflect differing wage levels among areas. As
discussed in section II. of this notice, we are applying a budget
neutrality adjustment factor of 1.078 to the labor-related portion of
the limits to ensure that aggregate payments to HHAs are not affected
by the updating of the wage index. Based on the database used to
calculate the cost limits, there is no significant discernable
redistribution of expenditures between types of agencies (freestanding
or hospital-based) or regions as a result of this notice.
We are using settled cost report data from Medicare cost reports
for cost reporting periods ending on or after June 30, 1991, and
settled before October 1, 1995, to develop the HHA cost-per visit limit
values for each type of home health service: skilled nursing care,
physical therapy, speech pathology, occupational therapy, medical
social services, and home health aide. The majority of the cost reports
were from FY 1993. The data have been adjusted by the most recent
market basket factors to reflect the expected cost increases occurring
between the cost reporting periods for the data contained in the
database and June 30, 1998. The intermediary determines the aggregate
cost limit for each HHA by multiplying the number of Medicare visits
for each type of service furnished by the HHA by the respective
[[Page 35634]]
per-visit cost limit. Each HHA's aggregate limit cannot be determined
prospectively, but depends on each HHA's Medicare visits for each type
of service and actual costs for the cost reporting period subject to
this notice.
The methodology used to calculate these new limits is the same as
the 1996 cost limit methodology. The projected aggregate Medicare
expenditures under the new limits are approximately equal to the
projected aggregate expenditures under the old limits in effect for
cost reporting periods beginning on or after July 1, 1996, updated by
the market basket increases since those limits took effect. In the
absence of this notice, these market basket increases will still take
effect under current law. Therefore, this notice is expected to change
Medicare expenditures by less than $5 million.
The cost limits for HHAs are statutorily driven and the impact of
the market basket increases has already been reflected in the current
law baseline of the President's FY 1998 budget.
We are unable to identify the effects of changes to the cost limits
on individual HHAs. In general, we believe that most HHAs will
experience small revenue increases under the new limits; the degree of
that increase will vary depending on the proportion of an HHA's
revenues that come from Medicare, the distribution of services provided
by the HHA, and the HHA's ability to operate within the cost limits. As
stated earlier, there is no significant discernable redistribution
effect between freestanding and hospital-based home health agencies in
the aggregate.
Table 7 below illustrates the proportion of HHAs that are likely to
be affected by the limits. The results are based on both the data used
to determine the limits and all available settled hospital-based cost
reports for the same time period:
Table 7.--HHAs Exceeding the Cost Limits
------------------------------------------------------------------------
Percentage
HHAs in HHAs of HHAs
database exceeding exceeding
the limits the limits
------------------------------------------------------------------------
Total HHAs....................... 4986 1569 31
Freestanding..................... 3202 698 22
Hospital-based................... 1784 871 49
------------------------------------------------------------------------
Section 1102(b) of the Act requires the Secretary to prepare a
regulatory impact analysis if a notice may have a significant impact on
the operations of a substantial number of small rural hospitals. Such
an analysis must conform to the provisions of section 603 of the RFA.
For purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital located outside a Metropolitan Statistical Area
with fewer than 50 beds.
We are not preparing a rural impact statement because we have
determined, and certify, that this notice will not have a significant
impact on a substantial number of rural hospitals.
In accordance with the provisions of Executive Order 12866, this
notice was reviewed by the Office of Management and Budget.
XII. Other Required Information
A. Waiver of Proposed Notice
In adopting notices such as this, we ordinarily publish a proposed
notice in the Federal Register with a 60-day period for public comment
as required under section 1871(b)(1) of the Act. However, we may waive
this procedure if we find good cause that prior notice and comment are
impracticable, unnecessary or contrary to public interest.
Section 1861(v)(1)(L)(iii) of the Act requires that the Secretary
establish revised HHA cost limits for cost reporting periods beginning
on or after July 1, 1991 and annually thereafter (except for cost
reporting periods beginning on or after July 1, 1994 and before July 1,
1996). As discussed in section III above, in accordance with the
statute, we have used the same methodology to develop the schedule of
limits that was used in setting the limits effective for cost reporting
periods beginning on or after July 1, 1996. The cost limits have been
updated by the appropriate market basket adjustment factor to reflect
the cost increases occurring between the cost reporting periods for the
data contained in the database and June 30, 1998. In addition, as
required under section 1861(v)(1)(L)(iii) of the Act, we have updated
the wage index using the most recent hospital wage index.
If HHAs are to receive timely the benefits of these new cost limits
based on the updated wage index and market basket adjustment factors,
it is necessary that these limits be published in time to take effect
for cost reporting periods beginning on or after July 1, 1997. Because
the methodology used to develop this schedule of limits is for the most
part dictated by the statute and has been previously published for
public comment, we believe that in this instance it would be
impracticable, unnecessary and contrary to the public interest to
publish a proposed notice. Therefore, we find good cause to waive
publication of a proposed notice. However, we are providing a 60-day
period for public comment, as indicated at the beginning of this
notice.
C. Public Comments
Because of the large number of items of correspondence we normally
receive on a notice with comment period, we are not able to acknowledge
or respond to them individually. However, we will consider all comments
concerning the provisions of this notice that we receive by the date
and time specified in the Dates section of this notice, and we will
respond to those comments in a subsequent notice.
Authority: Section 1861(v)(1)(L) of the Social Security Act (42
U.S.C. 1395x(v)(1)(L)); section 4207(d) of Pub. L. 101-508 (42
U.S.C. 1395x (note)).
(Catalog of Federal Domestic Assistance Program No. 93.773
Medicare--Hospital Insurance)
Dated: April 9, 1997.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
Dated: April 30, 1997.
Donna E. Shalala,
Secretary.
[FR Doc. 97-17235 Filed 6-30-97; 8:45 am]
BILLING CODE 4120-01-P
