[Federal Register Volume 64, Number 150 (Thursday, August 5, 1999)]
[Notices]
[Pages 42766-42789]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-20012]
[[Page 42765]]
_______________________________________________________________________
Part II
Department of Health and Human Services
_______________________________________________________________________
Health Care Financing Administration
_______________________________________________________________________
Medicare Program; Schedules of Per-Visit and Per-Beneficiary
Limitations on Home Health Agency Costs for Cost Reporting Periods
Beginning On or After October 1, 1999 and Portions of Cost Reporting
Periods Beginning Before October 1, 2000; Notice
Federal Register / Vol. 64, No. 150 / Thursday, August 5, 1999 /
Notices
[[Page 42766]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[HCFA-1060-NC]
RIN 0938-AJ57
Medicare Program; Schedules of Per-Visit and Per-Beneficiary
Limitations on Home Health Agency Costs for Cost Reporting Periods
Beginning on or After October 1, 1999 and Portions of Cost Reporting
Periods Beginning Before October 1, 2000
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Notice with comment period.
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SUMMARY: This notice with comment period sets forth revised schedules
of limitations on home health agency costs that may be paid under the
Medicare program for cost reporting periods beginning on or after
October 1, 1999 and portions of cost reporting periods beginning before
October 1, 2000. These limitations replace the limitations that were
set forth in our August 11, 1998 notice with comment period (63 FR
42912).
DATES: Effective Date: These schedules of limitations are effective for
cost reporting periods beginning on or after October 1, 1999 and
portions of cost reporting periods beginning before October 1, 2000.
Comment Date: Written comments will be considered if we receive
them at the appropriate address, as provided below, no later than 5 p.
m. on October 4, 1999.
ADDRESSES: Mail written comments (one original and three copies) to the
following address:
Health Care Financing Administration, Department of Health and Human
Services, Attention: HCFA-1060-NC, P.O. Box 31850, Baltimore, Maryland
21207-8850
If you prefer, you may deliver your written comments (one original
and three copies) to one of the following addresses:
Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, D.C. 20201, or
Room C5-16-03, 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.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code HCFA-1060-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 443/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).
FOR FURTHER INFORMATION CONTACT: Michael Bussacca, (410) 786-4602.
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I. Background
Section 1861(v)(1)(A) of the Social Security Act (the Act)
authorizes the Secretary to establish limitations on allowable costs
incurred by a provider of services that may be paid under the Medicare
program, based on estimates of the costs necessary for the efficient
delivery of needed health services. Under this authority, we have
maintained limitations on home health agency (HHA) costs since 1979.
Additional statutory provisions specifically governing the limitations
applicable to HHAs are contained at section 1861(v)(1)(L) of the Act.
On October 21, 1998, the Omnibus Consolidated and Emergency
Supplemental Appropriations Act (OCESAA), 1999 (Public Law 105-277) was
signed into law. Section 5101 of OCESAA amended section 1861(v)(1)(L)
of the Act by providing for adjustments to the per-beneficiary and per-
visit limitations for cost reporting periods beginning on or after
October 1, 1998. Program Memoranda (Transmittal) Nos. A-98-38 and A-99-
1 were issued in November 1998 and January 1999, respectively,
outlining the specific provisions affecting the Interim Payment System
(IPS). We had published a notice with comment period establishing the
cost limitations for cost reporting periods beginning on or after
October 1, 1998 in the Federal Register that was entitled ``Medicare
Program; Schedules of Per-Visit and Per-Beneficiary Limitations on Home
Health Agency Costs for Cost Reporting Periods Beginning On or After
October 1, 1998'' (HCFA-1035-NC) on August 11, 1998 (63 FR 42912).
OCESAA made the following adjustments to these limitations:
Providers with a 12-month cost reporting period ending during
Fiscal Year (FY) 1994, whose per-beneficiary limitations were less than
the national median, which is to be set at 100 percent for comparison
purposes, will get their current per-beneficiary limitation plus \1/3\
of the difference between their rate and the adjusted national median
per-beneficiary limitation. New providers or providers without a 12-
month cost reporting period ending in Federal Fiscal Year (Federal FY)
1994 whose first cost reporting period begins before October 1, 1998
will receive 100 percent of the national median per-beneficiary
limitation.
New providers whose first cost reporting periods begin during
Federal FY 1999 will receive 75 percent of the national median per-
beneficiary limitation as published in the August 11, 1998 notice. In
the case of a new provider or a provider that did not have a 12-month
cost reporting period ending during Federal FY 1994 that filed an
application for HHA provider status before September 15, 1998 or that
was approved as a branch of its parent agency before that date and
becomes a
[[Page 42767]]
subunit of the parent agency or a separate freestanding agency on or
after that date, the per-beneficiary limitation will be set at 100
percent of the national median. The per-visit limitation effective for
costreporting periods beginning on or after October 1, 1998 is set at
106 percent of the median instead of 105 percent of the median, as
previously required in the Balanced Budget Act of 1997 (BBA) (Public
Law 105-33), enacted on August 5, 1997.
There is contingency language for the home health prospective
payment system (PPS) provided in the BBA that was also amended by
section 5101 of OCESAA. If the Secretary for any reason does not
establish and implement the PPS for home health services, the Secretary
will provide for a reduction by 15 percent to the per-visit cost limits
and per-beneficiary limits, as those limits would otherwise be in
effect on September 30, 2000.
Section 1861(v)(1)(L)(i)(V) of the Act specifies that the per-visit
limits shall not exceed 106 percent of the median of the labor-related
and nonlabor per-visit costs for freestanding HHAs. The reasonable
costs used in the per-visit calculations will be updated by the home
health market basket reduced by 1.1 percentage points as required by
section 1861(v)(1)(L)(ix) of the Act and excluding any change in the
home health market basket with respect to cost reporting periods that
began on or after July 1, 1994 and before July 1, 1996 as required by
section 1861(v)(1)(L)(iv) of the Act.
Section 1861(v)(1)(L)(v)(I) of the Act requires the per-beneficiary
annual limitation be a blend of (1) an agency-specific per-beneficiary
limitation based on 75 percent of 98 percent of the reasonable costs
(including nonroutine medical supplies) for the agency's 12-month cost
reporting period ending during Federal FY 1994, and (2) a census region
division per-beneficiary limitation based on 25 percent of 98 percent
of the regional average of these costs for the agency's census division
for cost reporting periods ending during FY 1994, standardized by the
hospital wage index. However, section 1861(v)(1)(L)(viii)(I) of the Act
provides that if the per-beneficiary limitation imposed under this
section of the Act is less than the median described under section
1861(v)(1)(L)(vi)(I) of the Act (but determined as if any reference
under section 1861(v)(1)(L)(v) of the Act to ``98 percent'' were a
reference to ``100 percent''), the per-beneficiary limitation imposed
under section 1861(v)(1)(L)(v) will be increased by \1/3\ of this
difference. The reasonable costs used in the per-beneficiary limitation
calculations in (1) and (2) above will be updated by the home health
market basket reduced by 1.1 percentage points and excluding any
changes in the home health market basket with respect to cost reporting
periods that began on or after July 1, 1994 and before July 1, 1996 as
required by sections 1861(v)(1)(L)(ix) and (iv) of the Act
respectively. This per-beneficiary limitation based on the blend of the
agency-specific and census region division per-beneficiary limitations
will then be multiplied by the agency's unduplicated census count of
beneficiaries (entitled to benefits under Medicare) to calculate the
HHA's aggregate per-beneficiary limitation for the cost reporting
period or portion of cost reporting period subject to the limitation.
Section 1861(v)(1)(L)(viii)(II) provides that for new providers and
providers without a 12-month cost reporting period ending in Federal FY
1994 but for which the first cost reporting period begins before
Federal FY 1999, the per-beneficiary limitation will be a national per-
beneficiary limitation that will be determined as if any reference to
98 percent were a reference to 100 percent. The national per-
beneficiary limitation is defined in section 1861(v)(1)(L)(vi) of the
Act.
For new providers for which the first cost reporting period begins
during or after Federal FY 1999 as defined in section
1861(v)(1)(L)(viii)(III) of the Act, the per-beneficiary limitation
will be equal to 75 percent of the national per-beneficiary limitation.
In the case of a new provider or a provider without a 12-month cost
reporting period ending in FY 1994, section 1861(v)(1)(L)(viii)(II)
shall apply to an HHA that filed an application for HHA provider status
under Medicare before September 15, 1998 or that was approved as a
branch of its parent agency before that date and becomes a subunit of
the parent agency or a separate agency on or after that date.
Payments by Medicare under this system of payment limitations must
be the lower of an HHA's actual reasonable allowable costs, per-visit
limitations in the aggregate, or a per-beneficiary limitation in the
aggregate.
Section 1895(a) of the Act, as amended by OCESAA, requires the
Secretary to provide for payments for home health services in
accordance with a PPS for cost reporting periods and portions of cost
reporting periods beginning on or after October 1, 2000. This, in
effect, will result in a dual payment system for agencies with cost
reporting periods spanning both Federal FY 2000 and Federal FY 2001.
Section 5101(e) of OCESAA also amended the contingency clause in
section 4603(e) of the BBA, whereby, if the Secretary does not
establish and implement the home health PPS, the per-visit and per-
beneficiary limitations in effect on September 30, 2000 will be reduced
by 15 percent and applied to portions of cost reporting periods
beginning on or after October 1, 2000.
Whether there is a home health PPS or a continuation of the IPS on
or after October 1, 2000, agencies will need to separately aggregate
visits and the unduplicated census count for services furnished before
and after October 1, 2000. These statistics will be needed in order to
recalculate the appropriate Medicare liability on the Medicare cost
report. The visits and unduplicated census counts for home health
services furnished on or after October 1, 1999 and before October 1,
2000 will have the per-visit and per-beneficiary limitations updated to
the end of the agency's cost reporting period applied. For services
furnished after October 1, 2000, the agency will be paid either under
the home health PPS or the per-visit and per-beneficiary limitations
set forth in this notice less 15 percent. We will be modifying our
Provider Statistical and Reimbursement Report (PS & R), which is used
by our contractors for verifying statistical data used for the payment
of Medicare services, to accommodate the change from IPS to PPS or IPS
to a reduced IPS effective October 1, 2000.
This notice with comment period sets forth cost limitations for
cost reporting periods beginning on or after October 1, 1999 and
portions of cost reporting periods beginning before October 1, 2000. 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 home health service is furnished. For purposes of this notice, the
HHA wage index is based on the most recent available final hospital
wage index, that is, the preclassified hospital wage index effective
for hospital discharges on or after March 1, 1999, which uses data from
Medicare cost reports for cost reporting periods beginning in FY 1995.
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 Board (MGCRB) under section
1886(d)(10) of the Act, or decisions by the Secretary.
[[Page 42768]]
II. Analysis of and Responses to Public Comments to the August 11,
1998 Per-Visit and Per-Beneficiary Limitations Notice
We received nine items of timely correspondence on the August 11,
1998 notice. The comments pertaining to the per-visit and per-
beneficiary limitations and our responses are discussed below.
Comment: Commenters recommended that we explain specifically and
provide an example of how we envision prorating the unduplicated census
count between agencies for a beneficiary that receives services from
multiple agencies with different fiscal year ends.
Response: In the final rule with comment period entitled ``Schedule
of Per-Beneficiary Limitations on Home Health Agency Costs for Cost
Reporting Periods Beginning on or After October 1, 1997'' published in
the Federal Register on March 31, 1998 (63 FR 15718), we specifically
stated, ``The per-beneficiary limitation will be prorated based on a
ratio of the number of visits furnished to the individual beneficiary
by the HHA during its cost reporting period to the total number of
visits furnished by all HHAs to that individual beneficiary during the
same period.'' (63 FR 15727) The number of agencies providing visits to
the beneficiary is irrelevant. It is the total number of visits the
beneficiary receives by all agencies during the specified agency's cost
reporting period that triggers whether proration is required. What
point the other agencies are in their cost reporting period does not
enter into the computation. However, the total number of visits could
be different for each agency because of their individual cost reporting
periods.
Comment: Commenters encouraged us to explain how the data needed
for proration will be gathered and made available to intermediaries and
providers.
Response: The requirement to prorate the per-beneficiary limitation
when a beneficiary receives home health services from multiple agencies
is statutory. Due to other systems priorities for compliance with Y2K,
we are unable to make the necessary changes in our systems to
accommodate the data needed to do proration at a national level. That
does not, however, preclude contractors from making the necessary
adjustments for proration within their current operating systems.
Comment: Commenters stated that it is unclear in the Federal
Register when and under what circumstances the intermediaries are to
apply the Offset Adjustment for the Implementation of the Home Health
Outcome Assessment Information (OASIS) adjustment factor. Commenters
questioned whether the intermediaries should apply the adjustment
factor immediately and across the board to all agencies that request
the adjustment factor, or upon instructions from HCFA.
Response: In the August 11, 1998 Federal Register (63 FR 42916), we
specifically state that the OASIS adjustment will only apply to the
labor component of the specified per-visit limitations in the first
year of implementation of a new assessment tool. See section III.F of
this notice with comment period regarding our overall application of
the OASIS adjustment.
Comment: Commenters recommended that we clarify whether the option
for being classified as an ``old'' or ``new'' provider applies to
merged providers whose per-beneficiary limitation is based on a weight-
average. Commenters also recommend that we clarify whether the option
will be extended to HHAs that undergo similar mergers or
consolidations, including changes in status and ownership, after the
October 1, 1998 notification deadline.
Response: Agencies that experienced certain changes in status were
given the option to apply the provisions in the March 31, 1998 Federal
Register or the provisions in the August 11, 1998 Federal Register up
to the October 1, 1998 notification deadline. The option mainly
impacted those agencies that may have been classified as new providers
subject to the national per-beneficiary limitation. However, old
providers that merged after the cost reporting period ending during
Federal FY 1994 will be treated the same under this August 11, 1998
provision. That is, the surviving provider number will dictate the per-
beneficiary limitation that will be applied to the merged agencies for
all mergers after October 1, 1998.
Comment: Commenters stated that some intermediaries for hospital-
based agencies have yet to notify providers of their per-beneficiary
amounts or unduplicated census counts. The per-beneficiary amount and
unduplicated census count are important factors that enable providers
to make informed decisions regarding the providers' requests to change
their provider status. Therefore, commenters recommended that we
consider extending the deadline for HCFA notifying providers of their
decision to its end of the comment period (October 13, 1998).
Response: We do not believe it is necessary to extend the
notification deadline. Considering the importance of the per-
beneficiary limitations on an agency's financial needs, the
notification deadline of October 1, 1998 provided agencies adequate
time to assess the impact of the earlier provisions relating to new
provider status and make the election if warranted.
Comment: Commenters disagreed with our position that providers may
not request exceptions to their per-beneficiary amounts. Commenters
believed that we acknowledge that there will be valid circumstances not
anticipated by the per-visit limitation methodology that will cause an
agency to incur cost in excess of that allowed by the per-visit
limitation. Commenters stated that we provide ``atypical'' home health
service exceptions for those unique situations through 42 CFR
413.30(f)(1). Therefore, it appears that, since the statute is silent
on the matter of exceptions, we have the discretion to extend
authorization for exceptions of the per-beneficiary limitations.
Response: We do not agree. Section 1861(v)(1)(L)(ii) of the Act
specifically provides for exemptions and exceptions to the per-visit
limitations so deemed by the Secretary. As we stated in the March 31,
1998 Federal Register, we do not believe that the Congress intended the
general rules at Sec. 413.30 to apply to the establishment of the per-
beneficiary limitations. The statute does not provide any such
exceptions or exemptions to the per-beneficiary limitations.
Comment: A commenter stated that the limits as published used the
wrong wage indices. Section 1861(v)(1)(L)(iii) of the Act requires the
use of the most recently published hospital wage index, which would be
the hospital wage indices published in the final rule entitled
``Changes to the Hospital Inpatient Prospective Payment Systems and
Fiscal Year 1999 Rates'' Federal Register on July 31, 1998 (63 FR
40954).
Response: The statute requires us to use the most recent available
area wage indices applicable under section 1886(d)(3)(E) of the Act to
establish the limitations, which will be those indices that have been
published and in effect for hospitals. The wage indices published in
the Federal Register on July 31, 1998 were not effective under section
1886(d)(3)(E) of the Act until October 1, 1998. Therefore, when the
home health limitations were published, the wage indices in effect for
hospitals were those published in August, 1997 and effective October 1,
1997. Therefore, we believe the wage indices published for HHAs are in
accordance with the statute.
Comment: Commenters recommended that the Medicare cost report and
the Payment Statistical and Reimbursement report should be changed to
[[Page 42769]]
accommodate the requirement to use the wage index that corresponds to
the location where the home health service is furnished.
Response: Both the Medicare cost report and the Payment Statistical
and Reimbursement report have been modified to accommodate the site-of-
service requirement for applying the wage index.
Comment: Commenters believed it is our intent to allow retroactive
application of the August 11, 1998 new and old agency provisions to
both Federal FY 1998 and 1999 cost reports.
Response: Before October 1, 1998, providers will have the option of
being paid as either an ``old'' or ``new'' agency when the surviving
provider number had a 12-month cost reporting period ending in Federal
FY 1994. After October 1, 1998, providers will be paid on the basis of
being an ``old'' provider only if the surviving provider number had a
12-month cost reporting period ending in Federal FY 1994. Providers
will no longer have the option of being ``old'' or ``new'' after
October 1, 1998.
Comment: Commenters stated that the failure to consider the effects
of proration on the calculation on the per-beneficiary limitations is
questionable. If proration of the per-beneficiary limitation is to be
applied to cost reporting periods covered by the interim payment
system, proration must be considered in the calculation of the per-
beneficiary limitation.
Response: During the period used for establishing the per-
beneficiary limitations, proration of the unduplicated census count was
not required. As we stated in the August 11, 1998 Federal Register, the
proration as specified in the statute applies to the application of the
per-beneficiary limitation and not the calculation of the per-
beneficiary limitation. The methodology for establishing the per-
beneficiary limitations in the statute could have specifically
incorporated a proration provision in the methodology, but it did not.
Comment: Commenters stated that an HHA that was required to file
two partial year cost reports during Federal FY 1994 solely due to the
fact that it was located in a State where it was forced to change
fiscal intermediaries should be considered an ``old clause v''
provider. For example, an HHA operating for several years as a
hospital-based HHA has the hospital cease operations during Federal FY
1994. The HHA continues operations under the same ownership as a
freestanding entity and later experiences a change in ownership. Due to
the State where the HHA is located, the HHA was required to change to a
new fiscal intermediary and the partial year cost reports were required
to be filed. If the HHA were located in a different State, a change in
fiscal intermediary would not have occurred.
Response: Section 1861(v)(1)(L)(vi)(I) of the Act requires that for
new providers and those providers without a 12-month cost reporting
period ending in FY 1994, the per-beneficiary shall equal the median of
those limitations applied to old providers. The situation described in
the comment is a provider with less than a 12-month cost reporting
period. The provider does not meet the statutory requirements for
treatment as an ``old clause v'' provider.
Comment: Commenters believed that the OASIS adjustment should not
be phased out after 1 year. They recommended that we should clarify the
start and end dates for the OASIS adjustment and consider extending the
adjustment until cost limits can adequately account for the costs
associated with complying with OASIS requirements.
Response: We recognize there are various costs associated with
complying with OASIS reporting requirements. There are one-time costs
as described in the August 11, 1998 Federal Register that include
training of data entry staff, telephone installation, and other costs
associated with setting up OASIS. There are also ongoing OASIS costs
that include audits to ensure data accuracy, data entry, editing and
auditing, supplies, and telephone costs. We have broken these costs
down to the various elements and have grouped the costs into various
categories. See section III. F of this notice on how these costs are
broken down and the various time frames associated with adjusting the
per-visit limitations for these costs.
Comment: The commenters believed that the OASIS adjustment should
encompass the full range of costs associated with OASIS implementation.
Response: We agree that any adjustment derived for OASIS should
encompass the full range of reasonable costs associated with each
necessary expenditure. Section III. F of this notice, fully explains
the adjustments to the per-visit limitations for the costs associated
with the OASIS requirement.
Comment: The commenters believed that the OASIS adjustment should
apply to both the per-visit and per-beneficiary limitations. This
adjustment could possibly be included in the market basket index used
to update the per-beneficiary limitations for new and old providers.
Response: As we stated in the Federal Register dated August 11,
1998 (63 FR 42920), the statute requires the per-beneficiary
limitations to be based upon the costs incurred during a particular
base year, the Federal FY 1994, and does not contemplate adjustments
due to costs incurred subsequent to the base year.
III. Update of Per-Visit Limitations
The methodology used to develop the schedule of per-visit
limitations in this notice is the same as that used in setting the
limitations effective October 1, 1998. We are using the latest settled
cost report data from freestanding HHAs to develop the per-visit cost
limitations. We have updated the per-visit cost limitations to reflect
the expected cost increases between the cost reporting periods in the
database and September 30, 2000 by the home health market basket
reduced by 1.1 percentage points as required by section
1861(v)(1)(L)(ix) of the Act, and excluding any changes in the home
health market basket with respect to cost reporting periods that began
on or after July 1, 1994 and before July 1, 1996 as required by section
1861(v)(1)(L)(iv) of the Act.
A. Data Used
To develop the schedule of per-visit limitations effective for cost
reporting periods beginning on or after October 1, 1999, we extracted
actual cost per-visit data from the most recent settled Medicare cost
reports for periods beginning on or after October 1, 1994 and settled
by March 1999. The majority of the cost reports were from Federal FY
1996. We then adjusted the data using the latest available market
basket indices to reflect expected cost increases occurring between the
cost reporting periods contained in our database and September 30,
2000, reduced by 1.1 percentage points as required by section
1861(v)(1)(L)(ix) of the Act and excluding any changes in the home
health market basket with respect to cost reporting periods that began
on or after July 1, 1994 and before July 1, 1996 as required by section
1861(v)(1)(L)(iv) of the Act.
B. Wage Index
A wage index is used to adjust the labor-related portion of the
per-visit limitation to reflect differing wage levels among areas. In
establishing the per-visit limitation, we used the FY 1999 hospital
wage index effective for hospital discharges on or after March 1, 1999,
which is based on 1995 hospital wage data.
Each HHA's labor market area is determined based on the definitions
of
[[Page 42770]]
Metropolitan Statistical Areas (MSAs) issued by the Office of
Management and Budget (OMB). Section 1861(v)(1)(L)(iii) of the Act
requires us to use the most recently published hospital wage index
(that is, the FY 1999 hospital wage index, which was published in the
Federal Register on February 25, 1999 (63 FR 9378)) without regard to
whether those hospitals have been reclassified to a new geographic
area, to establish the HHA cost limitations. Therefore, the schedule of
per-visit limitations reflects the MSA definitions that are currently
in effect under the hospital PPS.
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 entitled ``Schedule of Limits on
Home Health Agency Costs Per Visit'' (57 FR 29410). These exceptions
have been recognized in setting hospital cost limitations 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 (Public 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 purposes of the hospital PPS. This provision is
intended to ensure equitable treatment under the hospital PPS. Under
this authority, the following counties have been deemed to be urban
areas for purposes of payment under the inpatient hospital prospective
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 Medicare hospital wage index to the HHA per-visit
limitations. These exceptions result in the same New England County
Metropolitan Area (NECMA) definitions for hospitals, skilled nursing
facilities, 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, these four counties are urban under
either definition, NECMA or MSA.
Section 1861(v)(1)(L)(iii) requires the use of the area wage index
applicable under section 1886(d)(3)(E) of the Act and determined using
the survey of the most recent available wages and wage-related costs of
hospitals located in the geographic area in which the home health
service is furnished without regard to whether these hospitals have
been reclassified to a new geographic area under section 1886(d)(8)(B)
of the Act. The wage-index, as applied to the labor portion of the per-
visit limitation, must be based on the geographic location in which the
home health service is actually furnished rather than the physical
location of the HHA itself.
C. Standardization for Wage Levels
After adjustment by the market basket index reduced by 1.1
percentage points, as required by section 1861(v)(1)(L)(ix) of the Act,
and excluding any changes in the home health market basket with respect
to cost reporting periods that began on or after July 1, 1994 and
before July 1, 1996, as required by section 1861(v)(1)(L)(iv) of the
Act, we divided each HHA's per-visit costs into labor and nonlabor
portions. The labor portion of cost (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 cost 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 median cost and standard
deviation for each group. We then eliminated all ``outlier'' costs,
which were all per-visit costs less than $10 and per-visit costs more
than $800, retaining only those per-visit costs within two standard
deviations of the median in each service.
E. Basic Service Limitation
We calculate a basic service limitation to 106 percent of the
median labor and nonlabor portions of the per-visit costs of
freestanding HHAs for each type of service. (See Table 6a in section
VIII.)
F. Offset Adjustment for the Implementation of the Home Health Outcome
Assessment Information
In the August 11, 1998 per-visit and per-beneficiary limitations
notice (63 FR 42912), we discussed a proposed adjustment for HHAs for
the agency collection of OASIS data. Collecting and reporting OASIS is
a condition of participation for HHAs who bill Medicare. As we stated
in the August 11, 1998 notice, we believe there will be no permanent
ongoing incremental costs associated with OASIS collection. We do,
however, believe both one-time and ongoing costs are associated with
reporting OASIS data. Our proposed OASIS adjustment is based on
information from the Medicare Quality and Improvement Demonstration as
well as OASIS demonstration data. We assume, for purposes of deriving
the OASIS proposed adjustment, that the typical HHA has 486 admissions
and 30,000 visits per year and an 18-person staff. OASIS reporting
adjustments are unlike the one-time OASIS collection adjustments
published in the August 11, 1998 Federal Register, which were based
only on the number of skilled visits. These reporting adjustments are
based on total Medicare visits. This adjustment factor was calculated
by including the estimated OASIS costs in the baseline costs used to
determine the median of the per-visit costs. The per-beneficiary
limitation cannot be adjusted for OASIS.
The three tables below reflect our estimates of the costs to an HHA
for OASIS reporting for a typical agency and form the basis for the
per-visit OASIS reporting adjustment. Those agencies that exceed the
per-visit limit may use the tables in this notice and in our August 11,
1998 notice to calculate an additional adjustment, over the limit, to
account for their recurring and nonrecurring costs for OASIS collection
and reporting. No adjustment is available for the per-beneficiary
limit, which is set explicitly in the statute. Once the OASIS reporting
system is fully implemented and we have gathered sufficient data, we
plan to review the ongoing cost and time components that constitute the
tables below.
[[Page 42771]]
Table 1.--Continuous OASIS Adjustment: Base
[For data reporting]
----------------------------------------------------------------------------------------------------------------
Cost per
Type of adjustment Source Formula visit
----------------------------------------------------------------------------------------------------------------
Audits to ensure data accuracy.......... University of Colorado (((((10 records per month * $.02542
(CHPR), BLS Occupational 12 months)) * .25 hrs) *
Employment Survey (1996), $25.42)/30,000 avg
1994 & 1995 HCFA Cost visits)...professional
Report Data. staff.
Data entry, editing, & auditing......... University of ((((8.5 hrs per month * 12) .06
Colorado(CHPR), Estimated + (5 hrs per month * 12) +
average salary for (1 hr per month * 12) + (5
clerical staff 1994 & 1995 hrs per year)) * $10 per
HCFA Cost Report Data. hour) / 30,000 avg visits).
Supplies................................ HCFA-3006-IFC OASIS $250 avg cost/30,000 avg .008333
Reporting (64 FR 3748), visits.
1994 & 1995 HCFA Cost
Report Data.
Ongoing telephone costs................. Bell Atlantic 1994 & 1995 (((($13.14 per month, per .007808
HCFA Cost Report Data (for line) + ($ 6.38 per month
average size HHA). subscriber fee)) * 12
months)/30,000 avg visits).
-------------
Total............................... ........................... ........................... $.101561
----------------------------------------------------------------------------------------------------------------
Table 2.--Continuous OASIS Adjustment: 5-Year Depreciation Averaging
[For data reporting]
----------------------------------------------------------------------------------------------------------------
Cost per
Type of adjustment Source Formula visit
----------------------------------------------------------------------------------------------------------------
Computer Hardware........................ American Hospital
Association's Health Data
& Coding Standards Group's
``Estimated Useful Lives
of Depreciable Hospital
Assets {revised 1998}
--Computer........................... Average cost for PC with $2050 computer depreciated $.022777
minimal acceptable over 3 years (($2050/3)/
standards 1994 & 1995 HCFA 30,000 avg visits
Cost Report Data
--Printer............................ Average cost for printer $600 printer cost .004
with minimal acceptable depreciated over 5 years
standards 1994 & 1995 HCFA (($600/5)/30,000 avg
Cost Report Data visits
First 3 Year's Adjustment.. * Note: computer & printer .026777
depreciation.
Next 2 Year's Adjustment... * Note: printer ONLY .004
depreciation.
5-Year Average Adjustment.. (((.026777 * 3) + (.004 * .01766
2))/5).
----------------------------------------------------------------------------------------------------------------
Personal Computer Minimal Specifications
------------------------------------------------------------------------
Description Minimal specifications
------------------------------------------------------------------------
Warranty..................... Minimum 3 year.
Processor.................... Pentium II Processor running at 400Mhz w/
512 Cache.
Operating System............. 32-bit operating system with Graphical
User Interface.
Hard Drive................... 3 Gb Hard drive minimum.
Memory....................... 32Mb minimum.
CD ROM....................... 14-32X, IDE, integrated sound.
Floppy Drive................. 3.5'' 1.44Mb diskette drive.
Fax Modem.................... 56K v.90 Data/Fax.
Monitor...................... 17'' Color Monitor.
Graphics..................... 8Mb AGP.
Mouse........................ Wheel mouse.
Keyboard..................... 104 key ergonomic keyboard.
Anti Virus................... Anti Virus Software.
Management Software.......... System management client software/
license.
Printer...................... 600 dpi Laser printer with cable.
------------------------------------------------------------------------
Table 3.--OASIS Adjustment: ``One-Time''
[For data reporting]
----------------------------------------------------------------------------------------------------------------
Cost per
Type of adjustment Source Formula visit
----------------------------------------------------------------------------------------------------------------
Training of Data Entry Staff............ BLS Employer Provided (24 hrs * $10)/30,000 avg $.008
Training (Hrs of Training visits.
[1995] & an estimated
average salary for
clerical personnel 1994 &
1995 HCFA Cost Report Data.
[[Page 42772]]
Telephone installation.................. 1994 & 1995 HCFA Cost ($28 processing fee) + ($40 .002266
Report Data. per line connect fee)/
30,000 avg visits.
-------------
Total One Time Adjustment............. ........................... ........................... $.010266
----------------------------------------------------------------------------------------------------------------
Discussion of OASIS Adjustment Tables
These tables reflect our estimates of the costs to an HHA for
complying with the requirement to report data using the OASIS data set.
We are using three tables based on time parameters. Table 1 shows the
continuous OASIS costs for an HHA that include labor costs for the
audits that are conducted to ensure data accuracy, labor costs for data
entry and the editing and auditing costs associated with it, costs of
supplies, and telephone costs. We estimate these continuous OASIS costs
to total $.101561 per visit. Table 2 shows the OASIS personal computer
costs for those HHAs that are unable to run OASIS because they lack the
requisite hardware needed to support automation of it. We estimate this
percentage to be 50 percent as explained in the OASIS reporting
regulation (HCFA-3006-IFC 64 FR 3748). These costs consist of a
personal computer and printer as described in Table 2. For years 1
through 3, HHAs are able to depreciate both their personal computer and
printer. We estimate this OASIS cost to be $.0267 per visit. For years
4 and 5, HHAs can only depreciate their printer. We estimate this OASIS
cost to be $.004 per visit.
In order for HHAs to keep pace with ever evolving computing
standards, to include enhancements to computer hardware and software,
as well as future versions of HAVEN's OASIS software, this process of
the depreciation of computer hardware is one that would repeat itself
every 5 years. In that vein, a yearly average computer hardware
depreciation adjustment was computed so as to yield a continuous OASIS
adjustment for each year. This was accomplished by multiplying the
first 3 years' computer hardware depreciation adjustment of $.026777 by
3, multiplying the following 2 years' computer hardware depreciation
adjustment of $.004 by 2, summing those two factors, and dividing that
sum by the total number of depreciable years (5) to get a yearly
average for the computer hardware depreciation adjustment of $.01766.
This yearly average computer hardware depreciation adjustments
($.01766), when added to the base continuous OASIS adjustment
($.10156), results in a total continuous OASIS adjustment of $.11916.
Table 3 shows one-time OASIS costs (year 1) for an HHA that include
training of data entry staff and telephone installation. We estimate
these one-time OASIS costs to total $.0103 per visit. Any OASIS costs
recognized under the revised per-visit limits established by this
notice will be reflected in the budget neutral baseline for computing
HHA prospective rates when we convert to that payment system.
IV. 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 requirements of section 4207(d)(2) of OBRA '90
that updating the wage indices be budget neutral, we determined that it
is necessary to apply a budget neutrality adjustment factor of 1.039 to
the labor-related portions of the per-visit and per-beneficiary
limitations for cost reporting periods beginning on or after October 1,
1999. This is the first year for which the per-beneficiary limitations
have been in place long enough to be affected by an update in the wage
indices. Because aggregate payments to HHAs encompass both the per-
visit and the per-beneficiary limitations, the budget neutrality
adjustment factor had to be determined using both per-visit and per-
beneficiary limitations in order to comply with the OBRA '90 budget
neutrality requirement. Therefore, overall payments to HHAs are not
affected by changes in the wage index values as applied to the labor-
related portions of both limitations.
To determine the budget neutrality adjustment factor, we used the
data obtained from the 574 providers in the audited cost report data
set developed for home health prospective payment. This sample was
extrapolated to reflect a national total of HHAs. We believe this is
the most current and accurate data we can obtain to reflect the effects
of both the per-visit limits and the per-beneficiary limits. This data
set includes a count of the number of beneficiaries served by each
agency. This information is not available on the data set used to
calculate the per-visit limitations. For each agency in the per-visit
limitation database, we replaced its current wage index with the one
corresponding to the 1982 hospital wage index. For each agency in the
per-beneficiary limitation database, we replaced their current wage
index with one corresponding to the 1994 hospital wage index. Some MSAs
that currently exist did not exist at the time this index was created
and therefore have no matching 1982 or 1994 wage index. Since the
unmatchable MSAs represented a small percentage of the total visits in
the databases, we deleted these agencies from the analysis. We then
determined what Medicare program payments would be using the 1982 and
1994 wage indices. 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 and 1994 wage indices were used with
respect to both limitations. (See the examples in section VIII. of this
notice regarding the adjustment of the per-visit and per-beneficiary
limitations by the wage index and the budget neutrality adjustment
factor.)
V. Update of the Per-Beneficiary Limitations
The methodologies and data used to develop the schedule of per-
beneficiary limitations set forth in this notice are the same as those
used in setting the per-beneficiary limitations that were effective for
cost reporting periods beginning on or after October 1, 1998. We have
updated the per-beneficiary limitations to reflect the expected cost
increases occurring between the cost reporting periods ended during FY
1994 and September 30, 2000, reduced by 1.1 percentage points and
excluding any changes in the home health market
[[Page 42773]]
basket with respect to cost reporting periods that began on or after
July 1, 1994 and before July 1, 1996.
A. Data Used
The cost report data used to develop the schedule of per-
beneficiary limitations set forth in this notice are for cost reporting
periods ending in Federal FY 1994, as required by section 1861(v)(1)(L)
of the Act. We have updated the per-beneficiary limitations to reflect
the expected cost increases occurring between the cost reporting
periods for the data contained in the database and September 30, 2000
reduced by 1.1 percentage points and excluding any changes in the home
health market basket for cost reporting periods beginning on or after
July 1, 1994 and before July 1, 1996.
The interim payment system sets limitations according to two
different methodologies. For agencies with cost reporting periods
ending during FY 1994, the limitation is based on 75 percent of 98
percent of the agencies' own reasonable costs and 25 percent of 98
percent of the average census region division costs. At the end of the
agency's cost reporting period subject to the per-beneficiary
limitations, the labor component of the census region division per-
beneficiary limitation is adjusted by a wage index based on where the
home health services are furnished.
For new providers and providers without a cost reporting period
ending during FY 1994, the per-beneficiary limitation is based on the
standardized national median of the blended agency-specific and census
region division per-beneficiary limitations described above. See
section C. below, which further defines how these limitations are
effectuated for new providers and providers without a 12-month cost
reporting period ending during FY 1994. This is done by arraying the
agencies' per-beneficiary limitations and selecting the median case.
The national per-beneficiary limitation is then standardized for the
effect of the wage index. The wage index is applied to the labor
component of the national per-beneficiary limitation at the end of the
cost reporting period beginning on or after October 1, 1999 and is
based on where the home health services are furnished.
B. Wage Index
A wage index is used to adjust the labor-related portion of the
standardized regional average per-beneficiary limitation and the
national per-beneficiary limitation to reflect differing wage levels
among areas. In establishing the regional average per-beneficiary
limitation and national per-beneficiary limitation, we used the FY 1999
hospital wage index effective with discharges on or after March 1,
1999, which is based on 1995 hospital wage data.
Each HHA's labor market area is determined based on the definitions
of MSAs issued by OMB. Section 1861(v)(1)(L)(iii) of the Act requires
us to use the current hospital wage index (that is, the FY 1999
hospital wage index, which was published in the Federal Register on
February 25, 1999 (63 FR 9378)), without regard to whether these
hospitals have been reclassified to a new geographic area, to establish
the HHA cost limitations. Therefore, the schedules of standardized
regional average per-beneficiary limitations and the national per-
beneficiary limitation reflect the MSA definitions that are currently
in effect under the hospital PPS.
As we did for the per-visit limitations, 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
limitations 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 (Public 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 purposes of the hospital
PPS. This provision is intended to ensure equitable treatment under the
hospital PPS. Under this authority, the following counties have been
deemed to be urban areas for purposes of payment under the inpatient
hospital prospective 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 Medicare hospital wage index to the HHA standardized
regional average per-beneficiary limitations and the national per-
beneficiary limitation. These exceptions result in the same NECMA
definitions for hospitals, skilled nursing facilities, 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, these
four counties are urban under either definition, NECMA or MSA.
Section 1861(v)(1)(L)(iii) of the Act requires the use of the area
wage index applicable under section 1886(d)(3)(E) of the Act and
determined using the survey of the most recent available wages and
wage-related costs of hospitals located in the geographic area in which
the home health service is furnished without regard to whether these
hospitals have been reclassified to a new geographic area under section
1886(d)(8)(B) of the Act. The wage index, as applied to the labor
portion of the regional per-beneficiary limitation and the labor
portion of the national per-beneficiary limitation, must be based on
the geographic location in which the home health service is actually
furnished.
C. New Providers and Providers Without a 12-Month Cost Reporting Period
Ending During Federal Fiscal Year 1994
For a new provider or a provider without a 12-month cost reporting
period ending in FY 1994 but for which the first cost reporting period
began before October 1, 1998, the per-beneficiary limitation will be a
national per-beneficiary limitation, that will be equal to the median
of these limitations applied to other HHAs without the 2 percent
reduction.
For a new provider whose first cost reporting period begins on or
after October 1, 1998, the per-beneficiary limitation will be 75
percent of the national per-beneficiary limitation including the 2
percent reduction.
A new provider or a provider without a 12-month cost reporting
period ending in FY 1994, which filed an application for HHA provider
status before September 15, 1998, or which was approved as a branch of
its parent agency before that date and becomes a subunit of the parent
agency or a separate agency on or after that date, will be subject to
the national per-beneficiary limitation (without the 2 percent
reduction).
VI. Market Basket
The 1993-based cost categories and weights are listed in Table 4
below.
[[Page 42774]]
Table 4.--1993-Based Cost Categories, Basket Weights, and Price Proxies
------------------------------------------------------------------------
------------------------------------------------------------------------
Compensation including allocated 77.668
Contract Services' Labor.
Wages and Salaries including 64.226 HHA Occupational Wage
allocated Contract Services' Index.
Labor.
Employee benefits, including 13.442 HHA Occupational
allocated Contract Services' Benefits Index.
Labor.
Operations & Maintenance......... 0.832 CPI-U Fuel & Other
Utilities.
Administrative & General, 9.569
including allocated Contract
Services' Non-labor.
Telephone.................... 0.725 CPI-U Telephone.
Paper & Printing............. 0.529 CPI-U Household Paper,
Paper Products &
Stationery Supplies.
Postage...................... 0.724 CPI-U Postage.
Other Administrative & 7.591 CPI-Services.
General, 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.
Movable Capital.............. 0.880 PPI Machinery &
Equipment.
Other Expenses, including 5.322 CPI-U All Items Less
allocated Contract Services\1\ Food & Energy.
Non-Labor.
-------------
Total...................... 100.000
------------------------------------------------------------------------
VII. Update of Database
The data used to develop the cost per-visit limitations, the census
region per-beneficiary limitations, and the national per-beneficiary
limitation were adjusted using the latest available market basket
factors to reflect expected cost increases occurring between the cost
reporting periods contained in our database and September 30, 2000,
reduced by 1.1 percentage points as required by section
1861(v)(1)(L)(ix) of the Act and excluding any changes in the home
health market basket with respect to cost reporting periods that began
on or after July 1, 1994 and before July 1, 1996 as required by section
1861(v)(1)(L)(iv) of the Act. The following inflation factors were used
in calculating the per-visit limitations, the census region per-
beneficiary limitations, and national per-beneficiary limitations:
Table 5.--Factors for Inflating Database Dollars to September 30, 1999
[Inflation adjustment factors \1\]
----------------------------------------------------------------------------------------------------------------
FY end 1993 1994 1995 1996 1997 1998
----------------------------------------------------------------------------------------------------------------
October 31.................................... 1.13775 1.10901 1.10487 1.10291 1.07843 1.04734
November 30................................... 1.13492 1.10771 1.10487 1.10193 1.07571 1.04500
December 31................................... 1.13210 1.10652 1.10487 1.10076 1.07305 1.04272
January 31.................................... ......... 1.12929 1.10568 1.10487 1.09935 1.07042
February 28................................... ......... 1.12650 1.10519 1.10487 1.09771 1.06782
March 31...................................... ......... 1.12374 1.10503 1.10487 1.09585 1.06524
April 30...................................... ......... 1.12107 1.10492 1.10487 1.09381 1.06263
May 31........................................ ......... 1.11850 1.10487 1.10487 1.09162 1.05999
June 30....................................... ......... 1.11604 1.10487 1.10487 1.08926 1.05732
July 31....................................... ......... 1.11388 1.10487 1.10468 1.08674 1.05472
August 31..................................... ......... 1.11202 1.10487 1.10428 1.08405 1.05219
September 30.................................. ......... 1.11045 1.10487 1.10369 1.08121 1.04974
----------------------------------------------------------------------------------------------------------------
\1\ Source: The HHA Price Index, produced by HCFA. The forecasts are from Standard and Poor's DRI HCC 1st QTR
1999;@USSIM/[email protected]/Control 1991 forecast exercise which has historical data through 1999:1.
Multiplying nominal dollars for a given FY end by their respective
inflation adjustment factor will express those dollars in the dollar
levels for the FY ending September 30, 1999.
The procedure followed to develop these tables, based on
requirements from BBA, was to hold the June 1994 level for input price
index constant through June 1996. From July 1996 forward, we trended
the revised index forward using the percentage gain each month from the
HCFA Home Health Agency Input Price Index reduced by 1.1 percentage
points for cost reporting periods beginning in Federal FY 2000.
A. Short Period Adjustment Factors for Cost Reporting Periods
Consisting of Less Than 12 Months
HHAs with cost reporting periods beginning on or after October 1,
1999 may have cost reporting periods that are less than 12 months in
length. This may happen, for example, when a new provider enters the
Medicare program after its selected FY has already begun or when a
provider experiences a change of ownership before the end of the cost
reporting period. The data used in calculating the limitations were
updated to September 30, 2000. Therefore, the cost limitations
published in this notice are for a 12-month cost reporting period
beginning October 1, 1999 and ending September 30, 2000. For 12-month
cost reporting periods beginning after October 1, 1999 and before
October 1, 2000, cost reporting period adjustment factors are provided
in Addendum 2. However, when a cost reporting period consists of
[[Page 42775]]
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 limitations to agencies with cost
reporting periods of fewer than 12 months, we are publishing an example
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 16th of the month, we will consider the period to have begun on the
1st of that month. If the start of the cost reporting period begins on
or after the 16th 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 16th 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
16th of the month, it will be considered to have ended at the end of
that month.
Example: 1. After approval by its intermediary, an HHA that had a
1994 base year changed its FY end from June 30 to December 31. Due to
this change, the HHA had a short cost reporting period beginning on
July 1, 2000 and ending on December 31, 2000. The cost reporting period
ending during FY 1994 was the cost reporting period ending on June 30,
1994. The limitations that apply to this short period must be adjusted
as follows:
Step 1--From Addendum 3, sum the index levels for the months of
July 2000 through December 2000: 6.89916
Step 2--Divide the results from Step 1 by the number of months in
short period: 6.899166=1.14986
Step 3--From Addendum 3, sum the index levels for the months in the
common period of October 1999 through September 2000: 13.6905
Step 4--Divide the results in Step 3 by the number of months in the
common period: 13.6905 x 12 = 1.140875
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 per-visit
and per-beneficiary limitations: 1.14986 x 1.140875 = 1.00788
Step 6--Apply the results from Step 5 to the published limitations.
For example:
a. Urban skilled nursing per-visit labor portion
$78.07 x 1.00788 = $78.69
b. Urban skilled nursing per-visit nonlabor portion
$22.45 x 1.00788 = $22.63
c. West South Central Census region division labor portion per-
beneficiary limitation
$4,667.91 x 1.00788 = $4,704.69
d. West South Central Census region division nonlabor portion per-
beneficiary limitation
$1,342.17 x 1.0788 = $1,447.93
Step 7--Also apply the results from Step 5 to the calculated
agency-specific per-beneficiary amount that has been updated to
September 30, 2000 using Table 2.
B. Adjustment Factor for Reporting Year Beginning After October 1, 1999
and Before October 1, 2000
If an HHA has a 12-month cost reporting period beginning on or
after November 1, 1999, the per-visit limitation and the adjusted
census region division per-beneficiary limitation and the agency-
specific per-beneficiary limitation or the adjusted national per-
beneficiary limitations are again revised by an adjustment factor from
Addendum 2 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 reduced by 1.1 percentage points as required by
section 1861(v)(1)(L)(ix) of the Act and excluding any changes in the
home health market basket with respect to cost reporting periods that
began on or after July 1, 1994 and before July 1, 1996 as required by
section 1861(v)(1)(L)(iv) of the Act and is used to account for
inflation in costs that will occur after the date on which the per-
beneficiary limitations become effective.
In adjusting the agency-specific per-beneficiary limitation for the
market basket increases since the end of the cost reporting period
ending during Federal FY 1994, the intermediary will increase the
agency-specific per-beneficiary limitation to September 30, 2000. That
way when the limitations need to be further adjusted for the cost
reporting period, all elements of the limitation calculations can be
adjusted by the same factor. For example, if an HHA is providing
services in the Dallas MSA only and has a cost reporting period
beginning January 1, 2000, its occupational therapy per-visit
limitation and its per-beneficiary limitation would be further adjusted
as follows:
Computation of Revised Per-Visit Limitations for Occupational Therapy
------------------------------------------------------------------------
------------------------------------------------------------------------
Adjusted per-visit limitation.............................. $113.24
Adjustment factor from Addendum 2.......................... 1.00394
Revised per-visit limitation............................... $113.69
------------------------------------------------------------------------
\1\ Adjusted by appropriate wage index applicable to the Dallas MSA and
the budget neutrality adjustment factor of 1.039.
Computation of Revised Per-Beneficiary Limitations for an HHA With a
1994 Base Period
------------------------------------------------------------------------
------------------------------------------------------------------------
Agency-specific component inflated through December 31, $4,086.60
2000: $5,560.00 x .98 x .75...........................
West south central division component: $5,886.10 \1\ x \1\ $1,442.
.98 x .25............................................... 091
Blended per-beneficiary limitation for Dallas-MSA.......... $5,528.69
Adjustment factor from Addendum 2.......................... 1.00394
Adjusted blended per-beneficiary limitation for Dallas MSA. $5,550.47
------------------------------------------------------------------------
\1\ Adjusted by the appropriate wage index applicable to the Dallas MSA
and the budget neutrality factor of 1.039.
Computation of Revised Per-Beneficiary Limitation for a New Provider
Whose First Cost Reporting Period Began Before October 1, 1997 in the
Dallas MSA
------------------------------------------------------------------------
------------------------------------------------------------------------
National per-beneficiary limitation for Dallas MSA \1\..... \1\ $3,513.
73
Adjustment factor from Addendum 2.......................... 1.00394
Adjusted national per-beneficiary limitation............... $3,527.57
------------------------------------------------------------------------
\1\ From Table 6C Adjusted by the appropriate wage index applicable to
the Dallas MSA and the budget neutrality factor of 1.039.
VIII. Schedules of Per-Visit and Per-Beneficiary Limitations
The schedules of limitations set forth below apply to cost
reporting periods beginning on or after October 1, 1999. The
intermediaries will compute the adjusted limitations using the wage
indicies published in Addenda 1a and 1b for each MSA and non-MSA for
which the HHA provides services to Medicare beneficiaries. The
intermediary will notify each HHA it services of its applicable
limitations for the area(s) where the HHA furnishes HHA services to
Medicare beneficiaries. Each HHA's aggregate limitations cannot be
determined prospectively but depend on each HHA's Medicare utilization
(visits and unduplicated
[[Page 42776]]
census count) by location of the HHA services furnished for the cost
reporting periods subject to this document.
Section 1861(v)(1)(L)(vi)(II) of the Act requires the per-
beneficiary limitations to be prorated among HHAs for Medicare
beneficiaries who use services furnished by more than one HHA. The per-
beneficiary limitation will be prorated based on a ratio of the number
of visits furnished to the individual beneficiary by the HHA during its
cost reporting period to the total number of visits furnished by all
HHAs to that individual beneficiary during the same period.
The proration of the per-beneficiary limitation will be done based
on the fraction of services the beneficiary received from the HHA. For
example, if an HHA furnished 100 visits to an individual beneficiary
during its cost reporting period ending September 30, 2000, and that
same individual received a total of 400 visits during that same period
from that and other agencies, the HHA would count the beneficiary as a
.25 unduplicated census count of Medicare patients for the cost
reporting period ending September 30, 2000.
The HHA costs that are subject to the per-visit limitations include
the cost of medical supplies routinely furnished in conjunction with
patient care. Durable medical equipment, orthotic, prosthetic, 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 the per-visit schedule of limitations. (See Chapter
IV of the Home Health Agency Manual (HCFA Pub. II).)
The HHA costs that are subject to the per-beneficiary limitations
include the costs of medical supplies routinely furnished and
nonroutine medical supplies furnished in conjunction with patient care.
Durable medical equipment directly identifiable as services to an
individual patient is excluded from the per-beneficiary limitations and
is paid without regard to this schedule of per-beneficiary limitations.
The intermediary will determine the aggregate limitations for each
HHA according to the location where the services are furnished by the
HHA. Medicare payment is based on the lower of the HHA's total
allowable Medicare costs plus the allowable Medicare costs of
nonroutine medical supplies, the aggregate per-visit limitation plus
the allowable Medicare costs of nonroutine medical supplies, or the
aggregate per-beneficiary limitation. An example of how the aggregate
limitations are computed for an HHA providing HHA service to Medicare
beneficiaries in both Dallas, Texas, and rural Texas is as follows:
Example: HHA X, an HHA located in Dallas, TX, has 11,550 skilled
nursing visits, 4,300 physical therapy visits, 8,900 home health aide
visits and an unduplicated census count of 400 Medicare beneficiaries
in the Dallas MSA and 5,000 skilled nursing visits, 2,300 physical
therapy visits, 4,300 home health aide visits, and an unduplicated
census count of 200 Medicare beneficiaries in rural Texas during its
12-month cost reporting period ending September 30, 2000. The
unadjusted agency-specific per-beneficiary amount for the base period
(cost reporting period ending September 30, 1994) is $4,825.00. The
aggregate limitations are calculated as follows:
Determining the Aggregate Per-Beneficiary Limitation
----------------------------------------------------------------------------------------------------------------
Unduplicated
census count Total per-
MSA/Non-MSA area Per-beneficiary limitation of Medicare beneficiary
beneficiaries limitation
----------------------------------------------------------------------------------------------------------------
Dallas, TX...................................... ($4,825.00 x 1.11045 x .98 x 400 $2,152,064
.75) plus (($4,667.91 x .9369
x 1.039) plus $1,342.17)) x
.98 x .25.
Rural, TX....................................... ($4,825.00 x 1.11045 .98 x 200 1,033,162
.75) plus (($4,667.91 x .7565
x 1.039) plus 1,342.17)) x .98
x .25.
Aggregate Limitation............................ .................................. ............. 3,185,226
----------------------------------------------------------------------------------------------------------------
Determining the Aggregate Per-Visit Limitation
------------------------------------------------------------------------
Number of Per-visit
Area/Type of visit visits limit \1\ Total limit
------------------------------------------------------------------------
Dallas-MSA:
Skilled nursing.............. 11,550 $ 98.45 $1,137,098
Physical therapy............. 4,300 112.84 485,212
Home health aide............. 8,900 45.36 403,704
Rural Texas:
Skilled nursing.............. 5,000 92.33 461,650
Physical therapy............. 2,300 105.71 243,133
Home health aide............. 4,300 38.80 166,840
Aggregate limitation............. ........... ........... $2,897,637
------------------------------------------------------------------------
\1\ The per-visit has been adjusted by the appropriate wage index and
the budget neutrality adjustment factor of 1.039.
For the cost reporting period ending September 30, 2000, the HHA
incurred $2,935,500 in Medicare costs for the discipline services and
$335,000 for the costs of Medicare nonroutine medical supplies.
Medicare reimbursement for this HHA would be $3,185,226, which is the
lesser of the actual costs of $2,935,500 plus the costs of nonroutine
medical supplies of $335,000 or the aggregate per-visit limitation of
$2,897,637 plus the costs of nonroutine medical supplies of $335,000 or
the aggregate per-beneficiary limitation of $3,185,226.
Before the limitations are applied during settlement of the cost
report, the HHA's actual costs are reduced by the amount of individual
items of costs (for example, administrative compensation and contract
services) that are found to be excessive under the Medicare principles
of provider payment. That is,
[[Page 42777]]
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
Sec. 413.106) and the limitation on costs that are substantially out of
line with those of comparable HHAs (see Sec. 413.9).
Table 6a.--Per-Visit Limitations
------------------------------------------------------------------------
Per-Visit Labor Nonlabor
Type of visit limitation portion Portion \1\
------------------------------------------------------------------------
MSA (NECMA) location:
Skilled nursing care......... $100.52 $78.07 $22.45
Physical therapy............. 115.22 89.49 25.73
Speech therapy............... 116.71 90.65 26.06
Occupational therapy......... 115.63 89.81 25.82
Medical social services...... 140.99 109.51 31.49
Home health aide............. 46.32 35.98 10.34
NonMSA location:
Skilled nursing care......... 110.74 86.01 24.73
Physical therapy............. 126.78 98.47 28.31
Speech therapy............... 132.64 103.02 29.62
Occupational therapy......... 132.12 102.61 29.50
Medical social services...... 173.67 134.89 38.78
Home health aides............ 46.53 36.14 10.39
------------------------------------------------------------------------
\1\ Nonlabor portion of per-visit limitations for HHAs located in
Alaska, Hawaii, Puerto Rico, and the Virgin Islands is increased by
multiplying it by the following cost-of-living adjustment factors.
------------------------------------------------------------------------
Adjustment
Location factor
------------------------------------------------------------------------
Alaska..................................................... 1.250
Hawaii:
County of Honolulu..................................... 1.250
County of Hawaii....................................... 1.150
County of Kauai........................................ 1.225
County of Maui......................................... 1.225
County of Kalawao...................................... 1.225
Puerto Rico................................................ 1.100
Virgin Islands............................................. 1.200
------------------------------------------------------------------------
Table 6b.--Standardized Per-Beneficiary Limitation by Census Region
Division, Labor/Nonlabor
------------------------------------------------------------------------
Labor Nonlabor
Census region division component component
------------------------------------------------------------------------
New England (CT, ME, MA, NH, RI, VT).......... $2,797.47 $804.37
Middle Atlantic (NJ, NY, PA).................. 2,073.06 596.06
South Atlantic (DE, DC, FL, GA, MD, NC, SC, 3,127.39 899.23
VA, WV)......................................
East North Central (IL, IN, MI, OH, WI)....... 2,535.84 729.14
East South Central (AL, KY, MS, TN)........... 4,808.31 1,382.55
West North Central (IA, KS, MN, MO, NE, ND, 2,435.65 700.32
SD)..........................................
West South Central (AR, LA, OK, TX)........... 4,667.91 1,342.17
Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..... 3,076.15 884.49
Pacific (AK, CA, HI, OR, WA).................. 2,383.02 685.20
------------------------------------------------------------------------
Table 6c.\1\--Standardized Per-Beneficiary Limitation for New Agencies
and Agencies Without a 12-month Cost Report Ending During FY 1994 for
Which the First Cost Reporting Began Before October 1, 1998
------------------------------------------------------------------------
Labor Nonlabor
component component
------------------------------------------------------------------------
National...................................... $2,786.53 $801.21
------------------------------------------------------------------------
\1\ This is the national rate set at 100 percent.
Table 6d.\2\--Standardized Per-Beneficiary Limitations for New Providers
for Which the First Cost Reporting Period Begins on or After October 1,
1998
------------------------------------------------------------------------
Labor Nonlabor
component component
------------------------------------------------------------------------
National...................................... $2,048.10 $588.89
------------------------------------------------------------------------
\2\ This is the national rate set at 75 percent of 98 percent of Table
6c.
Table 6e.--Standardized Per-Beneficiary Limitations for Puerto Rico and
Guam
------------------------------------------------------------------------
Labor Nonlabor
component component
------------------------------------------------------------------------
Puerto Rico................................... $2,030.66 $583.88
Guam.......................................... 1,962.40 564.25
------------------------------------------------------------------------
IX. Regulatory Impact Statement
A. Introduction
We have examined the impacts of this notice with comment as
required by Executive Order 12866, the Regulatory Flexibility Act (RFA)
(Pub. L. 96-354), and the Unfunded Mandates Reform Act
[[Page 42778]]
of 1995 (Pub. L. 104-4). Executive Order 12866 directs agencies to
assess all costs and benefits of available regulatory alternatives and,
when regulation is necessary, to select regulatory approaches that
maximize net benefits (including potential economic, environmental,
public health and safety effects; distributive impacts; and equity).
For purposes of the RFA, small entities include small business as
defined under the Small Business Administration, nonprofit
organizations, and small governmental jurisdictions. Most HHAs are
considered small entities either by nonprofit status or by meeting the
Small Business Administration's standard for a small business (annual
revenues of $5 million or less) .
Table 7 illustrates the Distribution of HHAs by type participating
in Medicare as of April 13, 1999.
Table 7.--Number of HHAs by Provider Type
------------------------------------------------------------------------
HHA provider type Number
------------------------------------------------------------------------
Visiting Nurse Association................................. 484
Combination Gov't and Voluntary............................ 34
Official Health Agency..................................... 1067
Rehab Facility-Based....................................... 2
Hospital-Based............................................. 2486
Skilled Nursing Facility-Based............................. 174
Other...................................................... 4612
------------
Total.................................................. 8859
------------------------------------------------------------------------
Source: HCFA--On Line Survey Certification and Reporting System
Standard Report 10--4/13/99
The following RFA analysis, together with the rest of this
preamble, explains the rationale for and purposes of this notice,
analyzes alternatives, and presents the measures we propose to minimize
the burden on small entities.
We anticipate this notice, in total, will not have a significant
impact on a substantial number of small entities. The policies set
forth in this notice are consistent with those set forth in the
``Schedules of Per-Visit and Per-Beneficiary Limitations on Home Health
Agency Costs for Cost Reporting Periods Beginning On or After October
1, 1998'' (63 FR 42912) as subsequently amended by section 5101 of
OCESAA '99, and the financial effect os this notice on HHAs is confined
to our rebasing of the per-visit limitations. We estimate that the
financial effect of this notice will be a cost to the Medicare program
of approximately $40 million in Federal FY 2000, which amount does not
meet the $100 million RFA threshold for an economically significant
rule.
In addition, we have examined the options for lessening the burden
on small entities; however, the statute does not allow for any
exceptions to these limitations based on size of entity. Therefore,
there are no options to lessen the regulatory burden that are
consistent with the statute. Although this notice does not meet the
$100 million threshold for an RFA analysis, we are preparing a
voluntary one because this notice with comment is an integral part of
the HHA IPS.
Section 202 of the Unfunded Mandates Reform Act requires agencies
to prepare an assessment of anticipated costs and benefits before
proposing any rule that may result in an annual expenditure by State,
local, or tribal governments, in the aggregate, or by private sector,
of $100 million (adjusted annually for inflation). We believe that
there are no costs associated with this notice with comment that apply
to these governmental and private sectors. Therefore, the law does not
apply.
This notice with comment is not a major rule as defined in title 5,
United States Code, section 804(2) and is not an economically
significant rule under Executive Order 12866. However, we are preparing
a regulatory impact statement because this notice with comment is an
integral part of the HHA IPS.
1. Background
This notice with comment period sets forth revised schedules of
limitations on HHA costs that may be paid under the Medicare program
for cost reporting periods beginning on or after October 1, 1999 and
portions of cost reporting periods beginning before October 1, 2000.
These limitations replace the limitations that were set forth in our
August 11, 1998 notice with comment period (63 FR 42912).
The methodology used to develop the schedule of per-visit
limitations in this notice is the same as that used in setting the
limitations effective October 1, 1998. We are using the latest settled
cost report data from freestanding HHAs to develop the per-visit cost
limitations. We have updated the per-visit cost limitations to reflect
the expected cost increases between the cost reporting periods in the
database and September 30, 2000 reduced by 1.1 percentage points as
required by section 1861(v)(1)(L)(ix) of the Act and excluding any
changes in the home health market basket with respect to cost reporting
periods that began on or after July 1, 1994 and before July 1, 1996 as
required by section 1861(v)(1)(l)(iv) of the Act.
To develop the schedule of per-visit limitations effective for cost
reporting periods beginning on or after October 1, 1999, we extracted
actual cost per-visit data from the most recent settled Medicare cost
reports for periods beginning on or after October 1, 1994 and settled
by March 1999. The majority of the cost reports were from Federal FY
1996. We then adjusted the data using the latest available market
basket indices to reflect expected cost increases occurring between the
cost reporting periods contained in our database and September 30,
2000, reduced by 1.1 percentage points as required by section
1861(v)(1)(L)(ix) of the Act and excluding any changes in the home
health market basket with respect to cost reporting periods that began
on or after July 1, 1994 and before July 1, 1996 as required by section
1861(v)(1)(L)(iv) of the Act.
A wage index is used to adjust the labor-related portion of the
per-visit limitation to reflect differing wage levels among areas. In
establishing the per-visit limitation, we used the FY 1999 hospital
wage index, which is based on 1995 hospital wage data.
The methodologies and data used to develop the schedule of per-
beneficiary limitations set forth in this notice are the same as those
used in setting the per-beneficiary limitations that were effective for
cost reporting periods beginning on or after October 1, 1998. We have
updated the per-beneficiary limitations to reflect the expected cost
increases occurring between the cost reporting periods ended during
Federal FY 1994 and September 30, 2000, excluding any changes in the
home health market basket with respect to cost reporting periods that
began on or after July 1, 1994 and before July 1, 1996 as required by
law.
The cost report data used to develop the schedule of per-
beneficiary limitations set forth in this notice are for cost reporting
periods ending in Federal FY 1994, as required by section 1861(v)(1)(L)
of the Act. We have updated the per-beneficiary limitations to reflect
the expected cost increases occurring between the cost reporting
periods for the data contained in the database and September 30, 2000
(excluding, as required by statute, any changes in the home health
market basket for cost reporting periods beginning on or after July 1,
1994 and before July 1, 1996).
A wage index is used to adjust the labor-related portion of the
standardized regional average per-beneficiary limitation and the
national per-
[[Page 42779]]
beneficiary limitation to reflect differing wage levels among areas. In
establishing the regional average per-beneficiary limitation and
national per-beneficiary limitation, we used the FY 1999 hospital wage
index effective with discharges on or after March 1, 1999, which is
based on 1995 hospital wage data.
For new providers and providers without a 12-month cost reporting
period ending in Federal FY 1994 but for which the first cost reporting
period began before October 1, 1998, the per-beneficiary limitation
will be a national per-beneficiary limitation that will be equal to the
median of these limitations applied to other HHAs without the two
percent reduction required in the original BBA legislation.
For new providers for which the first cost reporting period begins
on or after October 1, 1998, the per-beneficiary limitation will be the
75 percent of the national per-beneficiary limitations with the 2
percent reduction.
A new provider or a provider without a 12-month cost reporting
period in Federal FY 1994 that filed an application for home HHA
provider status before September 15, 1998, or that was approved as a
branch of its parent agency before that date and becomes a subunit of
the parent agency or a separate agency on or after that date will be
subject to the national per-beneficiary limitation without the 2
percent reduction.
The requirements for the per-visit and per-beneficiary limitations
are set forth in Section 1861(v)(1)(L) of the Act. (See Section I of
this notice for an expanded discussion.) These requirements are
numerically explicit and allow us no administrative latitude. Thus, it
is not possible to consider other alternatives for these limitations.
2. Effects of This Notice With Comment on HHAs
This notice updates the HHA IPS for Federal FY 2000. As we
mentioned earlier in this regulatory impact analysis, we estimate that
there will be a cost to the Medicare program of approximately $40
million in Federal FY 2000. Payments by Medicare under this system of
payment limitations must be the lower of an HHA's actual reasonable
allowable costs, per-visit limitations in the aggregate, or a per-
beneficiary limitation in the aggregate. The settled cost report data
that we are using have been adjusted by the most recent market basket
factors, reduced by 1.1 percentage points as required by section
1861(v)(1)((l)(ix) of the Act, and excluding market basket increases
for cost reporting periods beginning on or after July 1, 1994 and
before July 1, 1996, as required by section 1861(v)(1)(L)(iv) of the
Act to reflect the expected cost increases occurring between the cost
reporting periods for the data contained in the database and September
30, 2000.
The following quantitative analysis presents the projected effects
of the statutory changes effective for Federal FY 2000. We are unable
to identify the effects of the changes to the cost limits on individual
HHAs. However, Table 8 below illustrates the proportion of HHAs that
are likely to be affected by the limits. This table is a model of our
estimate of the revision in the schedule of the per-visit and per-
beneficiary limitations.
Table 8 represents the projected effects of the HHA IPS and is
based on the 574 providers in the audited cost report sample developed
for HHA PPS extrapolated into a national weighted total of 7,161 HHAs.
This sample has 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 September
30, 2001. Table 8 reflects cost reporting periods beginning Federal FY
2000 and those portions of cost reporting periods after October 1, 2000
that have a cost reporting period beginning in Federal FY 2000. These
portions will be subject to the limits in this notice minus 15 percent.
Column one of this table divides HHAs by a number of
characteristics including provider type, region, and urban versus rural
location. For purposes of this impact table four regions have been
defined: Northeast, South, Midwest, and West. The Northeast Region
consists of Connecticut, Massachusetts, Maine, New Hampshire, New
Jersey, New York, Pennsylvania, Puerto Rico, Rhode Island, Vermont, and
the Virgin Islands. The South Region consists of Alabama, Arkansas, the
District of Columbia, Delaware, Florida, Georgia, Kentucky, Louisiana,
Maryland, Mississippi, North Carolina, Oklahoma, South Carolina,
Tennessee, Texas, Virginia, and West Virginia. The Midwest Region
consists of Iowa, Illinois, Indiana, Kansas, Michigan, Minnesota,
Missouri, North Dakota, Nebraska, Ohio, South Dakota, and Wisconsin.
The West Region consists of Alaska, Arizona, California, Colorado,
Hawaii, Idaho, Montana, New Mexico, Nevada, Oregon, Utah, Washington,
and Wyoming.
This table takes into account the behaviors that we believe HHAs
will engage in to reduce the adverse effects of section 4602 of the BBA
on their allowable costs. We believe these behavioral offsets might
include an increase in the number of low-cost beneficiaries served, a
general decrease in the number of visits provided, and earlier
discharge of patients who are not eligible for Medicare home health
benefits because they no longer need skilled services but have only
chronic, custodial care needs. We believe that, on average, these
behavioral offsets will result in a 65 percent reduction in the effects
these limits might otherwise have on an individual HHA for the per-
beneficiary limitations and a 50 percent reduction for the per-visit
limitations.
Column one of this table divides HHAs by a number of
characteristics including their ownership, whether they are old or new
agencies, whether they are located in an urban or rural area, and the
region in which they are located. Column two shows the number of
agencies that fall within each characteristic or group of
characteristics. For example, there are 2,549 rural freestanding HHAs
in our database. Column three shows the percent of HHAs within a group
that are projected to exceed the per-visit limitation (and therefore
will not be affected by the per-beneficiary limitation) before the
behavioral offsets are taken into account. Column four shows the
average percent of costs over the per-visit limitation for an agency in
that cell, including behavioral offsets. Column five shows the percent
of HHAs within a group that are projected to exceed the per-beneficiary
limitation (and therefore will not be affected by the per-visit
limitation) before the behavioral offsets are taken into account.
Column six shows the average percent of costs over the per-beneficiary
limitation for an agency in that category, including behavioral
offsets. It is important to note that in determining the expected
percentage of an agency's costs exceeding the cost limitations, column
four (percent of costs exceeding visit limits) and column six (percent
of costs exceeding beneficiary limits) are not to be added together.
Either the per-visit limitation or the per-beneficiary limitation is
exceeded, but not both.
[[Page 42780]]
Impact of Table 8.--The IPS HHA Limits, Effective 10/1/99
----------------------------------------------------------------------------------------------------------------
Percent of Percent of Percent of Percent of
agencies costs agencies costs
Number of exceeding exceeding exceeding exceeding
agencies visit visit beneficiary beneficiary
limits limits limits limits
----------------------------------------------------------------------------------------------------------------
GEOGRAPHIC AREA
ALL AGENCIES................................... 7161 14.9 1.3 78.6 12.1
FREESTANDING................................... 4703 6.8 0.3 86.0 14.1
HOSPITAL-BASED................................. 2458 30.4 2.8 64.3 9.1
OLD AGENCIES............................... 4467 17.2 1.6 78.2 10.3
FREESTANDING........................... 2467 7.9 0.4 87.6 11.5
HOSPITAL-BASED......................... 2000 28.8 2.7 66.7 9.1
NEW AGENCIES*.............................. 2693 10.9 0.7 79.2 17.2
FREESTANDING........................... 2235 5.5 0.3 84.3 18.4
HOSPITAL-BASED......................... 458 37.2 4.1 54.3 9.4
ALL URBAN...................................... 4612 15.2 1.5 79.1 12.0
FREESTANDING............................... 3397 7.1 0.4 85.7 14.0
HOSPITAL BASED............................. 1215 38.0 3.0 60.4 9.1
OLD AGENCIES............................... 2574 16.0 1.7 82.0 10.2
FREESTANDING........................... 1611 8.9 0.5 88.3 11.4
HOSPITAL-BASED......................... 963 37.6 2.9 62.4 9.1
NEW AGENCIES............................... 2038 12.2 0.9 74.8 16.9
FREESTANDING........................... 1786 5.5 0.3 83.4 18.0
HOSPITAL-BASED......................... 252 39.3 4.0 52.9 8.8
ALL RURAL...................................... 2549 14.2 0.8 77.7 12.4
FREESTANDING............................... 1306 5.9 0.1 86.7 14.3
HOSPITAL-BASED............................. 1243 23.0 2.1 68.2 9.3
OLD AGENCIES............................... 1894 10.1 1.0 80.2 10.5
FREESTANDING........................... 857 6.0 0.1 86.1 11.6
HOSPITAL-BASED......................... 1037 20.6 2.1 70.6 9.1
NEW AGENCIES............................... 655 10.9 0.2 80.4 18.9
FREESTANDING........................... 449 5.7 0.0 88.0 20.3
HOSPITAL-BASED................................. 206 34.7 1.4 55.9 11.6
BY: REGION
OLD AGENCIES............................... 4467 17.2 1.6 78.2 10.3
MIDWEST................................ 1298 16.9 2.6 78.6 6.8
NORTHEAST.............................. 649 7.4 0.3 89.2 10.3
SOUTH.................................. 1857 17.0 1.2 80.1 12.0
WEST................................... 662 28.4 4.1 61.4 8.4
NEW AGENCIES............................... 2693 10.9 0.7 79.2 17.2
MIDWEST................................ 607 15.2 1.0 73.1 10.9
NORTHEAST.............................. 247 19.6 2.4 60.2 9.9
SOUTH.................................. 1316 7.2 0.4 83.5 21.4
WEST................................... 524 11.3 0.3 84.4 16.2
----------------------------------------------------------------------------------------------------------------
* New Agencies Are Those Without a 12-Month Cost Reporting Period Beginning in Federal FY 1994.
B. Percent of Costs Exceeding Per-Visit Limitations (Column Four)
Results from this column indicate that, for an HHA that reaches the
per-visit limitation first, the average percent of the agency's costs
exceeding the per-visit limitation for an HHA in the ``all agencies''
category is 1.3 percent after the behavioral offset. This relatively
low number should not be surprising since the intent of section 4602 of
the BBA is to control the soaring expenditures of the Medicare home
health benefit that have been driven largely by increased utilization
rather than the price per visit. For the all agencies category sorted
by provider type, the average percent of freestanding HHAs exceeding
the per-visit limitation is 0.3 percent; for hospital-based HHAs, it is
2.8 percent. This also should not be surprising as hospital-based HHAs
have historically had higher overhead costs. All discussion of the
analysis of the per-visit limitation is based on the fact that HHAs in
these categories reached the per-visit limitation and therefore are not
affected by the per-beneficiary limitation. For the overall old
agencies category (HHAs that filed a 12-month cost report that ended
during Federal FY 1994), the average percent of the agency's costs
exceeding the per-visit limitation is 1.6 percent; for freestanding
HHAs, it is 0.4 percent; and for hospital-based HHAs, it is 2.7
percent. For the overall new agencies category (such as HHAs that did
not have a 12-month cost reporting period ended in Federal FY 1994 or
that entered the Medicare program after Federal FY 1994), the average
percent of the agency's costs exceeding the per-visit limitation is 0.7
percent, for freestanding HHAs, it is 0.3 percent; and for hospital-
based HHAs, it is 4.1 percent.
For the urban areas HHA category, the average percent of the
agency's costs exceeding the per-visit limitation is 1.5 percent. For
freestanding HHAs, it is 0.4 percent; and for hospital-based HHAs, it
is 3.0 percent. For the rural areas HHA category, the average percent
of such agency's cost exceeding the per-visit limitation is 0.8
percent; for freestanding HHAs, it is 0.1 percent; and for hospital-
based HHAs, it is 2.1 percent.
For the old agencies urban provider type category, the average
percent of the agency's costs exceeding the per-visit limitation for
freestanding HHAs is 0.5 percent; and for hospital-based HHAs, it is
2.9 percent. For the old agencies rural provider type, the average
percent of the agency's costs exceeding the per-visit limitation for
freestanding HHAs is 0.1
[[Page 42781]]
percent; and for hospital-based HHAs, is 2.1 percent. For the old
agencies region category, the average percent of the agency's costs
exceeding the per-visit limitation ranges from a low of 0.3 percent in
the Northeast region to a high of 4.1 percent in the West region. The
other regions range between 1.2 and 2.6 percent.
For the new agencies urban provider type category, the average
percent of the agency's costs exceeding the per-visit limitation for
freestanding HHAs is 0.3 percent while for hospital-based HHAs it is
4.0 percent. For the new agencies rural provider type category the
average percent; of the agency's costs exceeding the per-visit
limitation for freestanding HHAs is 0.0 percent and for hospital based
HHAs is 1.4 percent. For the new agencies region category, the average
percent of the agency's costs exceeding the per-visit limitation ranges
from a low of 0.3 percent in the West region to a high of 2.4 percent
in the Northeast region. The other regions range between 0.4 percent
and 1.0 percent.
C. Percent of Costs Exceeding Per-Beneficiary Limitation (Column Six)
Results from this column indicate that, for an HHA that reaches the
per-beneficiary limitation first, the average percent of the agency's
costs exceeding the per-beneficiary limitation for an HHA in the ``all
agencies'' category is 12.1 percent after the behavioral offset; for
freestanding HHAs, it is 14.1 percent; and for hospital-based HHAs, it
is 9.1 percent. All discussion of the analysis of the per-beneficiary
limitation is based on the fact that HHAs in these categories reached
the per-beneficiary limitation and therefore are not affected by the
per-visit limitation.
For the overall old agencies category (HHAs that filed a 12-month
cost report that ended during Federal FY 1994), the average percent of
the agency's costs exceeding the per-beneficiary limitation is 10.3
percent; for freestanding HHAs, it is 11.5 percent; and for hospital-
based HHAs it is 9.1 percent. For the overall new agencies category
(including HHAs that did not have a 12-month cost reporting period
ended in Federal FY 1994 or that entered the Medicare program after
Federal FY 1994), the average percent of the agency's costs exceeding
the per-beneficiary limitation is 17.2 percent; for freestanding HHAs,
it is 18.4 percent; and for hospital-based HHAs, it is 9.4 percent. Old
agencies will not be affected as much by the per-beneficiary
limitations as the new agencies, on average, because the new agencies
have, in general, reported higher costs per patient related to higher
levels of utilization. Moreover, the statutory provision for old
providers that bases 75 percent of the limitation on their own cost
experience would implicitly result in less of an impact than
experienced by the new providers whose limitations are based on a
national median that may be higher or lower than their previous costs.
Also, we believe the differing impacts of these limits is an inherent
result of beginning to draw unexplained variation among providers
utilization and cost closer to national norms that existed before the
rapid increase in home health expenditures of the post '93 to '94
period.
For the urban areas HHA category, the average percent of the
agency's costs exceeding the per-beneficiary limitation is 12.0
percent; for freestanding HHAs, it is 14.0 percent; and for hospital-
based HHAs, it is 9.1 percent. For the rural areas HHA category, the
average percent of the agency's costs exceeding the per-beneficiary
limitation is 12.4 percent; for freestanding HHAs, it is 14.3 percent;
and for hospital-based HHAs, it is 9.3 percent. For the old agencies
urban provider type category, the average percent of the agency's costs
exceeding the per-beneficiary limitation for freestanding HHAs is 11.4
percent; and for hospital-based HHAs is 9.1 percent. For the old
agencies rural provider type category, the average percent of the
agency's costs exceeding the per-beneficiary limitation for
freestanding HHAs is 11.6 percent; and for hospital-based HHAs is 9.1
percent. For the old agencies region category, the average percent of
the agency's costs exceeding the per-beneficiary limitation ranges from
a low of 6.8 percent in the Midwest region to a high of 12.0 percent in
the South region. The other regions range between 8.4 percent and 10.3
percent. The differences between regions reflect the pattern of highly
disparate costs that have been reported historically between geographic
areas that cannot be explained by differences in patient
characteristics but appear more related to patterns of HHA business
practices. The impact tracks the pre-HH IPS pattern of regions with
highest costs.
For the new agencies urban provider type category, the average
percent of the agency's costs exceeding the per-beneficiary limitation
for freestanding HHAs is 18.0 percent; and for hospital based HHAs, it
is 8.8 percent. For the new agencies rural provider type category the
average percent of the agency's costs exceeding the per-beneficiary
limitation for freestanding HHAs is 20.3 percent; and for hospital-
based HHAs is 11.6 percent. For the new agencies region category, the
average percent of the agency's costs exceeding the per-beneficiary
limitation ranges from a low of 9.9 percent in the Northeast region to
a high of 21.4 percent in the South region. The other regions range
from 10.9 percent to 16.2 percent. In general, newer agencies in
regions that have exceptionally high cost histories experience a bigger
impact due to their being limited to the national median.
Although there is considerable variation in these limitations, we
believe this is a reflection of the wide variation in payments that
have been recognized under the present cost reimbursement system.
Moreover, we believe the differing impacts of these limitations is an
inherent result of beginning to draw unexplained variation among
providers closer to which existed before the rapid increase in home
health expenditures of the post '93 to '94 period. Because this rule
limits payments to HHAs to the lesser of actual cost, the per-visit
limitations, or the per-beneficiary limitation, we have estimated the
combined impact of these limitations in terms of the number of agencies
affected to a greater or lesser extent by both limits.
We estimate that in Federal FY 2000, 15 percent of the HHAs will be
limited by the per-visit limitation while 79 percent will be limited to
the per-beneficiary limitation. It is important to note again that an
HHA is affected either by the per-visit limitation or the per-
beneficiary. They will not be affected by both.
Medicare payments to managed care plans are based on fee-for-
service Medicare benefits. Although we do not know what home health
services are supplied for these payments, we know how much we pay the
plans as a result of fee-for-service home health payments. Thus,
managed care payments are figured in as part of our cost/savings
estimates. Managed care plans are not expected to reduce home health
services as a result of this notice. For Federal FY 2000, we estimate
that 20 percent of the Medicare cost will be for payments to managed
care plans, our estimate for Federal FY 2003 is 26 percent.
We believe that the effect of this notice on State Medicaid
programs overall will be small. However, because of the flexibility and
variation in State Medicaid policies and service delivery systems as
well as differences in provider behavior in reaction to these limits,
it is impossible to predict which States will be affected or the
magnitude of the impact.
We have reviewed this notice under the threshold criteria of
Executive Order 12612. We have determined that it does
[[Page 42782]]
not significantly affect the rights, roles, and responsibilities of
States.
X. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, agencies are required to
provide a 60-day notice in the Federal Register and solicit public
comments before a collection of information requirement is submitted to
the Office of Management and Budget for review and approval. This
document does not impose information collection and record keeping
requirements. Consequently, it need not be reviewed by the Office of
Management and Budget under the authority of the Paperwork Reduction
Act of 1995.
XI. Other Required Information
A. Waiver of Proposed Notice
In adopting notices such as this, we ordinarily publish a proposed
notice in the Federal Register to provide a period for public comment
before the provisions of the notice take effect. However, we may waive
this procedure if for good cause we find that prior notice and comment
are impracticable, unnecessary, or contrary to public interest. (5 USC
section 553(b)(B)).
Section 1861(v)(1)(L) 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). In accordance with the statute, we have used the same
methodology to develop the schedules of limits that were used in
setting the limits effective for cost reporting periods beginning on or
after October 1, 1997. These 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 September 30, 2000 as required by section
1861(v)(1)(L)(ix) of the Act excluding market basket increases, reduced
by 1.1 percentage points with respect to cost reporting periods that
began on or after July 1, 1994 and before July 1, 1996 as required by
section 1861(v)(1)(L)(iv) of the Act. In addition, as required under
section 1861(v)(1)(L) of the Act, we have used the most recently
published hospital wage index.
Therefore, for good cause we find that it was unnecessary to
undertake notice and comment procedures. Generally, the methodology
used to develop these schedules of limits is dictated by statute and
does not require the exercise of discretion. These methodologies have
also been previously published for public comment. It was also
necessary to inform HHAs of their new cost limitations in a timely
manner so that HHAs could benefit from the most recently published wage
index and updated market basket adjustment factor.
Accordingly, for good cause, we waive prior notice and comment
procedures. However, we are providing a 60-day comment period for
public comment, as indicated at the beginning of this notice.
B. 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 document.
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: June 16, 1999.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.
Dated: June 29, 1999.
Donna E. Shalala,
Secretary.
Addendum 1a.--Wage Index for Urban Areas
------------------------------------------------------------------------
Wage
Urban area (Constituent counties) index
------------------------------------------------------------------------
0040 Abilene, TX............................................. 0.7981
Taylor, TX
0060 Aguadilla, PR........................................... 0.4727
Aguada, PR
Aguadilla, PR
Moca, PR
0080 Akron, OH............................................... 0.9900
Portage, OH
Summit, OH
0120 Albany, GA.............................................. 0.7975
Dougherty, GA
Lee, GA
0160 Albany-Schenectady-Troy, NY............................. 0.8610
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200 Albuquerque, NM......................................... 0.8613
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220 Alexandria, LA.......................................... 0.8526
Rapides, LA
0240 Allentown-Bethlehem-Easton, PA.......................... 1.0204
Carbon, PA
Lehigh, PA
Northampton, PA
0280 Altoona, PA............................................. 0.9335
Blair, PA
0320 Amarillo, TX............................................
Potter, TX 0.8474
Randall, TX
0380 Anchorage, AK........................................... 1.2818
Anchorage, AK
0440 Ann Arbor, MI........................................... 1.1033
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450 Anniston, AL............................................ 0.8658
Calhoun, AL
0460 Appleton-Oshkosh-Neenah, WI............................. 0.8825
Calumet, WI
Outagamie, WI
Winnebago, WI
0470 Arecibo, PR............................................. 0.4867
Arecibo, PR
Camuy, PR
Hatillo, PR
0480 Asheville, NC........................................... 0.8940
Buncombe, NC
Madison, NC
0500Athens, GA................................................ 0.8673
Clarke, GA
Madison, GA
Oconee, GA
0520 Atlanta, GA............................................. 0.9915
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
0560 Atlantic-Cape May, NJ................................... 1.1536
Atlantic, NJ
Cape May, NJ
0600 Augusta-Aiken, GA-SC.................................... 0.9233
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640 Austin-San Marcos, TX................................... 0.8782
Bastrop, TX
[[Page 42783]]
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680 Bakersfield, CA......................................... 0.9531
Kern, CA
0720 Baltimore, MD........................................... 0.9642
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733 Bangor, ME.............................................. 0.9474
Penobscot, ME
0743Barnstable-Yarmouth, MA................................... 1.5382
Barnstable, MA
0760 Baton Rouge, LA......................................... 0.8872
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX................................ 0.8659
Hardin, TX
Jefferson, TX
Orange, TX
0860 Bellingham, WA.......................................... 1.1434
Whatcom, WA
0870 Benton Harbor, MI....................................... 0.8531
Berrien, MI
0875 Bergen-Passaic, NJ...................................... 1.2186
Bergen, NJ
Passaic, NJ
0880 Billings, MT............................................ 0.9143
Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS.......................... 0.8276
Hancock, MS
Harrison, MS
Jackson, MS
0960 Binghamton, NY.......................................... 0.9059
Broome, NY
Tioga, NY
1000 Birmingham, AL.......................................... 0.9073
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010 Bismarck, ND............................................ 0.8025
Burleigh, ND
Morton, ND
1020 Bloomington, IN......................................... 0.8965
Monroe, IN
1040 Bloomington-Normal, IL.................................. 0.8851
McLean, IL
1080 Boise City, ID.......................................... 0.9160
Ada, ID
Canyon, ID
1123 Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH........ 1.1269
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
Strafford, NH
1125 Boulder-Longmont, CO.................................... 1.0038
Boulder, CO
1145 Brazoria, TX............................................ 0.8906
Brazoria, TX
1150 Bremerton, WA........................................... 1.1055
Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX.................... 0.8237
Cameron, TX
1260 Bryan-College Station, TX............................... 0.7820
Brazos, TX
1280 Buffalo-Niagara Falls, NY............................... 0.9587
Erie, NY
Niagara, NY
1303 Burlington, VT.......................................... 0.9577
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310 Caguas, PR.............................................. 0.4400
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320 Canton-Massillon, OH.................................... 0.8813
Carroll, OH
Stark, OH
1350 Casper, WY.............................................. 0.8701
Natrona, WY
1360 Cedar Rapids, IA........................................ 0.8814
Linn, IA
1400 Champaign-Urbana, IL.................................... 0.8723
Champaign, IL
1440 Charleston-North Charleston, SC......................... 0.9114
Berkeley, SC
Charleston, SC
Dorchester, SC
1480 Charleston, WV.......................................... 0.8990
Kanawha, WV
Putnam, WV
1520 Charlotte-Gastonia-Rock Hill, NC-SC..................... 0.9686
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Stanly, NC
Union, NC
York, SC
1540 Charlottesville, VA..................................... 1.0272
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560 Chattanooga, TN-GA...................................... 0.9074
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580 Cheyenne, WY............................................ 0.8149
Laramie, WY
1600 Chicago, IL............................................. 1.0461
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620 Chico-Paradise, CA...................................... 1.0145
Butte, CA
1640 Cincinnati, OH-KY-IN.................................... 0.9595
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-Hopkinsville, TN-KY......................... 0.8040
Christian, KY
Montgomery, TN
1680 Cleveland-Lorain-Elyria, OH............................. 0.9886
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720 Colorado Springs, CO.................................... 0.9390
El Paso, CO
1740 Columbia, MO............................................ 0.8942
Boone, MO
1760 Columbia, SC............................................ 0.9290
Lexington, SC
Richland, SC
1800 Columbus, GA-AL.........................................
Russell, AL 0.8511
Chattahoochee, GA
Harris, GA
Muscogee, GA
1840 Columbus, OH............................................ 0.9781
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880 Corpus Christi, TX...................................... 0.8513
Nueces, TX
San Patricio, TX
1900 Cumberland, MD-WV....................................... 0.8242
Allegany, MD
Mineral, WV
1920 Dallas, TX.............................................. 0.9369
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950 Danville, VA............................................ 0.9045
Danville City, VA
Pittsylvania, VA
[[Page 42784]]
1960 Davenport-Moline-Rock...................................
Island, IA-IL 0.8413
Scott, IA
Henry, IL
Rock Island, IL
2000 Dayton-Springfield, OH.................................. 0.9605
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020 Daytona Beach, FL..................................... 0.9134
Flagler, FL
Volusia, FL
2030 Decatur, AL............................................. 0.8233
Lawrence, AL
Morgan, AL
2040 Decatur, IL............................................. 0.8035
Macon, IL
2080 Denver, CO.............................................. 1.0331
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120 Des Moines, IA.......................................... 0.8448
Dallas, IA
Polk, IA
Warren, IA
2160 Detroit, MI............................................. 1.0544
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180 Dothan, AL.............................................. 0.7892
Dale, AL
Houston, AL
2190 Dover, DE............................................... 0.9363
Kent, DE
2200 Dubuque, IA............................................. 0.8222
Dubuque, IA
2240 Duluth-Superior, MN-WI.................................. 0.9962
St. Louis, MN
Douglas, WI
2281 Dutchess County, NY..................................... 1.0530
Dutchess, NY
2290 Eau Claire, WI.......................................... 0.8573
Chippewa, WI
Eau Claire, WI
2320 El Paso, TX............................................. 0.9215
El Paso, TX
2330 Elkhart-Goshen, IN...................................... 0.9305
Elkhart, IN
2335 Elmira, NY.............................................. 0.8440
Chemung, NY
2340Enid, OK.................................................. 0.7983
Garfield, OK
2360 Erie, PA................................................ 0.9271
Erie, PA
2400 Eugene-Springfield, OR.................................. 1.1193
Lane, OR
2440 Evansville-Henderson, IN-KY............................. 0.8528
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520 Fargo-Moorhead, ND-MN................................... 0.9520
Clay, MN
Cass, ND
2560 Fayetteville, NC........................................ 0.8389
Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR...................... 0.8614
Benton, AR
Washington, AR
2620 Flagstaff, AZ-UT........................................ 0.9483
Coconino, AZ
Kane, UT
2640 Flint, MI............................................... 1.1031
Genesee, MI
2650 Florence, AL............................................ 0.7676
Colbert, AL
Lauderdale, AL
2655 Florence, SC............................................ 0.8501
Florence, SC
2670 Fort Collins-Loveland, CO............................... 1.0770
Larimer, CO
2680 Ft. Lauderdale, FL...................................... 0.9807
Broward, FL
2700 Fort Myers-Cape Coral, FL............................... 0.8942
Lee, FL
2710 Fort Pierce-Port St. Lucie, FL.......................... 1.0241
Martin, FL
St. Lucie, FL
2720 Fort Smith, AR-OK....................................... 0.7623
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750 Fort Walton Beach, FL................................... 0.8615
Okaloosa, FL
2760 Fort Wayne, IN.......................................... 0.9047
Adams, IN
Allen, IN
De Kalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800 Forth Worth-Arlington, TX............................... 0.9719
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840 Fresno, CA.............................................. 1.0700
Fresno, CA
Madera, CA
2880 Gadsden, AL............................................. 0.8779
Etowah, AL
2900 Gainesville, FL......................................... 0.9453
Alachua, FL
2920 Galveston-Texas City, TX................................ 1.0894
Galveston, TX
2960 Gary, IN................................................ 0.9435
Lake, IN
Porter, IN
2975 Glens Falls, NY......................................... 0.8490
Warren, NY
Washington, NY
2980 Goldsboro, NC........................................... 0.8530
Wayne, NC
2985 Grand Forks, ND-MN...................................... 0.8836
Polk, MN
Grand Forks, ND
2995 Grand Junction, CO...................................... 0.8279
Mesa, CO
3000 Grand Rapids-Muskegon-Holland, MI....................... 0.9971
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040 Great Falls, MT......................................... 0.8872
Cascade, MT
3060 Greeley, CO............................................. 0.9457
Weld, CO
3080 Green Bay, WI........................................... 0.9156
Brown, WI
3120 Greensboro-Winston-Salem-High Point, NC................. 0.9547
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NCGuilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150 Greenville, NC.......................................... 0.9434
Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC..................... 0.9222
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180 Hagerstown, MD.......................................... 1.0183
Washington, MD
3200 Hamilton-Middletown, OH................................. 0.9233
Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA......................... 1.0060
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283 Hartford, CT 1 2........................................ 1.1831
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285 Hattiesburg, MS......................................... 0.7261
Forrest, MS
Lamar, MS
3290 Hickory-Morganton-Lenoir, NC............................ 0.8904
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320 Honolulu, HI............................................ 1.1510
Honolulu, HI
3350 Houma, LA............................................... 0.8197
Lafourche, LA
Terrebonne, LA
3360 Houston, TX............................................. 0.9889
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400 Huntington-Ashland, WV-KY-OH............................ 0.9647
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
[[Page 42785]]
Wayne, WV
3440 Huntsville, AL.......................................... 0.8385
Limestone, AL
Madison, AL
3480 Indianapolis, IN........................................ 0.9831
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500 Iowa City, IA........................................... 0.9481
Johnson, IA
3520 Jackson, MI............................................. 0.9224
Jackson, MI
3560 Jackson, MS............................................. 0.8292
Hinds, MS
Madison, MS
Rankin, MS
3580 Jackson, TN............................................. 0.8560
Madison, TN
Chester, TN
3600 Jacksonville, FL........................................ 0.8900
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605 Jacksonville, NC........................................ 0.7556
Onslow, NC
3610 Jamestown, NY........................................... 0.7660
Chautauqua, NY
3620 Janesville-Beloit, WI................................... 0.9051
Rock, WI
3640 Jersey City, NJ......................................... 1.1598
Hudson, NJ
3660 Johnson City-Kingsport-Bristol, TN-VA................... 0.8773
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680 Johnstown, PA........................................... 0.8619
Cambria, PA
Somerset, PA
3700 Jonesboro, AR........................................... 0.7407
Craighead, AR
3710 Joplin, MO.............................................. 0.7873
Jasper, MO
Newton, MO
3720 Kalamazoo-Battlecreek, MI............................... 1.1331
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740 Kankakee, IL............................................ 0.9418
Kankakee, IL
3760 Kansas City, KS-MO...................................... 0.9645
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............................................. 0.9129
Kenosha, WI
3810 Killeen-Temple, TX...................................... 1.0109
Bell, TX
Coryell, TX
3840 Knoxville, TN........................................... 0.8918
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850 Kokomo, IN.............................................. 0.9275
Howard, IN
Tipton, IN
3870 La Crosse, WI-MN........................................ 0.8913
Houston, MN
La Crosse, WI
3880 Lafayette, LA........................................... 0.8255
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920 Lafayette, IN........................................... 0.8841
Clinton, IN
Tippecanoe, IN
3960 Lake Charles, LA........................................ 0.7674
Calcasieu, LA
3980 Lakeland-Winter Haven, FL............................... 0.8939
Polk, FL
4000 Lancaster, PA........................................... 0.9561
Lancaster, PA
4040 Lansing-East Lansing, MI................................ 1.0090
Clinton, MI
Eaton, MI
Ingham, MI
4080 Laredo, TX.............................................. 0.7343
Webb, TX
4100 Las Cruces, NM.......................................... 0.8870
Dona Ana, NM
4120 Las Vegas, NV-AZ........................................ 1.1413
Mohave, AZ
Clark, NV
Nye, NV
4150 Lawrence, KS............................................ 0.8655
Douglas, KS
4200 Lawton, OK.............................................. 0.8697
Comanche, OK
4243 Lewiston-Auburn, ME..................................... 0.9149
Androscoggin, ME
4280 Lexington, KY........................................... 0.8506
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320 Lima, OH................................................ 0.8949
Allen, OH
Auglaize, OH
4360 Lincoln, NE............................................. 0.9303
Lancaster, NE
4400 Little Rock-North Little Rock, AR....................... 0.8503
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420 Longview-Marshall, TX................................... 0.8698
Gregg, TX
Harrison, TX
Upshur, TX
4480 Los Angeles-Long Beach, CA.............................. 1.2085
Los Angeles, CA
4520 Louisville, KY-IN....................................... 0.9093
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600 Lubbock, TX............................................. 0.8496
Lubbock, TX
4640 Lynchburg, VA........................................... 0.8900
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680 Macon, GA............................................... 0.8980
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720 Madison, WI............................................. 1.0018
Dane, WI
4800 Mansfield, OH........................................... 0.8534
Crawford, OH
Richland, OH
4840 Mayaguez, PR............................................ 0.4401
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880 McAllen-Edinburg-Mission, TX............................ 0.8893
Hidalgo, TX
4890 Medford-Ashland, OR..................................... 1.0020
Jackson, OR
4900 Melbourne-Titusville-Palm Bay, FL....................... 0.9216
Brevard, FL
4920 Memphis, TN-AR-MS....................................... 0.8361
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940 Merced, CA.............................................. 1.0033
Merced, CA
5000 Miami, FL............................................... 1.0017
Dade, FL
5015 Middlesex-Somerset-Hunterdon, NJ........................ 1.1152
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080 Milwaukee-Waukesha, WI.................................. 0.9356
Milwaukee, WI
Ozaukee, WI
[[Page 42786]]
Washington, WI
Waukesha, WI
5120 Minneapolis-St. Paul, MN-WI............................. 1.0854
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
5140 Missoula, MT............................................ 0.9189
Missoula, MT
5160 Mobile, AL.............................................. 0.8377
Baldwin, AL
Mobile, AL
5170 Modesto, CA............................................. 1.0346
Stanislaus, CA
5190 Monmouth-Ocean, NJ...................................... 1.1317
Monmouth, NJ
Ocean, NJ
5200 Monroe, LA.............................................. 0.8219
Ouachita, LA
5240 Montgomery, AL.......................................... 0.7821
Autauga, AL
Elmore, AL
Montgomery, AL
5280 Muncie, IN.............................................. 0.9414
Delaware, IN
5330 Myrtle Beach, SC........................................ 0.8179
Horry, SC
5345 Naples, FL.............................................. 1.0177
Collier, FL
5360 Nashville, TN........................................... 0.9480
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford, TN
Sumner, TN
Williamson, TN
Wilson, TN
5380 Nassau-Suffolk, NY...................................... 1.3593
Nassau, NY
Suffolk, NY
5483 New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT..... 1.2328
Fairfield, CT
New Haven, CT
5523 New London-Norwich, CT.................................. 1.1616
New London, CT
5560 New Orleans, LA......................................... 0.9310
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. James, LA
St. John The Baptist, LA
St. Tammany, LA
5600 New York, NY............................................ 1.4461
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640 Newark, NJ.............................................. 1.1866
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660 Newburgh, NY-PA......................................... 1.1155
Orange, NY
Pike, PA
5720 Norfolk-Virginia Beach-Newport News, VA-NC.............. 0.8275
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............................................. 1.4993
Alameda, CA
Contra Costa, CA
5790 Ocala, FL............................................... 0.9152
Marion, FL
5800 Odessa-Midland, TX...................................... 0.8656
Ector, TX
Midland, TX
5880 Oklahoma City, OK....................................... 0.8708
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910 Olympia, WA ........................................... 1.1522
Thurston, WA
5920 Omaha, NE-IA............................................ 0.9972
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945 Orange County, CA....................................... 1.1522
Orange, CA
5960 Orlando, FL............................................. 0.9813
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990 Owensboro, KY........................................... 0.7771
Daviess, KY
6015 Panama City, FL......................................... 0.8507
Bay, FL
6020 Parkersburg-Marietta, WV-OH............................. 0.8016
Washington, OH
Wood, WV
6080 Pensacola, FL........................................... 0.8246
Escambia, FL
Santa Rosa, FL
6120 Peoria-Pekin, IL........................................ 0.8058
Peoria, IL
Tazewell, IL
Woodford, IL
6160 Philadelphia, PA-NJ..................................... 1.1370
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200 Phoenix-Mesa, AZ........................................ 0.9591
Maricopa, AZ
Pinal, AZ
6240 Pine Bluff, AR.......................................... 0.7912
Jefferson, AR
6280 Pittsburgh, PA.......................................... 0.9789
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323 Pittsfield, MA.......................................... 1.0819
Berkshire, MA
6340 Pocatello, ID........................................... 0.8792
Bannock, ID
6360 Ponce, PR............................................... 0.4788
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403 Portland, ME............................................ 0.9561
Cumberland, ME
Sagadahoc, ME
York, ME
6440 Portland-Vancouver, OR-WA............................... 1.1178
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483 Providence-Warwick-Pawtucket, RI........................ 1.0801
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520 Provo-Orem, UT.......................................... 0.9885
Utah, UT
6560 Pueblo, CO.............................................. 0.8712
Pueblo, CO
6580 Punta Gorda, FL......................................... 0.9031
Charlotte, FL
6600 Racine, WI.............................................. 0.9130
Racine, WI
6640 Raleigh-Durham-Chapel Hill, NC.......................... 0.9812
Chatham, NC
[[Page 42787]]
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660 Rapid City, SD.......................................... 0.8208
Pennington, SD
6680 Reading, PA............................................. 0.9234
Berks, PA
6690 Redding, CA............................................. 1.1858
Shasta, CA
6720 Reno, NV................................................ 1.1095
Washoe, NV
6740 Richland-Kennewick-Pasco, WA............................ 1.0287
Benton, WA
Franklin, WA
6760 Richmond-Petersburg, VA................................. 0.9211
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 Bernardino, CA............................ 1.0757
Riverside, CA
San Bernardino, CA
6800 Roanoke, VA............................................. 0.8509
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820 Rochester, MN........................................... 1.1698
Olmsted, MN
6840 Rochester, NY........................................... 0.9657
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880 Rockford, IL............................................ 0.8615
Boone, IL
Ogle, IL
Winnebago, IL
6895 Rocky Mount, NC......................................... 0.9012
Edgecombe, NC
Nash, NC
6920 Sacramento, CA.......................................... 1.1962
El Dorado, CA
Placer, CA
Sacramento, CA
6960 Saginaw-Bay City-Midland, MI............................ 0.9487
Bay, MI
Midland, MI
Saginaw, MI
6980 St. Cloud, MN........................................... 0.9586
Benton, MN
Stearns, MN
7000 St. Joseph, MO.......................................... 0.9889
Andrew, MO
Buchanan, MO
7040 St. Louis, MO-IL........................................ 0.9151
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............................................... 0.9904
Marion, OR
Polk, OR
7120 Salinas, CA............................................. 1.5142
Monterey, CA
7160 Salt Lake City-Ogden, UT................................ 0.9398
Davis, UT
Salt Lake, UT
Weber, UT
7200 San Angelo, TX.......................................... 0.7646
Tom Green, TX
7240 San Antonio, TX......................................... 0.8100
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320 San Diego, CA........................................... 1.2265
San Diego, CA
7360 San Francisco, CA....................................... 1.3957
Marin, CA
San Francisco, CA
San Mateo, CA
7400 San Jose, CA............................................ 1.3827
Santa Clara, CA
7440 San Juan-Bayamon, PR.................................... 0.4623
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
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-Atascadero-Paso Robles, CA.............. 1.1264
San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA.................... 1.1194
Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA.............................. 1.3981
Santa Cruz, CA
7490 Santa Fe, NM............................................ 0.9652
Los Alamos, NM
Santa Fe, NM
7500 Santa Rosa, CA.......................................... 1.3597
Sonoma, CA
7510 Sarasota-Bradenton, FL.................................. 0.9532
Manatee, FL
Sarasota, FL
7520 Savannah, GA............................................ 1.0060
Bryan, GA
Chatham, GA
Effingham, GA
7560 Scranton--Wilkes-Barre--Hazleton, PA.................... 0.8299
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600 Seattle-Bellevue-Everett, WA............................ 1.1526
Island, WA
King, WA
Snohomish, WA
7610 Sharon, PA.............................................. 0.8847
Mercer, PA
7620 Sheboygan, WI........................................... 0.8225
Sheboygan, WI
7640 Sherman-Denison, TX..................................... 0.8570
Grayson, TX
7680 Shreveport-Bossier City, LA............................. 0.9386
Bossier, LA
Caddo, LA
Webster, LA
7720 Sioux City, IA-NE....................................... 0.8481
Woodbury, IA
Dakota, NE
7760 Sioux Falls, SD......................................... 0.8912
Lincoln, SD
Minnehaha, SD
7800 South Bend, IN.......................................... 0.9859
St. Joseph, IN
7840 Spokane, WA............................................. 1.0928
Spokane, WA
7880 Springfield, IL......................................... 0.8720
Menard, IL
Sangamon, IL
7920 Springfield, MO......................................... 0.8071
Christian, MO
Greene, MO
Webster, MO
8003 Springfield, MA......................................... 1.0990
Hampden, MA
Hampshire, MA
8050 State College, PA....................................... 0.9449
Centre, PA
8080 Steubenville-Weirton, OH-WV............................. 0.8428
Jefferson, OH
Brooke, WV
Hancock, WV
8120 Stockton-Lodi, CA....................................... 1.1075
San Joaquin, CA
[[Page 42788]]
8140 Sumter, SC.............................................. 0.8127
Sumter, SC
8160 Syracuse, NY............................................ 0.9400
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200 Tacoma, WA.............................................. 1.0380
Pierce, WA
8240 Tallahassee, FL......................................... 0.8449
Gadsden, FL
Leon, FL
8280 Tampa-St. Petersburg-Clearwater, FL..................... 0.9113
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320 Terre Haute, IN......................................... 0.8991
Clay, IN
Vermillion, IN
Vigo, IN
8360 Texarkana, AR-Texarkana, TX............................. 0.8506
Miller, AR
Bowie, TX
8400 Toledo, OH.............................................. 0.9991
Fulton, OH
Lucas, OH
Wood, OH
8440 Topeka, KS.............................................. 0.9812
Shawnee, KS
8480 Trenton, NJ............................................. 1.0509
Mercer, NJ
8520 Tucson, AZ.............................................. 0.9028
Pima, AZ
8560 Tulsa, OK............................................... 0.8463
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600 Tuscaloosa, AL.......................................... 0.7641
Tuscaloosa, AL
8640 Tyler, TX............................................... 0.8818
Smith, TX
8680 Utica-Rome, NY.......................................... 0.8418
Herkimer, NY
Oneida, NY
8720 Vallejo-Fairfield-Napa, CA.............................. 1.3413
Napa, CA
Solano, CA
8735 Ventura, CA............................................. 1.1014
Ventura, CA
8750 Victoria, TX............................................ 0.8381
Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ........................ 1.0440
Cumberland, NJ
8780 Visalia-Tulare-Porterville, CA.......................... 1.0083
Tulare, CA
8800 Waco, TX................................................ 0.8371
McLennan, TX
8840 Washington, DC-MD-VA-WV................................. 1.0807
District of Columbia, DC
Calvert, MD
Charles, MD
Frederick, MD
Montgomery, MD
Prince Georges, MD
Alexandria City, VA
Arlington, VA
Clarke, VA
Culpeper, 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, IA 0.7958
Black Hawk, IA
8940 Wausau, WI.............................................. 0.9733
Marathon, WI
8960 West Palm Beach-Boca Raton, FL.......................... 1.0219
Palm Beach, FL
9000 Wheeling, WV-OH......................................... 0.7627
Belmont, OH
Marshall, WV
Ohio, WV
9040 Wichita, KS............................................. 0.8898
Butler, KS
Harvey, KS
Sedgwick, KS
9080 Wichita Falls, TX....................................... 0.7830
Archer, TX
Wichita, TX
9140 Williamsport, PA........................................ 0.8556
Lycoming, PA
9160 Wilmington-Newark, DE-MD................................ 1.1868
New Castle, DE
Cecil, MD
9200 Wilmington, NC.......................................... 0.9343
New Hanover, NC
Brunswick, NC
9260 Yakima, WA.............................................. 1.0318
Yakima, WA
9270 Yolo, CA................................................ 1.1233
Yolo, CA
9280 York, PA................................................ 0.9410
York, PA
9320 Youngstown-Warren, OH 0.9815
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340 Yuba City, CA........................................... 1.0865
Sutter, CA
Yuba, CA
9360 Yuma, AZ................................................ 1.0058
Yuma, AZ
------------------------------------------------------------------------
Addendum 1b.--Wage Index for Rural Areas
------------------------------------------------------------------------
Wage
Nonurban area index
------------------------------------------------------------------------
Alabama....................................................... 0.7294
Alaska........................................................ 1.2430
Arizona....................................................... 0.7989
Arkansas...................................................... 0.7250
California.................................................... 0.9979
Colorado...................................................... 0.8436
Connecticut................................................... 1.2074
Delaware...................................................... 0.8807
Florida....................................................... 0.8877
Georgia....................................................... 0.7888
Guam.......................................................... 0.6516
Hawaii........................................................ 1.0910
Idaho......................................................... 0.8477
Illinois...................................................... 0.7916
Indiana....................................................... 0.8380
Iowa.......................................................... 0.7777
Kansas........................................................ 0.7319
Kentucky...................................................... 0.7844
Louisiana..................................................... 0.7454
Maine......................................................... 0.8467
Maryland...................................................... 0.8555
Massachusetts................................................. 1.0834
Michigan...................................................... 0.8875
Minnesota..................................................... 0.8595
Mississippi................................................... 0.7312
Missouri...................................................... 0.7452
Montana....................................................... 0.8398
Nebraska...................................................... 0.7674
Nevada........................................................ 0.9256
New Hampshire................................................. 1.0240
New Jersey \1\................................................ ........
New Mexico.................................................... 0.8269
New York...................................................... 0.8588
North Carolina................................................ 0.8112
North Dakota.................................................. 0.7497
Ohio.......................................................... 0.8519
Oklahoma...................................................... 0.7124
Oregon........................................................ 0.9910
Pennsylvania.................................................. 0.8664
Puerto Rico................................................... 0.4080
Rhode Island \1\.............................................. ........
South Carolina................................................ 0.8046
South Dakota.................................................. 0.7508
Tennessee..................................................... 0.7492
Texas......................................................... 0.7565
Utah.......................................................... 0.8859
Vermont....................................................... 0.9416
Virginia...................................................... 0.7857
Virgin Islands................................................ 0.4588
Washington.................................................... 1.0489
West Virginia................................................. 0.7875
Wisconsin..................................................... 0.8711
Wyoming....................................................... 0.8768
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.
Addendum 2.--Cost Reporting Year--Adjustment Factor 1
------------------------------------------------------------------------
The
If the HHA cost reporting period begins adjustment
factor is
------------------------------------------------------------------------
November 1, 1999........................................... 1.00113
December 1, 1999........................................... 1.00244
January 1, 2000............................................ 1.00394
February 1, 2000........................................... 1.00544
March 1, 2000.............................................. 1.00696
April 1, 2000.............................................. 1.00850
[[Page 42789]]
May 1, 2000................................................ 1.01013
June 1, 2000............................................... 1.01186
July 1, 2000............................................... 1.01369
August 1, 2000............................................. 1.01558
September 1, 2000.......................................... 1.01753
------------------------------------------------------------------------
1 Based on compounded projected market basket inflation rates.
Source: The Home Health Agency Input Price Index, produced by HCFA for
the period between 1983:1 and 2008:4. The forecasts are from Standard
and Poor's DRI 3rd QTR 1997: @USSIM/[email protected]/Control973
forecast exercise which has historical data through 1997:2.
Addendum 3.--Monthly Index Levels for Calculating Inflation Factors To
Be Applied to Home Health Agency Per-Beneficiary Limitations
------------------------------------------------------------------------
Month Index level
------------------------------------------------------------------------
October 1992............................................... .98672
November 1992.............................................. .98800
December 1992.............................................. .98928
January 1993............................................... .99313
February 1993.............................................. .99700
March 1993................................................. 1.00088
April 1993................................................. 1.00244
May 1993................................................... 1.00400
June 1993.................................................. 1.00556
July 1993.................................................. 1.00878
August 1993................................................ 1.01200
September 1993............................................. 1.01523
October 1993............................................... 1.01662
November 1993.............................................. 1.01800
December 1993.............................................. 1.01939
January 1994............................................... 1.02318
February 1994.............................................. 1.02700
March 1994................................................. 1.03083
April 1994................................................. 1.03141
May 1994................................................... 1.03200
June 1994.................................................. 1.03259
July 1994.................................................. 1.03259
August 1994................................................ 1.03259
September 1994............................................. 1.03259
October 1994............................................... 1.03259
November 1994.............................................. 1.03259
December 1994.............................................. 1.03259
January 1995............................................... 1.03259
February 1995.............................................. 1.03259
March 1995................................................. 1.03259
April 1995................................................. 1.03259
May 1995................................................... 1.03259
June 1995.................................................. 1.03259
July 1995.................................................. 1.03259
August 1995................................................ 1.03259
September 1995............................................. 1.03259
October 1995............................................... 1.03259
November 1995.............................................. 1.03259
December 1995.............................................. 1.03259
January 1996............................................... 1.03259
February 1996.............................................. 1.03259
March 1996................................................. 1.03259
April 1996................................................. 1.03259
May 1996................................................... 1.03259
June 1996.................................................. 1.03259
July 1996.................................................. 1.03479
August 1996................................................ 1.03700
September 1996............................................. 1.03921
October 1996............................................... 1.04141
November 1996.............................................. 1.04361
December 1996.............................................. 1.04582
January 1997............................................... 1.04849
February 1997.............................................. 1.05117
March 1997................................................. 1.05385
April 1997................................................. 1.05581
May 1997................................................... 1.05778
June 1997.................................................. 1.05974
July 1997.................................................. 1.06395
August 1997................................................ 1.06817
September 1997............................................. 1.07317
October 1997............................................... 1.07406
November 1997.............................................. 1.07572
December 1997.............................................. 1.07738
January 1998............................................... 1.07986
February 1998.............................................. 1.08233
March 1998................................................. 1.08481
April 1998................................................. 1.08735
May 1998................................................... 1.08989
June 1998.................................................. 1.09243
July 1998.................................................. 1.09588
August 1998................................................ 1.09933
September 1998............................................. 1.10280
October 1998............................................... 1.10390
November 1998.............................................. 1.10500
December 1998.............................................. 1.10610
January 1999............................................... 1.10979
February 1999.............................................. 1.11350
March 1999................................................. 1.11722
April 1999................................................. 1.11960
May 1999................................................... 1.12200
June 1999.................................................. 1.12440
July 1999.................................................. 1.12791
August 1999................................................ 1.13144
September 1999............................................. 1.13498
October 1999............................................... 1.13509
November 1999.............................................. 1.13520
December 1999.............................................. 1.13531
January 2000............................................... 1.13714
February 2000.............................................. 1.13898
March 2000................................................. 1.14081
April 2000................................................. 1.14179
May 2000................................................... 1.14276
June 2000.................................................. 1.14374
July 2000.................................................. 1.14515
August 2000................................................ 1.14656
September 2000............................................. 1.14797
October 2000............................................... 1.15056
November 2000.............................................. 1.15316
December 2000.............................................. 1.15576
January 2001............................................... 1.15778
February 2001.............................................. 1.15980
March 2001................................................. 1.16182
April 2001................................................. 1.16414
May 2001................................................... 1.16647
June 2001.................................................. 1.16881
July 2001.................................................. 1.17100
August 2001................................................ 1.17319
September 2001............................................. 1.17539
October 2001............................................... 1.17655
------------------------------------------------------------------------
[FR Doc. 99-20012 Filed 7-30-99; 1:30 pm]
BILLING CODE 4120-03-P
