Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System Payment Update for Rate Year Beginning July 1, 2006 (RY 2007), 27040-27156 [06-4202]
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Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
42 CFR Parts 412 and 424
[CMS–1306–F]
RIN 0938–AN82
Medicare Program; Inpatient
Psychiatric Facilities Prospective
Payment System Payment Update for
Rate Year Beginning July 1, 2006 (RY
2007)
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Final rule.
AGENCY:
SUMMARY: This final rule updates the
prospective payment rates for Medicare
inpatient hospital services provided by
inpatient psychiatric facilities (IPFs).
These changes are applicable to IPF
discharges occurring during the rate
year beginning July 1, 2006 through
June 30, 2007. In addition, we are
adopting the new Office of Management
and Budget (OMB) labor market area
definitions for the purpose of
geographic classification and the wage
index. We are also making revisions to
existing policies and implementing new
polices.
DATES: Effective Date: These regulations
are effective on July 1, 2006.
FOR FURTHER INFORMATION CONTACT:
Dorothy Colbert, (410) 786–4533 for
general information. Mary Lee Seifert,
(410) 786–0030 for information
regarding the market basket and laborrelated share. Theresa Bean, (410) 786–
2287 for information regarding the
regulatory impact analysis. Matthew
Quarrick, (410) 786–9867 for
information on the wage index.
SUPPLEMENTARY INFORMATION:
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Table of Contents
To assist readers in referencing
sections contained in this document, we
are providing the following table of
contents.
I. Background
A. General and Legislative History
B. Overview of the Establishment of the
IPF PPS
C. Applicability of the IPF PPS
II. Overview for Updating the IPF PPS
A. Requirements for Updating the IPF PPS
B. Transition Period for Implementation of
the IPF PPS
III. Provisions of the Proposed Regulation
IV. Analysis of and Responses to Public
Comments
V. Updates to the IPF PPS for RY Beginning
July 1, 2006
A. Calculation of the Average Per Diem
Cost
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B. Determining the Standardized BudgetNeutral Federal Per Diem Base Rate
1. Standardization of the Federal Per Diem
Base Rate
2. Calculation of the Budget Neutrality
Adjustment
a. Outlier Adjustment
b. Stop-Loss Provision Adjustment
c. Behavioral Offset
3. Revision of Standardization Factor
C. Update of the Federal Per Diem Base
Rate
1. Market Basket for IPFs Reimbursed
Under the IPF PPS
a. Market Basket Index for IPF PPS
b. Overview of the RPL Market Basket
2. Methodology for Operating Portion of
the RPL Market Basket
3. Methodology for Capital Portion of the
RPL Market Basket
4. Labor-Related Share
VI. Update of the IPF PPS Adjustment
Factors
A. Overview of the IPF PPS Adjustment
Factors
B. Patient-Level Adjustments
1. Adjustment for DRG Assignment
2. Payment for Comorbid Conditions
3. Patient Age Adjustments
4. Variable Per Diem Adjustments
C. Facility-Level Adjustments
1. Wage Index Adjustment
a. Revisions of IPF PPS Geographic
Classifications
b. Current IPF PPS Labor Market Areas
Based on MSAs
c. Core-Based Statistical Areas
d. Revision of the IPF PPS Labor Market
Areas
i. New England MSAs
ii. Metropolitan Divisions
iii. Micropolitan Areas
e. Implementation of the Revised Labor
Market Areas Under the IPF PPS
f. Wage Index Budget Neutrality
2. Adjustment for Rural Location
3. Teaching Adjustment
4. Cost of Living Adjustment for IPFs
Located in Alaska and Hawaii
5. Adjustment for IPFs With a Qualifying
Emergency Department (ED)
a. New Source of Admission Code To
Implement the ED Adjustment
b. Applicability of the ED Adjustment to
IPFs in Critical Access Hospitals
D. Other Payment Adjustments and
Policies
1. Outlier Payments
a. Update to the Outlier Fixed Dollar Loss
Threshold Amount
b. Statistical Accuracy of Cost-to-Charge
Ratios
2. Stop-Loss Provision
3. Patients Who Receive Electroconvulsive
Therapy (ECT)
4. Physician Certification and
Recertification Requirements
5. Provision of Therapeutic Recreation in
IPFs
6. Same Day Transfers
VII. Miscellaneous Public Comments Within
the Scope of the Proposed Rule
VIII. Provisions of the Final Rule
IX. Collection of Information Requirements
X. Regulatory Impact Analysis
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Acronyms
Because of the many terms to which
we refer by acronym in this final rule,
we are listing the acronyms used and
their corresponding terms in
alphabetical order below:
BBA Balanced Budget Act of 1997, (Pub. L.
105–33)
BBRA Medicare, Medicaid and SCHIP
[State Children’s Health Insurance
Program] Balanced Budget Refinement Act
of 1999, (Pub. L. 106–113)
BIPA Medicare, Medicaid, and SCHIP [State
Children’s Health Insurance Program]
Benefits Improvement and Protection Act
of 2000, (Pub. L. 106–554)
CBSA Core-Based Statistical Area
CCR Cost-to-charge ratio
CMS Centers for Medicare & Medicaid
Services
CMSA Consolidated Metropolitan
Statistical Area
DSM–IV–TR Diagnostic and Statistical
Manual of Mental Disorders Fourth
Edition—Text Revision
DRGs Diagnosis-related groups
FY Federal fiscal year
HCRIS Hospital Cost Report Information
System
ICD–9–CM International Classification of
Diseases, 9th Revision, Clinical
Modification
IPFs Inpatient psychiatric facilities
IRFs Inpatient rehabilitation facilities
LTCHs Long-term care hospitals
MedPAR Medicare provider analysis and
review file
MMA Medicare Prescription Drug,
Improvement and Modernization Act of
2003, (Pub. L. 108–173)
MSA Metropolitan Statistical Area
NECMA New England County Metropolitan
Area
OMB Office of Management and Budget
PIP Periodic Interim Payments
RY Rate Year (July 1 through June 30)
TEFRA Tax Equity and Fiscal
Responsibility Act of 1982, (Pub. L. 97–
248)
I. Background
A. General and Legislative History
The Congress directed
implementation of a prospective
payment system (PPS) for acute care
hospitals with the enactment of Pub. L.
98–21. Section 601 of the Social
Security Amendments of 1983 (Pub. L.
98–21) added a new section 1886(d) to
the Social Security Act (the Act) that
replaced the reasonable cost-based
payment system for most hospital
inpatient services with a PPS.
Although most hospital inpatient
services became subject to the PPS,
certain hospitals, including IPFs,
inpatient rehabilitation facilities (IRFs),
long term care hospitals (LTCHs), and
children’s hospitals were excluded from
the PPS for acute care hospitals. These
hospitals and units were paid their
reasonable costs for inpatient services,
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subject to a per discharge limitation or
target amount under the authority of the
Tax Equity and Fiscal Responsibility
Act of 1982 (TEFRA), Pub. L. 97–248.
The regulations implementing the
TEFRA (reasonable cost-based) payment
provisions are located at 42 CFR part
413. Cancer hospitals were added to the
list of excluded hospitals by section
6004(a) of the Omnibus Budget
Reconciliation Act of 1989, (Pub. L.
101–239).
The Congress enacted various
provisions in the Balanced Budget Act
of 1997 (BBA) (Pub. L. 105–33), the
Medicare, Medicaid, and SCHIP (State
Children’s Health Insurance Program)
Balanced Budget Refinement Act of
1999 (BBRA) (Pub. L. 106–113), and the
Medicare, Medicaid, and SCHIP
Benefits Improvement and Protection
Act of 2000 (BIPA) (Pub. L. 106–554) to
replace the reasonable cost-based
method of reimbursement with a PPS
for IRFs, LTCHs, and IPFs. Section 124
of the BBRA required implementation of
the IPF PPS.
Section 124 of the BBRA mandated
that the Secretary—(1) Develop a per
diem PPS for inpatient hospital services
furnished in psychiatric hospitals and
psychiatric units; (2) include in the PPS
an adequate patient classification
system that reflects the differences in
patient resource use and costs among
psychiatric hospitals and psychiatric
units; (3) maintain budget neutrality; (4)
permit the Secretary to require
psychiatric hospitals and psychiatric
units to submit information necessary
for the development of the PPS; and (5)
submit a report to the Congress
describing the development of the PPS.
Section 124 of the BBRA also required
that the IPF PPS be implemented for
cost reporting periods beginning on or
after October 1, 2002.
Section 405(g)(2) of the Medicare
Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) (Pub.
L. 108–173) extended the IPF PPS to
distinct part psychiatric units of critical
access hospitals (CAHs).
To implement these provisions, the
following were published: a proposed
rule in the Federal Register on
November 28, 2003 (68 FR 66920); a
final rule on November 15, 2004 (69 FR
66922); and a correction notice to the
final rule on April 1, 2005 (70 FR
16724). For more detail, see the program
memorandum Web site, https://
www.cms.hhs.gov/transmittals/
01_overview.asp.
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B. Overview of the Establishment of the
IPF PPS
The November 2004 IPF PPS final
rule established regulations for the IPF
PPS under 42 CFR 412, subpart N.
The IPF PPS established the Federal
per diem base rate for each patient day
in an IPF derived from the national
average daily routine operating,
ancillary, and capital costs in IPFs in FY
2002. The average per diem cost was
updated to the midpoint of the first year
under the IPF PPS, standardized to
account for the overall positive effects of
the IPF PPS payment adjustments, and
adjusted for budget neutrality. The
Federal per diem payment under the IPF
PPS is comprised of the Federal per
diem base rate described above and
certain patient and facility payment
adjustments that were found in the
regression analysis to be associated with
statistically significant per diem cost
differences (see 69 FR 66933 through
66936 for a description of the regression
analysis). The patient-level adjustments
include age, DRG assignment,
comorbidities, and variable per diem
adjustments to reflect the higher cost
incurred in the early days of a
psychiatric stay. Facility-level
adjustments include adjustments for the
IPF’s wage index, rural location,
teaching status, a cost of living
adjustment for IPFs located in Alaska
and Hawaii, and presence of a
qualifying emergency department (ED).
The IPF PPS provides additional
payments for outlier cases, stop-loss
protection which is applicable only
during the IPF PPS transition period,
includes special payment provisions for
interrupted stays, and a per treatment
adjustment for patients who undergo
electroconvulsive therapy (ECT). We
refer readers to the November 2004 IPF
PPS final rule for a comprehensive
discussion of the research and data that
supported the establishment of the IPF
PPS.
We established a CMS Web site that
contains useful information regarding
the IPF PPS including the proposed
rules, final rules, and the correction
notices. The Web site URL is https://
www.cms.hhs.gov/
InpatientPsychFacilPPS/ and may be
accessed to download or view
publications and other information
pertinent to the IPF PPS.
C. Applicability of the IPF PPS
The IPF PPS is applicable to
freestanding psychiatric hospitals,
including government-operated
psychiatric hospitals, and distinct part
psychiatric units of acute care hospitals
and CAHs.
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The regulations at § 412.402 define an
IPF as a hospital that meets the
requirements specified in § 412.22,
§ 412.23(a), § 482.60, § 482.61, and
§ 482.62, and units that meet the
requirements specified in § 412.22,
§ 412.25, and § 412.27.
However, the following hospitals are
paid under a special payment provision,
as described in § 412.22(c) and,
therefore, are not subject to the IPF PPS
rules:
• Veterans Administration hospitals.
• Hospitals that are reimbursed under
State cost control systems approved
under 42 CFR part 403.
• Hospitals that are reimbursed in
accordance with demonstration projects
specified in section 402(a) of Pub. L. 90–
248 (42 U.S.C. 1395b–1) or section
222(a) of Pub. L. 92–603 (42 U.S.C.
1395b–1(note)).
• Non-participating hospitals
furnishing emergency services to
Medicare beneficiaries.
II. Overview for Updating the IPF PPS
A. Requirements for Updating the IPF
PPS
Section 124 of the BBRA does not
specify an update strategy for the IPF
PPS and is broadly written to give the
Secretary discretion in establishing an
update methodology. Therefore, we
reviewed the update approach used in
other hospital PPSs (specifically, the
IRF and LTCH PPS update
methodologies). As a result of this
analysis, we stated in the November
2004 IPF PPS final rule (69 FR 66966)
that we would implement the IPF PPS
using the following update strategy—(1)
Calculate the final Federal per diem
base rate to be budget neutral for the 18month period (that is, January 1, 2005
through June 30, 2006); (2) use a July 1
through June 30 annual update cycle;
and (3) allow the IPF PPS first update
to be effective for discharges July 1,
2006 through June 30, 2007.
As explained in the November 2004
IPF PPS final rule, we believe it is
important to delay updating the
adjustment factors derived from the
regression analysis until we have IPF
PPS data that include as much
information as possible regarding the
patient-level characteristics of the
population that each IPF serves. For this
reason, we do not intend to update the
regression analysis and recalculate the
Federal per diem base rate until we
analyze IPF PPS data (that is, no earlier
than FY 2008). Until that analysis is
complete, we stated our intention to
publish a notice in the Federal Register
each spring to update the IPF PPS as
specified in § 412.428.
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However, since the implementation of
the IPF PPS, a new market basket index
was announced in the August 2005 IPPS
final rule. We believe that this new
market basket should be implemented
in the IPF PPS as well in order to update
the system using the best data available.
Therefore, rather than publish a notice
to update the IPF PPS in 2006, we
published a proposed rule in the
Federal Register on January 23, 2006
(71 FR 3616) to allow interested parties
an opportunity to comment on the
proposed changes.
Updates to the IPF PPS as specified in
§ 412.428 include:
• A description of the methodology
and data used to calculate the updated
Federal per diem base payment amount.
• The rate of increase factor as
described in § 412.424(a)(2)(iii), which
is based on the excluded hospital with
capital market basket under the update
methodology of 1886(b)(3)(B)(ii) of the
Act for each year.
• The best available hospital wage
index and information regarding
whether an adjustment to the Federal
per diem base rate is needed to maintain
budget neutrality.
• Updates to the fixed dollar loss
amount in order to maintain the
appropriate outlier percentage.
• Describe the ICD–9–CM coding and
DRG classification changes discussed in
the annual update to the hospital IPPS
regulations.
• Update the ECT adjustment by a
factor specified by CMS.
B. Transition Period for Implementation
of the IPF PPS
In the November 2004 IPF PPS final
rule, we established § 412.426 to
provide for a 3-year transition period
from reasonable cost-based
reimbursement to full prospective
payment for IPFs. New IPFs, as defined
in § 412.426(c), are paid 100 percent of
the Federal per diem rate. However, for
those IPFs that are transitioning to the
new system, during the 3-year period as
specified in the November 2004 IPF PPS
final rule, payment is based on an
increasing percentage of the PPS
payment and a decreasing percentage of
each IPF’s facility-specific TEFRA
reimbursement rate. The blend
percentages are as follows:
TABLE 1.—IPF PPS FINAL RULE TRANSITION BLEND FACTORS
Transition
year
1 ..................
2 ..................
3 ..................
January
January
January
January
1,
1,
1,
1,
2005
2006
2007
2008
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
.............................................................................................................................
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Changes to the blend percentages
occur at the beginning of an IPF’s cost
reporting period. We note that we are
currently in year two of the transition
period. As a result, for discharges
occurring during IPF cost reporting
periods beginning in calendar year (CY)
2006, IPFs would receive a blended
payment consisting of 50 percent of the
facility-specific TEFRA payment and 50
percent of the IPF PPS payment amount.
However, regardless of when an IPF’s
cost reporting year begins, the payment
update will be effective for discharges
occurring on or after July 1, 2006
through June 30, 2007. We note that we
are not making any changes to the
transition approach established in the
November 2004 IPF PPS final rule.
III. Provisions of the Proposed
Regulation
In January 2006, we published a
proposed rule that appeared in the
Federal Register at (71 FR 3616), and on
February 24, 2006, a correction notice
appeared in the Federal Register (71 FR
9505) to correct technical errors in the
proposed rule and to extend the
comment period for our policy
concerning Electroconvulsive Therapy
(ECT). The January 2006 proposed rule
(hereinafter referred to as the Rate Year
(RY) 2007 proposed rule) set forth the
proposed annual update to the proposed
prospective payment for IPFs for
discharges occurring during the RY
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percentage
Cost reporting periods beginning on or after
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beginning July 1, 2006. As part of the
update, we proposed to incorporate
OMB’s revised definitions for MSAs and
its new definitions of Micropolitan
Statistical Areas and Core-Based
Statistical Areas (CBSAs). In addition,
we proposed the following——
• Update payments for IPFs using a
market basket reflecting the operating
and capital cost structures of IRFs, IPFs,
and LTCHs.
• Develop cost weights for benefits,
contract labor, and blood and blood
products using the FY 2002-based IPPS
market basket.
• Provide weights and proxies for the
FY 2002-based RPL market basket.
• Indicate the methodology for the
capital portion of the FY 2002-based
RPL market basket.
• Update the outlier threshold
amount to maintain total estimated
outlier payments at 2 percent of total
estimated payments.
• Use source code ‘‘D’’ to identify IPF
patients who have been transferred to
the IPF from the same hospital or CAH.
• Retain the 17 percent adjustment
for IPFs located in rural areas, the 1.31
adjustment for IPFs with a qualifying
ED, the 0.5150 teaching adjustment to
the Federal per diem base rate, and the
DRG adjustment factors currently being
paid to IPFs for discharges occurring
during RY 2007.
• Update the payment rate for ECT.
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75
50
25
0
IPF PPS
Federal rate
percentage
25
50
75
100
• Update the DRG listing and
comorbidity categories to reflect the
ICD–9–CM revisions effective October 1,
2005.
In addition to addressing these issues
in the proposed rule for RY 2007, we
also proposed making the following
specific revisions to the existing text of
the regulations. We proposed to make
conforming changes in 42 CFR parts 412
and 424, as discussed throughout this
preamble.
In § 412.27, we proposed to revise
paragraph (b) to remove the reference to
recreational therapy.
In § 412.402, we proposed to revise
the heading of ‘‘Fixed dollar lossthreshold’’ to ‘‘Fixed dollar loss
threshold amount’’ and revise the
definitions of ‘‘Fixed dollar loss
threshold amount’’, ‘‘Qualifying
emergency department’’, ‘‘Rural area’’
and ‘‘Urban area.’’ For consistency, we
proposed to make conforming changes
to these terminologies wherever they
appear in the regulations text.
In § 412.424, we proposed to add
paragraph (d)(1)(iii)(E) to clarify that the
teaching adjustment is made on a claim
basis as an interim payment and the
final payment in full is made during the
final settlement of the cost report. For
clarity, we also proposed to revise
paragraph (d)(2) introductory text. The
current language in (d)(2)(iii) would
become the introductory text for
paragraph (d)(2) and paragraph
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(d)(2)(iii) would be removed. In
addition, we proposed to revise
§ 412.424(d)(3)(i)(A) to clarify that an
outlier payment is made if an IPF’s
estimated total cost for a case exceeds a
fixed dollar loss threshold amount plus
the Federal payment amount for the
case.
In § 412.426(a), we proposed to
correct the cross reference to the Federal
per diem payment amount. We
incorrectly referenced the Federal per
diem base rate as § 412.424(c). The
correct cross reference to the Federal per
diem payment amount is § 412.424(d).
In § 412.428, we proposed to revise
paragraph (b) to specify that for
discharges occurring on or after January
1, 2005 but before July 1, 2006 the rate
of increase factor for the Federal portion
of the payment is based on the FY 1997based excluded hospital with capital
market basket and for discharges
occurring on or after July 1, 2006, the
rate of increase factor for the Federal
portion of the payment is based on the
FY 2002-based Rehabilitation,
Psychiatric, and Long-Term Care (RPL)
market basket.
In addition, we proposed to add a
new paragraph (g) to state that we
would update the national urban and
rural cost to charge ratio medians and
ceilings. Paragraph (1) through (3)
would specify the types of IPFs in
which to apply the national cost to
charge ratio. Furthermore, we proposed
to add a new paragraph (h) to update the
cost of living adjustment factors, if
appropriate.
In § 424.14, we proposed to revise the
title to read, ‘‘Requirements for
inpatient services of inpatient
psychiatric facilities,’’ to ensure
consistency in compliance with the
requirements among all IPFs. We also
proposed to add a new paragraph (c)(3)
to clarify for purposes of payment under
the IPF PPS, that the physician would
also recertify that the patient continues
to need, on a daily basis, active
inpatient psychiatric care (furnished
directly by or requiring the supervision
of inpatient psychiatric facility
personnel) or other professional services
that can only be provided on an
inpatient basis.
In addition, we proposed to revise
paragraph (d)(2) to state that the first
recertification is required as of the 12th
day of hospitalization. Subsequent
recertifications would be required at
intervals established by the hospital’s
utilization review committee (on a caseby-case basis if it so chooses), but no
less frequently than every 30 days.
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IV. Analysis of and Responses to Public
Comments
We provided for a 60 day comment
period on the RY 2007 proposed rule.
The correction notice to correct
technical errors that appeared in the RY
2007 proposed rule appeared in the
Federal Register on February 24, 2006.
The correction notice extended the
public comment period on the ECT
policy, to allow the public an
opportunity to comment on the
corrected policy.
We received approximately 32 public
comments from hospital associations,
psychiatric hospitals and units, and
acute care hospitals. In general,
commenters expressed some concern
about a few of our proposals and
suggested that we wait to implement
specific updates to the IPF PPS until we
can analyze 2005 claims data. A few
commenters requested that we provide
the provider impact files that are
comparable to the files prepared for the
Inpatient Prospective Payment System
(IPPS). In addition, several commenters
requested that we retain the rural
adjustment or provide a 3-year hold
harmless provision for IPFs that would
lose their rural adjustment if we
adopted the proposed CBSA definitions.
Several commenters supported the
proposed changes to the IPF PPS.
Summaries of the public comments
received and our responses to those
comments are provided in the
appropriate sections in the preamble of
this final rule.
V. Updates to the IPF PPS for RY
Beginning July 1, 2006
The IPF PPS is based on a
standardized Federal per diem base rate
calculated from IPF average per diem
costs and adjusted for budget-neutrality
in the implementation year. The Federal
per diem base rate is used as the
standard payment per day under the IPF
PPS and is adjusted by the applicable
wage index factor and the patient-level
and facility-level adjustments that are
applicable to the IPF stay.
The following is an explanation of
how we calculated the Federal per diem
base rate and the standardization and
budget neutrality factors as described in
the November 2004 IPF PPS final rule.
A. Calculation of the Average Per Diem
Cost
As indicated in the November 2004
IPF PPS final rule, to calculate the
Federal per diem base rate, we
estimated the average cost per day for—
(1) routine services from FY 2002 cost
reports (supplemented with FY 2001
cost reports if the FY 2002 cost report
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was missing); and (2) ancillary services
using data from the FY 2002 Medicare
claims and corresponding data from
facility cost reports.
For routine services, the per diem
operating and capital costs were used to
develop the average per diem cost
amount. The per diem routine costs
were obtained from each facility’s
Medicare cost report. To estimate the
costs for routine services included in
the Federal per diem base rate
calculation, we added the total routine
costs (including costs for capital)
submitted on the cost report for each
provider and divided it by the total
Medicare days.
Some average routine costs per day
were determined to be aberrant, that is,
the costs were extraordinarily high or
low and most likely contained data
errors. We provided a detailed
discussion in the November 2004 IPF
PPS final rule (69 FR 66926 through
66927) of the method used to trim
extraordinarily high or low cost values
from the per diem rate development file
in order to improve the accuracy of our
results. For ancillary services, we
calculated the costs by converting
charges from the FY 2002 Medicare
claims into costs using facility-specific,
cost-center specific cost-to-charge ratios
obtained from each provider’s
applicable cost reports. We matched
each provider’s departmental cost-tocharge ratios from their Medicare cost
report to each charge on their claims
reported in the MedPAR file.
Multiplying the total charges for each
type of ancillary service by the
corresponding cost-to-charge ratio
provided an estimate of the costs for all
ancillary services received by the
patient during the stay. We determined
the average ancillary amount per day by
dividing the total ancillary costs for all
stays by the total number of covered
Medicare days.
Adding the average ancillary costs per
day and the average routine costs per
day including capital costs provided the
estimated average per diem cost for each
patient day of inpatient psychiatric care
in FY 2002.
B. Determining the Standardized
Budget-Neutral Federal Per Diem Base
Rate
Section 124(a)(1) of the BBRA
requires that the implementing IPF PPS
be budget neutral. In other words, the
amount of total payments under the IPF
PPS, including any payment
adjustments, must be projected to be
equal to the amount of total payments
that would have been made if the IPF
PPS were not implemented. Therefore,
in the November 2004 IPF PPS final
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rule, we calculated the budget neutrality
factor by setting the total estimated IPF
PPS payments to be equal to the total
estimated payments that would have
been made under the TEFRA
methodology had the IPF PPS not been
implemented.
The November 2004 IPF PPS final
rule includes a step-by-step description
of the methodology we used to estimate
payments under the TEFRA payment
system (69 FR 66930). For the IPF PPS
methodology, we calculated the final
Federal per diem base rate to be budget
neutral during the implementation
period under the IPF PPS using a July
1 update cycle. Thus, the
implementation period for the IPF PPS
is the 18-month period January 1, 2005
through June 30, 2006.
We updated the average cost per day
to the midpoint of the IPF PPS
implementation period (that is, October
1, 2005). We used the most recent
projection of the full percentage
increase in the 1997-based excluded
hospital with capital market basket
index for FY 2003 and later in
accordance with § 413.40(c)(3)(viii). The
updated average cost per day was used
in the payment model to establish the
budget neutrality adjustment.
Public comments and our responses
on changes for determining the
standardized budget neutral federal per
diem base rate are summarized below.
Comment: We received several
comments regarding the determination
of the target amount and the temporary
caps on the facility-specific TEFRA
payments which expired in FY 2002.
Specifically, the commenters stated that
even though the temporary caps on the
facility-specific (TEFRA) payments
expired in FY 2002, the capped
payment amounts which were used to
establish the baseline for budget
neutrality purposes, were inflated by the
market basket rate for each year until
the PPS began in 2005.
The commenters believe that CMS
should have used what would have
been spent, absent the expired
temporary caps inflated using the
market basket rate, to establish the
baseline rather than capped payments.
The commenters stated that using the
capped payments could have
inappropriately reduced the allowed
aggregate spending under the PPS each
year.
Response: We are aware that there
have been concerns over the method we
used for calculating the target amount
for cost reporting periods beginning
after FY 2002 for those hospitals and
units that were subject to the ‘‘payment
caps’’ in accordance with section
1886(b)(3)(H) of the Act and regulations
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at § 413.40(c)(4)(iii). We have addressed
this issue several times, but most
recently in the FY 2006 IPPS final rule
(70 FR 47278 and 70 FR 47464).
Specifically, we addressed the issue of
whether § 413.40(c)(4)(iii) (specifically
paragraph (c)(4)(iii)(A)) continues to
apply beyond FY 2002. In that rule, we
stated that § 413.40(c)(4)(iii) applies
only to cost reporting periods beginning
on or after October 1, 1997 through
September 30, 2002, for IPFs, IRFs, and
LTCHs. In addition, we clarify that once
the 75th percentile cap provision in
paragraph (c)(4)(iii) of § 413.40 expired,
the target amount is then determined
based on § 413.40(c)(4)(ii) which states
that, ‘‘Subject to the provisions of
[§ 413.40] paragraph (c)(4)(iii) of this
section, for subsequent cost reporting
periods, the target amount equals the
hospital’s target amount for the previous
cost reporting period increased by the
update factor for the subject cost
reporting period’’ unless the provisions
of paragraph (c)(5)(ii) of this section
apply. Thus, under the requirements of
§ 413.40 (c)(4)(ii), in this instance, the
previous cost reporting period’s target
amount would be increased by the
applicable update factor to arrive at the
target amount for FY 2003. Similarly, for
cost reporting periods beginning in
years subsequent to FY 2003, we
calculate a hospital’s target amount by
taking its previous year’s target amount
and updating it by the updated factor for
the subject cost reporting period unless
the provision of paragraph (c)(5)(ii) of
this section apply. We followed the
methodology in § 413.40(c)(4)(ii) and
therefore our projections of what would
have been spent under TEFRA and the
budget neutrality adjustment are correct.
Final Rule Action: To clarify, in order
to calculate the target amounts for cost
reporting periods beginning in FY 2003,
our policy is that the target amounts for
cost reporting periods beginning in FY
2002 are updated as described in
§ 413.40(c)(4)(ii). Similarly, for cost
reporting periods beginning in years
subsequent to FY 2003, we calculate
target amounts by taking the previous
year’s target amount and updating it,
consistent with § 413.40(c)(4)(ii).
1. Standardization of the Federal Per
Diem Base Rate
In the November 2004 IPF PPS final
rule, we standardized the IPF PPS
Federal per diem base rate in order to
account for the overall positive effects of
the IPF PPS payment adjustment factors.
To standardize the IPF PPS payments,
we compared the IPF PPS payment
amounts calculated from the FY 2002
MedPAR file to the projected TEFRA
payments from the FY 2002 cost report
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Fmt 4701
Sfmt 4700
file updated to the midpoint of the IPF
PPS implementation period (that is,
October 2005). The standardization
factor was calculated by dividing total
estimated payments under the TEFRA
payment system by estimated payments
under the IPF PPS. The standardization
factor was calculated to be 0.8367. As a
result, in the November 2004 IPF PPS
final rule, the $724.43 average cost per
day was reduced by 16.33 percent (100
percent minus 83.67 percent).
2. Calculation of the Budget Neutrality
Adjustment
To compute the budget neutrality
adjustment for the IPF PPS, we
separately identified each component of
the adjustment, that is, the outlier
adjustment, stop-loss adjustment, and
behavioral offset.
a. Outlier Adjustment
Since the IPF PPS payment amount
for each IPF includes applicable outlier
amounts, we reduced the standardized
Federal per diem base rate to account
for aggregate IPF PPS payments
estimated to be made as outlier
payments. The appropriate outlier
amount was determined by comparing
the adjusted prospective payment for
the entire stay to the computed cost per
case. If costs were above the prospective
payment plus the adjusted fixed dollar
loss threshold amount, an outlier
payment was computed using the
applicable risk-sharing percentages (see
section VI.D.1 of this final rule). The
outlier amount was computed for all
stays, and the total outlier amount was
added to the final IPF PPS payment. The
outlier adjustment was calculated to be
2 percent. As a result, the standardized
Federal per diem base rate was reduced
by 2 percent to account for projected
outlier payments.
b. Stop-Loss Provision Adjustment
As explained in the November 2004
IPF PPS final rule, we provide a stoploss payment to ensure that an IPF’s
total PPS payments are no less than a
minimum percentage of their TEFRA
payment, had the IPF PPS not been
implemented. We reduced the
standardized Federal per diem base rate
by the percentage of aggregate IPF PPS
payments estimated to be made for stoploss payments.
The stop-loss payment amount was
determined by comparing aggregate
prospective payments that the provider
would receive under the IPF PPS to
aggregate TEFRA payments that the
provider would have otherwise received
without implementation of the IPF PPS.
If an IPF’s aggregate IPF PPS payments
are less than 70 percent of its aggregate
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payments under TEFRA, a stop-loss
payment was computed for that IPF.
The stop-loss payment amounts were
computed for those IPFs that were
projected to receive the payments, and
the total amount was added to the final
IPF PPS payment amount. As a result,
the standardized Federal per diem base
rate was reduced by 0.39 percent to
account for stop-loss payments.
c. Behavioral Offset
As explained in the November 2004
IPF PPS final rule, implementation of
the IPF PPS may result in certain
changes in IPF practices especially with
respect to coding for comorbid medical
conditions. As a result, Medicare may
incur higher payments than assumed in
our calculations. Accounting for these
effects through an adjustment is
commonly known as a behavioral offset.
Based on accepted actuarial practices
and consistent with the assumptions
made in other prospective payment
systems, we assumed in determining the
behavioral offset that IPFs would regain
15 percent of potential ‘‘losses’’ and
augment payment increases by 5
percent. We applied this actuarial
assumption, which is based on our
historical experience with new payment
systems, to the estimated ‘‘losses’’ and
‘‘gains’’ among the IPFs. The behavioral
offset for the IPF PPS was calculated to
be 2.66 percent. As a result, we reduced
the standardized Federal per diem base
rate by 2.66 percent to account for
behavioral changes.
To summarize, the $724.43 updated
average per diem cost was reduced by
16.33 percent to account for
standardization to projected TEFRA
payments for the implementation
period, by 2 percent to account for
outlier payments, by 0.39 percent to
account for stop-loss payments, and by
2.66 percent reduction to account for
the behavioral offset. The final
standardized budget-neutral Federal per
diem base rate for the IPF PPS
implementation year was calculated to
be $575.95. We discuss the Federal per
diem base rate for RY 2007 below.
Public comments and our responses
on the behavioral offset are summarized
below.
Comment: Several commenters
expressed concern that CMS continues
to maintain the behavioral offset which
is intended to account for changes in
provider practice patterns as a result of
movement to prospective payment
which could result in higher Medicare
payments. A few commenters stated that
accurate coding is already a high
priority in distinct part units and
freestanding facilities. Therefore, coding
practices in these facilities should not
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undergo major changes. The
commenters suggested that because the
PPS is being phased in, and only 50
percent of the payment in the second
year would be based on the IPF PPS, the
incentive for behavior change is
diminished.
Several commenters recommended
that CMS analyze the preliminary 2005
claims data and adjust the calculations
for the behavioral offset to maintain IPF
spending at appropriate levels. A few
commenters expressed concern that
CMS did not indicate whether an
analysis was conducted to determine if
continuing the adjustment for
behavioral offset is warranted. They
believe the assumptions made for both
the proposed RY and the
implementation year of the IPF PPS
overestimated the likely impact of
changes in hospital behavior.
Response: We explained in the
November 2004 IPF PPS final rule and
the RY 2007 proposed rule that we
believe it is reasonable to expect
changes in IPFs’ practices especially
with respect to coding for comorbid
medical conditions and changes in
length of stay (LOS), as a result of the
implementation of the IPF PPS.
In addition, based on accepted
actuarial practices and consistent with
the assumptions made in implementing
other prospective payment systems, we
assumed in determining the behavioral
offset, that IPFs would regain 15 percent
of potential ‘‘losses’’ and augment
payment increases by 5 percent. We
applied this actuarial assumption,
which is based on our historical
experience with new payment systems,
to the estimated ‘‘losses’’ and ‘‘gains’’
among the IPFs.
As indicated in the RY 2007 proposed
rule, we do not plan to change
adjustment factors or projections,
including the behavioral offset, until we
analyze IPF PPS data. At that time, we
will re-assess the accuracy of the
behavioral offset along with the other
factors impacting budget neutrality. We
anticipate analyzing 2005 IPF PPS
claims and cost report data in the future.
Comment: Several commenters
inquired why CMS is continuing to
include budget neutrality factors in the
Federal per diem base rate (behavioral
offset, stop-loss adjustment, and outlier
adjustment), effectively lowering the
base rate. Since the PPS is only budget
neutral for the implementation year, the
commenters believe the base rate should
not reflect budget neutrality factors that
effectively lower the amount.
Response: We acknowledge that the
PPS is only budget neutral for the
implementation year. The
standardization factor, behavioral offset,
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Sfmt 4700
27045
stop-loss adjustment, and outlier
adjustment were included in the 2005
Federal per diem base rate of $575.95.
In implementing the RY 2007 final rule,
we adjust the standardization factor (see
section V.B.3 of this final rule), and
apply the market basket update and the
wage index budget neutrality factor to
the base rate. As indicated above, we do
not plan to change any adjustment
factors or projections, including the
budget neutrality factors (behavioral
offset, stop-loss adjustment, and outlier
adjustment), until we analyze IPF PPS
data. We will revisit all assumptions
used to calculate the budget neutrality
adjustment and make any necessary
prospective changes to the Federal per
diem base rate. In section VI.D.3 of this
final rule, we address these comments
with respect to the calculation of the
ECT rate.
Final Rule Action: In summary, for
future RYs, we will reassess the
appropriateness of the behavior offset
along with the other factors impacting
budget neutrality. For the RY 2007 IPF
PPS, we will continue to adjust the
standardization factor and apply the
market basket updates and the wage
index budget neutrality factors.
3. Revision of the Standardization
Factor
In reviewing the methodology used to
simulate the IPF PPS payments used for
the November 2004 IPF PPS final rule,
we discovered that the computer code
incorrectly assigned non-teaching status
to most teaching facilities. As a result,
total IPF PPS payments were
underestimated by about 1.36 percent.
The underestimated IPF PPS payment
total was used in calculating the IPF
PPS standardization factor. The
standardization factor represents the
amount by which the IPF PPS per diem
payment rate and the ECT rate must be
reduced in order to make total IPF PPS
payments equal to estimated total
TEFRA payments assuming IPFs
continued to be paid solely under
TEFRA for the first PPS payment year.
The standardization factor is
calculated as the ratio of estimated total
TEFRA payments to estimated total IPF
PPS payments assuming no reduction to
the per diem and ECT payment rates.
Since the IPF PPS payment total should
have been larger than the estimated
figure, the standardization factor should
have been smaller (0.8254 vs. 0.8367). In
turn, the Federal per diem base rate and
the ECT rate should have been reduced
by 0.8254 instead of 0.8367.
To resolve this issue, we proposed to
amend the Federal per diem base rate
and the ECT payment rate
prospectively. Using the standardization
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factor of 0.8254, the base rate should
have been $568.17 for the
implementation year of the IPF PPS. It
is this base rate that we proposed to
update using the market basket rate of
increase of 4.3 percent and the budgetneutral wage index factor of 1.0042 (see
section VI.C.1.f of this final rule).
Applying these factors yields a
proposed Federal per diem base rate of
$595.09 for the RY beginning July 1,
2006 through June 30, 2007.
Public comments and our responses
on the revision of the standardization
factor are summarized below.
Comment: One commenter asked
whether the overall increase in the base
rate is appropriately calculated and
sufficient.
Response: As explained above and in
the RY 2007 proposed rule, the
correction of the standardization factor
reveals that last year’s per diem rate
should have been $568.17, and not
$575.95. To correct this error
prospectively, we apply the market
basket increase of 4.3 percent to
$568.17, and then apply the wage index
budget neutrality factor to compute the
Federal per diem base rate.
Final Rule Action: In summary, we
are finalizing our decision to revise the
standardization factor prospectively,
and the Federal per diem base rate for
RY 2007 is $595.09.
C. Update of the Federal Per Diem Base
Rate
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1. Market Basket for IPFs Reimbursed
Under the IPF PPS
a. Market Basket Index for IPF PPS
The market basket index used to
develop the IPF PPS is the excluded
hospital with capital market basket.
This market basket was based on 1997
Medicare cost report data and includes
data for Medicare participating IPFs,
IRFs, LTCHs, cancer, and children’s
hospitals.
We are presently unable to create a
separate market basket specifically for
psychiatric hospitals due to the small
number of facilities and the limited data
that are provided (for instance,
approximately 4 percent of psychiatric
facilities reported contract labor cost
data for FY 2002). However, since all
IRFs, LTCHs, and IPFs are now paid
under a PPS, we are updating PPS
payments made under the IRF PPS, the
LTCH PPS, and the IPF PPS using a
market basket reflecting the operating
and capital cost structures for IRFs,
IPFs, and LTCHs (hereafter referred to as
the rehabilitation, psychiatric, long-term
care (RPL) market basket). We have
excluded children’s and cancer
hospitals from the RPL market basket
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because their payments are based
entirely on reasonable costs subject to
rate-of-increase limits established under
the authority of section 1886(b) of the
Act, which is implemented in
regulations at § 413.40. They are not
reimbursed under a PPS. Also, the FY
2002 cost structures for children’s and
cancer hospitals are noticeably different
than the cost structures of the IRFs,
IPFs, and LTCHs.
The services offered in IRFs, IPFs, and
LTCHs are typically more laborintensive than those offered in cancer
and children’s hospitals. Therefore, the
compensation cost weights for IRFs,
IPFs, and LTCHs are larger than those in
cancer and children’s hospitals. In
addition, the depreciation cost weights
for IRFs, IPFs, and LTCHs are noticeably
smaller than those for children’s and
cancer hospitals.
In the following discussion, we
provide an overview on the market
basket and describe the methodologies
we are using for purposes of
determining the operating and capital
portions of the FY 2002-based RPL
market basket.
b. Overview of the RPL Market Basket
The RPL market basket is a fixed
weight, Laspeyres-type price index that
was constructed in three steps. First, a
base period was selected (in this case,
FY 2002) and total base period
expenditures were estimated for a set of
mutually exclusive and exhaustive
spending categories based upon type of
expenditure. Then the proportion of
total costs that each category represents
was determined. These proportions are
called cost or expenditure weights.
Second, each expenditure category was
matched to an appropriate price or wage
variable, referred to as a price proxy. In
nearly every instance, these price
proxies are price levels derived from
publicly available statistical series that
are published on a consistent schedule,
preferably at least on a quarterly basis.
Finally, the expenditure weight for
each cost category was multiplied by the
level of its respective price proxy for a
given period. The sum of these products
(that is, the expenditure weights
multiplied by their price levels) for all
cost categories yields the composite
index level of the market basket in a
given period. Repeating this step for
other periods produces a series of
market basket levels over time. Dividing
an index level for a given period by an
index level for an earlier period
produces a rate of growth in the input
price index over that time period.
A market basket is described as a
fixed-weight index because it answers
the question of how much it would cost,
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Fmt 4701
Sfmt 4700
at another time, to purchase the same
mix of goods and services purchased to
provide hospital services in a base
period. The effects on total expenditures
resulting from changes in the quantity
or mix of goods and services (intensity)
purchased subsequent to the base period
are not measured. In this manner, the
market basket measures only pure price
change. Only when the index is rebased
would the quantity and intensity effects
be captured in the cost weights.
Therefore, we rebase the market basket
periodically so that cost weights reflect
changes in the mix of goods and
services that hospitals purchase
(hospital inputs) to furnish patient care
between base periods.
The terms rebasing and revising,
while often used interchangeably,
actually denote different activities.
Rebasing means moving the base year
for the structure of costs of an input
price index (for example, shifting the
base year cost structure from FY 1997 to
FY 2002). Revising means changing data
sources, methodology, or price proxies
used in the input price index. We have
rebased and revised the market basket
used to update the IPF PPS.
2. Methodology for Operating Portion of
the RPL Market Basket
The operating portion of the FY 2002based RPL market basket consists of
several major cost categories derived
from the FY 2002 Medicare cost reports
for IRFs, IPFs, and LTCHs: wages, drugs,
professional liability insurance, and a
residual. We chose to use FY 2002 as
the base year because we believe this is
the most recent, complete year of
Medicare cost reports. Due to
insufficient Medicare cost report data
for IRFs, IPFs, and LTCHs, we have
developed cost weights for benefits,
contract labor, and blood and blood
products using the FY 2002-based IPPS
market basket (70 FR 23384), which we
explain in more detail later in this
section. For example, less than 30
percent of IRFs, IPFs, and LTCHs
reported benefit cost data in FY 2002.
We have noticed an increase in cost data
for these expense categories over the last
4 years. The next time we rebase the
RPL market basket there may be
sufficient IRF, IPF, and LTCH cost
report data to develop the weights for
these expenditure categories.
Since the cost weights for the RPL
market basket are based on facility costs,
as proposed and for this final rule, we
are limiting our sample to hospitals
with a Medicare average LOS within a
comparable range of the total facility
average LOS. We believe this provides
a more accurate reflection of the
structure of costs for Medicare covered
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days. Our goal is to measure cost shares
that are reflective of case mix and
practice patterns associated with
providing services to Medicare
beneficiaries.
As proposed and for this final rule,
we are using those cost reports for IRFs
and LTCHs whose Medicare average
LOS is within 15 percent (that is, 15
percent higher or lower) of the total
facility average LOS for the hospital.
This is the same edit applied to the FY
1992-based and FY 1997-based
excluded hospital with capital market
basket. We are using 15 percent because
it includes those LTCHs and IRFs whose
Medicare LOS is within approximately
5 days of the facility LOS.
As proposed and for this final rule,
we use a less stringent measure of
Medicare LOS for IPFs whose average
LOS is within 30 or 50 percent
(depending on the total facility average
LOS) of the total facility average LOS.
Using this less stringent edit allows us
to increase our sample size by over 150
cost reports and produce a cost weight
more consistent with the overall facility.
The edit we applied to IPFs when
developing the FY 1997-based excluded
hospital with capital market basket was
based on the best available data at the
time.
Public comments and our responses
on the proposed changes for
implementing the methodology for the
operating portion of the RPL market
basket are summarized below.
Comment: One commenter disagreed
with our proposed LOS methodology,
which included those cost reports for
IRFs and LTCHs whose Medicare
average LOS is within 15 percent (that
is, 15 percent higher or lower) of the
total facility average LOS and those cost
reports for IPFs whose average LOS is
within 30 or 50 percent (depending on
the total facility average LOS) of the
total facility average LOS.
A commenter stated that the LOS
methodology appears to factor into the
calculation a disproportionate share of
27047
psychiatric facilities with a longer LOS.
In addition, the commenter indicated
that the RY 2007 proposed rule stated
that costs decrease further into a
patient’s stay and that CMS assumes
that IPFs have an incompatible cost per
discharge when grouped with the lower
LOS in the IRFs and LTCHs.
Response: As stated previously, since
the cost weights for the RPL market
basket are based on facility costs, we
limited our sample to hospitals with a
Medicare average LOS within a
comparable range of the total facility
average LOS. We believe this provides
a more accurate reflection of the
structure of costs for Medicare
treatments.
We disagree with the commenter that
the IPF LOS edit includes a
disproportionate share of IPFs with a
longer LOS. For clarity, we are
providing below a table that compares
the distribution of the Medicare and
facility LOSs for IPFs using no edit and
the proposed 30/50 edit.
TABLE 2.—IPFS FY 2002 MEDICARE AND FACILITY LOS DISTRIBUTIONS
Medicare length of stay
No trim
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100% Max ........................................................................................................
99% ..................................................................................................................
95% ..................................................................................................................
90% ..................................................................................................................
75% Q3 ............................................................................................................
50% Median .....................................................................................................
25% Q1 ............................................................................................................
10% ..................................................................................................................
5% ....................................................................................................................
1% ....................................................................................................................
0% Min .............................................................................................................
The Medicare and facility LOS
distributions are consistent when the
proposed edit is applied. However, not
applying the edit would include in the
market basket those IPFs whose facility
LOS are dramatically different from
their Medicare LOS. In addition, the
Medicare LOS distribution with the 30/
50 edit is similar to the Medicare LOS
distribution with no edit. Therefore, we
believe that the proposed edit does not
include a disproportionate share of IPFs
with a longer LOS in the market basket.
Applying these LOS edits left us with
a sample of hospitals whose average
Medicare utilization was approximately
50 percent, while those excluded from
the market basket had a Medicare
utilization of approximately 10 percent.
Given this, we firmly believe that these
LOS edits help us meet our goal to
measure cost shares that are reflective of
case mix and practice patterns
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30/50 trim
93
86
59
49
28
13
10
8
7
4
1
associated with providing services to
Medicare beneficiaries.
The detailed cost categories under the
residual (that is, the remaining portion
of the market basket after excluding
wages and salaries, drugs, and
professional liability cost weights) are
derived from the FY 2002-based IPPS
market basket and the 1997 Benchmark
Input-Output (I-O) Tables published by
the Bureau of Economic Analysis, U.S.
Department of Commerce. The FY 2002based IPPS market basket was
developed using FY 2002 Medicare
hospital cost reports with the most
recent and detailed cost data (see the
August 12, 2005 IPPS final rule (70 FR
47388)). The 1997 Benchmark I-O is the
most recent, comprehensive source of
cost data for all hospitals. The RPL cost
weights for benefits, contract labor, and
blood and blood products were derived
using the FY 2002-based IPPS market
basket. For example, the ratio of the
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Sfmt 4700
Facility length of stay
No trim
70
54
36
23
15
11
9
7
7
5
3
5334
822
333
227
57
13
8
6
6
5
1
30/50 trim
75
63
39
26
15
10
8
6
5
5
3
benefit cost weight to the wages and
salaries cost weight in the FY 2002based IPPS market basket was applied to
the RPL wages and salaries cost weight
to derive a benefit cost weight for the
RPL market basket. As proposed and for
this final rule, the remaining RPL
operating cost categories were derived
using the 1997 Benchmark I-O Tables,
aged to 2002 using relative price
changes. (The methodology we used to
age the data involves applying the
annual price changes from the price
proxies to the appropriate cost
categories. We repeated this practice for
each year.) Therefore, using this
methodology, roughly 59 percent of the
RPL market basket was accounted for by
wages, drugs, and professional liability
insurance data from FY 2002 Medicare
cost report data for IRFs, LTCHs, and
IPFs.
Additional comments and our
responses on the methodology for
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operating portion of the RPL market
basket are summarized below.
Comment: Several commenters
proposed that CMS regularly re-analyze
the RPL cost report data, which are the
basis of the RPL market basket. The
commenters indicated that the
methodology used for the RPL market
basket includes data from the IPPS
hospital market basket rather than
relying solely on IPF, IRF, and LTCH
data.
The commenters recommended that
CMS work with providers to improve
the cost reports from rehabilitation,
psychiatric, and LTCHs in order to
ensure that the data used for the market
basket represent only the types of
excluded hospitals for which the RPL
market basket was developed. The
commenters believe that improving the
data reported on the RPL cost reports
would not only refine the RPL market
basket but also improve the accuracy of
the labor-related share to which the
wage index is applied.
Response: We rely on the IPPS cost
report data to supplement the IRF, IPF,
and LTCH Medicare cost report data for
benefits, contract labor, and blood and
blood products. For example, the ratio
of the benefit cost weight to the wages
and salaries cost weight in the FY 2002based IPPS market basket was applied to
the RPL wages and salaries cost weight
to derive a benefit cost weight for the
RPL market basket. We did not use
expenditure levels from the IPPS data
directly but, as explained, we developed
and used the ratios from IPPS data to
determine these RPL cost weights.
The wages and salaries cost weight
was derived using the IRF, IPF, and
LTCH Medicare cost reports and
accounts for 50 percent of the RPL
market basket. Due to data limitations,
this was the best methodology for
developing the latter cost weights.
We agree with the commenters that
improving the data reported on the RPL
cost reports could improve the RPL
market basket and labor-related share.
We have noticed this data improvement
on other provider-type cost reports and
encourage IRF, IPF, and LTCH providers
to fully complete their cost reports. We
believe that this would help us develop
the most complete and accurate market
basket possible. We will analyze RPL
cost report data on a regular basis and
continue to consider the possibility of
provider-specific market basket indices.
Comment: One commenter requested
that CMS explain how it computes cost
category weights based on Medicare cost
report data. The commenter stated that
if they understood which data elements
were used and how they were used,
CMS could develop educational
programs to improve their member
hospitals’ reporting.
Response: The RPL market basket cost
weights are based on freestanding
Medicare cost report data for IRFs, IPFs,
and LTCHs. We mainly rely on data
from worksheets A through G to derive
the cost weights. Worksheet S–3, part II
is the only worksheet which allows for
the reporting of benefits and contract
labor data; however, it is not a required
worksheet for IRFs, IPFs, and LTCHs. As
stated previously, we relied on the IPPS
Medicare cost report worksheet S–3,
part II data to derive the relationships
for benefits and contract labor to wages
and salaries.
Additionally, capital cost weights are
derived using worksheet A–7. The
estimates generated using this
worksheet, as well as worksheet G,
could be enhanced with higher
reporting rates. Again, we encourage
IRF, IPF, and LTCH providers to fully
complete their cost reports to help us in
developing the most complete and
accurate market basket.
Table 3 below sets forth the complete
2002-based RPL market basket including
cost categories, weights, and price
proxies. For comparison purposes, the
corresponding FY 1997-based excluded
hospital with capital market basket is
listed as well.
As proposed and for this final rule,
wages and salaries are 52.895 percent of
total costs in the FY 2002-based RPL
market basket compared to 47.335
percent for the FY 1997-based excluded
hospital with capital market basket.
Employee benefits are 12.982 percent in
the FY 2002-based RPL market basket
compared to 10.244 percent for the FY
1997-based excluded hospital with
capital market basket. As a result,
compensation costs (wages and salaries
plus employee benefits) for the FY 2002based RPL market basket are 65.877
percent of costs compared to 57.579
percent for the FY 1997-based excluded
hospital with capital market basket. Of
the 8 percentage-point difference
between the compensation shares,
approximately 3 percentage points were
due to the new base year (FY 2002
instead of FY 1997), 3 percentage points
were due to the revised LOS edit, and
the remaining 2 percentage points were
due to the exclusion of other hospitals
(that is, only including IPFs, IRFs, and
LTCHs in the market basket).
Following the table is a summary
outlining the choice of the proxies we
chose to use for the operating portion of
the market basket. The price proxies for
the capital portion are described in
more detail in the capital methodology
section (see section V.C.3 of this final
rule).
TABLE 3.—FY 2002-BASED RPL MARKET BASKET COST CATEGORIES, WEIGHTS, AND PROXIES WITH FY 1997-BASED
EXCLUDED HOSPITAL WITH CAPITAL MARKET BASKET USED FOR COMPARISON
FY 1997-based
excluded hospital
with capital market
basket
Expense categories
FY 2002-based
RPL market
basket
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Total ..................................................................
Compensation ...................................................
Wages and Salaries * ................................
Employee Benefits * ..................................
Professional Fees, Non-Medical ......................
100.000
57.579
47.335
10.244
4.423
100.000
65.877
52.895
12.982
2.892
Utilities ..............................................................
Electricity ...................................................
Fuel Oil, Coal, etc .....................................
Water and Sewage ....................................
Professional Liability Insurance ........................
All Other Products and Services ......................
All Other Products .....................................
Pharmaceuticals .................................
Food: Direct Purchase .......................
Food: Contract Service ......................
1.180
0.726
0.248
0.206
0.733
27.117
17.914
6.318
1.122
1.043
0.656
0.351
0.108
0.197
1.161
19.265
13.323
5.103
0.873
0.620
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FY 2002 market basket price proxies
ECI—Wages and Salaries, Civilian Hospital Workers.
ECI—Benefits, Civilian Hospital Workers.
ECI—Compensation for Professional, Specialty &
Technical Workers.
PPI—Commercial Electric Power.
PPI—Commercial Natural Gas.
CPI–U—Water & Sewage Maintenance.
CMS Professional Liability Premium Index.
PPI Prescription Drugs.
PPI Processed Foods & Feeds.
CPI U Food Away From Home.
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27049
TABLE 3.—FY 2002-BASED RPL MARKET BASKET COST CATEGORIES, WEIGHTS, AND PROXIES WITH FY 1997-BASED
EXCLUDED HOSPITAL WITH CAPITAL MARKET BASKET USED FOR COMPARISON—Continued
FY 1997-based
excluded hospital
with capital market
basket
Expense categories
FY 2002-based
RPL market
basket
FY 2002 market basket price proxies
Chemicals ...........................................
Blood and Blood Products ** ..............
Medical Instruments ...........................
Photographic Supplies .......................
Rubber and Plastics ...........................
Paper Products ..................................
Apparel ...............................................
Machinery and Equipment .................
Miscellaneous Products .....................
All Other Services .....................................
Telephone ..........................................
Postage ..............................................
All Other: Labor Intensive .........................
All Other: Non-labor Intensive ...................
Capital-Related Costs .......................................
Depreciation ..............................................
Fixed Assets .......................................
Movable Equipment ...........................
Interest Costs ............................................
Nonprofit .............................................
2.133
0.748
1.795
0.167
1.366
1.110
0.478
0.852
0.783
9.203
0.348
0.702
4.453
3.700
8.968
5.586
3.503
2.083
2.682
2.280
1.100
PPI
Industrial Chemicals.
1.014
0.096
1.052
1.000
0.207
0.297
1.963
5.942
0.240
0.682
2.219
2.800
10.149
6.186
4.250
1.937
2.775
2.081
PPI
PPI
PPI
PPI
PPI
PPI
PPI
Medical Instruments & Equipment.
Photographic Supplies.
Rubber & Plastic Products.
Converted Paper & Paperboard Products.
Apparel.
Machinery & Equipment.
Finished Goods less Food & Energy.
For Profit ............................................
0.402
0.694
Other Capital-Related Costs .....................
0.699
1.187
CPI–U Telephone Services.
CPI–U Postage.
ECI-Compensation for Private Service Occupations.
CPI–U All Items.
Boeckh Institutional Construction 23-year useful life.
WPI Machinery & Equipment 11-year useful life.
Average yield on domestic municipal bonds (Bond
Buyer 20 bonds) vintage-weighted (23 years).
Average yield on Moody’s Aaa bonds vintage weighted (23 years).
CPI–U Residential Rent.
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* Labor-related
** Blood and blood-related products is included in miscellaneous products
Note: Due to rounding, weights may not sum to total.
Below we provide the proxies that we
are using for the FY 2002-based RPL
market basket. With the exception of the
Professional Liability proxy, all the
price proxies for the operating portion
of the RPL market basket are based on
Bureau of Labor Statistics (BLS) data
and are grouped into one of the
following BLS categories:
• Producer Price Indexes—Producer
Price Indexes (PPIs) measure price
changes for goods sold in other than
retail markets. PPIs are preferable price
proxies for goods that hospitals
purchase as inputs in producing their
outputs because the PPIs would better
reflect the prices faced by hospitals. For
example, we use a special PPI for
prescription drugs, rather than the
Consumer Price Index (CPI) for
prescription drugs because hospitals
generally purchase drugs directly from
the wholesaler. The PPIs that we use
measure price change at the final stage
of production.
• Consumer Price Indexes—
Consumer Price Indexes (CPIs) measure
change in the prices of final goods and
services bought by the typical
consumer. Because they may not
represent the price faced by a producer,
we use CPIs only if an appropriate PPI
were not available, or if the
expenditures were more similar to those
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of retail consumers in general rather
than purchases at the wholesale level.
For example, the CPI for food purchases
away from home is used as a proxy for
contracted food services.
• Employment Cost Indexes—
Employment Cost Indexes (ECIs)
measure the rate of change in employee
wage rates and employer costs for
employee benefits per hour worked.
These indexes are fixed-weight indexes
and strictly measure the change in wage
rates and employee benefits per hour.
Appropriately, they are not affected by
shifts in employment mix.
We evaluated the price proxies using
the criteria of reliability, timeliness,
availability, and relevance. Reliability
indicates that the index is based on
valid statistical methods and has low
sampling variability. Timeliness implies
that the proxy is published regularly,
preferably at least once a quarter.
Availability means that the proxy is
publicly available. Finally, relevance
means that the proxy is applicable and
representative of the cost category
weight to which it is applied. The CPIs,
PPIs, and ECIs in this regulation meet
these criteria.
We note that the proxies are the same
as those used for the FY 1997-based
excluded hospital with capital market
basket. Because these proxies meet our
criteria of reliability, timeliness,
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availability, and relevance, we believe
they continue to be the best measure of
price changes for the cost categories. For
further discussion on the FY 1997-based
excluded hospital with capital market
basket, see the August 1, 2002 IPPS final
rule (67 FR at 50042).
Wages and Salaries
For measuring the price growth of
wages in the FY 2002-based RPL market
basket, we are using the ECI for wages
and salaries for civilian hospital
workers as the proxy for wages in the
RPL market basket.
The rehabilitation, psychiatric, and
long-term care hospital (RPL) market
basket uses the Bureau of Labor
Statistics’ Employment Cost Indexes
(ECIs) as proxies for wages and salaries,
and benefits for civilian industry
workers classified in the Standard
Industrial Code (SIC) 806, Hospitals.
However, beginning April 28, 2006 with
the publication of March 2006 data, the
ECIs will be converted from the SIC
system to the North American Industrial
Classification System (NAICS). The
NAICS-based ECI for hospitals (NAICS
622) is similar (at least 90 percent
identical) to the SIC-based ECI for
hospitals. Therefore, when they are
available, we will use the NAICS-based
ECIs for hospitals as proxies to reflect
the rate-of-price change for the wages
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and salaries and employee benefits cost
categories in the 2002-based RPL market
basket.
The RPL market basket and laborrelated share in this final rule will use
the most recent data available from the
Bureau of Labor Statistics. We do not
expect the RPL market basket and laborrelated share to change significantly
when the conversion from the SIC
system to the NAICS system takes place.
Employee Benefits
The FY 2002-based RPL market basket
uses the ECI for employee benefits for
civilian hospital workers.
Nonmedical Professional Fees
The ECI for compensation for
professional and technical workers in
private industry is applied to this
category since it includes occupations
such as management and consulting,
legal, accounting, and engineering
services.
identified a preferred option, therefore
no change is made for the proxy in this
final rule.
Pharmaceuticals
The percentage change in the price of
prescription drugs as measured by the
PPI (PPI Code #PPI32541DRX) is used as
a proxy for this cost category. This is a
special index produced by BLS as a
proxy in the 1997-based excluded
hospital with capital market basket.
Food, Direct Purchases
The percentage change in the price of
processed foods and feeds as measured
by the PPI (Commodity Code #02) is
applied to this component.
Food, Contract Service
The percentage change in the price of
food purchased away from home as
measured by the CPI for all urban
consumers (CPI Code #CUUR0000SEFV)
is applied to this component.
Fuel, Oil, and Gasoline
Chemicals
The percentage change in the price of
gas fuels as measured by the PPI
(Commodity Code #0552) is applied to
this component.
The percentage change in the price of
industrial chemical products as
measured by the PPI (Commodity Code
#061) is applied to this component.
While the chemicals hospitals purchase
include industrial as well as other types
of chemicals, the industrial chemicals
component constitutes the largest
proportion by far. Thus we believe that
Commodity Code #061 is the
appropriate proxy.
Electricity
The percentage change in the price of
commercial electric power as measured
by the PPI (Commodity Code #0542) is
applied to this component.
Water and Sewerage
The percentage change in the price of
water and sewage maintenance as
measured by the Consumer Price Index
(CPI) for all urban consumers (CPI Code
#CUUR0000SEHG01) is applied to this
component.
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Professional Liability Insurance
The FY 2002-based RPL market basket
uses the percentage change in hospital
professional liability insurance (PLI)
premiums as estimated by the CMS
Hospital Professional Liability Index for
the proxy of this category. In the FY
1997-based excluded hospital with
capital market basket, the same proxy
was used.
We continue to research options for
improving our proxy for professional
liability insurance. This research
includes exploring various options for
expanding our current survey, including
the identification of another entity that
would be willing to work with us to
collect more complete and
comprehensive data. We are also
exploring other options such as third
party or industry data that might assist
us in creating a more precise measure of
PLI premiums. At this time we have not
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Medical Instruments
The percentage change in the price of
medical and surgical instruments as
measured by the PPI (Commodity Code
#1562) is applied to this component.
Photographic Supplies
The percentage change in the price of
photographic supplies as measured by
the PPI Commodity Code #1542) is
applied to this component.
Rubber and Plastics
The percentage change in the price of
rubber and plastic products as measured
by the PPI (Commodity Code #07) is
applied to this component.
Paper Products
The percentage change in the price of
converted paper and paperboard
products as measured by the PPI
(Commodity Code #0915) is applied to
this component.
Apparel
The percentage change in the price of
apparel as measured by the PPI
(Commodity Code #381) is applied to
this component.
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Machinery and Equipment
The percentage change in the price of
machinery and equipment as measured
by the PPI (Commodity Code #11) is
applied to this component.
Miscellaneous Products
The percentage change in the price of
all finished goods less food and energy
as measured by the PPI (Commodity
Code #SOP3500) is applied to this
component. Using this index removes
the double-counting of food and energy
prices, which are captured elsewhere in
the market basket. The weight for this
cost category is higher, in part, than in
the 1997-based index because the
weight for blood and blood products
(1.188) is added to it. In the 1997-based
excluded hospital with capital market
basket, we included a separate cost
category for blood and blood products,
using the BLS PPI for blood and
derivatives as a price proxy. A review of
recent trends in the PPI for blood and
derivatives suggests that its movements
may not be consistent with the trends in
blood costs faced by hospitals. While
this proxy did not match exactly with
the product hospitals are buying, its
trend over time appears to be reflective
of the historical price changes of blood
purchased by hospitals. However, an
apparent divergence over recent years
led us to reevaluate whether the PPI for
blood and derivatives was an
appropriate measure of the changing
price of blood. We ran test market
baskets classifying blood in three
separate cost categories: Blood and
blood products, contained within
chemicals as was done for the 1992based excluded hospital with capital
market basket, and within
miscellaneous products. These
categories use as proxies the following
PPIs: The PPI for blood and blood
products, the PPI for chemicals, and the
PPI for finished goods less food and
energy, respectively. Of these three
proxies, the PPI for finished goods less
food and energy moved most like the
recent blood cost and price trends. In
addition, the impact on the overall
market basket by using different proxies
for blood was negligible, mostly due to
the relatively small weight for blood in
the market basket.
Therefore, as proposed and for this
final rule, we are using the PPI for
finished goods less food and energy for
the blood proxy because we believe it
more appropriately proxies the price
changes (not quantities or required tests)
associated with blood purchased by
hospitals. We will continue to evaluate
this proxy for its appropriateness and
will explore the development of
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alternative price indexes to proxy the
price changes associated with this cost.
Telephone
The percentage change in the price of
telephone services as measured by the
CPI for all urban consumers (CPI Code
#CUUR0000SEED) is applied to this
component.
Postage
The percentage change in the price of
postage as measured by the CPI for all
urban consumers (CPI Code #
CUUR0000SEEC01) is applied to this
component.
All Other Services, Labor Intensive
The percentage change in the ECI for
compensation paid to service workers
employed in private industry is applied
to this component.
All Other Services, Nonlabor Intensive
The percentage change in the all items
component of the CPI for all urban
consumers (CPI Code # CUUR0000SA0)
is applied to this component.
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3. Methodology for Capital Portion of
the RPL Market Basket
Unlike for the operating costs of the
FY 2002-based RPL market basket, we
did not have IRF, IPF, and LTCH FY
2002 Medicare cost report data for the
capital cost weights, due to a change in
the FY 2002 reporting requirements.
Rather, as proposed and for this final
rule, we are using these hospitals’
expenditure data for the capital cost
categories of depreciation, interest, and
other capital expenses for FY 2001, and
aged the data to a FY 2002 base year
using relevant price proxies.
We calculated weights for the RPL
market basket capital costs using the
same set of Medicare cost reports used
to develop the operating share for IRFs,
IPFS, and LTCHs. The resulting capital
weight for the FY 2002 base year is
10.149 percent. This is based on FY
2001 Medicare cost report data for IRFs,
IPFs, and LTCHs, aged to FY 2002 using
relevant price proxies.
Lease expenses are not a separate cost
category in the market basket, but are
distributed among the cost categories of
depreciation, interest, and other,
reflecting the assumption that the
underlying cost structure of leases is
similar to capital costs in general. We
assumed 10 percent of lease expenses
were overhead and assigned them to the
other capital expenses cost category as
overhead. We base this assignment of 10
percent of lease expenses to overhead
on the common assumption that
overhead is 10 percent of costs. The
remaining lease expenses were
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distributed to the three cost categories
based on the weights of depreciation,
interest, and other capital expenses not
including lease expenses.
Depreciation contains two
subcategories: Building and fixed
equipment and movable equipment. As
proposed and for this final rule, the split
between building and fixed equipment
and movable equipment was
determined using the FY 2001 Medicare
cost reports for IRFs, IPFs, and LTCHs.
This methodology was also used to
compute the 1997-based index (67 FR at
50044).
As proposed and for this final rule,
the total interest expense cost category
is split between the government/
nonprofit and for-profit hospitals. The
1997-based excluded hospital with
capital market basket allocated 85
percent of the total interest cost weight
to the government nonprofit interest,
proxies by average yield on domestic
municipal bonds, and 15 percent to forprofit interest, proxies by average yield
on Moody’s Aaa bonds.
We derived the split using the relative
FY 2001 Medicare cost report data for
PPS hospitals on interest expenses for
the government/nonprofit and for-profit
hospitals. Due to insufficient Medicare
cost report data for IPFs, IRFs, and
LTCHs, as proposed and for this final
rule, we use the same split used in the
IPPS capital input price index. We
believe it is important that this split
reflect the latest relative cost structure
of interest expenses for hospitals and,
therefore, we have used a 75–25 split to
allocate interest expenses to
government/nonprofit and for-profit (70
FR at 47408).
Since capital is acquired and paid for
over time, capital expenses in any given
year are determined by both past and
present purchases of physical and
financial capital. The vintage-weighted
capital index is intended to capture the
long-term consumption of capital, using
vintage weights for depreciation
(physical capital) and interest (financial
capital). These vintage weights reflect
the purchase patterns of building and
fixed equipment and movable
equipment over time. Depreciation and
interest expenses were determined by
the amount of past and current capital
purchases. Therefore, as proposed and
for this final rule, we are using the
vintage weights to compute vintageweighted price changes associated with
depreciation and interest expense.
Vintage weights are an integral part of
the FY 2002-based RPL market basket.
Capital costs are inherently complicated
and are determined by complex capital
purchasing decisions, over time, based
on such factors as interest rates and debt
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27051
financing. In addition, capital is
depreciated over time instead of being
consumed in the same period it is
purchased. The capital portion of the FY
2002-based RPL market basket reflects
the annual price changes associated
with capital costs, and is a useful
simplification of the actual capital
investment process. By accounting for
the vintage nature of capital, we have
provided an accurate, stable annual
measure of price changes. Annual nonvintage price changes for capital are
unstable due to the volatility of interest
rate changes and, therefore, do not
reflect the actual annual price changes
for Medicare capital-related costs. The
capital component of the FY 2002-based
RPL market basket reflects the
underlying stability of the capital
acquisition process and provides
hospitals with the ability to plan for
changes in capital payments.
To calculate the vintage weights for
depreciation and interest expenses, we
needed a time series of capital
purchases for building and fixed
equipment and movable equipment. We
found no single source that provides the
best time series of capital purchases by
hospitals for all of the above
components of capital purchases. The
early Medicare Cost Reports did not
have sufficient capital data to meet this
need. While the American Hospital
Association (AHA) Panel Survey
provided a consistent database back to
1963, it did not provide annual capital
purchases. However, the AHA Panel
Survey provided a time series of
depreciation expenses through 1997
which could be used to infer capital
purchases over time. From 1998 to 2001,
hospital depreciation expenses were
calculated by multiplying the AHA
Annual Survey total hospital expenses
by the ratio of depreciation to total
hospital expenses from the Medicare
cost reports. Beginning in 2001, the
AHA Annual Survey began collecting
depreciation expenses. We hope to be
able to use these data in future
rebasings.
In order to estimate capital purchases
from AHA data on depreciation and
interest expenses, the expected life for
each cost category (building and fixed
equipment, movable equipment, and
debt instruments) is needed. Due to
insufficient Medicare cost report data
for IPFs, IRFs, and LTCHs, as proposed
and for this final rule, we are using FY
2001 Medicare Cost Reports for IPPS
hospitals to determine the expected life
of building and fixed equipment and
movable equipment. We believe this
data source reflects the latest relative
cost structure of depreciation expenses
for hospitals and is analogous to IPFs,
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IRFs, and LTCHs. The expected life of
any piece of equipment was determined
by dividing the value of the asset
(excluding fully depreciated assets) by
its current year depreciation amount.
This calculation yields the estimated
useful life of an asset if depreciation
were to continue at current year levels,
assuming straight-line depreciation.
From the FY 2001 Medicare cost reports
for IPPS hospitals the expected life of
building and fixed equipment was
determined to be 23 years, and the
expected life of movable equipment was
determined to be 11 years.
As proposed and for this final rule,
we are also using the fixed and movable
weights derived from FY 2001 Medicare
cost reports for IPFs, IRFs, and LTCHs
to separate the depreciation expenses
into annual amounts of building and
fixed equipment depreciation and
movable equipment depreciation. By
multiplying the annual depreciation
amounts by the expected life
calculations from the FY 2001 Medicare
cost reports, year-end asset costs for
building and fixed equipment and
movable equipment were determined.
We then calculated a time series back to
1963 of annual capital purchases by
subtracting the previous year asset costs
from the current year asset costs. From
this capital purchase time series we
were able to calculate the vintage
weights for building and fixed
equipment, movable equipment, and
debt instruments. An explanation of
each of these sets of vintage weights
follows.
As proposed and for this final rule, for
building and fixed equipment vintage
weights, the real annual capital
purchase amounts for building and
fixed equipment derived from the AHA
Panel Survey were used. The real
annual purchase amount was used to
capture the actual amount of the
physical acquisition, net of the effect of
price inflation. This real annual
purchase amount for building and fixed
equipment was produced by deflating
the nominal annual purchase amount by
the building and fixed equipment price
proxy, the Boeckh Institutional
Construction Index. This is the same
proxy used for the FY 1997-based
excluded hospital with capital market
basket. We believe this proxy continues
to meet our criteria of reliability,
timeliness, availability, and relevance.
Since building and fixed equipment has
an expected life of 23 years, the vintage
weights for building and fixed
equipment are deemed to represent the
average purchase pattern of building
and fixed equipment over 23-year
periods. With real building and fixed
equipment purchase estimates back to
1963, sixteen 23-year periods were
averaged to determine the average
vintage weights for building and fixed
equipment that are representative of
average building and fixed equipment
purchase patterns over time. Vintage
weights for each 23-year period were
calculated by dividing the real building
and fixed capital purchase amount in
any given year by the total amount of
purchases in the 23-year period. This
calculation was done for each year in
the 23-year period, and for each of the
sixteen 23-year periods. The average of
each year across the sixteen 23-year
periods was used to determine the 2002
average building and fixed equipment
vintage weights.
As proposed and for this final rule, for
movable equipment vintage weights, the
real annual capital purchase amounts
for movable equipment derived from the
AHA Panel Survey were used to capture
the actual amount of the physical
acquisition, net of price inflation. This
real annual purchase amount for
movable equipment was calculated by
deflating the nominal annual purchase
amount by the movable equipment price
proxy, the PPI for Machinery and
Equipment. This was the same proxy
used for the FY 1997-based excluded
hospital with capital market basket. We
believe this proxy, which meets our
criteria, is the best measure of price
changes for this cost category. Since
movable equipment has an expected life
of 11 years, the vintage weights for
movable equipment were deemed to
represent the average purchase pattern
of movable equipment over an 11-year
period. With real movable equipment
purchase estimates available back to
1963, twenty-eight 11-year periods
could be averaged to determine the
average vintage weights for movable
equipment that are representative of
average movable equipment purchase
patterns over time. Vintage weights for
each 11-year period were calculated by
dividing the real movable capital
purchase amount for any given year by
the total amount of purchases in the
11-year period. This calculation was
done for each year in the 11-year period,
and for each of the twenty-eight 11-year
periods. The average of the twenty-eight
11-year periods were used to determine
the FY 2002 average movable equipment
vintage weights.
As proposed and for this final rule, for
interest vintage weights, the nominal
annual capital purchase amounts for
total equipment (building and fixed and
movable) derived from the AHA Panel
and Annual Surveys were used.
Nominal annual purchase amounts were
used to capture the value of the debt
instrument. Since hospital debt
instruments have an expected life of 23
years, the vintage weights for interest
were deemed to represent the average
purchase pattern of total equipment
over 23-year periods. With nominal total
equipment purchase estimates available
back to 1963, sixteen 23-year periods
were averaged to determine the average
vintage weights for interest that are
representative of average capital
purchase patterns over time. Vintage
weights for each 23-year period were
calculated by dividing the nominal total
capital purchase amount for any given
year by the total amount of purchases in
the 23-year period. This calculation was
done for each year in the 23-year period
and for each of the sixteen 23-year
periods. The average of the sixteen 23year periods were used to determine the
FY 2002 average interest vintage
weights. The vintage weights for the
index are presented in Table 4 below.
In addition to the price proxies for
depreciation and interest costs
described above in the vintage weighted
capital section, as proposed and for this
final rule, we used the CPI–U for
Residential Rent as a price proxy for
other capital-related costs. The price
proxies for each of the capital cost
categories are the same as those used for
the IPPS final rule (67 FR at 50044)
capital input price index.
TABLE 4.—CMS FY 2002-BASED RPL MARKET BASKET CAPITAL VINTAGE WEIGHTS
Fixed assets
(23 year weights)
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Year
1
2
3
4
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
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Movable assets
(11 year weights)
0.021
0.022
0.025
0.027
Sfmt 4700
E:\FR\FM\09MYR2.SGM
0.065
0.071
0.077
0.082
09MYR2
Interest:
capitalrelated
(23 year weights)
0.010
0.012
0.014
0.016
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Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
TABLE 4.—CMS FY 2002-BASED RPL MARKET BASKET CAPITAL VINTAGE WEIGHTS—Continued
Fixed assets
(23 year weights)
Year
Interest:
capitalrelated
(23 year weights)
Movable assets
(11 year weights)
5 ...............................................................................................................
6 ...............................................................................................................
7 ...............................................................................................................
8 ...............................................................................................................
9 ...............................................................................................................
10 .............................................................................................................
11 .............................................................................................................
12 .............................................................................................................
13 .............................................................................................................
14 .............................................................................................................
15 .............................................................................................................
16 .............................................................................................................
17 .............................................................................................................
18 .............................................................................................................
19 .............................................................................................................
20 .............................................................................................................
21 .............................................................................................................
22 .............................................................................................................
23 .............................................................................................................
0.029
0.031
0.033
0.035
0.038
0.040
0.042
0.045
0.047
0.049
0.051
0.053
0.056
0.057
0.058
0.060
0.060
0.061
0.061
0.086
0.091
0.095
0.100
0.106
0.112
0.117
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
....................................
0.019
0.023
0.026
0.029
0.033
0.036
0.039
0.043
0.048
0.053
0.056
0.059
0.062
0.064
0.066
0.070
0.071
0.074
0.076
Total ..................................................................................................
1.000
1.000
1.000
The RY (that is, beginning July 1,
2006) update for the IPF PPS using the
FY 2002-based RPL market basket and
Global Insight’s 1st quarter 2006 forecast
is 4.3 percent. This includes increases
in both the operating section and the
capital section for the 18-month period
(that is, January 1, 2005 through June
30, 2006). Global Insight, Inc. is a
nationally recognized economic and
financial forecasting firm that contracts
with CMS to forecast the components of
the market baskets. Using the current FY
1997-based excluded hospital with
capital market basket (66 FR 41427),
Global Insight’s 1st quarter 2006 forecast
for the RY beginning July 1, 2006 is 3.4
percent. Table 5 below compares the RY
2002-based RPL market basket and the
FY 1997-based excluded hospital with
capital market basket percent changes.
For both the historical and forecasted
periods between RY 2000 and RY 2008,
the difference between the two market
baskets is minor with the exception of
RY 2002, where the FY–2002-based RPL
market basket increased three tenths of
a percentage point higher than the FY
1997-based excluded hospital with
capital market basket. This is primarily
due to the FY 2002-based RPL having a
larger compensation (that is, the sum of
wages and salaries and benefits) cost
weight than the FY 1997-based index
and the price changes associated with
compensation costs increasing much
faster than the prices of other market
basket components. Also contributing is
the ‘‘all other nonlabor intensive’’ cost
weight, which is smaller in the FY 2002based RPL market basket than in the FY
1997-based index, as well as the slower
price changes associated with these
costs.
TABLE 5.—FY 2002-BASED RPL MARKET BASKET AND FY 1997-BASED EXCLUDED HOSPITAL WITH CAPITAL MARKET
BASKET, PERCENT CHANGES
FY 2002-based
RPL market
basket
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Rate year (RY)
Historical data:
RY 2000 ................................................................................................................................................
RY 2001 ................................................................................................................................................
RY 2002 ................................................................................................................................................
RY 2003 ................................................................................................................................................
RY 2004 ................................................................................................................................................
RY 2005 ................................................................................................................................................
Average RY 2000–2005 .......................................................................................................................
Forecast:
RY 2006 ................................................................................................................................................
RY 2007 ................................................................................................................................................
RY 2008 ................................................................................................................................................
Average RY 2006–2008 .......................................................................................................................
FY 1997-based
excluded hospital
market basket
with capital
2.8
3.8
4.1
3.8
3.6
3.8
3.7
2.7
3.9
3.8
3.7
3.6
4.0
3.5
3.6
3.4
3.2
3.4
3.8
3.4
3.1
3.4
Source: Global Insight, Inc. 1stQtr 2006, @USMACRO/CONTROL0306 @CISSIM/CNTL08R3.SIM.
Note: The RY forecasts are based on the standard 12-month period of July 1 to June 30. For this rule, we are moving from an 18-month period to a 12-month period.
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4. Labor-Related Share
As described below in this file rule,
due to the variations in costs and
geographic wage levels, we believe that
payment rates under the IPF PPS should
continue to be adjusted by a geographic
wage index. This wage index applies to
the labor-related portion of the proposed
Federal per diem base rate, hereafter
referred to as the labor-related share.
The labor-related share is determined
by identifying the national average
proportion of operating costs that are
related to, influenced by, or vary with
the local labor market. Using our current
definition of labor-related, the laborrelated share is the sum of the relative
importance of wages and salaries, fringe
benefits, professional fees, laborintensive services, and a portion of the
capital share from an appropriate
market basket. We used the FY 2002based RPL market basket costs to
determine the labor-related share for the
IPF PPS. The labor-related share for RY
2007 is the sum of the RY 2007 relative
importance of each labor-related cost
category, and reflects the different rates
of price change for these cost categories
between the base year (FY 2002) and RY
2007. The sum of the relative
importance for RY 2007 for operating
costs (wages and salaries, employee
benefits, professional fees, and laborintensive services) is 71.586, as shown
in Table 6 below. The portion of capital
that is influenced by the local labor
market is estimated to be 46 percent,
which is the same percentage used in
the FY 1997-based IRF and IPF payment
systems. Since the relative importance
for capital is 8.867 percent of the FY
2002-based RPL market basket in RY
2007, we are taking 46 percent of 8.867
percent to determine the labor-related
share of capital for RY 2007. The result
is 4.079 percent, which we added to
71.586 percent for the operating cost
amount to determine the total laborrelated share for RY 2007. Thus, the
labor-related share that we are using for
IPF PPS in RY 2007 is 75.665 percent.
This labor-related share is determined
using the same methodology as
employed in calculating all previous IPF
labor-related shares (69 FR 66952).
Comment: One commenter noted that
the proposed labor-related share based
on the RPL market basket would benefit
hospitals with a wage index greater than
or equal to 1.000. The commenter also
recommended that CMS ensure that the
labor-related share is calculated
appropriately, based on recent and
comprehensive data for the facilities in
the market basket.
Response: We recognize that the
labor-related share would benefit
hospitals with a wage index greater than
1.000. However, the wage index is
estimated independently from the laborrelated share. We do not take into
consideration which hospitals would
benefit from the revised and rebased
labor-related share. We calculated the
labor-related share using the same
methodology used for the IPF
implementation year and reflected the
most recent and comprehensive data
available. The labor-related share
represents the national average while
the wage index reflects geographical
cost differences.
The proposed change in the laborrelated share is primarily attributable to
the exclusion of children’s and cancer
hospitals (which are less labor intensive
than IRFs, IPFs, and LTCHs) and the
update of the base year to reflect FY
2002 data. The FY 2002 data, the most
recent and comprehensive data
available, reflects that labor-related
costs are increasing faster than aggregate
non-labor-related costs. We will
continue to analyze RPL cost report data
on a regular basis to ensure it accurately
reflects the cost structures facing IRFs,
IPFs, and LTCHs serving Medicare
beneficiaries.
Table 6 below shows the RY 2007
relative importance of labor-related
shares using the FY 2002-based RPL
market basket and the FY 1997-based
excluded hospital with capital market
basket.
TABLE 6.—TOTAL LABOR-RELATED SHARE—RELATIVE IMPORTANCE FOR RY 2007
FY 2002-based
RPL market basket relative
importance
(percent) RY 2007
FY 1997 excluded
hospital with capital
market basket relative importance
(percent) RY 2007
Wages and salaries .................................................................................................................................
Employee benefits ...................................................................................................................................
Professional fees .....................................................................................................................................
All other labor-intensive services .............................................................................................................
52.506
14.042
2.886
2.152
48.021
11.534
4.495
4.411
Subtotal .............................................................................................................................................
Labor-related share of capital costs ........................................................................................................
71.586
4.079
68.461
3.222
Total ...........................................................................................................................................
75.665
71.683
Cost category
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IPFs Paid Based on a Blend of the
Reasonable Cost-Based Payments
Under the broad authority of sections
1886(b)(3)(A) and (b)(3)(B) of the Act
and as stated in the FY 2006 IPPS final
rule (70 FR 47399), for IPFs that are
transitioning to the fully Federal
prospective payment rate, we are now
using the rebased and revised FY 2002based excluded hospital market basket
to update the reasonable cost-based
portion of their payments. We rebase the
market basket periodically so that the
cost weights reflect changes in the mix
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of goods and services that hospitals
purchase to furnish inpatient care
between base periods. We chose FY
2002 as the base year for the excluded
hospital market basket because we
believe this is the most recent, complete
year of Medicare cost report data.
The reasonable cost-based payments,
subject to TEFRA limits, are determined
on a FY basis. The FY 2007 update
factor for the portion of the IPF PPS
transitional blend payment based on
reasonable costs will be published in
the FY 2007 IPPS proposed and final
rules.
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VI. Update of the IPF PPS Adjustment
Factors
A. Overview of the IPF PPS Adjustment
Factors
In developing the IPF PPS, in order to
ensure that the IPF PPS would be able
to account adequately for each IPF’s
case-mix, we performed an extensive
regression analysis of the relationship
between the per diem costs and certain
patient and facility characteristics to
determine those characteristics
associated with statistically significant
cost differences on a per diem basis. For
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characteristics with statistically
significant cost differences, we used the
regression coefficients of those variables
to determine the size of the
corresponding payment adjustments.
The IPF PPS payment adjustments
were derived from a regression analysis
of 100 percent of the FY 2002 MedPAR
data file which contained 483,038 cases.
We are using the same results of this
regression analysis to implement the RY
2007 IPF PPS final rule (See 69 FR
66935 through 66936 for a more detailed
description of the data file used for the
regression analysis.)
We computed a per diem cost for each
Medicare inpatient psychiatric stay,
including routine operating, ancillary,
and capital components using
information from the FY 2002 MedPAR
file and data from the FY 2002 Medicare
cost reports. To calculate the cost per
day for each inpatient psychiatric stay,
routine costs were estimated by
multiplying the routine cost per day
from the IPF’s FY 2002 Medicare cost
report by the number of Medicare
covered days on the FY 2002 MedPAR
stay record. Ancillary costs were
estimated by multiplying each
departmental cost-to-charge ratio by the
corresponding ancillary charges on the
MedPAR stay record. The total cost per
day was calculated by summing routine
and ancillary costs for the stay and
dividing it by the number of Medicare
covered days for each day of the stay.
The IPF PPS includes a payment
adjustment for IPFs with qualifying
Emergency Departments (EDs), and IPFs
that are part of acute care hospitals and
CAHs with qualifying EDs. As a result,
ED costs were excluded from the
dependent variable used in the cost
regression in order to remove the effects
of ED costs from other payment
adjustment factors with which ED costs
may be correlated and thus avoid
overpaying ED costs.
The log of per diem cost, like most
health care cost measures, appeared to
be normally distributed. Therefore, the
natural logarithm of the per diem cost
was the dependent variable in the
regression analysis. We included
variables in the regression to control for
psychiatric hospitals that do not bill
ancillary costs and for ECT costs that we
pay separately. The per diem cost was
adjusted for differences in labor cost
across geographic areas using the FY
2005 hospital wage index unadjusted for
geographic reclassifications, in order to
be consistent with our use of the market
basket labor share in applying the wage
index adjustment.
As discussed in the November 2004
IPF PPS final rule (69 FR 66936), we
computed a wage adjustment factor for
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each case by multiplying the Medicare
2005 hospital wage index based on MSA
definitions defined by OMB in 1993 for
each facility by the labor-related share
and adding the non-labor share. We
used the 1997-based excluded hospital
with capital market basket to determine
the labor-related share. The per diem
cost for each case was divided by this
factor before taking the natural
logarithm. The payment adjustment for
the wage index was computed
consistently with the wage adjustment
factor, which is equivalent to separating
the per diem cost into a labor portion
and a non-labor portion and adjusting
the labor portion by the wage index.
With the exception of the teaching
adjustment, the independent variables
were specified as one or more
categorical variables. Once the
regression model was finalized based on
the log normal variables, the regression
coefficients for these variables were
converted to payment adjustment
factors by treating each coefficient as an
exponent of the base ‘‘e’’ for natural
logarithms, which is approximately
equal to 2.718. The payment adjustment
factors represent the proportional effect
of each variable relative to a reference
variable. As a result of the regression
analysis, we established patient-level
payment adjustments for age, DRG
assignment based on patients’ principal
diagnoses, selected comorbidities, and a
day of stay adjustment (the variable per
diem adjustments) to reflect higher
resource use in the early days of an IPF
stay. We also established facility-level
payment adjustments for wage area,
rural location, teaching status, cost of
living adjustment for IPFs located in
Alaska and Hawaii, and an adjustment
for IPFs with a qualifying ED. We do not
plan to update the regression analysis
until we analyze IPF PPS data (that is,
no earlier than RY 2008). CMS plans to
monitor claims and payment data
independently from cost report data to
assess issues, or whether changes in
case-mix or payment shifts have
occurred between free standing
governmental, non-profit, and private
psychiatric hospitals, and/or psychiatric
units of general hospital, and other
impact issues of importance to
psychiatric facilities.
B. Patient-Level Adjustments
In the November 2004 IPF PPS final
rule, we provided payment adjustments
for the following payment-level
characteristics: DRG assignment of the
patient’s principal diagnosis, selected
comorbidities, patient age, and the
variable per diem adjustments.
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27055
1. Adjustment for DRG Assignment
The IPF PPS includes payment
adjustments for the psychiatric DRG
assigned to the claim based on each
patient’s principal diagnosis. In the
November 2004 IPF PPS final rule, we
explained that the IPF PPS includes 15
diagnosis-related group (DRG)
adjustment factors (69 FR 66936). The
adjustment factors were expressed
relative to the most frequently reported
DRG in FY 2002, that is, DRG 430. The
coefficient values and adjustment
factors were derived from the regression
analysis.
In accordance with § 412.27, payment
under the IPF PPS is made for claims
with a principal diagnosis included in
the Diagnostic and Statistical Manual of
Mental Disorder—Fourth Edition—Text
Revision (DSM–IV–TR) or Chapter Five
of the International Classification of
Diseases—9th Revision—Clinical
Modifications (ICD–9–CM). The
Standards for Electronic Transaction
final rule published in the Federal
Register on August 17, 2000 (65 FR
50312), adopted the ICD–9–CM as the
designated code set for reporting
diseases, injuries, impairments, other
health related problems, their
manifestations, and causes of injury,
disease, impairment, or other healthrelated problems. As a result, the DSM–
IV–TR, while essential for the diagnosis
and treatment of mentally ill patients,
may not be reported on Medicare
claims. However, in order to recognize
the importance of the DSM–IV–TR in
mental health treatment, we updated the
reference to the DSM in § 412.27 from
DSM–III–TR to DSM–IV–TR in the
November 2004 IPF PPS final rule. As
a result, under the revised § 412.27, IPFs
that are distinct part psychiatric units of
acute care hospitals and CAHs may only
admit patients who have a principal
diagnosis in the DSM–IV–TR or Chapter
Five of the ICD–9–CM although DSM
codes may not be reported on medical
claims.
IPF claims with a principal diagnosis
included in Chapter Five of the ICD–9–
CM or the DSM–IV–TR will be paid the
Federal per diem base rate under the IPF
PPS. Psychiatric principal diagnoses
that do not group to one of the 15
designated DRGs receive the Federal per
diem base rate and all other applicable
adjustments, but the payment would not
include a DRG adjustment. Only those
claims with diagnoses that group to one
of these psychiatric DRGs would receive
a DRG adjustment.
We believe it is vital to maintain the
same diagnostic coding and DRG
classification for IPFs that is used under
the IPPS for providing the same
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psychiatric care. As we explained in the
IPF PPS proposed rule (68 FR 66924),
all changes to the ICD–9–CM coding
system that would impact the IPF PPS
are addressed annually in the IPPS
proposed and final rules published each
year. The updated codes are effective
October 1 of each year and must be used
to report diagnostic or procedure
information. The official version of the
ICD–9–CM is available on CD–ROM
from the U.S. Government Printing
Office. The FY 2006 version can be
ordered by contacting the
Superintendent of Documents, U.S.
Government Printing Office, Department
50, Washington, DC 20402–9329,
telephone number (202) 512–1800. The
stock number is 017–022–01544–7, and
the price is $25.00. In addition, private
vendors publish the ICD–9–CM.
Questions concerning the ICD–9–CM
should be directed to Patricia E. Brooks,
Co-Chairperson, ICD–9–CM
Coordination and Maintenance
Committee, CMS, Center for Medicare
Management, Hospital and Ambulatory
Policy Group, Division of Acute Care,
Mailstop C4–08–06, 7500 Security
Boulevard, Baltimore, Maryland 21244–
1850. Questions and comments may be
sent via e-mail to:
Patricia.Brooks1@cms.hhs.gov.
Further information concerning the
Official Version of the ICD–9–CM can be
found in the IPPS final regulation,
‘‘Changes to the Hospital Inpatient
Prospective Payment Systems and Fiscal
Year 2006 Rates; Final Rule,’’ in the
August 12, 2005 Federal Register (70 FR
47278) and at https://www.cms.hhs.gov/
QuarterlyProviderUpdates/downloads/
cms1500f.pdf.
The following two tables below list
the FY 2006 new ICD diagnosis codes
and FY 2006 revised diagnosis code
titles, respectively. These tables are only
a listing of FY 2006 changes and do not
reflect all of the currently valid and
applicable ICD codes classified in the
DRGs. Table 7 below lists the new FY
2006 ICD diagnosis codes that are
classified to one of the 15 DRGs that are
provided a DRG adjustment in the IPF
PPS. When coded as a principal code or
diagnosis, these codes receive the
correlating DRG adjustment.
TABLE 7.—FY 2006 NEW DIAGNOSIS CODES
Diagnosis code
291.82
292.85
327.00
327.01
327.02
327.09
327.10
327.11
327.12
327.13
327.14
327.15
327.19
Description
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
......................................................
DRG
Alcohol induced sleep disorders ..............................................................................
Drug induced sleep disorders ..................................................................................
Organic insomnia, unspecified ................................................................................
Insomnia due to medical condition classified elsewhere ........................................
Insomnia due to mental disorder .............................................................................
Other organic insomnia ...........................................................................................
Organic hypersomnia, unspecified ..........................................................................
Idiopathic hypersomnia with long sleep time ..........................................................
Idiopathic hypersomnia without long sleep time .....................................................
Recurrent hypersomnia ...........................................................................................
Hypersomnia due to medical condition classified elsewhere ..................................
Hypersomnia due to mental disorder ......................................................................
Other organic hypersomnia .....................................................................................
Table 8 below lists ICD diagnosis
codes whose titles have been modified
in FY 2006. Title changes do not impact
the DRG adjustment. When used as a
521, 522, 523
521, 522, 523
432
432
432
432
432
432
432
432
432
432
432
principal diagnosis, these codes still
receive the correlating DRG adjustment.
TABLE 8.—REVISED DIAGNOSIS CODE TITLES
Diagnosis code
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307.45
780.52
780.54
780.55
780.58
Description
......................................................
......................................................
......................................................
......................................................
......................................................
Circadian rhythm sleep disorder of nonorganic origin ............................................
Insomnia, unspecified ..............................................................................................
Hypersomnia, unspecified .......................................................................................
Disruption of 24 hour sleep wake cycle, unspecified ..............................................
Sleep related movement disorder, unspecified .......................................................
In addition to the aforementioned, in
the August 2005 IPPS final rule, we
finalized ICD code 305.1, Tobacco Use
Disorder, in order to designate this code
as a noncovered Medicare service when
reported as the principal diagnosis.
Below we have republished the
explanation that was included in the
IPPS final rule (70 FR 47312) and
published on the CMS Web site at
https://www.cms.hhs.gov/
QuarterlyProviderUpdates/downloads/
cms1500f.pdf.
‘‘We have become aware of the possible need
to add code 305.1 (Tobacco use disorder) to
the MCE in order to make admissions for
tobacco use disorder a noncovered Medicare
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DRG
service when code 305.1 is reported as the
principal diagnosis. On March 22, 2005, CMS
published a final decision memorandum and
related national coverage determination
(NCD) on smoking cessation counseling
services on its Web site: (https://
www.cms.hhs.gov/coverage/). Among other
things, this NCD provides that: ‘Inpatient
hospital stays with the principal diagnosis of
305.1, Tobacco Use Disorder, are not
reasonable and necessary for the effective
delivery of tobacco cessation counseling
services. Therefore, we will not cover tobacco
cessation services if tobacco cessation is the
primary reason for the patient’s hospital
stay.’ Therefore, in order to maintain internal
consistency with CMS programs and
decisions, we proposed to add code 305.1 to
the MCE edit ‘Questionable Admission—
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432
432
432
432
432
Principal Diagnosis Only’ in order to make
tobacco use disorder a noncovered
admission.’’ (70 FR 47312).
In order to maintain consistency with
the IPPS, for discharges on or after
October 1, 2005, ICD code 305.1,
Tobacco Use Disorder, will not be a
covered principal diagnosis under the
IPF PPS.
Although we are updating the IPF PPS
to reflect ICD–9–CM coding changes and
DRG classification changes discussed in
the annual update to the IPPS, in the RY
2007 IPF PPS final rule, the DRG
adjustment factors currently being paid
to IPFs will remain the same (that is, for
discharges occurring during the RY July
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1, 2006 through June 30, 2007). As
indicated in the November 2004 IPF
PPS final rule, we do not plan to update
the regression analysis until we analyze
IPF PPS data.
As a result, we are adopting the DRG
adjustments factors, the ICD–9–CM
27057
coding changes and the DRG
classification changes that are currently
being paid as indicated in Table 9
below.
TABLE 9.—FY 2006 DRGS AND ADJUSTMENT FACTOR
DRG
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DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
424 ...................................................
425 ...................................................
426 ...................................................
427 ...................................................
428 ...................................................
429 ...................................................
430 ...................................................
431 ...................................................
432 ...................................................
433 ...................................................
521 ...................................................
522 ...................................................
523 ...................................................
12 .....................................................
23 .....................................................
O.R. Procedure with Principal Diagnosis of Mental Illness .........................................
Acute Adjustment Reaction & Psychosocial Dysfunction ............................................
Depressive Neurosis ....................................................................................................
Neurosis, Except Depressive .......................................................................................
Disorders of Personality & Impulse Control .................................................................
Organic Disturbances & Mental Retardation ...............................................................
Psychoses ....................................................................................................................
Childhood Mental Disorders .........................................................................................
Other Mental Disorder Diagnoses ...............................................................................
Alcohol/Drug Abuse or Dependence, Leave Against Medical Advice (LAMA) ...........
Alcohol/Drug Abuse or Dependence with CC .............................................................
Alcohol/Drug Abuse or Dependence with RehabilitationTherapy without CC .............
Alcohol/Drug Abuse or Dependence without Rehabilitation Therapy without CC ......
Degenerative Nervous System Disorders ....................................................................
Non-traumatic Stupor & Coma .....................................................................................
Section 412.424(d) separately
identifies both ‘‘Diagnosis-related group
assignment’’ and ‘‘Principal diagnosis’’
as patient level adjustments. Since
publication of the November 2004 IPF
PPS final rule, we have received
inquiries related to whether the IPF PPS
includes two patient-level payment
adjustments for principal diagnosis, an
adjustment for the diagnosis-related
group assignment, and a separate
adjustment for providing a principal
diagnosis in general. We intended that
the IPF PPS provide one patient-level
adjustment for principal diagnosis,
which is ‘‘Diagnosis-related group
assignment.’’
In order to clarify our policy, we
proposed to modify the language in
section 412.424(d) by deleting subparagraph § 412.424(d)(2)(iii). We
received no public comments on the
proposed amendment. We are adopting
this change in our final rule.
Public comments and our responses
on the proposed changes on the
adjustment for DRG assignment are
summarized below.
Comment: We received several
comments concerning the update to the
DRG adjustment factors. Overall, the
commenters supported our decision to
delay updating the patient-level
adjustment factors, stating that a delay
in running the regression analysis
would allow CMS to use more
comprehensive and accurate patientlevel coding data.
However, one commenter
recommended that CMS update the
DRGs and adjustment factors on an ongoing basis.
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Adjustment
factor
DRG definition
Jkt 208001
Response: We do not plan to update
the regression analysis until we analyze
IPF PPS data. We believe that this will
provide the best indication of current
IPF practices. Therefore, the DRG
adjustment factors currently being paid
to IPFs will remain the same for the RY
2007 (that is, for discharges occurring
during the RY July 1, 2006 through June
30, 2007).
Comment: Several commenters
requested clarification on the ‘‘code
first’’ instructions, believing them to be
contrary to regulations at § 412.27. The
commenters stated that § 412.27
requires that psychiatric units only
admit those patients who have a
psychiatric principal diagnosis listed in
the DSM or the Chapter Five of the ICD.
Response: Section 412.27 and the
‘‘code first’’ instructions are not
contrary to each other. As explained in
the November 2004 final rule (69 FR
66922) and in three subsequent Change
Requests (CR) (that is, CR 3541,
published December 1, 2004; CR 3678,
published January 21, 2005; and CR
3752, published March 4, 2005), correct
coding conventions should always be
followed, including ‘‘code first’’
situations. According to the ICD–9–CM
Official Guidelines for Coding and
Reporting, when a primary diagnosis
code has a code first notation, the
provider follows the applicable ICD–9–
CM coding convention which requires
the underlying condition (etiology) to be
sequenced first, followed by the
manifestation due to the underlying
condition. Therefore, we consider ‘‘code
first’’ diagnoses to be the primary
diagnosis. The submitted claim goes
through the IPF PPS claims processing
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1.22
1.05
0.99
1.02
1.02
1.03
1.00
0.99
0.92
0.97
1.02
0.98
0.88
1.05
1.07
system which identifies the primary
diagnosis code as non-psychiatric and
searches the secondary codes for a
psychiatric code to assign the DRG in
order to pay ‘‘code first’’ claims
properly.
For more coding guidance, please
refer to the ICD–9–CM Official
Guidelines for Coding and Reporting
which can be located on the CMS Web
site at https://new.cms.hhs.gov/
ICD9ProviderDiagnosticCodes/.
Comment: Commenters requested that
CMS include the ICD–9–CM obstetrical
series of codes 648.30 to 648.34 and
648.40 to 648.44, since they are subject
to sequencing priority guidelines, in our
code first logic.
Response: At this point in time, we do
not intend to update the regression
analysis until we have analyzed one
year of IPF PPS claims and cost report
data. However, when we update the
regression analysis, we will review the
obstetric codes noted above and
consider the appropriateness of
including them in our code first logic.
For RY 2007, no DRG Adjustment will
be made to these codes.
Final Rule Action: In summary, we
received no public comments
concerning the proposal to amend
§ 412.424(d). In order to clarify our
policy that the IPF PPS provides one
patient level adjustment for principal
diagnoses, we are modifying the
language in section § 412.424(d) by
deleting sub-paragraph
§ 412.424(d)(2)(iii). In addition, we are
adopting the DRG adjustment currently
in effect and as shown in Table 9.
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2. Payment for Comorbid Conditions
In the November 2004 IPF PPS final
rule, we established 17 comorbidity
categories and identified the ICD–9–CM
diagnosis codes that generate a payment
adjustment under the IPF PPS.
Comorbidities are specific patient
conditions that are secondary to the
patient’s primary diagnosis, and that
require treatment during the stay.
Diagnoses that relate to an earlier
episode of care and have no bearing on
the current hospital stay are excluded
and not reported on IPF claims.
Comorbid conditions must co-exist at
the time of admission, develop
subsequently, affect the treatment
received, affect the length of stay or
affect both treatment and LOS.
The intent of the comorbidity
adjustment was to recognize the
increased cost associated with comorbid
conditions by providing additional
payments for certain concurrent medical
or psychiatric conditions that are
expensive to treat. For each claim, an
IPF may receive only one comorbidity
adjustment per comorbidity category,
but it may receive an adjustment for
more than one comorbidity category.
Billing instructions require that IPFs
must enter the full ICD–9–CM codes for
up to 8 additional diagnoses if they coexist at the time of admission or
developed subsequently.
The comorbidity adjustments were
determined based on regression analysis
using the diagnoses reported by
hospitals in FY 2002. The principal
diagnoses were used to establish the
DRG adjustment and were not
accounted for in establishing the
comorbidity category adjustments,
except where ICD–9–CM ‘‘code first’’
instructions apply. As we explained in
the November 2004 IPF PPS final rule
(69 FR 66922), the code first rule applies
when a condition has both an
underlying etiology and a manifestation
due to the underlying etiology. For these
conditions, the ICD–9–CM has a coding
convention that requires the underlying
conditions to be sequenced first
followed by the manifestation.
Whenever a combination exists, there is
a ‘‘use additional code’’ note at the
etiology code and a ‘‘code first’’ note at
the manifestation code.
Although we are updating the IPF PPS
to reflect updates to the ICD–9–CM
codes, the comorbidity adjustment
factors currently in effect will remain in
effect for the RY beginning July 1, 2006.
As we indicated in the November 2004
IPF PPS final rule, we do not plan to
update the regression analysis until we
analyze IPF PPS data. The comorbidity
adjustments are shown in Table 12
below.
As previously discussed in the DRG
section, we believe it is essential to
maintain the same diagnostic coding set
for IPFs that is used under the IPPS for
providing the same psychiatric care.
Therefore, as proposed and in this final
rule, we are using the most current FY
2006 ICD codes. They are reflected in
the FY 2006 GROUPER, version 23.0
and are effective for discharges
occurring on or after October 1, 2005.
Table 10 lists the updated FY 2006
new ICD diagnosis codes that impact the
comorbidity adjustment under the IPF
PPS and Table 11 lists the invalid ICD
codes no longer applicable for the
comorbidity adjustment. Table 10 only
lists the FY 2006 new codes and does
not reflect all of the currently valid ICD
codes applicable for the IPF PPS
comorbidity adjustment.
We note that ICD diagnosis code 585
Chronic Renal Failure was modified in
two ways—(1) By expanding the level of
specificity to include seven new codes;
and (2) by changing the original code of
585 to invalid, thereby leaving the
remaining more specific codes
reportable. Since diagnosis code 585 is
no longer valid, we are eliminating this
code from the comorbidity category
‘‘Renal Failure, Chronic.’’
ICD diagnosis code 585 ‘‘Chronic
Renal Failure’’ is defined in the ICD–9–
CM as ‘‘Progressive, persistent
inadequate kidney function
characterized by anuria, accumulation
of urea and other nitrogenous bodies in
the blood, nausea, vomiting,
gastrointestinal bleeding, and yellowishbrown discoloration of the skin.’’ This
code included the various stages of
chronic kidney disease, but it is no
longer valid. The new codes listed
below reflect the various stages of
chronic kidney failure.
In this final rule, we are adopting as
proposed comorbidity adjustments for
585.3, ‘‘Chronic kidney disease, Stage III
(moderate),’’ 585.4, ‘‘Chronic kidney
disease, Stage IV (severe),’’ 585.5,
‘‘Chronic kidney disease, Stage V,’’
585.6, ‘‘End Stage renal disease,’’ and
585.9, ‘‘Chronic kidney disease,
unspecified.’’ However, since the
purpose of the comorbidity adjustment
is to account for the higher resource
costs associated with comorbid
conditions that are expensive to treat on
a per diem basis, we are not providing
a comorbidity adjustment for 585.1,
‘‘Chronic kidney disease, Stage I’’ and
585.2, ‘‘Chronic kidney disease, Stage II
(mild).’’
We believe that these conditions
(585.1 and 585.2) are less costly to treat
on a per diem basis because patients
with these conditions are either
asymptomatic or may have only mild
symptoms. These conditions represent a
minimal to mild decrease in kidney
function that is almost completely
compensated such that the only finding
is typically an abnormal laboratory test.
Unlike patients with more significant
kidney dysfunction, these patients do
not usually require more costly patient
care interventions such as additional
laboratory tests to monitor renal
function, special pharmacy attention to
reduced dosages or kidney-sparing
medications, or fluid and electrolyte
precautions with special diets, frequent
weights, input/output balance, and fluid
restriction. The resources and costs that
these patients require for staff time,
medications and supplies, and
administrative services are expected to
be similar to other patients without
these conditions.
TABLE 10.—FY 2006 NEW ICD CODES APPLICABLE FOR THE COMORBIDITY ADJUSTMENT
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Diagnosis
code
Description
DRG
585.3 .......
585.4 .......
585.5 .......
585.6 .......
585.9 .......
V46.13 .....
V46.14 .....
Chronic kidney disease, Stage III (moderate) .....................
Chronic kidney disease, Stage IV(severe) ..........................
Chronic kidney disease, Stage V ........................................
End stage renal disease ......................................................
Chronic kidney disease, unspecified ...................................
Encounter for weaning from respirator [ventilator] ..............
Mechanical complication of respirator [ventilator] ...............
315–316
315–316
315–316
315–316
315–316
467
467
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Comorbidity category
Renal Failure, Chronic.
Renal Failure, Chronic.
Renal Failure,Chronic.
Renal Failure,Chronic.
Renal Failure, Chronic.
Chronic Obstructive Pulmonary Disease.
Chronic Obstructive Pulmonary Disease.
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Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
In Table 11 below, we list the FY 2006
invalid ICD diagnosis code 585 that we
will be removing from the comorbidity
adjustment under the IPF PPS. This
table does not reflect all of the currently
27059
valid ICD codes applicable for the IPF
PPS comorbidity adjustment.
TABLE 11.—FY 2006 INVALID ICD CODES NO LONGER APPLICABLE FOR THE COMORBIDITY ADJUSTMENT
Diagnosis
code
Description
585 ..........
Chronic renal failure ............................................................
The seventeen comorbidity categories
for which we are providing an
DR
315–36
Comorbidity category
Renal Failure, Chronic.
adjustment, their respective codes,
including the new FY 2006 ICD codes,
and their respective adjustment factors,
are listed below in Table 12.
TABLE 12.—FY 2006 DIAGNOSIS CODES AND ADJUSTMENT FACTORS FOR COMORBIDITY CATEGORIES
Description of comorbidity
ICD–9CM code
Developmental Disabilities .............................................................
Coagulation Factor Deficits ............................................................
Tracheostomy .................................................................................
Renal Failure, Acute .......................................................................
317, 3180, 3181, 3182, and 319 ....................................................
2860 through 2864 .........................................................................
51900—through 51909 and V440 ..................................................
5845 through 5849, 63630, 63631, 63632, 63730, 63731, 63732,
6383, 6393, 66932, 66934, 9585.
40301, 40311, 40391, 40402, 40412, 40413, 40492, 40493,
5853, 5854, 5855, 5856, 5859, 586, V451, V560, V561, and
V562.
1400 through 2390 with a radiation therapy code 92.21–92.29 or
chemotherapy code 99.25.
25002, 25003, 25012, 25013, 25022, 25023, 25032, 25033,
25042, 25043, 25052, 25053, 25062, 25063, 25072, 25073,
25082, 25083, 25092, and 25093.
260 through 262 .............................................................................
3071, 30750, 31203, 31233, and 31234 ........................................
01000 through 04110, 042, 04500 through 05319, 05440 through
05449, 0550 through 0770, 0782 through 07889, and 07950
through 07959.
2910, 2920, 29212, 2922, 30300, and 30400 ................................
3910, 3911, 3912, 40201, 40403, 4160, 4210, 4211, and 4219 ...
44024 and 7854 .............................................................................
49121, 4941, 5100, 51883, 51884, V4611 and V4612, V4613
and V4614.
56960 through 56969, 9975, and V441 through V446 ..................
6960, 7100, 73000 through 73009, 73010 through 73019, and
73020 through 73029.
96500 through 96509, 9654, 9670 through 9699, 9770, 9800
through 9809,9830 through 9839, 986, 9890 through 9897.
Renal Failure, Chronic ....................................................................
Oncology Treatment .......................................................................
Uncontrolled Diabetes-Mellitus with or without complications .......
Severe Protein Calorie Malnutrition ...............................................
Eating and Conduct Disorders .......................................................
Infectious Disease ..........................................................................
Drug and/or Alcohol Induced Mental Disorders .............................
Cardiac Conditions .........................................................................
Gangrene ........................................................................................
Chronic Obstructive Pulmonary Disease .......................................
Artificial Openings—Digestive and Urinary ....................................
Severe Musculoskeletal and Connective Tissue Diseases ...........
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Poisoning ........................................................................................
We received several comments
offering suggestions on how we could
improve the comorbidity adjustment
category list. The suggestions ranged
from requests for the addition of a single
ICD–9–CM code to a request for
expanding the comorbidity categories to
account for every ICD–9–CM code.
Public comments and our responses
to the proposed changes to payment for
comorbid conditions are summarized
below.
Comment: We received a comment
expressing concern that the comorbidity
adjustment list does not include the
more common conditions seen in
psychiatric patients. This commenter
indicated that most psychiatric patients
are treated for multiple common
conditions and illnesses (for example,
heart conditions, and stroke), none of
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which would trigger a payment
adjustment under the IPF PPS.
Response: We explained in the
November 2004 IPF PPS final rule (69
FR 66922), that the data used in
calculating the Federal per diem base
rate included all the costs for comorbid
diagnoses submitted in the FY 2002
claims. Therefore, the cost for providing
patient care (for example, medications,
routine nursing care) required for
common conditions seen in the
psychiatric population, and
recommended for comorbidity
adjustment by commenters (that is,
heart conditions or strokes) are already
included in the Federal per diem base
rate and a comorbidity adjustment for
their presence was duplicative and
unnecessary.
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Adjustment
factor
1.04
1.13
1.06
1.11
1.11
1.07
1.05
1.13
1.12
1.07
1.03
1.11
1.10
1.12
1.08
1.09
1.11
Further, the design of the IPF PPS
with its Federal per diem base rate,
provides numerous adjustments for
complex cases and the availability of
outlier payments, and stop loss
payments during the 3-year transition.
Comment: A few commenters stated
that the range of diagnostic codes
proposed for adjustment did not include
all the ICD–9–CM codes within a
diagnostic category. A particular
commenter indicated that the list of
codes under diabetes did not include all
the diabetes codes. In addition, other
commenters provided a list of ICD–9–
CM codes and comorbidity adjustments
that they believe should be included in
the comorbidity adjustment category
list.
Response: The intent of the
comorbidity adjustment is to provide
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mmaher on PROD1PC60 with RULES2
additional payments for concurrent
medical or psychiatric conditions that
are expensive to treat and require
comparatively more costly treatment
during an IPF stay than other comorbid
conditions.
Although we are updating the IPF PPS
to reflect updates to the ICD–9–CM
codes, the comorbidity adjustment
categories and factors currently in effect
will remain in effect for the RY
beginning July 1, 2006. As indicated in
the November 2004 IPF PPS final rule,
we do not plan to update the regression
analysis until we analyze IPF PPS data.
Comment: A commenter
recommended that code 404.03
hypertensive heart and renal disease,
malignant, with heart failure and renal
failure continue to qualify for both
Cardiac Conditions and Chronic Renal
Failure comorbidity adjustments.
Response: We are aware that ICD code
404.03, hypertensive heart and renal
disease, malignant, with heart failure
and renal failure, has caused confusion
since this ICD code is currently used to
code an adjustment in two separate IPF
comorbidity categories, (that is, both
‘‘Renal Failure, Chronic’’ and ‘‘Cardiac
Conditions’’). We believe that it more
appropriately corresponds to the
‘‘Cardiac Conditions’’ comorbidity than
to the ‘‘Renal Failure, Chronic’’
comorbidity. Therefore, to be more
clinically cohesive and to eliminate
confusion, we are removing ICD code
404.03 from the comorbidity adjustment
category ‘‘Renal Failure, Chronic,’’ but
retaining it in the ‘‘Cardiac Conditions’’
comorbidity category. Since both
comorbidity categories have the same
adjustment factor of 1.11, we believe no
negative payment consequence will
result from this change.
Final Rule Action: We are adopting
the comorbidity adjustments currently
in effect and as shown in Table 12 above
for RY 2007 beginning July 1, 2006.
3. Patient Age Adjustments
As explained in the November 2004
IPF PPS final rule, we analyzed the
impact of age on per diem cost by
examining the age variable (that is, the
range of ages) for payment adjustments.
In general, we found that the cost per
day increases with increasing age. The
older age groups are more costly than
the under 45 years of age group; the
differences in per diem cost increase for
each successive age group, and the
differences are statistically significant.
Based on the results of the regression
analysis, we established 8 adjustment
factors for age beginning with age
groupings 45 and under 50, 50 and
under 55, 55 and under 60, 60 and
under 65, 65 and under 70, 70 and
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under 75, 75 and under 80, and 80 years
of age and over. Patients under 45 years
of age are assigned an age adjustment
factor of 1.00. As we indicated in the
November 2004 IPF PPS final rule, we
do not plan to update the regression
analysis until we analyze IPF PPS data.
As a result, we are adopting the patient
age adjustments currently in effect and
shown in Table 13 below.
emergency department (ED). If an IPF
has a qualifying ED, it receives a 1.31
adjustment for day 1 of each patient
stay. If an IPF does not have a qualifying
ED, it receives a 1.19 adjustment for day
1 of the stay. The ED adjustment is
explained in more detail in section
VI.C.5 of this final rule.
As we indicated in the November
2004 IPF PPS final rule, we do not plan
to make changes to the regression
TABLE 13.—AGE GROUPINGS AND
analysis until we analyze IPF PPS data.
ADJUSTMENT FACTORS
As a result, for the RY beginning July 1,
Adjustment 2006, we are adopting the variable per
Age
factor
diem adjustment factors currently in
effect. Table 14 below shows the
Under 45 ...................................
1.00
variable per diem adjustments that we
45 and under 50 .......................
1.01
50 and under 55 .......................
1.02 will be using for updating the IPF PPS.
55
60
65
70
75
80
and
and
and
and
and
and
under 60 .......................
under 65 .......................
under 70 .......................
under 75 .......................
under 80 .......................
over ..............................
1.04
1.07
1.10
1.13
1.15
1.17
Final Rule Action: In response to the
RY 2007 proposed rule, we received no
comments concerning the age
adjustment. We are adopting the age
adjustments currently in effect and as
shown in Table 13 above, for RY 2007.
4. Variable Per Diem Adjustments
We explained in the November 2004
IPF PPS final rule that cost regressions
indicated that per diem cost declines as
the LOS increases (69 FR 66947). The
variable per diem adjustments to the
Federal per diem base rate account for
ancillary and administrative costs that
occur disproportionately in the first
days after admission to an IPF.
We used regression analysis to
estimate the average differences in per
diem cost among stays of different
length. Regression analysis
simultaneously controls for cost
differences associated with the other
variables (for example, age, DRG, and
presence of specific comorbidities). The
regression coefficients measure the
relative average cost per day for stays of
differing lengths compared to a
reference group’s LOS. We analyzed
through cost regression the relative cost
per day for day 1 through day 30. We
determined that the average per diem
cost declined smoothly until the 22nd
day. As a result of this analysis, we
established variable per diem
adjustments that begin on day 1 and
decline gradually until day 21 of a
patient’s stay. For day 22 and thereafter,
the variable per diem adjustment
remains the same each day for the
remainder of the stay. However, the
adjustment applied to day 1 depends
upon whether the IPF has a qualifying
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TABLE 14.—VARIABLE PER DIEM
ADJUSTMENTS
Day-of-stay
Day 1—IPF Without a Qualified
ED .........................................
Day 1—IPF With a Qualified
ED .........................................
Day 2 ........................................
Day 3 ........................................
Day 4 ........................................
Day 5 ........................................
Day 6 ........................................
Day 7 ........................................
Day 8 ........................................
Day 9 ........................................
Day 10 ......................................
Day 11 ......................................
Day 12 ......................................
Day 13 ......................................
Day 14 ......................................
Day 15 ......................................
Day 16 ......................................
Day 17 ......................................
Day 18 ......................................
Day 19 ......................................
Day 20 ......................................
Day 21 ......................................
After Day 21 .............................
Adjustment
factor
1.19
1.31
1.12
1.08
1.05
1.04
1.02
1.01
1.01
1.00
1.00
0.99
0.99
0.99
0.99
0.98
0.97
0.97
0.96
0.95
0.95
0.95
0.92
Final Rule Action: In response to the
RY 2007 proposed rule, we received no
comments concerning the proposed
variable per diem adjustments. We are
adopting the variable per diem
adjustment factors currently in effect,
and as shown in Table 14 above for RY
2007.
C. Facility-Level Adjustments
The IPF PPS includes facility-level
adjustments for the wage index, IPFs
located in rural areas, teaching IPFs,
cost of living adjustments for IPFs
located in Alaska and Hawaii, and IPFs
with a qualifying ED.
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mmaher on PROD1PC60 with RULES2
1. Wage Index Adjustment
a. Revisions of IPF PPS Geographic
Classifications
In the November 2004 IPF PPS final
rule, we explained that in establishing
an adjustment for area wage levels, the
labor-related portion of an IPF’s Federal
prospective payment is adjusted by
using an appropriate wage index. We
also explained that an IPF’s wage index
is determined based on the location of
the IPF in an urban or rural area as
defined in § 412.62(f)(1)(ii) and
(f)(1)(iii), respectively.
An urban area under the IPF PPS is
defined at § 412.62(f)(1)(ii)(A) and (B).
In general, an urban area is defined as
a Metropolitan Statistical Area (MSA) or
New England County Metropolitan Area
(NECMA) as defined by the Office of
Management and Budget (OMB). In
addition, a few counties located outside
of MSAs are considered urban as
specified at § 412.62(f)(1)(ii)(B). Under
§ 412.62(f)(1)(iii), a rural area is defined
as any area outside of an urban area.
The geographic classifications defined
in § 412.62(f)(1)(ii) and (f)(1)(iii), were
used under the IPPS from FYs 1984
through 2004 (§ 412.62(f) and
§ 412.63(b)), and have been used under
the IPF PPS since it was implemented
for cost reporting periods beginning on
or after January 1, 2005.
Under the IPPS, the wage index is
calculated and assigned to hospitals on
the basis of the labor market area in
which the hospital is located or
geographically reclassified to in
accordance with sections 1886(d)(8) and
(d)(10) of the Act. Under the IPF PPS,
the wage index is calculated using IPPS
wage index data (as discussed below in
section VI.C.1.d of this preamble) on the
basis of the labor market area in which
the IPF is located, without taking into
account geographic reclassification
under sections 1886(d)(8) and (d)(10) of
the Act and without applying the ‘‘rural
floor’’ established under section 4410 of
the BBA. (Section 4410 of the BBA
provides that for the purposes of section
1886(d)(3)(E) of the Act, the area wage
index applicable to hospitals located in
an urban area of a State may not be less
than the area wage index applicable to
hospitals located in rural areas in the
State. This provision is commonly
referred to as the ‘‘rural floor’’ under the
IPPS.) However, when we established
the IPF PPS, we did not apply the rural
floor to IPFs. For this reason, the
hospital wage index used for IPFs is
commonly referred to as the ‘‘pre-floor’’
hospital wage index indicating that the
‘‘rural floor’’ provision of the BBA is not
applied. As a result, the applicable IPF
wage index value is assigned to the IPF
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on the basis of the labor market area in
which the IPF is geographically located.
As noted above, the current IPF PPS
labor market areas are defined based on
the definitions of MSAs, Primary MSAs
(PMSAs), and NECMAs issued by the
OMB (commonly referred to collectively
as ‘‘MSAs’’). The MSA definitions,
which are discussed in greater detail
below, are currently used under the IPF
PPS and other PPSs (that is, the IRF
PPS, the LTCH PPS, and the PPSs for
home health agencies (HHA PPS) and
skilled nursing facilities (SNF PPS)). In
the FY 2005 IPPS final rule (69 FR
49026 through 49034), revised labor
market area definitions were adopted
under the IPPS (§ 412.64(b)), which
were effective October 1, 2004. These
new standards, called Core-Based
Statistical Areas (CBSAs), were
announced by the OMB late in CY 2000
and are discussed in greater detail
below.
b. Current IPF PPS Labor Market Areas
Based on MSAs
When we published the November
2004 IPF PPS final rule, we explained
that we were not adopting the new
statistical area definitions defined by
OMB for the following reasons. First,
the change in labor market areas under
the IPPS had not changed at the time we
published the IPF PPS proposed rule on
November 28, 2003. As a result, IPFs
and other interested parties were not
afforded an opportunity to comment on
the use of the new labor market area
definitions under the IPF PPS. Second,
we wanted to conduct a thorough
analysis of the impact of the new labor
market area definitions on payments
under the IPF PPS. Finally, in the
November 2004 IPF PPS final rule, we
indicated our intent to publish in a
proposed rule any changes we were
considering for new labor market
definitions.
The analysis of the impact of the new
labor market definitions has been
completed. In the RY 2007 proposed
rule, we proposed to adopt the new
CBSA-based labor market area
definitions. In this final rule, we are
adopting these labor market area
definitions for the IPF PPS. We believe
it is helpful to provide a detailed
description of the current IPF PPS labor
market areas to help explain the changes
to the IPF PPS labor market areas.
As mentioned earlier, since the
implementation of the IPF PPS, we have
used labor market areas to further
characterize urban and rural areas as
determined under § 412.62(f)(1)(ii) and
(iii). To this end, we have defined labor
market areas under the IPF PPS based
on the definitions of MSAs, PMSAs, and
NECMAs issued by the OMB in 1993,
which is consistent with the IPPS
approach prior to FY 2005. We note that
OMB also defines Consolidated MSAs
(CMSAs). A CMSA is a metropolitan
area with a population of 1 million or
more, comprising two or more PMSAs
(identified by their separate economic
and social character). However, for
purposes of the wage index, we use the
PMSAs rather than CMSAs because they
allow a more precise breakdown of labor
costs. If a metropolitan area is not
designated as part of a PMSA, we use
the applicable MSA.
These different designations use
counties as the building blocks upon
which they are based. Therefore, under
the IPF PPS, hospitals are assigned to
either an MSA, PMSA, or NECMA based
on whether the county in which the IPF
is located is part of that area. All of the
counties in a State outside a designated
MSA, PMSA, or NECMA are designated
as rural.
c. Core-Based Statistical Areas
The OMB reviews its Metropolitan
Area definitions preceding each
decennial census. As discussed in the
FY 2005 IPPS final rule (69 FR 49026),
in the fall of 1998, OMB chartered the
Metropolitan Area Standards Review
Committee to examine the Metropolitan
Area standards and develop
recommendations for possible changes
to those standards. Three notices related
to the review of the standards, providing
an opportunity for public comment on
the recommendations of the Committee,
were published in the Federal Register
on the following dates: December 21,
1998 (63 FR 70526); October 20, 1999
(64 FR 56628); and August 22, 2000 (65
FR 51060).
In the December 27, 2000 Federal
Register (65 FR 82228 through 82238),
OMB announced its new standards. In
that notice, OMB defines a Core-Based
Statistical Area (CBSA), beginning in
2003, as ‘‘a geographic entity associated
with at least one core of 10,000 or more
population, plus adjacent territory that
has a high degree of social and
economic integration with the core as
measured by commuting ties. The
standards designate and define two
categories of CBSAs: Metropolitan
Statistical Areas and Micropolitan
Statistical Areas.’’ (65 FR 82236 through
82238).
According to the OMB, MSAs are
based on urbanized areas of 50,000 or
more population, and Micropolitan
Statistical Areas (referred to in this
discussion as Micropolitan Areas) are
based on urban clusters of at least
10,000 population, but less than 50,000
population. Counties that do not fall
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within CBSAs (either MSAs or
Micropolitan Areas) are deemed
‘‘Outside CBSAs.’’ In the past, OMB
defined MSAs around areas with a
minimum core population of 50,000,
and smaller areas were ‘‘Outside
MSAs.’’ On June 6, 2003, the OMB
announced the new CBSAs, comprised
of MSAs and the new Micropolitan
Areas based on Census 2000 data. (A
copy of the announcement may be
obtained at the following Internet
address: https://www.whitehouse.gov/
omb/bulletins/fy04/b04-03.html.)
The new CBSA designations
recognize 49 new MSAs and 565 new
Micropolitan Areas, and extensively
revise the composition of many of the
existing MSAs. There are 1,090 counties
in MSAs under the new CBSA
designations (previously, there were 848
counties in MSAs). Of these 1,090
counties, 737 are in the same MSA as
they were prior to the change in
designations, 65 are in a different MSA,
and 288 were not previously designated
to any MSA. There are 674 counties in
Micropolitan Areas. Of these, 41 were
previously in an MSA, while 633 were
not previously designated to an MSA.
There are five counties that previously
were designated to an MSA but are no
longer designated to either an MSA or
a new Micropolitan Area: Carter County,
KY; St. James Parish, LA; Kane County,
UT; Culpepper County, VA; and King
George County, VA. For a more detailed
discussion of the conceptual basis of the
new CBSAs, refer to the FY 2005 IPPS
final rule (67 FR 49026 through 49034).
d. Revision of the IPF PPS Labor Market
Areas
In its June 6, 2003 announcement,
OMB cautioned that these new
definitions ‘‘should not be used to
develop and implement Federal, State,
and local nonstatistical programs and
policies without full consideration of
the effects of using these definitions for
such purposes. These areas should not
serve as a general-purpose geographic
framework for nonstatistical activities,
and they may or may not be suitable for
use in program funding formulas.’’
We currently use MSAs to define
labor market areas for purposes of
Medicare wage indices in the IPF PPS
since its implementation for cost
reporting periods beginning on or after
January 1, 2005. Until recently, MSAs
were used to define labor market areas
for purposes of the wage index for many
of the other Medicare payment systems
(for example, IRF PPS, SNF PPS, HHA
PPS, and Outpatient PPS). While we
recognize MSAs are not designed
specifically to define labor market areas,
we believe they represent a useful proxy
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for this purpose, because they are based
upon characteristics we believe also
generally reflect the characteristics of
unified labor market areas. For example,
CBSAs consist of a core population plus
an adjacent territory that reflects a high
degree of social and economic
integration. This integration is measured
by commuting ties, thus demonstrating
that these areas may draw workers from
the same general areas. In addition, the
most recent CBSAs reflect the most upto-date information. Our analysis and
discussion here are focused on issues
related to adopting the new CBSA
designations to define labor market
areas for the purposes of the IPF PPS.
Historically, Medicare PPSs have
utilized Metropolitan Area definitions
developed by the OMB. As noted above,
the labor market areas currently used
under the IPF PPS are based on the
Metropolitan Area definitions issued by
the OMB and the OMB reviews its
Metropolitan Area definitions preceding
each decennial census to reflect more
recent population changes. The CBSAs
are OMB’s latest Metropolitan Area
definitions based on the Census 2000
data. Because we believe that the OMB’s
latest Metropolitan Area designations
more accurately reflect the local
economies and wage levels of the areas
in which hospitals are currently located,
we adopted the revised labor market
area designations based on the OMB’s
CBSA designations under the IPPS
effective October 1, 2004. When we
implemented the wage index
adjustment at § 412.424(d)(1)(i) under
the November 2004 IPF PPS final rule
(69 FR 66952 through 66954), we
explained that the IPF PPS wage index
adjustment was intended to reflect the
relative hospital wage levels in the
geographic area of the hospital as
compared to the national average
hospital wage level. The OMB’s CBSA
designations based on Census 2000 data
reflect the most recent available
geographic classifications (Metropolitan
Area definitions). Therefore, we are
revising the labor market area
definitions used under the IPF PPS
based on the OMB’s CBSA designations.
This change ensures that the IPF PPS
wage index adjustment most
appropriately accounts for and reflects
the relative hospital wage levels in the
geographic area of the hospital as
compared to the national average
hospital wage level.
Specifically, we are revising the IPF
PPS labor market definitions based on
the OMB’s new CBSA designations (as
discussed in greater detail below)
effective for IPF PPS discharges
occurring on or after July 1, 2006.
Accordingly, we are revising § 412.402,
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definitions for rural and urban areas.
Effective for discharges occurring on or
after July 1, 2006, ‘‘rural’’ and ‘‘urban’’
areas will be defined in
§ 412.64(b)(1)(ii)(A) through (C). These
definitions are the labor market
definitions based on OMB’s CBSA
designations. For clarity, we are also
revising the regulation text to include
the urban and rural definitions
applicable to discharges occurring
during cost reporting periods beginning
on or after January 1, 2005, but before
July 1, 2006, under § 412.62(f)(1)(ii) and
§ 412.62(f)(1)(iii).
We note that these are the same labor
market area definitions (based on the
OMB’s new CBSA designations)
implemented for acute care hospitals
under the IPPS at § 412.64(b), which
were effective for those hospitals
beginning October 1, 2004 as discussed
in the FY 2005 IPPS final rule (69 FR
49026–49034). The IPF PPS uses the
acute care inpatient hospitals’ wage data
in calculating the IPF PPS wage index.
However, unlike the IPPS, and similar
to other Medicare payment systems (for
example, SNF PPS and IRF PPS), the
IPF PPS uses the pre-floor, prereclassified hospital wage index.
Below, we discuss the composition of
the RY 2007 IPF PPS labor market areas
based on OMB’s new CBSA
designations. It should be noted that
OMB’s new CBSA designations are
comprised of several county-based area
definitions as explained above, which
include Metropolitan Areas,
Micropolitan Areas, and areas ‘‘outside
CBSAs.’’ We implemented the IPF PPS
using two types of labor market areas,
that is, urban and rural. In this final
rule, we are adopting the revised labor
market areas based on OMB’s new
CBSA-based designations. As proposed
in the RY 2007 proposed rule, we will
continue to have 2 types of labor market
areas (urban and rural). In the
discussion that follows, we explain how
we are recognizing Metropolitan Areas,
which include New England MSAs and
Metropolitan Divisions, as urban. We
also explain how we are recognizing
Micropolitan Areas and areas ‘‘outside
CBSAs’’ as rural. As discussed below in
this final rule and as described in the
RY 2007 proposed rule, we describe the
methodology for mapping OMB’s CBSAbased designations into the IPF PPS
(urban area or rural area) format.
i. New England MSAs
As stated above, we currently use
NECMAs to define labor market areas in
New England, because these are countybased designations, rather than the 1990
MSA definitions for New England,
which used minor civil divisions such
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as cities and towns. Under the current
MSA definitions, NECMAs provided
more consistency in labor market
definitions for New England compared
with the rest of the country, where
MSAs are county-based. Under the new
CBSAs, the OMB has now defined the
MSAs and Micropolitan Areas in New
England on the basis of counties. The
OMB also established New England City
and Town Areas, which are similar to
the previous New England MSAs.
In order to create consistency across
all IPF labor market areas, as proposed
and in this final rule, we are using the
county-based areas for all MSAs in the
nation, including those in New England.
The OMB has now defined the New
England area based on counties, creating
a city- and town-based system as an
alternative. We believe that adopting
county-based labor market areas for the
entire country except those in New
England will lead to inconsistencies in
our designations. Adopting countybased labor market areas for the entire
country provides consistency and
stability in Medicare program payment
because all of the labor market areas
throughout the country, including New
England, will be defined using the same
system (that is, counties) rather than
different systems in different areas of
the county, and minimizes
programmatic complexity.
In addition, we have consistently
employed a county-based system for
New England for precisely that reason:
To maintain consistency with the labor
market definitions used throughout the
country. Since we have never used
cities and towns for defining IPF labor
market areas, employing a county-based
system in New England maintains that
consistent practice. We note that this is
consistent with the implementation of
the CBSA-based designations under the
IPPS for New England (69 FR 49028).
Accordingly, for the IPF PPS, we are
using the New England MSAs as
determined under the new CBSA-based
labor market area definitions in defining
the revised IPF PPS labor market areas.
ii. Metropolitan Divisions
Under OMB’s new CBSA
designations, a Metropolitan Division is
a county or group of counties within a
CBSA that contains a core population of
at least 2.5 million, representing an
employment center, plus adjacent
counties associated with the main
county or counties through commuting
ties. A county qualifies as a main county
if 65 percent or more of its employed
residents work within the county and
the ratio of the number of jobs located
in the county to the number of
employed residents is at least 0.75. A
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county qualifies as a secondary county
if 50 percent or more, but less than 65
percent, of its employed residents work
within the county and the ratio of the
number of jobs located in the county to
the number of employed residents is at
least 0.75. After all the main and
secondary counties are identified and
grouped, each additional county that
already has qualified for inclusion in
the MSA falls within the Metropolitan
Division associated with the main/
secondary county or counties with
which the county at issue has the
highest employment interchange
measure. Counties in a Metropolitan
Division must be contiguous (65 FR
82236).
The construct of relatively large MSAs
being comprised of Metropolitan
Divisions is similar to the current
construct of CMSAs comprised of
PMSAs. As noted above, in the past, the
OMB designated CMSAs as
Metropolitan Areas with a population of
1 million or more and comprised of two
or more PMSAs. Under the IPF PPS, we
currently use the PMSAs rather than
CMSAs to define labor market areas
because they comprise a smaller
geographic area with potentially varying
labor costs due to different local
economies. We believe that CMSAs may
be too large of an area with a relatively
large number of hospitals, to accurately
reflect the local labor costs of all of the
individual hospitals included in that
relatively ‘‘large’’ area. A large market
area designation increases the
likelihood of including many hospitals
located in areas with very different labor
market conditions within the same
market area designation. This variation
could increase the difficulty in
calculating a single wage index that will
be relevant for all hospitals within the
market area designation. Similarly, we
believe that MSAs with a population of
2.5 million or greater may be too large
of an area to accurately reflect the local
labor costs of all of the individual
hospitals included in that relatively
‘‘large’’ area. Furthermore, as indicated
above, Metropolitan Divisions represent
the closest approximation to PMSAs,
the building block of the current IPF
PPS labor market area definitions, and
therefore, will most accurately maintain
our current structuring of the IPF PPS
labor market areas. As implemented
under the IPPS (69 FR 49029), we
proposed and for this final rule, we are
using the Metropolitan Divisions where
applicable (as described below) under
the new CBSA-based labor market area
definitions.
In addition to being comparable to the
organization of the labor market areas
under current MSA designations (that
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27063
is, the use of PMSAs rather than
CMSAs), we believe that using
Metropolitan Divisions where
applicable (as described below) under
the IPF PPS will result in a more
accurate adjustment for the variation in
local labor market areas for IPFs.
Specifically, if we recognize the
relatively ‘‘larger’’ CBSA that comprises
two or more Metropolitan Divisions as
an independent labor market area for
purposes of the wage index, it will be
too large and include data from too
many hospitals to compute a wage
index that will accurately reflect the
various local labor costs of all of the
individual hospitals included in that
relatively ‘‘large’’ CBSA. As mentioned
earlier, a large market area designation
increases the likelihood of including
many hospitals located in areas with
very different labor market conditions
within the same market area
designation. This variation could
increase the difficulty in calculating a
single wage index that will be relevant
for all hospitals within the market area
designation. Rather, by recognizing the
Metropolitan Divisions where
applicable (as described below) under
the proposed new CBSA-based labor
market area definitions under the IPF
PPS, we believe that in addition to more
accurately maintaining the current
structuring of the IPF PPS labor market
areas, the local labor costs will be more
accurately reflected, thereby resulting in
a wage index adjustment that better
reflects the variation in the local labor
costs of the local economies of the IPFs
located in these relatively ‘‘smaller’’
areas.
Below we describe where
Metropolitan Divisions will be
applicable under the new CBSA-based
labor market area definitions under the
IPF PPS.
Under OMB’s new CBSA-based
designations, there are 11 MSAs
containing Metropolitan Divisions:
Boston; Chicago; Dallas; Detroit; Los
Angeles; Miami; New York;
Philadelphia; San Francisco; Seattle;
and Washington, D.C. Although these
MSAs were also CMSAs under the prior
definitions, in some cases these areas
have been significantly altered. Under
the current IPF PPS MSA designations,
Boston is a single NECMA. Under the
CBSA-based labor market area
designations, it is comprised of four
Metropolitan Divisions. Los Angeles
will go from four PMSAs under the
current IPF PPS MSA designations to
two Metropolitan Divisions under the
CBSA-based labor market area
designations because two MSAs became
separate MSAs. The New York CMSA
will go from 15 PMSAs under the
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current IPF PPS MSA designations to
only four Metropolitan Divisions under
the CBSA-based labor market area
designations. The five PMSAs in
Connecticut under the current IPF PPS
MSA designations will become separate
MSAs under the CBSA-based labor
market area designations, and the
number of PMSAs in New Jersey under
the current IPF PPS MSA designations
will go from five to two, with the
consolidation of two New Jersey PMSAs
(Bergen-Passaic and Jersey City) into the
New York-Wayne-White Plains, NY–NJ
Division, under the CBSA-based labor
market area designations. In San
Francisco, under the CBSA-based labor
market area designations, there are only
two Metropolitan Divisions. Currently,
there are six PMSAs, some of which are
now separate MSAs under the current
IPF PPS labor market area designations.
Under the current IPF PPS labor
market area designations, Cincinnati,
Cleveland, Denver, Houston,
Milwaukee, Portland, Sacramento, and
San Juan are all designated as CMSAs,
but will no longer be designated as
CMSAs under the CBSA-based labor
market area designations. As noted
previously, the population threshold to
be designated as a CMSA under the
current IPF PPS labor market area
designations is 1 million. In most of
these cases, counties currently in a
PMSA under the current IPF PPS labor
market area designations will become
separate, independent MSAs under the
CBSA-based labor market area
designations.
We note that subsequent to the
publication of the RY 2007 IPF PPS
proposed rule, titles to certain CBSAs
were changed based on OMB Bulletin
No. 06–01 (December 2005). The title
changes listed below are nomenclatures
that do not result in substantive changes
to the CBSA-based designations. Thus,
these changes are listed below and will
be incorporated into the FY 2007 CBSAbased urban wage index tables.
• CBSA 26900: Indianapolis-Carmel,
IN
• CBSA 42680: Sebastian-Vero Beach,
FL
• CBSA 19780: Des Moines-West Des
Moines, IA
• CBSA 47644: Warren-TroyFarmington Hills, MI
• CBSA 31140: Louisville-Jefferson
County, KY–IN
iii. Micropolitan Areas
Under OMB’s new CBSA-based
designations, Micropolitan Areas are
essentially a third area definition
consisting primarily of currently rural
areas, but also include some or all of
areas that are currently designated as an
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urban MSA. As discussed in greater
detail in the FY 2005 IPPS final rule (69
FR 49029 through 49032), how these
areas are treated will have significant
impacts on the calculation and
application of the wage index.
Specifically, whether or not
Micropolitan Areas are included as part
of the respective statewide rural wage
indices will impact the value of
statewide rural wage index of any State
that contains a Micropolitan Area
because a hospital’s classification as
urban or rural affects which hospitals’
wage data are included in the statewide
rural wage index. We combine all of the
counties in a State outside a designated
urban area together to calculate the
statewide rural wage index for each
State.
Including Micropolitan Areas as part
of the statewide rural labor market area
would result in an increase to the
statewide rural wage index because
hospitals located in those Micropolitan
Areas typically have higher labor costs
than other rural hospitals in the State.
Alternatively, if Micropolitan Areas
were to be recognized as independent
labor market areas, because there would
be so few hospitals in each labor market
area, the wage indices for IPFs in those
areas could become relatively unstable
as they might change considerably from
year to year.
We currently use MSAs to define
urban labor market areas and group all
the hospitals in counties within each
State that are not assigned to an MSA
together into a statewide rural labor
market area. We have used the terms
‘‘urban’’ and ‘‘rural’’ wage indexes in
the past for ease of reference. However,
the introduction of Micropolitan Areas
by the OMB potentially complicates this
terminology because these areas include
many hospitals that are currently
included in the statewide rural labor
market areas.
We proposed to treat Micropolitan
Areas as rural labor market areas under
the IPF PPS for the reasons outlined
below. That is, counties that are
assigned to a Micropolitan Area under
the CBSA-based designations would be
treated the same as other ‘‘rural’’
counties that are not assigned to either
an MSA (Metropolitan Statistical Area)
or a Micropolitan Area. Therefore, in
determining an IPF’s applicable wage
index (based on IPPS hospital wage
index data), an IPF in a Micropolitan
Area under OMB’s CBSA-based
designations would be classified as
‘‘rural’’ and would be assigned the
statewide rural wage index for the State
in which it resides.
In the FY 2005 IPPS final rule (69 FR
49029 through 49032), we discuss our
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evaluation of the impact of treating
Micropolitan Areas as part of the
statewide rural labor market area
instead of treating Micropolitan Areas as
independent labor market areas for
hospitals paid under the IPPS. As
discussed in that same final rule, one of
the reasons Micropolitan Areas have
such a dramatic impact on the wage
index is because Micropolitan Areas
encompass smaller populations than
MSAs. In addition, they tend to include
fewer hospitals per Micropolitan Area.
Currently, there are only 25 MSAs with
one hospital in the MSA. However,
under the new CBSA-based definitions,
there are 373 Micropolitan Areas with
one hospital, and 49 MSAs with only
one hospital.
Since Micropolitan Areas encompass
smaller populations than MSAs, they
tend to include fewer hospitals per
Micropolitan Area, recognizing
Micropolitan Areas as independent
labor market areas will generally
increase the potential for dramatic shifts
in those areas’ wage indices from 1 year
to the next because a single hospital (or
group of hospitals) could have a
disproportionate effect on the wage
index of the area. The large number of
labor market areas with only one
hospital and the increased potential for
dramatic shifts in the wage indexes from
1 year to the next is a problem for
several reasons. First, it creates
instability in the wage index from year
to year for a large number of hospitals.
Second, it reduces the averaging effect
(averaging effect allows for more data
points to be used to calculate a
representative standard of measured
labor costs within a market area.)
lessening some of the incentive for
hospitals to operate efficiently. This
incentive is inherent in a system based
on the average hourly wages for a large
number of hospitals, as hospitals could
profit more by operating below that
average. In labor market areas with a
single hospital, high wage costs are
passed directly into the wage index with
no counterbalancing averaging with
lower wages paid at nearby competing
hospitals. Third, it creates an arguably
inequitable system when so many
hospitals have wage indexes based
solely on their own wages, while other
hospitals’ wage indexes are based on an
average hourly wage across many
hospitals.
For the reasons noted above, and
consistent with the treatment of these
areas under the IPPS, as proposed and
consist with this final rule, we are not
adopting Micropolitan Areas as
independent labor market areas under
the IPF PPS. Under the CBSA-based
labor market area definitions,
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Micropolitan Areas are considered a
part of the statewide rural labor market
area. Accordingly, we will determine an
IPF PPS statewide rural wage index
using the acute-care IPPS hospital wage
data from hospitals located in non-MSA
areas (for example, rural areas,
including Micropolitan Areas) and that
statewide rural wage index will be
assigned to IPFs located in those nonMSA areas.
e. Implementation of the Revised Labor
Market Areas Under the IPF PPS
Section 124 of the BBRA is broadly
written and gives the Secretary
discretion in developing and making
adjustments to the IPF PPS.
When the revised labor market areas
based on the OMB’s new CBSA-based
designations were adopted under the
acute care hospital IPPS beginning on
October 1, 2004, a transition to the new
labor market area designations was
established due to the scope and
substantial implications of these new
boundaries and to buffer the subsequent
significant impacts it may have on
payments to numerous hospitals. As
discussed in the FY 2005 IPPS final rule
(69 FR 49032), during FY 2005, a blend
of wage indexes is calculated for those
acute care IPPS hospitals experiencing a
drop in their wage indexes because of
the adoption of the new labor market
areas.
While we recognize that, just like
IPPS hospitals, some IPFs may
experience decreases in their wage
index as a result of the labor market area
changes, our analysis shows that a
majority of IPFs either expect no change
in wage index or an increase in wage
index based on CBSA definitions. In
addition, a very small number of IPFs
(fewer than 3 percent) will experience a
decline of 5 percent or more in the wage
index based on CBSA designations. We
also found that a very small number of
IPFs (approximately 5 percent) will
experience a change in either rural or
urban designation under the CBSAbased definitions. Since a majority of
IPFs will not be significantly impacted
by the labor market areas, we believe it
is not necessary for a transition to the
new CBSA-based labor market area for
the purposes of the IPF PPS wage index.
We received several comments on our
proposed changes for implementing the
area wage adjustments. Public
comments and our responses on the
proposed changes for implementing the
area wage adjustments are summarized
below:
Comment: Several commenters
requested that CMS provide a transition
period to phase in the CBSA-based labor
market definitions. One commenter
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requested that IPFs should be allowed to
choose whether or not they wanted a
phase-in of the CBSA wage indices.
Response: For cost reporting periods
beginning in 2006, IPFs are paid based
on a blend of 50 percent reasonable cost
payments and 50 percent PPS payments.
The wage index adjustment is being
phased in on the PPS portion of the
payment. Since we are already in the
middle of a transition to a full wageindex adjustment under the IPF PPS, we
believe that the effects on the IPF PPS
wage index from the changes to the IPF
PPS labor market areas definitions will
be mitigated. Specifically, most IPFs
will be in their FY 2006 cost reporting
period and therefore will be in the
second year of the 3-year phase-in of the
IPF PPS wage index adjustment when
the revised labor market area
designations will be applied. During the
second year of the transition to the IPF
PPS, the applicable wage index value is
one-half (50 percent) of the applicable
full IPF PPS wage index adjustment.
Since most IPFs will be in the second
year of the 3-year phase-in of the wage
index adjustment, for most IPFs, the
labor-related portion of the Federal rate
is only adjusted by 50 percent of the
applicable full wage index (that is, onehalf wage index value). As noted above,
the IPF PPS wage index adjustment is
made by multiplying the labor-related
share of the IPF PPS Federal per diem
base rate (75.66 percent) by the
applicable wage index value.
Consequently, for most IPFs, only
approximately 38 percent of the Federal
per diem base rate is affected by the
wage index adjustment (75.665 percent
× 0.50 = 37.8325 percent), and the
revision to the labor market area
definitions based on OMB’s new CBSAbased designations will only have a
minimal impact on IPF PPS payments.
For the reasons discussed above, and
also addressed in the RY 2007 proposed
rule (71 FR 3633), we are not providing
a transition under the IPF PPS from the
current MSA-based labor market areas
designations to the new CBSA-based
labor market area designations. Rather,
we are adopting the current CBSA-based
labor market area definitions beginning
July 1, 2006 without a transition period.
Comment: Several commenters do not
believe that because the IPF PPS is in
the second year of the transition blend,
the effects of the wage index changes
would be mitigated. The commenters
stated that similar wage transitions have
been applied in HHA and IRF, and
therefore inconsistencies exist between
payment systems.
Response: We do not believe a need
exists to implement a separate transition
for the wage index changes. We
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acknowledge that similar wage
transitions exist in other PPSs.
However, unlike the IPF PPS, in those
instances, the payment systems were
not already in a transition period (as
described above).
Comment: Several commenters agreed
with CMS’s approach to wait 1 full year
until IPF PPS claims and cost report
data could be analyzed before changing
the wage index definitions. Other
commenters indicated that if CMS were
to implement this change now, it would
be inconsistent with the approach to
wait a year before analyzing IPF PPS
data.
The same commenters expressed
concern that if CMS changes urban and
rural classifications without any
recourse (such as the Medicare
Geographic Classification Review Board
(MGCRB)) when CMS analyzes the PPS
data and compares urban and rural IPFs,
rural IPF data under MSA definitions
would not be comparable to rural IPF
data under CBSA definitions.
Response: In the November 2004 IPF
PPS rule, we stated that we would use
the best available hospital wage index
data, and that we would propose any
changes to the wage index in a proposed
rule. We note that all of the other PPSs
have adopted, or begun to adopt, the
CBSA definitions. Consistent with other
Medicare PPSs, and in order to utilize
the best available data, as we indicated
we would do, the IPF PPS will adopt the
CBSA definitions. We want to ensure
that the IPF PPS wage index adjustment
most appropriately accounts for and
reflects the relative hospital wage levels
in the geographic area of the hospital as
compared to the national average
hospital wage level, and we believe that
OMB’s CBSA designations based on
Census 2000 data reflect the most recent
available geographic classifications.
With respect to the last comment, the
meaning is not completely clear. If the
commenters are concerned that changes
to the area wage definitions will limit
our ability to analyze the impact of the
IPF PPS, CMS does not believe this is
an issue. When we analyze the first year
of IPF PPS claims and cost report data,
the urban and rural designations will be
under MSA definitions. We are now
adopting the latest OMB definitions of
urban and rural under CBSAs and we
will view rural IPFs under these
definitions. Finally, we want to note
that, since the IPF PPS Provider Specific
File is cumulative, CMS will have a
record of which IPFs changed
designations.
Comment: One commenter expressed
support for the proposed change to the
CBSA-based labor market definitions.
The commenter believes that the CBSAs
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provide an accurate measure of the labor
market areas in the United States.
Response: We agree with the
commenter that the CBSAs represent the
best available wage data.
Comment: The IPPS adopted a holdharmless policy and an ‘‘out-commuting
adjustment.’’ Several commenters
believe that since the majority of IPFs
are distinct part units, there is an
inconsistency when the acute care
hospitals are paid the out-commuting or
out-migration adjustment and the IPFs
are not paid the adjustment. The
commenters stated that CMS should
assume that IPF employees follow the
same commuting patterns as those who
work in the acute care hospital.
In addition, the commenters indicated
that distinct part units would be at a
disadvantage in recruiting and retaining
workers for the IPF unless CMS adopted
an out-commuting or out-migration
adjustment.
Response: We are not providing a
hold harmless policy or an ‘‘outcommuting’’ adjustment under the IPF
PPS from the current MSA-based labor
market areas designations to the new
CBSA-based labor market area
designations. Nor do we believe that we
are required to provide an outcommuting adjustment. We note that
section 505 of the MMA established
new section 1886(d)(13) of the Act.
Section 1886(d)(13) of the Act requires
that the Secretary establish a process to
make adjustments to the hospital wage
index based on commuting patterns of
hospital employees. We believe that this
requirement for an ‘‘out-commuting’’ or
‘‘out-migration’’ adjustment applies
specifically to the IPPS and not to other
PPS. Therefore, consistent with other
PPS (for example, IRF and LTCH PPS),
we did not propose out-commuting or
out-migration adjustment under the IPF
PPS, nor are we establishing such an
adjustment under the IPF PPS in this
final rule.
We believe that our decisions not to
adopt a transition or an out-commuting
adjustment are appropriate for IPFs
because, despite some similarities
between the IPF PPS and the IPPS, there
are clear distinctions between the
payment systems, particularly regarding
wage index issues.
For example, a wage index adjustment
has been a stable feature of the acute
care hospital IPPS since its 1983
implementation and the IPPS had
utilized the prior MSA-based labor
market area designation for over 10
years. The IPF PPS has only been
implemented since January 1, 2005.
The most significant distinction
between acute care hospitals under the
IPPS and IPFs is that acute care
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hospitals have been paid using full wage
index adjusted payments since 1983 and
had used the previous IPPS MSA-based
labor market area designations for over
10 years, whereas under the IPF PPS, a
wage index adjustment is being phasedin over a 3-year period. As previously
explained, the impact that the wage
index can have on IPF PPS payments is
limited at this point, since only a small
percentage of the IPF PPS Federal per
diem base rate is affected by the wage
index (approximately 38 percent in
most cases) because of the 3-year phasein of the wage index adjustment.
In contrast, a transition policy to the
revised IPPS labor market area
definitions under the IPPS was
appropriate because there is no phasein of a wage index adjustment under the
IPPS and the full labor-related share of
the IPPS standardized amount (that is,
Federal rate) is affected by the IPPS
wage index adjustment, which resulted
in a more significant projected impact
for acute care hospitals under the IPPS.
Comment: Several commenters
indicated that IPFs that are distinct part
units should be allowed to be
reclassified to the same geographic area
as the acute care hospital. The
commenters also stated that wage issues
between acute care hospitals and IPFs
are similar, and that it is not logical for
IPFs that are distinct part units to
receive a different area wage index
value than the acute care hospital.
Commenters requested that CMS
implement a rural floor like that of IPPS.
Response: As stated above, the IPF
PPS wage index is calculated using IPPS
wage index data on the basis of the labor
market area in which the IPF is located,
without taking into account geographic
reclassification under sections
1886(d)(8) and (d)(10) of the Act and
without applying the ‘‘rural floor’’
established under section 4410 of the
BBA. We believe that the actual location
of an IPF (as opposed to the location of
affiliated providers) is most appropriate
for determining the wage adjustment
because the prevailing wages in the area
in which the IPF is located influence the
cost of a case. In addition, we are using
the latest OMB labor market area
definitions based on 2000 Census data.
Since these data are more recent than
the data used for the wage index in the
IPF PPS implementation year (2000
versus 1993 data), we do not see a need
for a reclassification policy. Finally, as
discussed above, by recognizing the
Metropolitan Divisions where
applicable under the new CBSA-based
labor market area definitions under the
IPF PPS, we believe that the local labor
costs will be more accurately reflected,
thereby resulting in a wage index
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adjustment that better reflects the
variation in the local labor costs of the
local economies of the IPFs located in
these relatively ‘‘smaller’’ areas when
compared with CMSAs.
Although some commenters request
CMS to develop a ‘‘rural floor’’ like the
IPPS, we believe the ‘‘rural floor’’ is
required only for the acute care hospital
payment system because, as stated in
section VI.B.2, section 4410 of the
Balanced Budget Act of 1997 (Pub. L.
105–33) applies specifically to acute
care hospitals and not excluded
hospitals and excluded units. We
believe that the ‘‘pre-reclassification and
pre-floor’’ wage data is the best proxy
and most appropriate wage index for
IPFs.
Comment: Many commenters
expressed concern regarding those IPFs
who would lose the rural adjustment if
they are redefined as urban under the
CBSA-based labor market definitions.
Specifically, the commenters stated that
IPFs’ reimbursement would decrease
over the next several years due to the
wage index changes. The commenters
also indicated that the loss of the rural
adjustment would increase the financial
vulnerability of IPFs that are necessary
to provide continued access to care in
previously rural areas. As a result, the
commenters requested that CMS
provide a grandfathering provision to
allow IPFs to continue to receive the
rural adjustment or a hold harmless
provision that would prevent payments
from dropping below what the IPF
would have received had they remained
designated as a rural IPF.
Response: We are finalizing our
proposal to transition IPFs to CBSAbased labor market definitions. We
recognize that IPFs that were previously
considered rural will lose the 17 percent
rural facility-level adjustment when
they are redesignated as urban.
However, as discussed above, since we
are currently in the middle of a
transition period from reasonable-cost
based payments to PPS payments, the
effects of changing to CBSA-based
definitions are mitigated, since
currently the wage index affects
approximately 38 percent of an IPF’s
payment, and the rural adjustment
affects 50 percent of an IPF’s payment.
In addition, the IPF PPS has a stoploss policy in place to protect IPFs that
receive less than 70 percent of what
they would have received under
TEFRA. In general, the group of
providers that stands to lose the rural
adjustment did well under TERFA, and
the purpose of the transition from
TERFA to PPS is to allow IPFs to control
and reduce their costs.
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As discussed in the August 11, 2004
IPPS final rule (69 FR 49032), during FY
2005, a hold harmless policy was
implemented to minimize the overall
impact of hospitals that were designated
in FY 2004 as urban under the MSA
designations, but would become rural
under the CBSA designations. In the
same final rule, hospitals were afforded
a 3-year hold harmless policy because
the IPPS determined that acute-care
hospitals that changed designations
from urban to rural would be
substantially impacted by the significant
change in wage index. Currently, under
the IPF PPS, urban facilities that become
rural would receive the rural facility
adjustment (that is, 17 percent). As
discussed in section VI.C.2 of this final
rule, we are adopting the 17 percent
rural adjustment. The rural facility
adjustment will be applied in the same
way to urban facilities that will become
rural under the CBSA-based definitions.
Thus, we believe that the impact of the
wage index changes on any urban
facilities that become rural under the
new definitions will be mitigated by the
rural adjustment. Finally, as discussed
above, the IPF PPS has a stop-loss
policy in effect during the transition
from TEFRA to PPS payments.
Therefore, we do not believe it is
appropriate or necessary to adopt a hold
harmless policy for facilities that would
experience a change in designation
under the CBSA-based definitions.
We note that for the CBSA
designations, we identified some
geographic areas where there were no
hospitals, and thus no hospital wage
index data on which to base the
calculation of the RY 2007 IPF PPS
wage index. In addressing this situation,
we proposed approaches that we believe
would serve as proxies for hospital wage
data and provide an appropriate
standard that accounts for geographic
variation in labor costs.
The first situation involves rural
locations in Massachusetts and Puerto
Rico. We have determined that there are
no rural hospitals in those locations.
Since there is no reasonable proxy for
more recent rural data within those
areas, we are using last year’s wage
index value for rural Massachusetts and
rural Puerto Rico. This approach is
consistent with other Medicare PPSs
(for example, SNF PPS and IRF PPS).
The second situation has to do with
the urban area of Hinesville, GA (CBSA
25980). Under the new labor market
areas there are no urban hospitals
within this area. Therefore, we are using
the urban areas within the State to serve
as a reasonable proxy for the urban areas
without specific hospital wage index
data in determining the IPF PPS wage
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index. In this final rule, we are
calculating the urban wage index value
for purposes of the wage index for these
areas without urban hospital data as the
average wage index for all urban areas
within the State. This approach is
consistent with other Medicare PPSs
(for example, SNF PPS and IRF PPS).
We could not apply a similar
averaging in rural areas because in the
rural areas there are no State rural
hospital wage data available for
averaging on a State-wide basis. We did
not receive comments on these
approaches for calculating the wage
index values for areas without hospitals
for RY 2007 and subsequent years. We
are adopting the proposed approach in
this final rule.
To facilitate an understanding of the
policies related to the changes to the IPF
PPS labor market areas discussed above,
in the MSA/CBSA Crosswalk included
as Addendum B of this final rule, we are
providing a listing of each Social
Security Administration (SSA) State and
county location code; State and county
name; existing MSA-based labor market
area designation; MSA-based wage
index value; CBSA-based labor market
area; and the new CBSA-based wage
index value. We are also providing in
Addenda C the wage index for urban
and rural areas based on CBSA labor
market areas.
Final Rule Action: In summary, we
are finalizing our proposal to adopt the
CBSA labor market area definitions
without a transition, without a holdharmless policy, and without an outcommuting or out-migration adjustment.
f. Wage Index Budget Neutrality
Any adjustment or update to the IPF
wage index will be made in a budget
neutral manner that assures that the
estimated aggregated payments under
this subsection in the RY beginning July
1, 2006 are not greater or less than those
that would have been made in the year
without such an adjustment. Therefore,
as proposed and in this final rule, we
calculate a budget-neutral wage index
adjustment factor using the following
steps:
Steps 1: Determine the total amount of
the estimated IPF PPS payments for the
implementation year using the laborrelated share and wage indices from FY
2005 (based on MSAs).
Step 2: Calculate the total amount of
estimated IPF PPS payments for RY
2007 using the labor-related share and
wage indices from FY 2006 (based on
CBSAs).
Step 3: Divide the amount calculated
in Step 1 by the amount calculated in
Step 2 which yields a RY 2007 budgetneutral wage adjustment of 1.0042.
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This factor is applied in the update of
the Federal per diem base rate for RY
2007.
2. Adjustment for Rural Location
In the November 2004 IPF PPS final
rule, we provided a 17 percent payment
adjustment for IPFs located in a rural
area. This adjustment was based on the
regression analysis which indicated that
the per diem cost of rural facilities was
17 percent higher than that of urban
facilities after accounting for the
influence of the other variables included
in the regression. Many rural IPFs are
small psychiatric units within small
general acute care hospitals. We also
stated in the November 2004 IPF PPS
final rule that small-scale facilities are
more costly on a per diem basis because
there are minimum levels of fixed costs
that cannot be avoided, and they do not
have the economies of size advantage.
Based on the results of our regression
analysis, we provided a payment
adjustment for IPFs located in rural
areas of 17 percent. In this final rule, we
are not changing this adjustment factor.
In addition, we stated in the November
2004 IPF PPS final rule that we do not
plan to conduct another regression
analysis until we analyze IPF PPS data.
At that time, we can compare rural and
urban IPFs to determine how much
more costly rural facilities are on a per
diem basis under the IPF PPS. In the
meantime, we are applying a 17 percent
payment adjustment for IPFs located in
a rural area as defined at
§ 412.64(b)(1)(ii)(C).
Final Rule Action: In summary, we
are adopting the 17 percent rural
adjustment currently in effect for RY
2007.
3. Teaching Adjustment
In the November 2004 IPF PPS final
rule, we established a facility-level
adjustment for IPFs that are, or are part
of, teaching institutions. The teaching
status adjustment accounts for the
higher indirect operating costs
experienced by facilities that participate
in graduate medical education (GME)
programs. We have received numerous
requests for clarification of the IPF PPS
teaching adjustment, especially with
regard to comparisons with the IPPS
IME adjustment that were included in
the November 2004 IPF PPS final rule.
As a result, we are including an
expanded explanation of the IPF PPS
teaching status adjustment and are
clarifying the changes to
§ 412.424(d)(1)(iii) regarding the
teaching adjustment.
Medicare makes direct GME payments
(for direct costs such as resident and
teaching physician salaries, and other
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direct teaching costs) to all teaching
hospitals including those paid under the
IPPS, and those that were once paid
under the TEFRA rate-of-increase limits
but are now paid under other PPSs.
These direct GME payments are made
separately from payments for hospital
operating costs and are not part of the
PPSs. However, the direct GME
payments do not address the higher
indirect operating costs experienced by
teaching hospitals. For teaching
hospitals paid under the TEFRA rate-ofincrease limits, Medicare did not make
separate medical education payments
because payments to these hospitals
were based on the hospitals’ reasonable
costs. Since payments under TEFRA
were based on hospitals’ reasonable
costs, the higher indirect costs that
might be associated with teaching
programs would automatically have
been factored into the TEFRA payments.
As previously mentioned, we
conducted regression analysis of FY
2002 IPF data as the basis for the
payment adjustments included in the
November 2004 IPF PPS final rule. In
conducting the analysis, we used the
resident counts reported on hospital
cost reports (worksheet S–3, Part 1, line
12, column 7 for freestanding
psychiatric hospitals and worksheet S–
3, Part 1, line 14 (or line 14.01 for
subprovider 2), column 7 for psychiatric
units of acute care hospitals). That is,
for the freestanding psychiatric
hospitals, we used the number of
residents and interns reported for the
entire hospital. For the psychiatric units
of acute care hospitals, we used the
number of residents and interns
reported for the psychiatric unit, which
are reported separately on the cost
report from the number reported for the
rest of the hospital.
The regression analysis (with the
logarithm of costs as the dependent
variable) showed that the indirect
teaching cost variable is significant in
explaining the higher costs of IPFs that
have teaching programs. We calculated
the teaching adjustment based on the
IPF’s ‘‘teaching variable,’’ which is one
plus the ratio of the number of full-time
equivalent (FTE) residents training in
the IPF (subject to limitations described
below) to the IPF’s average daily census
(ADC).
In the cost regressions conducted for
the November 2004 IPF PPS final rule,
the logarithm of the teaching variable
had a coefficient value of 0.5150. We
converted this cost effect to a teaching
payment adjustment by treating the
regression coefficient as an exponent
and raising the teaching variable to a
power equal to the coefficient value. In
other words, the teaching adjustment is
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calculated by raising the teaching
variable (1 + FTE residents/ADC) to the
0.5150 power. To compute the
percentage increase in the IPF PPS
payment attributable to the teaching
adjustment (that is, the amount to be
reconciled at cost report settlement),
raise the teaching variable (1 + FTE
residents/ADC) to the 0.5150 power. For
example, for an IPF with a teaching
variable of 0.10 and using a coefficient
value of 0.5150, the per diem payment
would increase by 5.03 percent; for an
IPF with a teaching variable of 0.05, the
per diem payment would increase by
2.54 percent. We note that the
coefficient value of 0.5150 was based on
regression analysis holding all other
components of the payment system
constant.
In addition, we established the
teaching adjustment in a manner that
limited the incentives for IPFs to add
FTE residents for the purpose of
increasing their teaching adjustment.
We imposed a cap on the number of
FTE residents that may be counted for
purposes of calculating the teaching
adjustment, similar to that established
by sections 4621 (IME FTE cap for IPPS
hospitals) and 4623 (direct GME FTE
cap for all hospitals) of the BBA. We
emphasize that the cap limits the
number of FTE residents that teaching
IPFs may count for the purposes of
calculating the IPF PPS teaching
adjustment, not the number of residents
teaching institutions can hire or train.
The FTE resident cap is applied the
same way in freestanding teaching
psychiatric hospitals and in distinct part
psychiatric units with GME programs.
Similar to the regulations for counting
FTE residents under the IPPS as
described in § 412.105(f), we calculated
the number of FTE residents that trained
in the IPF during a ‘‘base year’’ and use
that FTE resident number as the cap. An
IPF’s FTE resident cap would ultimately
be determined based on the final
settlement of the IPF’s most recent cost
report filed before November 15, 2004
(that is, the publication date of the IPF
PPS final rule).
Similar to teaching hospitals under
the IPPS, IPFs that first begin training
residents after November 15, 2004
initially receive an FTE cap of ‘‘0’’. The
FTE caps for teaching IPFs (whether
they are new or existing IPFs) that start
training residents in a new GME
program may be subsequently adjusted
in accordance with the IPPS policies
described in § 412.105(f)(1)(vii) and
GME policies described in
§ 413.79(e)(1)(i) and (ii). For purposes of
the teaching status adjustment for IPFs,
a new graduate medical education
program means a medical education
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program that receives initial
accreditation by the appropriate
accrediting body or begins training
residents on or after November 15, 2004.
However, contrary to the policy for IME
FTE resident caps under the IPPS, we
do not allow IPFs to aggregate the FTE
resident caps used to compute the IPF
PPS teaching adjustment through
affiliation agreements. We included
these policies because we believe it is
important to limit the total pool of
resident FTE cap positions within the
IPF community and avoid incentives for
IPFs to add FTE residents in order to
increase their payments.
Residents with less than full-time
status and residents rotating through the
psychiatric hospital or unit for less than
the entire cost reporting period are
counted in proportion to the time they
spend in their assignment with the IPF.
For example, a 3-month rotation by a
full-time resident to the IPF during a 12month cost reporting period will be
counted as 0.25 FTE for purposes of
counting residents to calculate the ratio.
No FTE resident time counted for
purposes of the IPPS IME adjustment is
permitted to be counted for purposes of
the teaching status adjustment for the
IPF PPS.
As noted previously, the denominator
used to calculate the teaching
adjustment under the IPF PPS is the
IPF’s ADC from the current cost
reporting period. We chose to use the
ADC because it is closely related to the
IPF’s patient load, which affects the
number of interns and residents the IPF
can train. We also believe the ADC is a
measure that can be defined precisely
and is difficult to manipulate. Although
the IPPS IME adjustment uses the
hospital’s number of beds as the
denominator, the capital PPS (as
specified at § 412.322) and the IRF PPS
(as specified at § 412.624(e)(4) both use
the ADC as the denominator for the
indirect medical education and teaching
adjustments, respectively.
If a psychiatric hospital’s or unit’s
FTE count of residents in a given year
is higher than the FTE count in the base
year (the base year being used to
establish the cap), we base payments in
that year on the lower number (the cap
amount). This approach is consistent
with the IME adjustment under the IPPS
and the teaching adjustment under the
IRF PPS. The IPF remains free to add
FTE residents above the cap amount,
but it cannot count the number of FTE
residents above the cap for purposes of
calculating the teaching adjustment.
This means that the cap serves as an
upper limit on the number of FTE
residents that may be counted for
purposes of calculating the teaching
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status adjustment. IPFs can adjust their
number of FTE residents counted for
purposes of calculating the teaching
adjustment as long as they remain under
the cap. On the other hand, if a
psychiatric hospital or unit were to have
fewer FTE residents in a given year than
in the base year (that is, fewer residents
than its FTE resident cap), teaching
adjustment payments in that year would
be based on the lower number (that is,
the current year’s FTE count of
resident).
In response to inquiries about how the
teaching adjustment is applied under
the IPF PPS, we proposed to add a new
paragraph § 412.424(d)(1)(iii)(E) to
clarify that the teaching adjustment is
made on a claim basis as an interim
payment and the final payment for the
claim would be made in full during the
final settlement of the cost report. The
difference between those interim
payments and the actual teaching
adjustment amount computed in the
cost report would be adjusted through
lump sum payments/recoupments when
the cost report is filed and later settled.
As noted in section VI.D.1.a of this
final rule, in reviewing the methodology
used to simulate the IPF PPS payments
used for the November 2004 IPF PPS
final rule, we discovered that the
computer code incorrectly assigned
non-teaching status to most teaching
facilities. As a result, total IPF PPS
payments were underestimated by about
1.36 percent. To resolve the issue, as
discussed in section V.B.3 of this final
rule, we are amending the Federal per
diem base rate prospectively for all IPFs.
As with other adjustment factors
derived through the regression analysis,
we do not plan to rerun the regression
analysis until we analyze IPF PPS data.
Until then, as proposed, we are
retaining the 0.5150 teaching
adjustment to the Federal per diem base
rate.
Public comments and our responses
on the proposed changes for
implementing the teaching adjustment
are summarized below:
Comment: A commenter stated that
the use of ‘‘final settled’’ cost reports
may allow hospitals to report accurate
counts during the audit process.
However, the commenter indicated that
if this is not correct, or if certain
hospitals’ 2004 cost reports have already
gone through final settlement, CMS
should take action to ensure that
accurate resident counts for purposes of
determining the IPF teaching
adjustment resident cap.
The commenter indicated that for the
regression analysis, CMS used the
resident count reported on Worksheet
S–3, Part 1, lines 14 and 14.01, column
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7 for psychiatric units of acute care
hospitals. The commenter expressed
concern regarding the data used for the
regression analysis due to the ambiguity
of the cost reporting instructions. The
commenter believes that this count may
not accurately reflect the resident count
in the hospital’s psychiatric unit.
Specifically, since the cost reporting
instructions state that one should ‘‘enter
the number of interns and full time
equivalents in an approved program
determined in accordance with 42 CFR
412.105(g) for the indirect medical
education adjustment.’’ The commenter
further stated that for cost reports before
November 15, 2004, psychiatric unit
resident counts were not eligible to be
counted for purposes of the acute
inpatient IME adjustment.
Response: As explained in the
November 2004 IPF PPS final rule and
the RY 2007 proposed rule, similar to
the regulations for counting FTE
residents under the IPPS as described in
§ 412.105(f), we calculate the number of
FTE residents that trained in the IPF
during a ‘‘base year’’ and use that FTE
resident number as the cap. An IPF’s
FTE resident cap would ultimately be
determined based on the final
settlement of the IPF’s most recent cost
report filed before November 15, 2004.
Although we are concerned about the
accuracy of the information reported in
the cost report, including the number of
FTE residents reported on Wkst. S–3,
Part 1, Column 7, it is, foremost, the
hospital’s responsibility to report this
data accurately. An official of the
hospital certifies that the information on
all the worksheets in the cost report is
correct to the best of his or her
knowledge and belief.
Although the instructions for Column
7 of Wkst. S–3, Part I contain an
outdated reference to § 412.105(g) (that
is, this reference was changed in the
Code of Federal Regulations to
§ 412.105(f) in 1997 but the Wkst. S–3,
Part I instructions were not updated
accordingly), these instructions specify
that the FTE resident count to be
reported in Column 7 is determined in
accordance with the policies for IME
adjustment. We do not believe the
redesignation of the relevant regulation
should have caused confusion.
If the hospitals believe that the FTE
resident counts on the base year cost
report are incorrect, they have an option
of submitting an amended cost report or
requesting a reopening.
Comment: One commenter indicated
a discrepancy between the reference to
the regulation regarding the base period
for determining the IPF’s FTE resident
in the RY 2007 IPF PPS proposed rule
(71 FR 3653) and the reference to that
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27069
regulation in the current Code of
Federal Regulations (CFR). The
commenter stated that the RY 2007 IPF
PPS proposed rule cited
§ 412.424(d)(1)(iii)(C) as the relevant
regulation, while the current CFR
reference can be found at
§ 412.424(d)(1)(iii)(B)(1).
Response: The existing regulation at
§ 412.424(d)(1)(iii)(C) implements the
FTE resident cap for purposes of the IPF
teaching status adjustment. The FTE
resident cap is established in the base
period as specified in the November
2004 IPF PPS final rule (69 FR 66979),
and codified in regulations at
§ 412.424(d)(1)(iii)(B)(1). The reference
in the RY 2007 IPF PPS proposed rule
(71 FR 3653) reflects the proposal to
redesignate portions of the reference to
the teaching status adjustment. In this
final rule, we will finalize the reference
(and all other changes as proposed) to
the base period to be
§ 412.424(d)(1)(iii)(C) and will replace
§ 412.424(d)(1)(iii)(B)(1) currently in the
CFR.
Comment: One commenter requested
clarification about application of the
FTE resident cap for those IPFs that
begin training residents after November
15, 2004.
Response: As we indicated in the RY
2007 proposed rule, IPFs that did not
train interns and residents during the
time period of the IPF’s most recent cost
report filed before November 15, 2005
would receive an FTE cap of ‘‘zero’’. As
a result, we would not apply a teaching
adjustment to claims submitted by the
IPF. However, if the IPF (whether it is
new or existing) begins training
residents in a new medical residency
training program after that date, the IPF
will begin to receive the teaching
adjustment under the IPF PPS in the
next cost reporting period based on the
FTE intern and resident count in
accordance with the policies applicable
under the IPPS.
In this case, the FTE resident cap
would not be revised until the
beginning of the fourth year of the new
training program. The cap is set based
on a review of the number of interns
and residents in each of the first three
program years. Before the completion of
the third year of the new training
program, the actual intern and resident
count is reported on the cost report and
used for the calculation of the teaching
adjustment for the first three years of the
new teaching program. After the third
year of the new program, we revise the
IPF’s FTE resident cap to reflect the new
training program. The revised cap is
calculated by multiplying the highest
number of interns and residents in any
program year by the number of years in
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which residents are expected to
complete the program.
For subsequent years, we compare the
actual number of interns and residents
trained in the IPF that year to the
revised FTE resident cap and base the
teaching adjustment on the lower
number.
Final Rule Action: In summary, we
are retaining the coefficient value of
0.5150 for the teaching adjustment. In
§ 412.402, we are providing a definition
for ‘‘new graduate medical education
program’’ to mean a medical education
program that receives initial
accreditation by the appropriate
accrediting body or begins training
residents on or after November 15, 2004.
We are also clarifying at
§ 412.424(d)(1)(iii)(E) that the teaching
adjustment is made on a claim basis as
an interim payment, and the final
payment in full for the claim is made
during the final settlement of the cost
report.
4. Cost of Living Adjustment for IPFs
Located in Alaska and Hawaii
The IPF PPS includes a payment
adjustment for IPFs located in Alaska
and Hawaii based upon the county in
which the IPF is located. As we
explained in the November 2004 IPF
PPS final rule, the FY 2002 data
demonstrated that IPFs in Alaska and
Hawaii had per diem costs that were
disproportionately higher than other
IPFs. Other Medicare PPSs (for example,
IPPS and IRF PPS) have adopted a cost
of living adjustment (COLA) to account
for the cost differential of care furnished
in Alaska and Hawaii. We analyzed the
effect of applying a COLA to payments
for IPFs located in Alaska and Hawaii.
The results of our analysis demonstrated
that a COLA for IPFs located in Alaska
and Hawaii would improve payment
equity for these facilities. As a result of
this analysis, we provided a COLA
adjustment in the November 2004 IPF
PPS final rule. We are also adopting the
same COLA adjustment in this final
rule.
In general, the COLA accounts for the
higher costs in the IPF and eliminates
the projected loss that IPFs in Alaska
and Hawaii would experience absent
the COLA. A COLA factor for IPFs
located in Alaska and Hawaii is made
by multiplying the non-labor share of
the Federal per diem base rate by the
applicable COLA factor based on the
county in which the IPF is located.
Table 15 below lists the specific
COLA for Alaska and Hawaii IPFs. The
COLA factors were obtained from the
U.S. Office of Personnel Management
(OPM). The COLA factors are published
on the U.S. Office of Personnel
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Management (OPM) Web site (https://
www.opm.gov/oca/cola/rates.asp). As
proposed and in this final rule, we are
adopting the COLA adjustments
obtained from OPM. We will update the
COLA factors if OPM updates them and
as updated by OPM. Any change in the
COLA factors will be made in one of our
IPF PPS RY update documents. We are
also amending § 412.428 to enable us to
update the COLA factors if appropriate.
receives a 19 percent adjustment as the
variable per diem adjustment for day 1
of each patient stay.
While any IPF with a qualifying ED
receives the adjustment, the adjustment
is paid most often to IPFs that are
psychiatric units of acute care hospitals
or critical access hospitals because these
providers are more likely to have an ED
that meets the definition of a qualified
ED in § 412.424(d)(1)(v). We defined a
qualifying ED in order to avoid
TABLE 15.—PROPOSED COLA FAC- providing the ED adjustment to an
TORS FOR ALASKA AND HAWAII IPFS
intake unit that is not comparable to a
full-service ED with respect to the array
Location
COLA
of emergency services available or cost.
We defined a qualifying ED as one that
Alaska .... All areas .................
1.25
is staffed and equipped to furnish a
Hawaii .... Honolulu County .....
1.25
comprehensive array of emergency
Hawaii County ........
1.165
Kauai County ..........
1.2325 services and that meets the definition of
Maui County ...........
1.2375 a ‘‘dedicated emergency department’’ as
Kalawao County .....
1.2375 specified in § 489.24(b) and the
definition of ‘‘provider-based status’’ as
Final Rule Action: In summary, we
specified in § 413.65. We intended that
did not receive any public comments on a qualifying ED provide a
the proposed COLA for IPFs located in
comprehensive array of medical and
Alaska and Hawaii. We are adopting the psychiatric services. In order to clarify
COLA adjustments obtained from OPM
that a comprehensive array of
currently in effect, and as shown in
emergency services includes medical as
Table 15 above. We will update the
well as psychiatric services, we
COLA factors as updated by OPM. In
proposed to amend
addition, we are amending § 412.428 to
§ 412.424(d)(1)(v)(A).
enable us to update the COLA factors,
As specified in § 489.24, a dedicated
if appropriate.
ED means ‘‘any department or facility of
the hospital, regardless of whether it is
5. Adjustment for IPFs With a
located on or off the main hospital
Qualifying Emergency Department (ED)
campus, that meets at least one of the
Currently, the IPF PPS includes a
following requirements:
facility-level adjustment for IPFs with
• It is licensed by the State in which
qualifying EDs. As explained in the
it is located under applicable State law
November 2004 IPF PPS final rule, we
as an emergency room or emergency
provide an adjustment to the
standardized Federal per diem base rate department;
• It is held out to the public (by
to account for the costs associated with
name, posted signs, advertising, or other
maintaining a full-service ED. The
means) as a place that provides care for
adjustment is intended to account for
emergency medical conditions on an
ED costs allocated to the hospital’s
urgent basis without requiring a
distinct part psychiatric unit for
previously scheduled appointment; or
preadmission services otherwise
• During the calendar year
payable under Medicare Part B
immediately preceding the calendar
furnished to a beneficiary during the
year in which a determination under
day immediately preceding the date of
this section is being made, based on a
admission to the IPF (see § 413.40(c))
representative sample of patient visits
and the overhead cost of maintaining
that occurred during the calendar year,
the ED. This payment is a facility-level
it provides at least one-third of all its
adjustment that applies to all IPF
outpatient visits for the treatment of
admissions (with the one exception as
described below), regardless of whether emergency medical conditions on an
urgent basis without requiring a
a particular patient receives
previously scheduled appointment.’’
preadmission services in the hospital’s
As specified in § 413.65, providerED.
based status means ‘‘the relationship
The ED adjustment is incorporated
between a main provider and a
into the variable per diem adjustment
provider-based entity or a department of
for the first day of each stay for IPFs
with a qualifying ED. That is, IPFs with
a provider, remote location of a hospital,
a qualifying ED receive a 31 percent
or satellite facility that complies with
adjustment as the variable per diem
the provisions.’’ Including provideradjustment for day 1 of each stay. If an
based status in the definition of a
IPF does not have a qualifying ED, it
qualifying ED reflects the common
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ownership of the hospital and the
distinct part psychiatric unit.
As discussed in the November 2004
IPF PPS final rule, three steps were
involved in the calculation of the ED
adjustment factor.
Step 1: We estimated the proportion
by which the ED costs of a case would
increase the cost of the first day of the
stay. Using the IPFs with ED admissions
in FY 2002, we divided their average ED
cost per stay admitted through the ED
($198) by their average cost per day
($715), which equals 0.28.
Step 2: We adjusted the factor
estimated in step 1 to account for the
fact that we would pay the higher first
day adjustment for all cases in the
qualifying IPFs, not just the cases
admitted through the ED. Since on
average, 44 percent of the cases in IPFs
with ED admissions are admitted
through the ED, we multiplied 0.28 by
0.44, which equals 0.12.
Step 3: We added the adjusted factor
calculated in the previous 2 steps to the
variable per diem adjustment derived
from the regression equation that we
used to derive our other payment
adjustment factors. The first day
payment factor from this regression is
1.19. Adding the 0.12, we obtained a
first day variable per diem adjustment
for IPFs with a qualifying ED equal to
1.31.
The ED adjustment is made on every
qualifying claim except as described
below. As specified in
§ 412.424(d)(1)(v)(B), the ED adjustment
is not made where a patient is
discharged from an acute care hospital
or CAH and admitted to the same
hospital’s or CAH’s psychiatric unit. An
ED adjustment is not made in this case
because the costs associated with ED
services are reflected in the DRG
payment to the acute care hospital or
through the reasonable cost payment
made to the CAH. As we explained in
the November 2004 IPF PPS final rule,
if we provided the ED adjustment in
these cases, the hospital would be paid
twice for the overhead costs of the ED
(69 FR 66960).
Therefore, when patients are
discharged from an acute care hospital
or CAH and admitted to the same
hospital’s or CAH’s psychiatric unit, the
IPF receives the 1.19 adjustment factor
as the variable per diem adjustment for
the first day of the patient’s stay in the
IPF. We do not intend to conduct a new
regression analysis for this IPF PPS
update. Rather, we plan to wait until we
analyze IPF PPS data. Therefore, we are
retaining the 1.31 adjustment factor for
IPFs with qualifying EDs for the RY
beginning July 1, 2006.
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As we indicated in the November
2004 IPF PPS final rule, in FY 2002, one
third of the IPFs admissions were
through the ED. In the November 2003
IPF proposed rule (68 FR 66920) the
percentage of admissions through the
ED were understated. We plan to
monitor claims data to determine the
number of IPF admissions admitted
through the ED.
Public comments and our responses
on the proposed adjustment for IPFs
with qualifying EDs are summarized
below:
Comment: A few commenters
questioned whether IPFs would have to
reapply for the ED adjustment annually.
Specifically, commenters asked whether
it is necessary to re-submit verification
of a qualifying ED each year.
Other commenters asked for
clarification as to whether the ED
adjustment can still be applied based on
the date the attestation letter is received
or would the IPFs lose the adjustment
for the entire cost reporting year.
Response: We indicated in
instructions ( Transmittal 384, CR 3541
dated December 1, 2004 and Transmittal
444, CR 3678 dated January 21, 2005)
that IPFs should notify their FIs 30 days
before the beginning of their cost
reporting period regarding if they have
a qualifying ED. FIs have the discretion
as to how they wish to be notified and
as to the type of documentation they
require. Once the FI is satisfied that the
IPF has a qualifying ED, the FI should
enter the information in the providerspecific file within a reasonable
timeframe so that the IPF can begin to
receive the ED adjustment. This is a
one-time verification. Application of the
ED adjustment is prospective.
FIs may also use the date the
documentation was received from the
IPF to implement the ED adjustment.
The provider-specific file can be
updated from the date of the attestation
and claims processed from that date will
receive the ED adjustment. We do not
intend that IPFs would have to wait
until the beginning of their next cost
report period to receive the ED
adjustment.
However, if an IPF no longer meets
the definition of a qualified ED, the IPF
must notify their FI. The FI would
immediately remove the flag from the
provider-specific file and the provider
will not receive the ED adjustment. If
the provider should once again meet the
definition of a qualified ED, they should
contact their FI immediately in order to
update their file.
Comment: One commenter asked
what criteria CMS would use to
determine what constitutes a
‘‘comprehensive’’ array of medical as
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27071
well as psychiatric services. In addition,
the commenter asked if the criteria are
appropriate and would ensure highquality care for psychiatric patients.
Response: In most cases, the FI would
be familiar enough with the providers
they service to know if the hospital has
a qualifying ED. In those rare cases
where the FI does not know whether the
hospital’s ED meets our definition of a
qualifying ED (for example, new IPFs),
the FI will establish that the IPF’s ED is
staffed and equipped to furnish a
comprehensive array of emergency
services. In response to the comment,
we are clarifying in § 412.424(d)(1)(v)(A)
that a qualifying ED is staffed and
equipped to furnish both medical as
well as psychiatric emergency services.
Final Rule Action: We are retaining
the 1.31 percent adjustment factor for
IPFs with qualifying EDs for the RY
2007.
a. New Source of Admission Code to
Implement the ED Adjustment
In order to ensure that the ED
adjustment is not paid for patients who
are discharged from an acute care
hospital or CAH and admitted to the
same hospital’s or CAH’s psychiatric
unit, we directed IPFs to enter source of
admission code ‘‘4’’ (transfers from
hospital inpatient) on those claims. The
source of admission code is a required
field on Medicare claims and indicates
the source of the patient admissions.
However, as we implemented the IPF
PPS, we realized that admission code
‘‘4’’ is too broad to distinguish these
claims because it reflects transfers from
any acute care hospital or CAH.
Currently, where admission code ‘‘4’’ is
entered on a claim, the ED adjustment
is not paid, even if the patient is
transferred from a different acute
hospital or CAH.
In order to pay these IPF claims
appropriately, CMS requested a new
source of admission code from the
National Uniform Billing Committee to
identify transfers from the same hospital
or CAH. On June 07, 2005, the National
Uniform Billing Committee granted our
request to establish a new source of
admission code to indicate transfers
from the same hospital or CAH. The
new source of admission code ‘‘D’’ is
effective April 1, 2006. As proposed and
in this final rule, the new code will be
used by IPFs to identify IPF patients
who have been transferred to the IPF
from the same hospital or CAH. Claims
with source of admission code ‘‘D’’ will
not receive the ED adjustment.
Public comments and our response on
the proposed new source of admission
code to implement the ED adjustment
are summarized below:
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Comment: Several commenters
indicated that CMS should not penalize
IPFs if they receive a transfer from the
acute care medical-surgical units of the
same hospital. A commenter stated that
there may only be one hospital with a
psychiatric emergency department in a
particular area. The commenter believes
that to penalize the transfers is unfair;
each facility whether it is the ED,
surgical unit, medical unit or
psychiatric unit is doing their job and
should be appropriately compensated.
Response: As stated in the November
2004 final rule and the RY 2007
proposed rule, in § 412.424(d)(1)(v)(B)
we specify that the ED adjustment is not
made when a patient is discharged from
an acute care hospital or CAH and
admitted to the same hospital’s or
CAH’s psychiatric unit. The ED
adjustment is not made in this case
because the costs associated with the ED
services are already reflected in the DRG
payment paid to the acute care hospital
or through the reasonable cost payment
made to the CAH. As explained in the
November 2004 IPF PPS final rule and
in the RY 2007 proposed rule, if we
provided the ED adjustment in these
cases, the hospital would be paid twice
for overhead costs of the ED (see 69 FR
66960 and 71 FR 3641 respectively).
We note that the ED adjustment is a
facility-level adjustment, rather than a
patient-level adjustment. This facilitylevel adjustment applies to psychiatric
hospitals and acute care hospitals with
distinct part units, and CAHs that
maintain a qualifying ED. We are
providing the adjustment to psychiatric
units in acute care hospitals or CAHs,
and psychiatric hospitals because the
costs of the ED are allocated to all
hospital departments, including the
psychiatric units. Also, the adjustment
is intended to account for ED costs
allocated to the distinct part psychiatric
unit for preadmission services otherwise
payable under Medicare Part B
furnished to a beneficiary during the
day immediately preceding the date of
admission to the IPF and the overhead
cost of maintaining the ED.
In order to ensure that Medicare does
not pay twice for these types of
transfers, we proposed that admission
code ‘‘D’’ be used by IPFs to identify IPF
patients who have been transferred to
the IPF from the same hospital or CAH.
Claims with source of admission code
‘‘D’’ will not receive the ED adjustment.
Final Rule Action: We are finalizing
our decision to adopt the new source of
admission code ‘‘D’’. Claims with source
of admission code ‘‘D’’ will not receive
the ED adjustment.
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b. Applicability of the ED Adjustment to
IPFs in Critical Access Hospitals
The BBA created the CAH program,
designed to represent a separate
provider type to provide acute care
services in rural areas. Generally, in
order to qualify as a CAH, a hospital
must—
• Be located in a rural area;
• Provide 24-hour emergency care
services;
• Have an average LOS of 96 hours or
less;
• Operate up to 25 beds for inpatient
critical access care;
• Be located more than 35 miles from
a hospital or another CAH or more than
15 miles in mountainous terrain or only
secondary roads;
• Or be certified by the State as of
December 31, 2005 as being a
‘‘necessary provider’’ of health care
services to residents in the area.
Section 405(g) of the MMA authorizes
CAHs to establish distinct part
psychiatric and rehabilitation units of
up to 10 beds effective for cost reporting
periods beginning on or after October 1,
2004. Services in these units are paid
under the payment methodology that
would apply if the services were
provided in a distinct part psychiatric or
rehabilitation unit of a hospital. As a
result, IPFs that are distinct part units
of CAHs are paid the same as if they
were a distinct part unit of a hospital.
Otherwise, the CAH is paid on a
reasonable cost basis for inpatient
critical access services.
In the November 2004 IPF PPS final
rule, we amended § 413.70(e) to clarify
that payments for services of distinct
part psychiatric units in CAHs are made
in accordance with the IPF PPS. In order
to pay CAHs the same as other IPFs,
CAHs would be subject to the 1-day
preadmission services bundling
provision specified in § 413.40(c)(2) for
patients who are admitted to the CAH’s
IPF. As a result, the cost of
preadmission services, including ED
services furnished to CAH IPF patients
would be allocated to the IPF.
D. Other Payment Adjustments and
Policies
The IPF PPS includes the following
payment adjustments: (1) An outlier
policy to promote access to IPF care for
those patients who require expensive
care and to limit the financial risk of
IPFs treating unusually costly patients;
(2) a stop-loss provision, applicable
during the transition period, to reduce
financial risk to IPFs projected to
experience substantial reductions in
Medicare payments under the IPF PPS;
(3) an interrupted stay policy to avoid
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overpaying stays that include a brief
absence from the IPF followed by
readmission to the IPF; and (4) a
payment for patients who receive ECT.
As proposed, we are updating those
policies in this final rule. We are also
making clarifications to the physician
certification and recertification
requirements in order to ensure
consistent practices across IPFs. In
addition, we are clarifying coverage of
recreation therapy.
1. Outlier Payments
In the November 2004 IPF PPS final
rule, we implemented regulations at
§ 412.424(d)(3)(i) to provide a payment
adjustment for IPF stays that have
extraordinarily high costs. Providing
additional payments for outlier cases to
IPFs that are beyond the IPF’s control
strongly improves the accuracy of the
IPF PPS in determining resource costs at
the patient and facility level because
facilities receive additional
compensation over and above the
adjusted Federal prospective payment
amount for uniquely high-cost cases.
These additional payments reduce the
financial losses that would otherwise be
caused by treating patients who require
more costly care and, therefore, reduce
the incentives to under-serve these
patients.
Under the IPF PPS, outlier payments
are made on a per case basis rather than
on a per diem basis because it is the
overall financial ‘‘gain’’ or ‘‘loss’’ of the
case, and not of individual days, that
determines an IPF’s financial risk. In
addition, because patient-level charges
(from which costs are estimated) are
typically aggregated for the entire IPF
stay, they are not reported in a manner
that would permit accurate accounting
on a daily basis.
Currently, we make outlier payments
for discharges in which an IPF’s
estimated total cost for a case exceeds a
fixed dollar loss threshold amount
(multiplied by the IPF’s facility-level
adjustments) plus the Federal per diem
payment amount for the case.
In instances when the case qualifies
for an outlier payment, we pay 80
percent of the difference between the
estimated cost for the case and the
adjusted threshold amount for days 1
through 9 of the stay (consistent with
the median length of stay for IPFs in FY
2002), and 60 percent of the difference
for day 10 and thereafter. We
established the 80 percent and 60
percent loss sharing ratios because we
were concerned that a single ratio
established at 80 percent (like other
Medicare hospital PPSs) might provide
an incentive under the IPF per diem
payment system to increase length of
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stay in order to receive additional
payments. After establishing the loss
sharing ratios, we determined the
current fixed dollar loss threshold
amount of $5,700 through payment
simulations designed to compute a
dollar loss beyond which payments are
estimated to meet the 2 percent outlier
spending target.
a. Update to the Outlier Fixed Dollar
Loss Threshold Amount
As indicated in section II.A. of this
final rule, in accordance with the
update methodology described in
§ 412.428(d), we are updating the fixed
dollar loss threshold amount used under
the IPF PPS outlier policy. Based on the
regression analysis and payment
simulations used to develop the IPF
PPS, we established a 2 percent outlier
policy to make an appropriate balance
between protecting IPFs from
extraordinarily costly cases while
ensuring the adequacy of the Federal
per diem base rate for all other cases
that are not outlier cases.
We continue to believe a 2 percent
outlier policy is an appropriate target
percentage and proposed to retain the 2
percent outlier policy. However, we
believe it is necessary to update the
fixed dollar loss threshold amount
because analysis of the latest available
data and rate increases indicates
adjusting the fixed dollar loss amount is
necessary in order to maintain an outlier
percentage that equals 2 percent of total
estimated IPF PPS payments. We intend
to continue to analyze estimated outlier
payments for subsequent years using the
best available data in order to maintain
estimated outlier payments at 2 percent
of total estimated IPF PPS payments.
We have determined that in certain
sections of the November 2004 IPF PPS
final rule, we used the phrase ‘‘Fixeddollar loss threshold’’ and, in other
sections, we used the phrase ‘‘Fixeddollar loss amount’’ to describe the
dollar amount by which the costs of a
case exceed payment in order to qualify
for an outlier payment. In order to avoid
confusion regarding these phrases, we
are using the term ‘‘fixed-dollar loss
threshold amount’’ when we are
referring to the dollar amount by which
the costs of a case exceed payment in
order to qualify for an outlier payment.
As a result of this clarification, in
§ 412.402, we are revising the term
‘‘Fixed dollar loss threshold’’ to ‘‘Fixed
dollar loss threshold amount.’’ We are
also making clarifying changes to
§ 412.424(d)(3)(i) and
§ 412.424(d)(3)(i)(A) to state that we will
provide an outlier payment if an IPF’s
estimated total cost for a case exceeds a
‘‘fixed dollar loss threshold amount’’
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plus the total IPF adjusted payment
amount for the stay, and that it is the
fixed dollar loss threshold amount that
is adjusted by the IPF’s facility-level
adjustments.
Aside from updating the terminology
‘‘fixed dollar loss threshold amount’’
and making the conforming changes to
the regulation text described above, we
did not propose to make any other
changes to the outlier policy. Therefore,
we will continue to adjust the fixed
dollar loss threshold amount by the
applicable facility-level payment
adjustments and add this amount to the
IPF PPS payment amount in order to
determine if a case qualifies for an
outlier payment. For cases that meet the
threshold amount, we will pay 80
percent for days 1 through 9 and 60
percent for day 10 and thereafter.
In the November 2004 IPF PPS final
rule, we described the process by which
we calculate the outlier fixed dollar loss
threshold amount. We will continue to
use this process in this final rule. We
begin by simulating aggregate payments
with and without an outlier policy, and
applying an iterative process to a fixed
dollar loss amount that will result in
outlier payments being equal to 2
percent of total simulated payments
under the simulation. Based on this
process, we proposed a fixed dollar loss
threshold amount of $6200 for RY 2007.
In this final rule, we are finalizing this
amount. For RY 2007, IPF PPS will use
$6200 as the fixed dollar loss threshold
amount in the outlier calculation in
order to maintain the proposed 2
percent outlier policy.
We note that the simulation analysis
used to calculate the $6200 fixed dollar
loss threshold amount includes all of
the changes to the IPF PPS discussed in
this final rule.
Public comments and our responses
to changes to the outlier fixed dollar
loss threshold amount are summarized
below.
Comment: Several commenters
requested that CMS use FY 2005 claims
data to ensure that the fixed dollar loss
threshold amount is correctly set, and if
that data are not available, the
commenters recommended that CMS
keep the threshold at its current level.
Other commenters suggested that
since CMS is not making any other
changes to the major adjustments,
changes should not be made to adjust
the fixed dollar loss threshold amount.
They felt that an increase in the
threshold is unnecessary and might lead
to a financial burden on IPFs. One
commenter asked how CMS could
accurately determine that 2 percent is
the best outlier percentage and that the
threshold amounts are appropriate.
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Response: A complete set of FY 2005
claims data will not be available until
later in the year, therefore we will not
be able to analyze this data in time for
publication of this final rule. It is
necessary to update the fixed dollar loss
threshold amount because we are
increasing the Federal per diem base
rate and the ECT payment rate. We are
using the best available data to compute
the updated fixed dollar loss threshold
amount in our payment simulations. As
stated above, we believe 2 percent is the
optimal outlier percentage because it
strikes an appropriate balance between
protecting IPFs from extraordinarily
costly cases while ensuring the
adequacy of the Federal per diem base
rate for all other cases that are not
outlier cases. In the future, as IPF PPS
data becomes available, we can analyze
the accuracy of the fixed dollar loss
threshold amount.
Comment: Several commenters
recommended that CMS provide a
detailed description of the methodology
used in calculating the fixed dollar loss
threshold amount.
Response: We estimate the cost of
each case and inflate these costs to RY
2007 dollars in our simulations. We
used FY 2002 claims and cost report
data to estimate the cost per stay. We
calculated these costs by taking routine
per diem costs from the cost report (for
the routine costs) and by taking
departmental charges and cost-to-charge
ratios (for the ancillary costs). These are
the costs we then inflated to RY 2007
dollars in our payment simulations. We
then applied RY 2007 rates and policies
in our payment simulations to compute
the updated fixed dollar loss threshold
amount.
Comment: Several commenters
requested that CMS use the same
methodology as IPPS to calculate the
threshold.
Response: The cost-to-charge ratio
applied to charges provides Medicare
the most accurate measure of a
provider’s per-case cost for the purpose
of paying for high-cost outlier cases at
the point that we process the initial
claim. The cost-to-charge ratio is based
on the providers’ own cost and charge
information as reported by the
providers. In this final rule, we have
applied the cost-to-charge ratios to the
reported charges to estimate the cost per
case, and inflated the costs to current
dollars. In the future, when more recent
data is available, we will consider
whether using the IPPS methodology of
inflating the charges and applying the
latest cost-to-charge ratios to estimate
the cost per case is an even more
accurate method of calculating the
threshold amount.
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Comment: One commenter suggested
that CMS investigate the possibility and
legality of carrying over any unused
outlier money from year to year.
Response: We have responded to
similar comments a number of times in
the context of other PPS regulations,
((70 FR 24168), (70 FR 24196 through
24197), (57 FR 39784), (58 FR 46347),
(59 FR 45408), (60 FR 45856), (61 FR
27496), (56 FR 43227), and (61 FR 46229
through 46230)). As we have explained
before and as explained below, we do
not make adjustments to PPS payment
rates to account for differences between
projected and actual outlier payments in
a previous year.
We implemented the IPF PPS outlier
policy at § 412.424(d)(3)(i). We set
outlier criteria so that outlier payments
are projected to equal 2 percent of
estimated total IPF PPS payments. In
doing so, we use the best available data
at the time to make our estimates.
Outlier payments are ‘‘funded’’
through a prospective adjustment to the
base rate. We do not set money aside
into a discrete ‘‘pool’’ dedicated solely
for outlier payments. Outlier payments
are based on estimates. If outlier
payments for a given year are greater
than projected, we do not recoup money
from IPFs; if outlier payments for a
given year are lower than projected, we
do not make an adjustment to account
for the difference. If estimates turn out
to be inaccurate, we believe the more
appropriate action is to continue to
examine the outlier policy and to try to
refine the methodology for setting
outlier thresholds. Thus, consistent with
this approach, for this final rule we are
finalizing our decision to update the
outlier threshold amount to $6200 for
RY 2007 to make estimated outlier
payments equal to 2 percent of total
estimated IRF PPS payments in RY
2007.
Final Rule Action: In this final rule,
we are adopting $6200 as the fixed
dollar loss threshold amount for RY
2007.
b. Statistical Accuracy of Cost-to-Charge
Ratios
As stated previously, under the IPF
PPS, an outlier payment is made if an
IPF’s cost for a stay exceeds a fixed
dollar loss threshold amount. In order to
establish an IPF’s cost for a particular
case, we multiply the IPF’s reported
charges on the discharge bill by their
overall cost to charge ratio (CCR). This
approach to determining a provider’s
cost is consistent with the approach
used under the IPPS and other
prospective payment systems. In FY
2004, we implemented changes to the
IPPS outlier policy used to determine
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CCRs for acute care hospitals because
we became aware that payment
vulnerabilities resulted in inappropriate
outlier payments. Under the IPPS, we
established a statistical measure of
accuracy for CCRs in order to ensure
that aberrant CCR data did not result in
inappropriate outlier payments. As we
indicated in the November 2004 IPF
PPS final rule, because we believe the
IPF outlier policy is susceptible to the
same payment vulnerabilities as the
IPPS, we adopted an approach to ensure
the statistical accuracy of CCRs under
the IPF PPS. Therefore, we adopted the
following in the November 2004 IPF
PPS final rule:
• We calculated two national ceilings,
one for IPFs located in rural areas and
one for IPFs located in urban areas. We
computed the ceilings by first
calculating the national average and the
standard deviation of the CCR for both
urban and rural IPFs.
To determine the rural and urban
ceilings, we multiplied each of the
standard deviations by 3 and added the
result to the appropriate national CCR
average (either rural or urban). The
upper threshold CCR for IPFs in RY
2007 is 1.7447 for rural IPFs, and 1.7179
for urban IPFs, based upon CBSA-based
geographic designations. If an IPF’s CCR
is above the applicable ceiling, the ratio
is considered statistically inaccurate
and we assign the appropriate national
(either rural or urban) median CCR to
the IPF.
Additional information regarding the
national median CCRs is included in the
November 2004 IPF PPS final rule (69
FR 66961).
• We do not apply the applicable
national median CCR when an IPF’s
CCR falls below a floor. We made this
decision because using the national
median CCR in place of the provider’s
actual CCR would overstate the IPF’s
costs. We are applying the national
CCRs to the following situations:
++ New IPFs that have not yet
submitted their first Medicare cost
report.
++ IPFs whose operating or capital
CCR is in excess of 3 standard
deviations above the corresponding
national geometric mean (that is, above
the ceiling).
++ Other IPFs for whom the fiscal
intermediary obtains inaccurate or
incomplete data with which to calculate
either an operating or capital CCR or
both.
For new facilities, we are using these
national ratios until the facility’s actual
CCR can be computed using the first
tentatively settled or final settled cost
report, which will then be used for the
subsequent cost report period.
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We are not making any changes to the
procedures for ensuring the statistical
accuracy of CCRs in RY 2007. However,
we are updating the national urban and
rural CCRs (ceilings and medians) for
IPFs for RY 2007 based on the full CY
2005 CCRs entered in the providerspecific file. In addition, we are
updating the ceilings and national
median CCRs will be based on CBSAbased geographic designations because
the CBSAs are the geographic
designations we are adopting for
purposes of computing the proposed
wage index adjustment to IPF payments
beginning July 1, 2006. The national
CCRs for RY 2007 were estimated to be
0.7100 for rural IPFs and 0.5500 for
urban IPFs and will be used in each of
the three situations cited above. These
estimates were based on the IPF’s
location (either urban or rural) using the
CBSA-based geographic designations.
In this final rule, we are finalizing our
decision to update the national urban
and rural CCRs (median and ceilings)
based on the previous full CYs’
provider-specific file. These CCRs will
be announced in each year’s annual
notice of prospective payment rates
published in the Federal Register. We
are adding a new paragraph (g) to
§ 412.428 to clarify that we intend to
update the national urban and rural
ceilings and medians as part of the
annual update of the IPF PPS and to
specify when the national median urban
and rural CCRs will be used.
Comment: One commenter asked that
a provision be added to the national
median CCR policy that an exception to
the computed CCR be allowed to be
filed with the FI if using the national
median CCR overstates the IPF’s costs.
Response: CMS believes that the
actual CCR reported on the cost report
should be used to calculate outlier
payments. In the vast majority of cases,
the IPF’s CCR will be updated within a
year, when the next cost report is filed.
An interim cost report can be filed for
special cases, in which case the updated
CCR can be used. However, allowing
IPFs to continually submit cost and
charge data could create a burden for
Fiscal Intermediaries. Finally, if the IPF
is dissatisfied with the amount of
payment, they can invoke existing
appeal rights.
2. Stop-Loss Provision
In the November 2004 IPF PPS final
rule, we implemented a stop-loss policy
to reduce financial risk for those
facilities expected to experience
substantial reductions in Medicare
payments during the IPF PPS transition
period. This stop-loss policy guarantees
that each facility receives total IPF PPS
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payments that are no less than 70
percent of its TEFRA payments, had the
IPF PPS not been implemented.
This policy is applied to the IPF PPS
portion of Medicare payments during
the 3-year transition. Hence, during year
1, when three-quarters of the payment
were based on TEFRA and one-quarter
on the IPF PPS; stop loss payments
guarantee payments which are at least
70 percent of the TEFRA payments. The
resulting 92.5 percent of TEFRA
payments in year 1 is the sum of 75
percent and 25 percent times 70
percent.
In year 2, one-half of the payment will
be based on TEFRA and one-half on the
IPF PPS. In year 3, one-quarter of the
payment will be based on TEFRA and
three-quarters on the IPF PPS. In year 4
of the IPF PPS, Medicare payments are
based 100 percent on the IPF PPS.
The combined effects of the transition
and the stop-loss policies will be to
ensure that the total estimated IPF PPS
payments are no less than 92.5 percent
in year 1, 85 percent in year 2, and 77.5
percent in year 3. We are not making
any changes to the Stop-Loss provision.
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3. Patients Who Receive
Electroconvulsive Therapy (ECT)
In developing the IPF PPS, we
received numerous public comments
recommending that we include a
payment adjustment for patients who
receive ECT treatments during their IPF
stay because furnishing ECT treatment,
either directly or under arrangements,
adds significantly to the cost of these
stays. When we analyzed the FY 2002
MedPAR data, we found that ECT cases
comprised about 6 percent of all cases
and that almost 95 percent of ECT cases
were treated in IPFs that are psychiatric
units of acute care hospitals. Even
among psychiatric units, ECT cases are
concentrated among a relatively small
number of facilities. Overall,
approximately 450 facilities had cases
with ECT. Among these facilities, we
estimated the mean number of ECT
cases per facility to be approximately
25. In addition, approximately one-half
of the IPFs providing ECT had no more
than 15 cases in FY 2002.
Our analysis confirmed that cases
with ECT are substantially more costly
than cases without ECT. We found that
on a per case basis, ECT cases are
approximately twice as expensive as
non-ECT cases ($16,287 compared to
$7,684). Most of this difference is due to
variation in LOS (20.5 days for ECT
cases compared to 11.6 days for nonECT cases). In addition, the ancillary
costs per case for ECT cases are $2,740
higher than those for non-ECT cases.
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Although we are able to determine the
cost of stays with ECT, we are unable to
develop an ECT cost per treatment using
the FY 2002 IPF claims data because the
claims do not include the number of
treatments. As a result, in the November
2004 IPF PPS final rule, we established
the following methodology for
calculating the IPF PPS ECT payment
adjustment.
We established an ECT base rate using
the pre-scaled and pre-adjusted median
hospital cost for CPT procedure code
90870 used for payment under hospital
outpatient PPS (OPPS), based on
hospital claims data. The median cost
for all OPPS services are posted after
publication of the OPPS proposed rule
at the following address: https://
www.cms.hhs.gov/
hospitaloutpatientPPS. We used
unadjusted hospital claims data under
the OPPS, that is, the pre-scaled and
pre-adjusted median hospital cost per
treatment, to establish the ECT base rate
because we did not want the ECT
payment under the IPF PPS to be
affected by factors that are relevant to
OPPS but not specifically applicable to
IPFs. The median cost ($311.88) was
then standardized and adjusted for
budget neutrality, resulting in an ECT
payment adjustment of $247.96 per
treatment. The ECT base rate is adjusted
for wage and COLA differences in the
same manner that we adjust the Federal
per diem base rate.
In order to receive the payment
adjustment, IPFs must indicate on their
claims the revenue code for ECT (901),
along with the total number of units
(ECT treatments) provided to the patient
during their IPF stay. In addition, IPFs
must include the ICD–9–CM procedure
code for ECT (94.27) and the date of the
last ECT treatment the patient received.
As we stated in the November 2004
IPF PPS final rule, although we
established the ECT adjustment as a
distinct payment under the IPF PPS, our
preferred approach would be to include
a patient level adjustment as a
component of the model (for example,
determined through the regression
analyses) to account for the higher costs
associated with ECT (69 FR 66951). We
believe the approach will better control
incentives towards over-utilization and
be more consistent with the approach
used for other patient level adjustments
under the PPS. During the transition
period we expect to collect more data on
the number of ECT treatments per stay,
and associated costs. We will utilize
these data to evaluate alternative
approaches for incorporating an
adjustment for ECT in the payment
system. To the extent that we change the
payment methodology, we would
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27075
propose the change first in a future
rulemaking. Although our analysis will
continue, we do not plan to redo the
regression analysis until we analyze IPF
PPS data.
It is important to note that since ECT
treatment is a specialized procedure, not
all providers are equipped to provide
the treatment. Therefore, many patients
who need ECT treatment during their
IPF stay must be referred to other
providers to receive the ECT treatments,
and then return to the IPF. In
accordance with § 412.404(d)(3), in
these cases where the IPF is not able to
furnish necessary treatment directly, the
IPF would furnish ECT under
arrangements with another provider.
While a patient is an inpatient of the
IPF, the IPF is responsible for all
services furnished, including those
furnished under arrangements by
another provider. As a result, the IPF
claim for these cases should reflect the
services furnished under arrangements
by other providers.
Public comments and our responses
on the proposed ECT payment policy
are summarized below.
Comment: Several commenters asked
why CMS was continuing to adjust the
ECT rate by the standardization factor,
behavioral offset, stop-loss adjustment,
and outlier adjustment when the IPF
PPS is no longer budget neutral after the
implementation year.
Response: We proposed to treat the
ECT rate in a similar manner to the
Federal per diem base rate. Specifically,
we proposed to adjust the CY 2006
OPPS median rate for ECT by the
standardization factor, behavioral offset,
stop-loss adjustment, and outlier
adjustment in addition to applying the
wage index budget neutrality factor.
This way, all of the adjustments that are
incorporated into the Federal per diem
base rate would be incorporated into the
ECT rate. However, based on the
comments we received, and in order to
improve consistency and give more
predictability in the ECT rate from year
to year, we believe it is more
appropriate to use the CY 2005 ECT rate
as a base, and then update that amount
by the market basket each rate year.
This methodology, we believe, will be
even more consistent with the
methodology we use to update the
Federal per diem base rate because we
will use the RPL market basket increase
to increase both rates. Exactly as the
standardization factor, behavioral offset,
stop-loss adjustment, and outlier
adjustment are already built into the
Federal per diem base rate before we
apply the market basket and the wage
index budget neutrality factor, the
implementation year ECT rate of
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$247.96 includes the standardization
factor, behavioral offset, stop-loss
adjustment, and outlier adjustment.
Then, just as we updated the federal per
diem base rate, we will then apply the
corrected standardization factor (please
see section V.B for a discussion of how
we adjust this factor on Federal per
diem base rate), the market basket
increase of 4.3 percent, and the wage
index budget neutrality factor of 1.0042
to compute a RY 2007 ECT rate of
$256.20.
We will monitor ECT payments and
usage under the IPF PPS and the OPPS
to ensure that the increased payments
for ECT do not lead to changes in the
frequency of utilization by reviewing
the FY 2005 MedPAR claims data.
Comment: One commenter stated that
CMS should ensure that the ECT
amount adequately reflects the cost of
providing the treatment.
Response: We believe using the CY
2005 median cost for ECT under the
OPPS as a basis for our ECT payment
rate is the best option at this time to
ensure the most appropriate payment
for ECT. We will continue to monitor
ECT payments as new data become
available, and will make changes, if
warranted.
Final Rule Action: In summary, we
will finalize the update methodology for
the ECT rate by using the CY 2005 ECT
rate as a base and then updating that
amount by the market basket increase
each rate year. We will also continue to
monitor ECT payments under the IPF
PPS and the OPPS.
4. Physician Certification and
Recertification Requirements
Since the publication of the
November 2004 IPF PPS final rule, we
have received inquiries related to
physician certification and
recertification. It appears that some
psychiatric units in acute care hospitals
have been following the timeframes that
are applicable to the acute care hospital
of which they are a part (as specified in
§ 424.13) rather than those that apply to
psychiatric hospitals (as specified in
§ 424.14).
To eliminate the confusion that we
believe may be caused by the titles of
§ 424.13 and § 424.14 and to ensure
consistency in compliance with the
requirements among all IPFs, in the RY
2007 proposed rule (71 FR 3616), we
proposed to revise the title of § 424.14
from ‘‘Requirements for inpatient
services of psychiatric hospitals’’ to
‘‘Requirements for inpatient services of
inpatient psychiatric facilities.’’ In
addition, we proposed that for the
purposes of payment under the IPF PPS,
all IPFs would follow the physician
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certification and recertification
requirements as specified in § 424.14.
In the November 28, 2003 IPF PPS
proposed rule (68 FR 66920), we
proposed to—(1) amend § 424.14 to state
that in recertifying a patient’s need for
continued inpatient care in an IPF, a
physician must indicate that the patient
continues to need, on a daily basis,
inpatient psychiatric care (furnished
directly by or requiring the supervision
of IPF personnel) or other professional
services that, as a practical matter, can
be provided only on an inpatient basis;
and (2) revise § 424.14(d) to require that
a physician recertify a patient’s
continued need for inpatient psychiatric
care on the 10th day following
admission to the IPF rather than the
18th day following admission to the IPF
(68 FR 66939).
However, in the November 2004 IPF
PPS final rule, we did not include the
proposed physician recertification
requirement changes because most of
the public comments we received on
this issue did not support the proposed
changes and indicated that there are
inconsistencies in the timeframes
currently required for IPFs that
warranted additional analysis. Instead,
we stated that we would continue to
require that a physician recertify a
patient’s continued need for inpatient
psychiatric care on the 18th day
following admission to the IPF.
Since publication of the November
2004 IPF PPS final rule, we have
received additional inquiries related to
the physician certification and
recertification timeframes that currently
apply to IPFs. As noted above, it
appears that some psychiatric units in
acute care hospitals have continued to
follow the timeframes that are
applicable to the acute care hospital of
which they are a part (as specified in
§ 424.13) rather than those that apply to
psychiatric hospitals (as specified in
§ 424.14). Section 424.13(d) requires the
initial certification no later than as of
the 12th day of hospitalization and the
first recertification is required no later
than as of the 18th day of
hospitalization. Section § 424.14(d)
requires certification at the time of
admission or as soon thereafter as is
reasonable and practicable and the first
recertification is required as of the 18th
day of hospitalization.
In order to clarify requirements and
establish further consistency among
provider types, for purposes of payment
under the IPF PPS, we proposed that all
IPFs (distinct part units of acute care
hospitals and CAHs and psychiatric
hospitals) meet the physician
certification and recertification
timeframes in § 424.14.
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As proposed, we are revising
§ 424.14(d) to provide that the initial
physician certification will be required
at the time of admission or as soon
thereafter as is reasonable and
practicable and the first recertification
will be required as of the 12th day of
hospitalization. Subsequent
recertifications will be required at
intervals established by the hospital’s
UR committee (on a case-by-case basis
if desired), but no less frequently then
every 30 days.
We chose to propose the 12th day
because it is more in line with the
median LOS and it is current practice
for certification in psychiatric units.
In addition, we received inquiries
from FIs requesting guidance on the
content requirement of physician
certifications at § 424.14(c), relating to
the medical necessity of continued
inpatient psychiatric care. As a result,
we are adding language to clarify that
for purposes of payment under the IPF
PPS, the physician will also recertify
that the patient continues to need, on a
daily basis, active treatment furnished
directly by or requiring the supervision
of inpatient psychiatric facility
personnel.
We received several comments related
to the various changes we proposed
making to the Certification and Plan of
Treatment Requirements of § 424.14.
Commenters were silent with respect
to our proposed title revision to § 424.14
from ‘‘Requirements for inpatient
services of psychiatric hospitals’’ to
‘‘Requirements for inpatient services of
inpatient psychiatric facilities.’’ We are
finalizing the title revision for § 424.14
as ‘‘Requirements for inpatient services
of inpatient psychiatric facilities.’’
Overall, commenters supported
making the physician certification
requirements consistent among distinct
part psychiatric units of acute care
hospitals and CAHs and psychiatric
hospitals. Therefore, for the purposes of
payment under the IPF PPS, we are
requiring that all IPFs (distinct part
psychiatric units of acute care hospitals
and CAHs and psychiatric hospitals)
follow the physician certification and
recertification requirements as specified
in § 424.14.
We received mixed responses from
commenters concerning our proposed
physician certification and
recertification timeframes.
Specific comments and our responses
on the proposed changes implementing
physician certification and
recertification requirements are
summarized below.
Comment: One hospital association
expressed support for a 12-day
recertification requirement, finding it
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preferable to 18 days. Other commenters
requested the current requirement of 18
days for the initial recertification remain
in place, citing added administrative
burden since most patients are
discharged before the 18th day. A
couple of the commenters
recommended maintaining the 18-day
recertification requirement since it is
part of the original language for § 424.14
and further believe it is the established
practice in psychiatric hospitals.
Response: When § 424.14(d)(2) was
developed in the 1980s, the average LOS
for inpatient psychiatric hospitalization
was much longer than the current
median LOS of 9 days, thereby
necessitating a parallel recertification
requirement of 18 days, which was
reflective of current treatment practice
at that time. However, as inpatient
psychiatric treatment has evolved with
the development of new medications
and therapies, so has the average length
of inpatient care.
According to the MedPar 2002 claims
data, the median LOS for Medicare
beneficiaries in IPFs is 9 days. Since the
duration of inpatient psychiatric
hospitalization stays have shortened,
the certification and recertification
timeframe and practices need to be
updated in order to remain consistent
with current practice. Thus, an earlier
recertification timeframe is indicated by
the shorter LOS for inpatient psychiatric
hospitalization. Therefore, we continue
to believe that an 18-day recertification
requirement is outdated and not
reflective of current inpatient
psychiatric treatment.
As a result, we are finalizing that for
§ 424.14(d)(2), the first recertification is
required as of the 12th day of
hospitalization. Subsequent
recertifications will be required at
intervals established by the hospital’s
Utilization Review committee (on a
case-by-case basis if desired), but no less
frequently then every 30 days.
Comment: In general, commenters
were silent concerning our proposal to
modify the certification and
recertification language of § 424.14(c),
relating to the medical necessity of
continued inpatient psychiatric care.
However, a couple of commenters
requested that the language required for
certification and recertification remain
consistent with § 424.14(b) and
§ 424.14(c). Another commenter
requested clarification on the proposed
language requiring ‘‘the physician
would recertify that the patient
continues to need, on a daily
basis* * *’’. The commenter
questioned whether physicians would
need to chart daily in the patient’s
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record that the patient continues to need
active treatment.
Response: We proposed only one
modification to § 424.14(c), ‘‘Content of
recertification’’, by adding language
requiring that the physician would also
recertify that the patient continues to
need, on a daily basis, active treatment
furnished directly by or requiring the
supervision of inpatient psychiatric
facility personnel. This means, the
patient continues to need daily, active
treatment that is furnished directly by or
requiring the supervision of inpatient
psychiatric facility personnel. To
clarify, physician certification and
recertification, under § 424.14, are not
the same as progress notes. A physician
must certify the necessity of the services
and, in some instances, recertify the
continued need for those services to
ensure that Medicare pays only for
services of the type appropriate for
Medicare coverage. Progress notes,
under § 412.27(c)(4), must also be
recorded by the patient’s physician, in
addition to a nurse, social worker, and
when appropriate, others significantly
involved in active treatment modalities,
but are used to document the progress
of the patient’s treatment, and are more
frequent than the certification and
recertification timelines. In addition to
the purpose of clarifying the
recertification content requirements,
this modification is consistent with the
medical necessity requirement for
continued inpatient psychiatric care.
As a result, for purposes of payment
under the IPF PPS, the physician would
also recertify that the patient continues
to need, on a daily basis, active
treatment furnished directly by or
requiring the supervision of inpatient
psychiatric facility personnel.
Final Rule Action: In summary, we
are changing the title for § 424.14 from
‘‘Requirements for inpatient services of
psychiatric hospitals’’ to ‘‘Requirements
for inpatient services of inpatient
psychiatric facilities.’’
In addition, for the purposes of
payment under the IPF PPS, we are
requiring that all IPFs (distinct part
psychiatric units of acute care hospitals
and CAHs and psychiatric hospitals)
follow the physician certification and
recertification requirements as specified
in § 424.14.
Furthermore, § 424.14(d)(2) will
require the first recertification as of the
12th day of hospitalization. Subsequent
recertifications will be required at
intervals established by the hospital’s
UR committee (on a case-by-case basis
if desired), but no less frequently than
every 30 days.
We are also finalizing the content
requirement of physician certifications
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at § 424.14(c)(iii) by adding the
following language, ‘‘the physician will
also recertify that the patient continues
to need, on a daily basis, active
treatment furnished directly by or
requiring the supervision of inpatient
psychiatric facility personnel.’’
5. Provision of Therapeutic Recreation
in IPFs
Before the implementation of the IPPS
payment methodology, Medicare
coverage guidelines gave specific
recognition to therapeutic recreation in
inpatient psychiatric hospitals. The
guidelines in § 3102.1.A of the Medicare
Intermediary Manual, Part 3 (MIM–3),
and in § 212.1 of the Medicare Hospital
Manual (which now appear in the CMS
Internet Online Manual at Pub. 100–02,
Chapter 2, § 20.1ff.) specifically identify
therapeutic recreation as one of the
services that can constitute ‘‘active
treatment’’ in this setting when they
are—
• Provided under an individualized
treatment or diagnostic plan;
• Reasonably expected to improve the
patient’s condition or for the purpose of
diagnosis; and
• Supervised and evaluated by a
physician.
However, these guidelines refer to
therapeutic recreation in terms of being
an ‘‘adjunctive’’ therapy, indicating that
even in this setting, it will not
independently serve as a patient’s sole
or primary form of therapeutic
treatment, but rather, will be furnished
in support of (but subordinate to) some
other, primary form of therapy.
When the IPPS was developed in
1983, to the extent that therapeutic
recreation and other services had been
furnished during the IPPS base period,
the bundled IPPS payment for that
setting would reflect these costs.
However, during the IPPS rulemaking
process, we received public comments
concerned that, ‘‘the cost-saving
incentives of the PPS would lead
hospitals paid under the system to stop
providing recreational therapy
services.’’ In response, in the January 3,
1984 IPPS final rule (49 FR 242) we
indicated that implementation of the
IPPS would not, in fact, prohibit the
provision of recreational therapy
services, and that ‘‘these services will
continue to be covered to the same
extent they always have been under
existing Medicare policies’’.
In implementing the IPPS regulations,
we included criteria for identifying
certain types of institutions (for
example, psychiatric hospitals) that
would be excluded from the IPPS and,
thus, would continue to be paid under
some other methodology. The
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regulations also introduced criteria for
identifying an IPPS-excluded inpatient
psychiatric unit housed within a larger
acute-care hospital that would itself be
subject to the IPPS. One of these
identifying criteria at 42 CFR
405.471(c)(4)(ii)(B) (later recodified at
42 CFR 412.27(b)) was the provision,
through the use of qualified personnel,
of a number of specified types of
services, including psychological
services, social work services,
psychiatric nursing, occupational
therapy, and recreational therapy.
As we explained in the IPPS interim
final rule published on September 1,
1983 (48 FR 39758), the regulations
designated these particular services
because their provision ‘‘is typical of
units which treat patients whose
characteristics are like those in
psychiatric hospitals. Consequently, the
provision of these services is an
identifier of such a patient population’’.
We note that the designation of these
particular services in this context did
not serve to define the scope of their
coverage under Medicare, nor to
mandate their provision in this setting,
but merely to identify them as being
characteristic of the type of psychiatric
unit that would qualify for exclusion
from the IPPS.
At the same time the IPPS was being
developed, a parallel evolution was
taking place in the certification
requirements that facilities must meet in
order to participate in the Medicare
program: a shift from primarily
‘‘process-oriented’’ requirements to
more ‘‘outcome-oriented’’ requirements,
which focus more on direct indicators of
the quality of care actually being
furnished to the facility’s patients (as
reflected in the presence of positive
results and the absence of negative
ones), and less on the specific ‘‘process’’
through which the facility achieves the
desired outcome.
In order to participate in the Medicare
program, psychiatric hospitals not only
had to meet the conditions of
participation (COPs) that apply to
general, acute-care hospitals, but
additionally had to meet special
conditions related to medical records
and staffing. Consistent with the
recognition of therapeutic recreation as
constituting active treatment in this one
particular setting (as discussed above),
the original COPs for psychiatric
hospitals at 42 CFR 405.1038(g)
mandated the presence of qualified
therapists, assistants, or aides
‘‘sufficient in number to provide
comprehensive therapeutic activities,
including at least occupational,
recreational and physical therapy, as
needed, to assure that appropriate
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treatment is rendered for each patient,
and to establish and maintain a
therapeutic milieu.’’ Furthermore, 42
CFR 405.1038(g)(3) specified that
‘‘recreational or activity therapy services
are available under the direct
supervision of a member of the staff
who has demonstrated competence in
therapeutic recreation programs,’’ and
§ 405.1038(g)(4) and § 405.1038(g)(5)
went on to prescribe additional
standards regarding therapy assistants
or aides and overall staffing for
recreational and activity therapy.
However, when the special medical
record and staffing COPs for psychiatric
hospitals were subsequently recodified
at § 482.62(g), the specific references to
recreation therapy were deleted and
replaced with a more general
requirement to provide a therapeutic
activities program. In response to public
comments that recommended us to
restore the deleted requirements, we
indicated that we believe that the
deleted requirements concerning
therapeutic activities were overly and
unnecessarily prescriptive and that the
hospital should have the flexibility to
determine which activities are most
appropriate to its patient population
and to determine the criteria to be met
by employees providing these services.
(See the IPPS PPS rule published on
June 17, 1986 (51 FR 22032)).
However, when the 1986 COP
changes applicable to psychiatric
hospitals were made, we inadvertently
retained specific references to recreation
therapy in § 412.27. Since the intent of
§ 412.27(b) is to identify services
provided in psychiatric units that are
characteristic of services furnished in
psychiatric hospitals, we believe it is no
longer appropriate to include references
to specific therapies in § 412.27.
Therefore, in order to have consistent
requirements among IPFs, in the RY
2007 IPF PPS proposed rule, we
proposed removing recreational therapy
from § 412.27(b).
We went on to further explain in the
RY 2007 IPF PPS proposed rule that in
addition to being consistent with
current provisions, we believe the IPF
PPS base rate which was developed
using FY 2002 data, already reflects the
provision of recreation therapy.
We received a few public comments
concerning our proposal to remove
reference to recreational therapy in
§ 412.27(b). Overall the commenters
recommended that we not delete the
reference to recreational therapy.
Public comments and our responses
on the proposed changes for removing
the reference to recreational therapy are
summarized below:
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Comment: An industry organization
suggested that if CMS’; goal is to
maintain consistency, CMS should
adopt the language as specified in
§ 482.62 from the COPs for § 412.27(b).
Response: We believe that this
commenter raises a valid concern in
terms of maintaining consistency. We
also agree with the suggestion of
applying the same language to both
§ 482.62 and § 412.27(b), thereby
maintaining consistent requirements
among IPFs. Since § 482.62 refers to
‘‘therapeutic activities,’’ we are revising
§ 412.27(b), to be consistent with
§ 482.62, by replacing the reference to
recreational and occupational therapy
with the term ‘‘therapeutic activities.’’
Comment: Several commenters stated
that the inclusion of recreational
therapy in § 412.27(b), is no more
specific than the references included for
social work or occupational therapy.
Response: As we indicated in the RY
2007 IPF PPS proposed rule, since the
intent of § 412.27(b) is to identify
services provided in psychiatric units
that are characteristic of services
furnished in psychiatric hospitals, we
believe it is essential to maintain
consistency among the provisions for
§ 482.62 and § 412.27(b). Therefore, we
are removing the reference to both
recreational and occupational therapy
from § 412.27(b) and replacing them
with the more general reference to
therapeutic activities which is currently
used in § 482.62.
However, we believe it is important to
maintain the reference to social work
services in § 412.27, since it is currently
included in § 482.62.
Comment: One commenter requested
that CMS continue to pay for
recreational therapy. Other commenters
were concerned that if the reference to
recreational therapy is removed, people
may not know that Medicare has
traditionally recognized recreational
therapy as an adjunctive therapy in
psychiatric facilities.
Response: As we discussed in the RY
2007 IPF PPS proposed rule, we believe
the IPF PPS base rate, which was
developed using FY 2002 data, reflects
the provision of recreation and
occupational therapy. Even though we
are removing the specific reference to
recreation and occupational therapy in
§ 412.27(b), both recreational and
occupational therapy services will
continue to be covered to the same
extent they always have been under
existing Medicare policies.
In addition, although we are removing
the specific references to recreational
and occupational therapy from
§ 412.27(b), we want to emphasize that
both therapies are, and continue to be,
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valuable therapeutic interventions in
psychiatric treatment.
Final Rule Action: In summary, for
consistency, we are adopting the
language as specified in § 482.62 from
the COPs for § 412.27(b). Specifically,
412.27(b) will state—‘‘Furnish, through
the use of qualified personnel,
psychological services, social work
services, psychiatric nursing services
and therapeutic activities.’’
6. Same Day Transfers
Currently, when a transfer, discharge,
or death occurs on the same day as an
admission to an IPF, the IPF PPS
PRICER does not recognize any covered
IPF days and the IPF claims are
suspended. Based on review of a limited
sample of the IPF and subsequent IPPS
claims, it appears that many of these
patients are first seen in a hospital’s ED,
are admitted to the hospital’s
psychiatric unit and, later the same day,
determined to be too medically
compromised to be managed in the
psychiatric unit. This scenario may
occur because the patient presents at the
ED and is admitted to the psychiatric
unit in the middle of the night, and
when the patient’s admission to the unit
is reviewed by a psychiatrist the next
morning, the physician determines that
the patient should be discharged for
acute care. In other cases, a patient may
have been admitted to a freestanding
psychiatric hospital based on the
information furnished by an ED of an
acute care hospital. However, after
admission, the psychiatric hospital staff
evaluates the patient and determines
that the patient has medical needs that
they are not staffed or equipped to meet.
The Provider Reimbursement Manual
addresses the same day transfer issue
from the perspective of counting
Medicare days for the purpose of
Medicare cost reporting. Section 2205
indicates that only full patient days may
be used to apportion inpatient routine
care service costs and that a day begins
at midnight and ends 24 hours later.
However, section 2205.1 explains how
to count a day if the day of admission
and the day of discharge are the same.
Section 2205.1 indicates that when a
patient is admitted and then transferred
from one participating provider to
another before midnight of the same
day, a day (except for utilization
purposes) is counted at both providers.
A day of Medicare utilization is charged
only for the admission to the second
provider. This distinction is important
for psychiatric admissions because IPF
stays are subject to the 190-day lifetime
limit on inpatient psychiatric care.
Section 1812(b) of the Act and 42 CFR
409.62 indicate that payment is not
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available for inpatient psychiatric
hospital services furnished beyond the
190-day lifetime limit. Thus, Medicare
coverage of IPF services, specifically IPF
services furnished in freestanding
psychiatric hospitals is limited to 190
days. In consideration of the limit on
coverage of IPF services, where there is
a same day transfer between Medicare
participating providers, we only count
the second admission for utilization
purposes. Therefore, the initial
admission to the IPF does not count
against a beneficiary’s lifetime
psychiatric services limit.
We have some concerns regarding
same day transfers from an IPF. Under
TEFRA, a hospital receives its cost up
to the hospital’s TEFRA limit. The
TEFRA limit is based on the hospital’s
average cost per discharge in a base
period. When an admission and
discharge occur on the same day, the
hospital’s cost is unlikely to exceed the
TEFRA limit, so the hospital receives its
cost for the day. These same day
transfers also improve the hospital’s
payment under TEFRA by slightly
reducing its cost per discharge. We are
also concerned that when the transfer
occurs in the same hospital, this
practice circumvents bundling rules
under the IPPS, in that it unbundles the
ED charges from the IPPS claim and
allocates the ED costs to the psychiatric
unit even though the patient may have
been inappropriately admitted to the
unit.
Based on the review of IPF PPS claims
we conducted, it did not appear that the
admissions to the IPF were medically
reasonable and necessary. However, we
believe it is important to base a decision
regarding coverage of these days on a
comprehensive review of the claims.
Therefore, in the RY 2007 IPF PPS
proposed rule, we did not propose a
change in payment policy. However, we
did consider several alternative methods
for addressing same day transfers under
the IPF PPS which are described below.
Any change to treatment of same day
transfers would be made prospectively.
We could treat these days as covered
days under the IPF PPS. However,
under the IPF PPS, a 19 percent
adjustment to the base rate is applied to
day 1 of the stay to reflect the additional
administrative and clinical costs
associated with admission and the day
1 adjustment is increased to 31 percent
when the IPF has a qualifying ED. The
IPF may also receive, for example, a
teaching adjustment or rural adjustment,
for these partial days of care. Several of
the claims in our analysis indicate a stay
of 2 hours. We are concerned that this
approach would overpay IPFs and
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encourage inappropriate admissions and
transfers.
Another option would be to make no
PPS payment, but continue making
TEFRA payments during the IPF PPS
transition period. For example, for cost
reporting periods beginning in 2006,
IPFs would receive a blended payment
consisting of 50 percent PPS and 50
percent TEFRA. Therefore, under this
approach we would allow some
payment for these days for cost
reporting periods in 2006 and 2007, but
once the IPF PPS transition period is
over, the IPFs would receive no
payment for these days. We think this
approach would encourage changes in
admission practices in order to avoid
the need to transfer patients. However,
once the IPF PPS transition is over,
there would be no payment mechanism
to pay IPFs for stays in which there is
a circumstance, not reasonably
foreseeable by the admitting IPF, for
example, a serious change in health
status on the day of admission.
We could treat these same day
transfer cases as covered days under the
IPF PPS but limit payment to the
Federal per diem base rate or some other
payment amount, for example, half the
Federal per diem base rate. This
approach would limit payment to IPFs
in order to provide an incentive for IPFs
to make medical clearance
determinations as early in the IPF stay
as possible. However, we are concerned
that this approach would not lead to
changes in admission practices to avoid
inappropriate admissions and the need
for subsequent transfers.
It is important to note that the cost for
these days was included in the cost
reports used to develop the IPF PPS,
and, as a result, the average cost per day
that was used to establish the Federal
per diem base rate is higher than it
would otherwise have been had those
days not been included.
We specifically request public
comment from IPFs on this issue to help
us to develop a payment policy that
pays IPFs appropriately for these days
and provides an incentive to avoid same
day transfers wherever possible.
Public comments and our responses
on the proposed changes for
implementing the same day transfers are
summarized below.
Comment: We received several
comments concerning the issue of an
appropriate payment for same day
transfers. Many commenters indicated
that CMS should conduct a thorough
examination of the 2005 claims because
they do not believe that same day
transfers would be found to be prevalent
occurrences. The same commenters also
stated that if CMS decides to investigate
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other options, the agency should
convene the field through an open-door
forum or other such venue to discuss
the possibilities.
In addition, several commenters
requested that when sufficient data is
available to fully evaluate same day
transfers, CMS should request input
from the field before making any
changes to current policy. Other
commenters also indicated that CMS
should continue to reimburse same day
transfers as 1-day stays unless it can
demonstrate empirically that the cost of
the former is sufficiently less than the
cost of the latter to justify a partial
payment.
Another commenter requested that
CMS release a version of the MedPar
with relevant information to qualified
researchers who would be pleased to
conduct an empirical analysis for the
agency.
Many commenters supported CMS’
instructions for its payment
methodology for the suspended IPF PPS
same day transfer claims from January 1,
2005. The instructions counted these
days as covered for cost reporting
purposes if the day of admission and the
day of discharge are the same. Other
commenters indicated that CMS should
not penalize provider’s evaluation and
treatment efforts, stating that the work
was done, therefore providers should be
compensated.
Furthermore, commenters support the
way section 2205.1 of the Provider
Reimbursement Manual instructs FIs to
count a day if the day of admission and
the day of discharge are the same. The
majority of the commenters
recommended paying the PPS per diem
for these transfers.
Response: We will take all comments
into consideration as we develop a
payment policy that not only pays
appropriately for these days, but will
also provide an incentive to avoid same
day transfers wherever possible.
Final Rule Action: In summary, we
received multiple comments on the
same day transfer. We will take all
comments into consideration as we
develop a payment policy for same day
transfers. We will develop the policy for
same day transfers in the future, after
we analyze IPF PPS data.
Response: We did not include an
explicit payment adjustment for inner
city facilities in the November 2004 IPF
PPS final rule nor did we propose an
urban adjustment in the RY 2007
proposed rule. As indicated in the
November 2004 IPF PPS final rule (69
FR 66954), we did not include an
adjustment for urban IPFs because the
regression analysis we conducted did
not indicate that urban IPFs were more
costly on a per diem basis.
As previously stated, we do not plan
to rerun the regression analysis until we
analyze IPF PPS data (that is no earlier
than FY 2008). When we rerun the
regression analysis, we will test for the
need for an urban or inner city
adjustment.
Comment: A commenter objected to
CMS not posting the proposed rule to
the CMS Web site until January 18, 2006
while the rule actually went on public
display January 13, 2006 and was not
published in the Federal Register until
January 23, 2006. The commenter stated
that if CMS chooses to start the
comment period based on the date of
display, CMS must ensure that the
display copy is promptly posted on the
Web site to provide interested parties
sufficient time to review the rule and
draft comments before the comment
period ends.
Response: It is our general practice to
post Federal Register documents on our
website as soon as practicable after the
documents are on public display at the
Office of the Federal Register. When we
chose to start the comment period from
the day of public display, while we are
not required to do so, it was our intent
to post the proposed rule on CMS
website immediately. However, due to
circumstances out of our control, we
were unable to immediately do so
because our Web site at https://
www.cms.hhs.gov was being redesigned.
However, we did publish a press release
on January 13, 2006, announcing the IPF
PPS proposed rule went on public
display at the Federal Register on
January 13, 2006 and that it would be
published in the Federal Register on
January 23, 2006. In addition, we posted
the rule as soon as was practicable for
us to do so, on Wednesday, January 18,
2006.
VII. Miscellaneous Public Comments
Within the Scope of the Proposed Rule
Comment: A commenter requested an
inner-city adjustment, indicating that
the difficulties of inner-city IPFs are
related to a high volume of nonpayment in contrast to the more likely
rural under use and low volume costs.
The commenter suggested a 20 percent
adjustment at least, for inner-city IPFs.
VIII. Provisions of the Final Rule
This final rule essentially
incorporates the provisions of the
proposed rule, in which we proposed to
update the IPF PPS for RY 2007
applicable to IPF discharges occurring
during the RY beginning July 1, 2006
through June 30, 2007. In addition, we
proposed to adopt the new OMB labor
market area definitions for our
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geographic classifications. The
provisions of this final rule that differ
from the proposed rule are as follows.
ECT policy Payment
In the RY 2007 IPF PPS proposed
rule, we proposed to update the ECT
base rate using the pre-scaled preadjusted hospital median cost for ECT
used for the CY 2006 update of the
OPPS. The median cost would then be
standardized, adjusted for budget
neutrality, and adjusted for wage and
COLA differences in the same manner
that we adjust the per diem rate.
However, based on the public
comments, we are changing the
methodology used for calculating the
ECT policy payment rate. In order to
improve consistency with our updates
to the Federal per diem base rate and
provide IPFs more predictability for the
ECT rate from year to year, we will use
the CY 2005 ECT rate as a base, and
then update that amount by the market
basket increase each rate year.
Section 412.402 Definition
In § 412.402, we are adding the
definition of ‘‘New GME education
program’’ to mean a medical education
program that receives initial
accreditation by the appropriate
accrediting body or begins training
residents on or after November 15, 2004.
Section 412.27 Excluded psychiatric
units: Additional requirements.
In § 412.27, we are amending
paragraph (b) to remove the specific
reference to ‘‘occupational therapy, and
recreational therapy.’’ We are adding in
its place ‘‘therapeutic activities’’ in
order to maintain consistency with
current provisions and since the IPF
PPS base rate already reflects the
provision of recreational therapy.
Section 412.428 Publication of
updates to the inpatient psychiatric
facility prospective payment system.
In § 412.428, we are revising
paragraph (b)(3) to reflect that the rate
of increase factor is revised as of
October 1 of each year.
Other Issues
In the Inpatient Prospective Payment
System proposed rule, published April
25, 2006 (71 FR 23996), we discussed in
detail the Health Care Information
Transparency Initiative and our efforts
to promote effective use of health
information technology (HIT) as a
means to help improve health care
quality and improve efficiency.
Specifically, with regard to the
transparency initiative, we discuss
several potential options for making
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pricing and quality information
available to the public (71 FR 24120
through 24121). We solicited comments
on ways the Department can encourage
transparency in health care quality and
pricing whether through its leadership
on voluntary initiatives or through
regulatory requirements. We also are
seeking comment on the Department’s
statutory authority to impose such
requirements.
In addition, we discussed the
potential for HIT to facilitate
improvements in the quality and
efficiency of health care services (71 FR
24100 through 24101). We solicited
comments on our statutory authority to
encourage the adoption and use of HIT.
The 2007 Budget states that ‘‘the
Administration supports the adoption of
health information technology (IT) as a
normal cost of doing business to ensure
patients receive high quality care.’’ We
also are seeking comments on the
appropriate role of HIT in potential
value-based purchasing program,
beyond the intrinsic incentives of a PPS
to provide efficient care, encourage the
avoidance of unnecessary costs, and
increase quality of care. In addition, we
are seeking comments on promotion of
the use of effective HIT through
Medicare conditions of participation.
We intend to consider both the health
care information transparency initiative
and the use of health information
technology as we refine and update all
Medicare payment systems. Therefore,
while these initiatives are not included
in this final rule, we are in the process
of seeking input on these initiatives in
various proposed Medicare payment
rules being issued this year and may
pursue these policies in future
rulemaking for the IPF PPS.
IX. Collection of Information
Requirement
This document does not impose
information collection and
recordkeeping requirements.
Consequently, it need not be reviewed
by the Office of Management and
Budget under the authority of the
Paperwork Reduction Act of 1995.
X. Regulatory Impact Analysis
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A. Overall Impact
We have examined the impact of this
final rule as required by Executive
Order 12866 (September 1993,
Regulatory Planning and Review), the
Regulatory Flexibility Act (RFA)
(September 19, 1980, Pub. L. 96–354),
section 1102(b) of the Social Security
Act, the Unfunded Mandates Reform
Act of 1995 (UMRA) (Pub. L. 104–4),
and Executive Order 13132.
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Executive Order 12866 (as amended
by Executive Order 13258, which
merely reassigns responsibility of
duties) directs agencies to assess all
costs and benefits of available regulatory
alternatives and, if regulation is
necessary, to select regulatory
approaches that maximize net benefits
(including potential economic,
environmental, public health and safety
effects, distributive impacts, and
equity). A regulatory impact analysis
(RIA) must be prepared for major rules
with economically significant effects
($100 million or more in any 1 year).
Based on the impact analysis, we
estimate the expenditures from the IPF
PPS implementation year to the 2007
IPF PPS RY will be increased by $160
million. The updates to the IPF laborrelated share and wage indices are made
in a budget neutral manner and thus
have no effect on estimated costs to the
Medicare program. Therefore, the
estimated increased cost to the Medicare
program is the result of a combination
of the updated IPF market baskets,
which is offset by the transition blend
and the revision of the standardization
factor. The IPF PPS was budget neutral
in the implementation year, but it is not
budget neutral in RY 2007. As discussed
in section V.B.2 of this final rule, the
standardization factor and budget
neutrality factors (behavioral offset,
stop-loss adjustment, and outlier
adjustment) are built into the Federal
per diem base rate and the ECT rate. We
are increasing these rates by the market
basket, resulting in a $160 million
increase in payments from the
implementation year to RY 2007.
We note that aspects of the transition,
including the stop-loss policy and the
transition to the 50/50 percent blend in
RY 2007 and the transition to the 75/25
percent blend in the 2008 IPF PPS RY,
were included in the November 2004
IPF PPS final rule and thus are not
incremental to this rule. Nevertheless, it
is essential to analyze the impact of the
transition blend in order to calculate the
increase in cost to the Medicare
program.
The impact of the transition blend is
an approximately 0.2 percent (about $10
million) decrease in overall payments in
RY 2007 and the distribution of that
impact is summarized in Table 15.
Therefore, the impact attributable to the
policy changes finalized in this
rulemaking, primarily the market basket
update and the standardization
correction, is approximately $170
million in the IPF PPS RY 2007.
Since costs to the Medicare program
are estimated to be greater than $100
million, this final rule is considered a
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27081
major economic rule, as defined in 5
U.S.C. 40(2).
The RFA requires agencies to analyze
options for regulatory relief of small
businesses. For purposes of the RFA,
small entities include small businesses,
nonprofit organizations, and
governmental jurisdictions. Most IPFs
and most other providers and suppliers
are considered small entities, either by
nonprofit status or by having revenues
of $6 million to $29 million in any 1
year. (For details, see the Small
Business Administration’s regulation
that set forth size standards for health
care industries at (65 FR 69432).)
HHS considers that a substantial
number of entities are affected if the
rule impacts more than 5 percent of the
total number of small entities as it does
in this rule. We included all
freestanding psychiatric hospitals (79
are non-profit hospitals) in the analysis
since their total revenues do not exceed
the $29 million threshold. We also
included psychiatric units of small
hospitals, that is, those hospitals with
fewer than 100 beds. We did not include
psychiatric units within larger hospitals
in the analysis because we believe this
final rule would not significantly impact
total revenues of the entire hospital that
supports the unit. We have provided the
following RFA analysis in section V.B to
emphasize that, although the final rule
will impact a substantial number of IPFs
that were identified as small entities, we
do not believe it will have a significant
economic impact. Based on the analysis
of the 1063 psychiatric facilities that
were classified as small entities as
described above, we estimate the
combined impact of the IPF PPS will be
a 4.2 percent increase in payments in
RY 2007 relative to their payments in
the implementation year of the IPF PPS.
Based on the information available, we
believe that Medicare payments may
constitute a small portion of
governmental IPFs’ revenue stream. We
have prepared the impact analysis in
section X.B.2 to describe the impact of
the final rule in order to provide a
factual basis for our conclusions
regarding small business impact.
In addition, section 1102(b) of the Act
requires us to prepare a regulatory
impact analysis if a final rule may have
a significant impact on the operations of
a substantial number of small rural
hospitals. This analysis must conform to
the provisions of section 604 of the
RFA. With the exception of hospitals
located in certain New England
counties, for purposes of section 1102(b)
of the Act, we previously defined a
small rural hospital as a hospital with
fewer than 100 beds that is located
outside of a Metropolitan Statistical
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Area (MSA) or New England County
Metropolitan Area (NECMA). However,
under the new labor market definitions,
we will no longer employ NECMAs to
define urban areas in New England.
Therefore, for purposes of this analysis,
we now define a small rural hospital as
a hospital with fewer than 100 beds that
is located outside of an MSA. We have
determined that this final rule will have
a substantial impact on hospitals
classified as located in rural areas. As
discussed earlier in this preamble, we
will continue to provide a payment
adjustment of 17 percent for IPFs
located in rural areas. In addition, we
have established a 3-year transition to
the new system to allow IPFs an
opportunity to adjust to the new system.
Therefore, the impacts shown in Table
15 below reflect the adjustments that are
designed to minimize or eliminate any
potentially significant negative impact
that the IPF PPS may otherwise have on
small rural IPFs.
Section 202 of the Unfunded
Mandates Reform Act of 1995 also
requires that agencies assess anticipated
costs and benefits before issuing any
final rule whose mandates require
spending in any 1 year of $100 million
in 1995 dollars, updated annually for
inflation. That threshold level is
currently approximately $120 million.
This final rule will not mandate any
requirements for State, local, or tribal
governments, nor would it affect private
sector costs.
Executive Order 13132 establishes
certain requirements that an agency
must meet when it promulgates a final
rule that imposes substantial direct
requirement costs on State and local
governments, preempts State law, or
otherwise has Federalism implications.
We have reviewed this final rule
under the criteria set forth in Executive
Order 13132 and have determined that
the final rule will not have any
substantial impact on the rights, roles,
and responsibilities of State, local, or
tribal governments.
mmaher on PROD1PC60 with RULES2
B. Anticipated Effects of the Final Rule
We discuss below the impact of this
final rule on the Federal Medicare
budget and on IPFs.
1. Budgetary Impact
As discussed in detail in the IPF PPS
proposed rule and summarized in
section V.B. of this final rule, we
applied a budget neutrality factor to the
Federal per diem and ECT base rates to
ensure that total payments under the
IPF PPS in the implementation period
would equal the amount that would
have been paid if the IPF PPS had not
been implemented. The budget
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neutrality factor includes the following
components: outlier adjustment, stoploss adjustment, and the behavioral
offset. We do not plan to change any of
these adjustment factors or projections
until we analyze IPF PPS data. In
accordance with § 412.424(c)(3)(ii), we
will evaluate the accuracy of the budget
neutrality adjustment within the first 5
years after implementation of the
payment system. We may make a onetime prospective adjustment to the
Federal per diem and ECT base rates to
account for differences between the
historical data on cost-based TEFRA
payments (the basis of the budget
neutrality adjustment) and estimates of
TEFRA payments based on actual data
from the first year of the IPF PPS. As
part of that process, we will re-assess
the accuracy of all of the factors
impacting budget neutrality.
In addition, as discussed in section
VI.C.1 of this final rule, we are adopting
the new CBSAs and labor market share
in a budget neutral manner by applying
a wage index budget neutrality factor to
the Federal per diem and ECT base
rates. Thus, the budgetary impact to the
Medicare program by the update of the
IPF PPS will be the combination of the
market basket updates (see section V.C
of this final rule), the revision of the
standardization factor (see section V.B.3
of this final rule), and the planned
update of the payment blend discussed
below.
2. Impacts on Providers
To understand the impact of the
changes to the IPF PPS discussed in this
final rule on providers, it is necessary to
compare estimated payments under the
IPF PPS rates and factors for the RY
2007 to estimated payments under the
IPF PPS rates and factors for the IPF PPS
implementation year. The estimated
payments for the IPF implementation
year are a blend of: 75 percent of the
facility-specific TEFRA payment and 25
percent of the IPF PPS payment with
stop loss payment. The estimated
payments for the IPF PPS RY 2007 are
a blend of: 50 percent of the facilityspecific TEFRA payment and 50 percent
of the IPF PPS payment with stop loss
payment. We determined the percent
change of estimated 2007 IPF PPS RY
payments to estimated IPF PPS
implementation year payments for each
category of IPFs. In addition, for each
category of IPFs, we have included the
estimated percent change in payments
resulting from the revision of the
standardization factor (as discussed in
section V.B.3 of this final rule, the ratio
of estimated total TEFRA payments to
estimated total PPS payments in the
implementation year was overestimated
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and therefore needed to be reduced. We
will apply the revised standardization
factor prospectively to the Federal per
diem base rate and ECT amount), the
wage index changes for the IPF PPS RY
2007, the market basket update to IPF
PPS payments, and the transition blend
for the IPF PPS RY 2007 payment and
the facility-specific TEFRA payment.
To illustrate the impacts of the final
RY 2007 changes, our analysis begins
with an implementation year baseline
simulation model based on FY 2002 IPF
payments inflated to 2005 with market
baskets; the estimated outlier payments
in 2005; the estimated stop-loss
payments in 2005; the MSA
designations for IPFs based on OMB’s
MSA definitions before June 2003; the
2005 MSA wage index; the
implementation year labor-market share;
and the implementation year percentage
amount of the rural adjustment. During
the simulation, the outlier payment is
maintained at the target of 2 percent of
total PPS payments.
Each of the following changes is
added incrementally to this baseline
model in order for us to isolate the
effects of each change:
• IPF PPS payments adjusted by the
revised standardization factor.
• The new CBSAs based on new
geographic area definitions announced
by OMB in June 2003 and the RY 2007
final budget-neutral labor-related share
and wage index adjustment.
• A blended market basket update of
4.5 percent resulting in an update to the
hospital-specific TEFRA target amount
and an update to the IPF PPS base rates
as discussed below.
++ In the IPPS final rule published
August 12, 2005 (70 FR 47707), we
established an update factor of 3.8
percent effective for cost reporting
periods beginning on or after October 1,
2005 using the 2002-based excluded
hospital market basket. The 3.8 percent
update is applied to the IPF’s
established TEFRA target amount for
cost reporting periods beginning on or
after October 1, 2005. However, since
the midpoints of the RY 2007 and the
IPF PPS implementation period are 15
months apart, the TEFRA payment
increase is projected to be 4.6 percent.
++ An update to the Federal per diem
base rate of 4.3 percent based on the
2002-based RPL market basket (see
section V.C.1.b of this final rule). The
market basket update is based on a 15month time period (from the midpoint
of the IPF PPS implementation period to
the midpoint of the RY 2007).
• The transition to 50 percent IPF
PPS payment and 50 percent facilityspecific TEFRA payment.
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Our final comparison illustrates the
percent change in payments from the
IPF PPS implementation year (that is,
January 1, 2005 to June 30, 2006) to RY
27083
2007 (that is, July 1, 2006 to June 30,
2007).
TABLE 15.—PROJECTED IMPACTS
mmaher on PROD1PC60 with RULES2
Facility by type
(1)
Number of
facilities
(2)
All Facilities
By Type of Ownership:
Psychiatric Hospitals:
Government
Non-profit
For-profit
Psychiatric
Units
Rural
Urban
By Urban or Rural
Classification:
Urban by Facility
Type:
Psychiatric Hospitals:
Government
Non-profit
For-profit
Psychiatric
Units
Rural by Facility
Type:
Psychiatric Hospitals:
Government
Non-profit
For-profit
Psychiatric
Units
By Teaching Status:
Non-teaching
Less than
10% interns and
residents
to beds
10% to 30%
interns and
residents
to beds
More than
30% interns and
residents
to beds
By Region:
New England
Mid-Atlantic
South Atlantic
East North
Central
East South
Central
West North
Central
West South
Central
Mountain
Pacific
By Bed Size:
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Standardization
factor correction
(percent)
(3)
00:49 May 09, 2006
CBSA wage
index and labor
share
(percent)
(4)
Market basket
(percent)
(5)
Transition blend
(percent)
(6)
Total
(percent)
(7)
1,806
¥0.3
0.0
4.5
¥0.2
4.0
178
79
150
¥0.5
¥0.4
¥0.4
0.1
0.1
0.1
4.5
4.5
4.5
11.0
1.6
4.3
15.6
6.0
8.7
1,399
385
1,421
¥0.3
¥0.3
¥0.3
0.0
0.0
0.0
4.5
4.5
4.5
¥1.8
¥0.9
¥0.1
2.3
3.2
4.1
144
73
143
¥0.5
¥0.4
¥0.4
0.1
0.1
0.1
4.5
4.5
4.5
10.9
1.7
4.4
15.4
6.1
8.8
1,061
¥0.3
0.0
4.5
¥1.7
2.4
34
6
7
¥0.5
¥0.3
¥0.2
¥0.1
0.3
¥0.1
4.5
4.5
4.5
12.0
¥0.7
¥1.8
16.3
3.9
2.4
338
¥0.3
0.0
4.5
¥2.0
2.1
1,537
¥0.3
0.0
4.5
¥0.4
3.8
148
¥0.3
0.1
4.5
0.5
4.7
72
¥0.3
0.0
4.5
0.4
4.6
49
¥0.4
0.1
4.5
0.0
4.3
126
306
¥0.3
¥0.4
0.0
0.2
4.5
4.5
¥0.4
2.9
3.8
7.3
238
¥0.3
¥0.2
4.5
0.1
4.0
325
¥0.3
¥0.1
4.5
¥1.5
2.6
159
¥0.4
¥0.1
4.5
¥0.3
3.7
169
¥0.3
¥0.2
4.5
¥1.0
3.0
237
83
156
¥0.3
¥0.3
¥0.3
¥0.1
¥0.1
0.3
4.5
4.5
4.5
¥2.7
¥0.4
¥0.5
1.4
3.7
4.0
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TABLE 15.—PROJECTED IMPACTS—Continued
Facility by type
(1)
Standardization
factor correction
(percent)
(3)
Number of
facilities
(2)
Psychiatric Hospitals:
Under 12
beds
12 to 25
beds
25 to 50
beds
50 to 75
beds
Over 75
beds
Psychiatric Units:
Under 12
beds
12 to 25
beds
25 to 50
beds
50 to 75
beds
Over 75
beds
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Transition blend
(percent)
(6)
Total
(percent)
(7)
¥0.2
0.1
4.5
¥3.8
0.6
46
¥0.3
¥0.2
4.5
0.2
4.3
91
¥0.4
0.1
4.5
4.2
8.6
82
¥0.4
0.1
4.5
3.8
8.3
162
¥0.5
0.1
4.5
8.6
13.0
600
¥0.3
¥0.1
4.5
¥4.5
¥0.5
474
¥0.3
0.0
4.5
¥1.9
2.2
228
¥0.3
0.0
4.5
¥0.6
3.5
58
¥0.3
0.0
4.5
0.1
4.3
39
¥0.4
0.0
4.5
1.3
5.5
Table 15 above displays the results of
our analysis. The table groups IPFs into
the categories listed below based on
characteristics provided in the Online
Survey and Certification and Reporting
(OSCAR) file and the FY 2002 cost
report data from HCRIS:
• Facility Type
• Location
• Teaching Status Adjustment
• Census Region
• Size
The top row of the table shows the
overall impact on the 1,806 IPFs
included in the analysis.
In column 3, we present the effects of
the revised standardization factor (see
section V.B.3 of this final rule for a
discussion of this revision). This is
defined to be the comparison of the
simulated implementation year
payments under the revised
standardization factor to the simulated
implementation year payments under
the original standardization factor. In
aggregate, the revision is projected to
result in a 0.3 percent decrease in
overall payments to IPFs. There are
small distributional effects among
different categories of IPFs. For
example, urban and rural government
psychiatric hospitals and psychiatric
hospitals with over 75 beds will receive
the largest decrease of 0.5 percent, while
rural for-profit psychiatric hospitals and
psychiatric hospitals with fewer than 12
00:49 May 09, 2006
Market basket
(percent)
(5)
26
3. Results
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CBSA wage
index and labor
share
(percent)
(4)
Jkt 208001
beds will receive the smallest decrease
of 0.2 percent.
In column 4, we present the effects of
the budget-neutral update to the laborrelated share and the wage index
adjustment under the new CBSA
geographic area definitions announced
by OMB in June 2003. This is a
comparison of the simulated
implementation year payments under
revised budget neutral factor and laborrelated share and wage index under
CBSA classification to the simulated
implementation year payments under
revised budget neutral factor and laborrelated share and wage index under
current MSA classifications. There is no
projected change in aggregate payments
to IPFs, as indicated in the first row of
column 4. There would, however, be
small distributional effects among
different categories of IPFs. For
example, several categories of IPFs, such
as IPFs located in the South Atlantic
and West North Central regions, and
psychiatric hospitals with between 12
and 25 beds, will experience a 0.2
percent decrease in payments. Rural
non-profit hospitals and hospitals
located in the Pacific region will receive
the largest increase of 0.3 percent.
In column 5, we present the effects of
the market basket update to the IPF PPS
payments by applying the TEFRA and
PPS updates to payments under revised
budget neutral factor and labor-related
share and wage index under CBSA
classification. In the aggregate this
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update is projected to be a 4.5 percent
increase in overall payments to IPFs.
This 4.5 percent reflects the current
blend of the 4.6 percent update for IPF
TEFRA payments and the 4.3 percent
update for the IPF PPS payments.
In column 6, we present the effects of
the payment change in transition blend
percentages to transition year 2 (TEFRA
Rate Percentage = 50 percent, IPF PPS
Federal Rate Percentage = 50 percent)
from transition year 1 (TEFRA Rate
Percentage = 75 percent, IPF PPS
Federal Rate Percentage = 25 percent) of
the IPF PPS under revised budget
neutral factor, labor-related share and
wage index under CBSA classification,
and TEFRA and PPS updates to RY
2007. The overall aggregate effect, across
all hospital groups, is projected to be a
0.2 percent decrease in payments to
IPFs. There are distributional effects of
these changes among different
categories of IPFs. The largest increases
will be among government psychiatric
hospitals, with rural government
hospitals receiving a 12.0 percent
increase and urban government
hospitals receiving a 10.9 percent
increase. Alternatively, psychiatric
hospitals and units with fewer than 12
beds will receive the largest decreases of
3.8 percent and 4.5 percent,
respectively.
Column 7 compares our estimates of
the changes reflected in this final rule
for RY 2007, to our estimates of
payments in the implementation year
E:\FR\FM\09MYR2.SGM
09MYR2
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(without these changes). This column
reflects all RY 2007 changes relative to
the implementation year (as shown in
columns 3 through 6). The average
increase for all IPFs is approximately
4.0 percent. This increase includes the
effects of the market basket updates
resulting in a 4.5 percent increase in
total RY 2007 payments. It also includes
a 0.3 percent decrease in RY 2007
payments for the standardization factor
revision and a 0.2 percent decrease in
RY 2007 payments for the transition
blend.
Overall, the largest payment increase
is projected to be among government
IPFs. Urban government psychiatric
hospitals will receive a 15.4 percent
increase and rural government
psychiatric hospitals will receive a 16.3
percent increase. Psychiatric hospitals
with fewer than 12 beds will receive a
0.6 percent increase and psychiatric
units with fewer than 12 beds will
receive a 0.5 percent decrease.
4. Effect on the Medicare Program
Based on actuarial projections
resulting from our experience with other
PPSs, we estimate that Medicare
spending (total Medicare program
payments) for IPF services over the next
5 years would be as follows:
TABLE 16.—ESTIMATED PAYMENTS
Rate year
mmaher on PROD1PC60 with RULES2
July 1, 2006 to June 30,
2007 ..................................
July 1, 2007 to June 30,
2008 ..................................
July 1, 2008 to June 30,
2009 ..................................
July 1, 2009 to June 30,
2010 ..................................
July 1, 2010 to June 30,
2011 ..................................
Dollars in
millions
5. Effect on Beneficiaries
$4,299
4,427
4,613
4,813
5,033
These estimates are based on the
current estimate of increases in the
excluded hospital with capital market
basket as follows:
• 3.4 percent for RY 2007;
• 3.1 percent for RY 2008;
• 2.8 percent for RY 2009;
• 2.3 percent for RY 2010; and
• 2.7 percent for RY 2011.
We estimate that there would be a
change in fee-for-service Medicare
beneficiary enrollment as follows:
• ¥0.3 percent in RY 2007;
• 0.1 percent in RY 2008;
• 0.2 percent in RY 2009;
• ¥0.3 percent in RY 2010; and
• ¥0.2 percent in RY 2011.
In the implementation year we
estimated aggregate payments under the
IPF PPS to equal the estimated aggregate
VerDate Aug<31>2005
00:49 May 09, 2006
Jkt 208001
payments that would be made if the IPF
PPS were not implemented. Our
methodology for estimating payments
for purposes of the budget-neutrality
calculations uses the best available data.
We will evaluate the accuracy of the
assumptions used to compute the
budget-neutrality calculation in the
implementation year. We intend to
analyze claims and cost report data from
the implementation year of the IPF PPS
to determine whether the factors used to
develop the Federal per diem base rate
are not significantly different from the
actual results experienced in that year.
We plan to compare payments under the
final IPF PPS (which relies on an
estimate of cost-based TEFRA payments
using historical data from a base year
and assumptions that trend the data to
the initial implementation period) to
estimated cost-based TEFRA payments
based on actual data from the first year
of the IPF PPS. If we find that an
adjustment is necessary, the percent
difference (either positive or negative)
would be applied prospectively to the
established prospective payment rates to
ensure the rates accurately reflect the
payment levels intended by the statute.
Section 124 of Pub. L. 106–113
provides the Secretary broad authority
to make an adjustment. We intend to
perform this analysis within the first 5
years of the implementation of the IPF
PPS.
Under the IPF PPS, IPFs will receive
payment based on the average resources
consumed by patients for each day. We
do not expect changes in the quality of
care or access to services for Medicare
beneficiaries under the IPF PPS. In fact,
we believe that access to IPF services
will be enhanced due to the patient and
facility level adjustment factors, all of
which are intended to adequately
reimburse IPFs for expensive cases.
Finally, the stop-loss policy is intended
to assist IPFs during the transition. In
addition, we expect that setting
payment rates prospectively for IPF
services would enhance the efficiency of
the Medicare program.
6. Computer Hardware and Software
We do not anticipate that IPFs would
incur additional systems operating costs
in order to effectively participate in the
IPF PPS. We believe that IPFs and CAHs
possess the computer hardware
capability to handle the billing
requirements under the IPF PPS. Our
belief is based on indications that
approximately 99 percent of hospital
inpatient claims are submitted
electronically. In addition, we are not
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27085
adopting significant changes in claims
processing.
C. Accounting Statement
As required by OMB Circular A–4
(available at https://
www.whitehouse.gov/omb/circulars/
a004/a-4.pdf), in Table 17 below, we
have prepared an accounting statement
showing the classification of the
expenditures associated with the
provisions of this final rule. This table
provides our best estimate of the
increase in Medicare payments under
the IPF PPS as a result of the changes
presented in this final rule based on the
data for 1,806 IPFs in our database. All
expenditures are classified as transfers
to Medicare providers (that is, IPFs).
TABLE 17.—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED EXPENDITURES, FROM THE
2006 IPF PPS RY TO THE 2007
IPF PPS RY
[In millions]
Category
Annualized Monetized
Transfers.
From Whom To
Whom?.
Transfers
$170.
Federal Government
To IPFs Medicare
Providers.
D. Alternatives Considered
We considered the following
alternatives in developing the update to
the IPF PPS:
One option we considered was
incorporating a transition from MSAbased labor market definitions to CBSAbased labor market definitions for the
purpose of applying the area wage
index. As stated in section VI.C.1.e of
this final rule, we are not adopting a
transition policy here because IPFs are
already in a transition from reasonable
cost based reimbursement to IPF PPS
payments. In addition, as evident in
Table 15 above, the wage index change
does not appear to have a large impact
on IPFs.
We also considered increasing our
outlier percentage so that outlier
payments would be projected to be 3
percent (or higher) of total PPS
payments. However, this approach
would not target the truly costly cases.
Instead, implementing such a policy
would have the effect of lowering the
fixed dollar loss threshold amount,
therefore spreading outlier payments
across more IPFs. In addition, the
Federal per diem base rate would have
to be reduced by another percentage
point.
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Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
In this final rule, we used the best
available complete data set (that is, FY
2002 claims and cost report data) to
assess the impact of the various policy
changes. As previously stated, we will
not know the true impact of the wage
index changes, the transition blend
period, or the market basket increases
until we analyze IPF PPS data.
We considered alternative policies in
order to reduce financial risk to
facilities in the event that they
experience substantial reductions in
Medicare payments during the period of
transition to the IPF PPS. The stop-loss
adjustment is applied to the IPF PPS
portion of Medicare payments during
the transition. We estimate that about 10
percent of IPFs would receive additional
payments under the stop-loss policy.
The 70 percent of TEFRA stop-loss
policy required a reduction in the per
diem rate to make the stop-loss policy
budget neutral during the
implementation year. As a result, in the
November 2004 IPF PPS final rule, we
made a reduction to the Federal per
diem base rate of 0.4 percent for budget
neutrality.
In developing this final rule, we again
considered an 80 percent stop-loss
policy for RY 2007. Adopting an 80
percent policy would require a
reduction in the Federal per diem base
rate of over 2.5 percent, and we estimate
that about 29 percent of IPFs would
receive additional payments. We chose
to stay with the 70 percent policy for the
same reasons discussed in the
November 2004 IPF PPS final rule.
Specifically, the 70 percent stop-loss
policy targets the IPFs that experience
the greatest impact relative to current
payments, and it limits the size of the
reduction to the Federal per diem base
rate.
In accordance with the provisions of
Executive Order 12866, this rule was
previously reviewed by OMB.
List of Subjects
42 CFR Part 412
Administrative practice and
procedure, Health facilities, Medicare,
Puerto Rico, Reporting and
recordkeeping requirements.
mmaher on PROD1PC60 with RULES2
42 CFR Part 424
Emergency medical services, Health
facilities, Health professions, Medicare,
Reporting and recordkeeping
requirements.
For the reasons set forth in the
preamble, the Centers for Medicare &
Medicaid Services amends 42 CFR
chapter IV as follows:
I
VerDate Aug<31>2005
00:49 May 09, 2006
Jkt 208001
PART 412—PROSPECTIVE PAYMENT
SYSTEMS FOR HOSPITAL SERVICES
1. The authority citation for part 412
is revised to read as follows:
I
Authority: Secs. 1102 and 1871 of the
Social Security Act (42 U.S.C. 1302 and
1395hh), Sec. 124 of Pub. L. 106–113, 113
Stat. 1515, and Sec. 405 of Pub. L. 108–173,
117 Stat. 2266.
2. Amend § 412.27 by revising
paragraph (b) to read as follows:
I
§ 412.27 Excluded psychiatric units:
Additional requirements.
*
*
*
*
*
(b) Furnish, through the use of
qualified personnel, psychological
services, social work services,
psychiatric nursing, and therapeutic
activities.
*
*
*
*
*
I 3. Section 412.402 is amended by—
I A. Republishing the introductory text.
I B. Removing the definition of ‘‘Fixed
dollar loss threshold.’’
I C. Adding the definitions of ‘‘Fixed
dollar loss threshold amount,’’ and
‘‘new graduate medical education
program’’ in alphabetical order.
I D. Revising the definitions of
‘‘Qualifying emergency department,’’
‘‘Rural area,’’ and ‘‘Urban area.’’
The revisions and additions read as
follows:
§ 412.402
Definitions.
As used in this subpart—
*
*
*
*
*
Fixed dollar loss threshold amount
means a dollar amount which, when
added to the Federal payment amount
for a case, the estimated costs of a case
must exceed in order for the case to
qualify for an outlier payment.
*
*
*
*
*
New graduate medical education
program means a medical education
program that receives initial
accreditation by the appropriate
accrediting body or begins training
residents on or after November 15, 2004.
*
*
*
*
*
Qualifying emergency department
means an emergency department that is
staffed and equipped to furnish a
comprehensive array of emergency
services and meeting the definitions of
a dedicated emergency department as
specified in § 489.24(b) of this chapter
and the definition of ‘‘provider-based
status’’ as specified in § 413.65 of this
chapter.
Rural area means for cost reporting
periods beginning January 1, 2005, with
respect to discharges occurring during
the period covered by such cost reports
but before July 1, 2006, an area as
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Frm 00048
Fmt 4701
Sfmt 4700
defined in § 412.62(f)(1)(iii). For
discharges occurring on or after July 1,
2006, rural area means an area as
defined in § 412.64(b)(1)(ii)(C).
Urban area means for cost reporting
periods beginning on or after January 1,
2005, with respect to discharges
occurring during the period covered by
such cost reports but before July 1, 2006,
an area as defined in § 412.62(f)(1)(ii).
For discharges occurring on or after July
1, 2006, urban area means an area as
defined in § 412.64(b)(1)(ii)(A) and
§ 412.64(b)(1)(ii)(B).
I 4. Section 412.424 is amended by—
I A. Revising paragraph (d)(l)(iii).
I B. Republishing the heading of
paragraph (d)(1)(v).
I C. Revising paragraph (d)(1)(v)(A).
I D. Adding paragraph (d)(2)
introductory text.
I E. Removing and reserving paragraph
(d)(2)(iii).
I F. Revising paragraphs (d)(3)(i)
introductory text and (d)(3)(i)(A).
The revisions and additions read as
follows:
§ 412.424 Methodology for calculating the
Federal per diem payment amount.
*
*
*
*
*
(d) * * *
(1) * * *
(iii) Teaching adjustment. CMS
adjusts the Federal per diem base rate
by a factor to account for indirect
teaching costs.
(A) An inpatient psychiatric facility’s
teaching adjustment is based on the
ratio of the number of full-time
equivalent residents training in the
inpatient psychiatric facility divided by
the facility’s average daily census.
(B) Residents with less than full-time
status and residents rotating through the
inpatient psychiatric facility for less
than a full year will be counted in
proportion to the time they spend in the
inpatient psychiatric facility.
(C) Except as described in paragraph
(d)(1)(iii)(D) of this section, the actual
number of current year full-time
equivalent residents used in calculating
the teaching adjustment is limited to the
number of full-time equivalent residents
in the inpatient psychiatric facility’s
most recently filed cost report filed with
its fiscal intermediary before November
15, 2004 (base year).
(D) If the inpatient psychiatric facility
first begins training residents in a new
approved graduate medical education
program after November 15, 2004, the
number of full-time equivalent residents
determined under paragraph
(d)(1)(iii)(C) of this section may be
adjusted using the method described in
§ 413.79(e)(1)(i) and (ii) of this chapter.
(E) The teaching adjustment is made
on a claim basis as an interim payment,
E:\FR\FM\09MYR2.SGM
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Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
and the final payment in full for the
claim is made during the final
settlement of the cost report.
*
*
*
*
*
(v) Adjustment for IPF with qualifying
emergency departments. (A) CMS
adjusts the Federal per diem base rate to
account for the costs associated with
maintaining a qualifying emergency
department. A qualifying emergency
department is staffed and equipped to
furnish a comprehensive array of
emergency services (medical and
psychiatric) and meets the requirements
of § 489.24(b) and § 413.65 of this
chapter.
*
*
*
*
*
(2) Patient-level adjustments. The
inpatient psychiatric facility must
identify a principal psychiatric
diagnosis as specified in § 412.27(a) for
each patient. CMS adjusts the Federal
per diem base rate by a factor to account
for the diagnosis-related group
assignment associated with the
principal diagnosis, as specified by
CMS.
*
*
*
*
*
(3) Other adjustments. (i) Outlier
payments. CMS provides an outlier
payment if an inpatient psychiatric
facility’s estimated total cost for a case
exceeds a fixed dollar loss threshold
amount for an inpatient psychiatric
facility as defined in § 412.402 plus the
Federal payment amount for the case.
(A) The fixed dollar loss threshold
amount is adjusted for the inpatient
psychiatric facility’s adjustments for
wage area, teaching, rural locations, and
cost of living adjustment for facilities
located in Alaska and Hawaii.
*
*
*
*
*
§ 412.426
[Amended]
5. In § 412.426, paragraph (a)
introductory text is amended by
removing the reference ‘‘§ 412.424(c)’’
and adding the reference ‘‘§ 412.424(d)’’
in its place.
I 6. Section 412.428 is amended by—
I A. Republishing the introductory text.
I B. Revising paragraph (b) and (d).
I C. Adding a new paragraph (g).
I D. Adding a new paragraph (h).
The revision and additions reads as
follows:
I
PART 424—CONDITIONS FOR
MEDICARE PAYMENT
mmaher on PROD1PC60 with RULES2
§ 412.428 Publication of updates to the
inpatient psychiatric facility prospective
payment system.
00:49 May 09, 2006
Jkt 208001
7. The authority citation for part 424
continues to read as follows:
I
CMS will publish annually in the
Federal Register information pertaining
to updates to the inpatient psychiatric
facility prospective payment system.
This information includes:
*
*
*
*
*
(b)(1) For discharges occurring on or
after January 1, 2005 but before July 1,
VerDate Aug<31>2005
2006, the rate of increase factor,
described in § 412.424(a)(2)(iii), for the
Federal portion of the inpatient
psychiatric facility’s payment is based
on the excluded hospital with capital
market basket under the update
methodology described in section
1886(b)(3)(B)(ii) of the Act for each year.
(2) For discharges occurring on or
after July 1, 2006, the rate of increase
factor for the Federal portion of the
inpatient psychiatric facility’s payment
is based on the Rehabilitation,
Psychiatric, and Long-Term Care (RPL)
market basket.
(3) For discharges occurring on or
after January 1, 2005 but before October
1, 2005, the rate of increase factor,
described in § 412.424(a)(2)(iii), for the
reasonable cost portion of the inpatient
psychiatric facility’s payment is based
on the 1997-based excluded hospital
market basket under the updated
methodology described in section
1886(b)(3)(B)(ii) of the Act for each year.
(4) For discharges occurring on or
after October 1, 2005, the rate of
increase factor for the reasonable cost
portion of the inpatient psychiatric
facility’s payment is based on the 2002based excluded hospital market basket.
*
*
*
*
*
(d) Updates to the fixed dollar loss
threshold amount in order to maintain
the appropriate outlier percentage.
*
*
*
*
*
(g) Update the national urban and
rural cost to charge ratio median and
ceilings. CMS will apply the national
cost to charge ratio to—
(1) New inpatient psychiatric facilities
that have not submitted their first
Medicare cost report.
(2) Inpatient psychiatric facilities
whose operating or capital cost to
charge ratio is in excess of 3 standard
deviations above the corresponding
national geometric mean.
(3) Other inpatient psychiatric
facilities for which the fiscal
intermediary obtains inaccurate or
incomplete data with which to calculate
either an operating or capital cost to
charge ratio or both.
(h) Update the cost of living
adjustment factor if appropriate.
Authority: Secs. 1102 and 1871 of the
Social Security Act (42 U.S.C. 1302 and
1395hh).
I
I
I
I
8. Section 424.14 is amended by—
A. Revising the heading.
B. Adding a new paragraph (c)(3).
C. Revising paragraph (d)(2).
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27087
The addition and revisions read as
follows:
§ 424.14 Requirements for inpatient
services of inpatient psychiatric facilities.
*
*
*
*
*
(c) * * *
(3) The patient continues to need, on
a daily basis, active inpatient
psychiatric care (furnished directly by
or requiring the supervision of inpatient
psychiatric facility personnel) or other
professional services that can only be
provided on an inpatient basis.
(d) * * *
(2) The first recertification is required
as of the 12th day of hospitalization.
Subsequent recertifications are required
at intervals established by the UR
committee (on a case-by-case basis if it
so chooses), but no less frequently than
every 30 days.
*
*
*
*
*
(Catalog of Federal Domestic Assistance
Program No. 93.778, Medical Assistance
Program)
(Catalog of Federal Domestic Assistance
Program No. 93.773, Medicare—Hospital
Insurance; and Program No. 93.774,
Medicare—Supplementary Medical
Insurance Program)
Dated: April 19, 2006.
Mark B. McClellan,
Administrator, Centers for Medicare &
Medicaid Services.
Approved: April 28, 2006.
Michael O. Leavitt,
Secretary.
Addendum A—Rate and Adjustment
Factors
PER DIEM RATE
Federal Per Diem Base Rate .......
Labor Share (0.75665) .................
Non-Labor Share (0.24335) .........
$595.09
450.27
144.82
FIXED DOLLAR LOSS THRESHOLD
AMOUNT
$6200
FACILITY ADJUSTMENTS
Rural Adjustment
Factor.
Teaching Adjustment
Factor.
Wage Index ...............
1.17.
0.5150.
Pre-reclass Hospital
Wage Index
(FY2006).
COST OF LIVING ADJUSTMENTS
(COLAS)
Alaska ...........................................
Hawaii:
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09MYR2
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Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
COST OF LIVING ADJUSTMENTS
(COLAS)—Continued
Honolulu County ....................
Hawaii County .......................
Kauai County .........................
Maui County ..........................
Kalawao County ....................
VARIABLE PER DIEM ADJUSTMENTS—
Continued
1.25
1.165
1.2325
1.2375
1.2375
PATIENT ADJUSTMENTS
ECT—Per Treatment ....................
$256.20
VARIABLE PER DIEM ADJUSTMENTS
Adjustment
factor
Day 1—Facility Without a
Qualifying Emergency Department ................................
Day 1—Facility With a Qualifying Emergency Department
1.19
1.31
VARIABLE PER DIEM ADJUSTMENTS—
Continued
Adjustment
factor
Adjustment
factor
Day
Day
Day
Day
Day
Day
Day
Day
Day
Day
Day
Day
Day
Day
Day
Day
Day
Day
Day
2 ........................................
3 ........................................
4 ........................................
5 ........................................
6 ........................................
7 ........................................
8 ........................................
9 ........................................
10 ......................................
11 ......................................
12 ......................................
13 ......................................
14 ......................................
15 ......................................
16 ......................................
17 ......................................
18 ......................................
19 ......................................
20 ......................................
1.12
1.08
1.05
1.04
1.02
1.01
1.01
1.00
1.00
0.99
0.99
0.99
0.99
0.98
0.97
0.97
0.96
0.95
0.95
Day 21 ......................................
After Day 21 .............................
0.95
0.92
AGE ADJUSTMENTS
Adjustment
factor
Age (in years)
Under 45 ...................................
45 and under 50 .......................
50 and under 55 .......................
55 and under 60 .......................
60 and under 65 .......................
65 and under 70 .......................
70 and under 75 .......................
75 and under 80 .......................
80 and over ..............................
1.00
1.01
1.02
1.04
1.07
1.10
1.13
1.15
1.17
DRG ADJUSTMENTS
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
DRG
424 ...........
425 ...........
426 ...........
427 ...........
428 ...........
429 ...........
430 ...........
431 ...........
432 ...........
433 ...........
521 ...........
522 ...........
523 ...........
12 .............
23 .............
O.R. Procedure with Principal Diagnosis of Mental Illness .....................................................................................
Acute Adjustment Reaction & Psychosocial Dysfunction ........................................................................................
Depressive Neurosis ................................................................................................................................................
Neurosis, Except Depressive ...................................................................................................................................
Disorders of Personality & Impulse Control .............................................................................................................
Organic Disturbances & Mental Retardation ...........................................................................................................
Psychosis .................................................................................................................................................................
Childhood Mental Disorders .....................................................................................................................................
Other Mental Disorders Diagnoses ..........................................................................................................................
Alcohol/Drug Abuse or Dependence Leave Against Medical Advice (LAMA) ........................................................
Alcohol/Drug Abuse or Dependence with Comorbid Conditions .............................................................................
Alcohol/Drug Abuse or Dependence with Rehabilitation Therapy without Comorbid Conditions ...........................
Alcohol/Drug Abuse or Dependence without Rehabilitation Therapy ......................................................................
Degenerative Nervous System Disorders without Comorbid Conditions ................................................................
Non-traumatic Stupor & Coma .................................................................................................................................
COMORBIDITY ADJUSTMENTS
Comorbidity
COMORBIDITY ADJUSTMENTS—
Continued
Adjustment
factor
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
.......
.......
.......
.......
.......
.......
.......
.......
VerDate Aug<31>2005
1.04
1.13
1.06
1.12
1.07
1.11
1.11
1.07
1.05
Severe Protein Calorie Malnutrition .................................
Drug/Alcohol Induced Mental
Disorders ...............................
Cardiac Conditions ...................
Gangrene ..................................
Chronic Obstructive Pulmonary
Disease .................................
County name
Autauga County, Alabama ....................................................
Baldwin County, Alabama .....................................................
Barbour County, Alabama .....................................................
Bibb County, Alabama ..........................................................
Blount County, Alabama .......................................................
Bullock County, Alabama ......................................................
Butler County, Alabama ........................................................
Calhoun County, Alabama ....................................................
00:49 May 09, 2006
Jkt 208001
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1.13
1.03
1.11
1.10
1.12
MSA No.
Frm 00050
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5240
5160
01
01
1000
01
01
0450
Sfmt 4700
1.22
1.05
0.99
1.02
1.02
1.03
1.00
0.99
0.92
0.97
1.02
0.98
0.88
1.05
1.07
COMORBIDITY ADJUSTMENTS—
Continued
Adjustment
factor
Comorbidity
Developmental Disabilities .......
Coagulation Factor Deficit ........
Tracheostomy ...........................
Eating and Conduct Disorders
Infectious Diseases ..................
Renal Failure, Acute .................
Renal Failure, Chronic ..............
Oncology Treatment .................
Uncontrolled Diabetes Mellitus
with or without Complications
01000
01010
01020
01030
01040
01050
01060
01070
Adjustment
factor
DRG definition
MSA
urban/
rural
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Adjustment
factor
Comorbidity
Artificial Openings - Digestive &
Urinary ...................................
Severe Musculoskeletal & Connective Tissue Diseases .......
Poisoning ..................................
1.08
1.09
1.11
Addendum B—RY 2007 IPF PPS Wage
Index Table
2006
MSAbased WI
CBSA
No.
0.8618
0.7861
0.7432
0.7432
0.9000
0.7432
0.7432
0.7682
E:\FR\FM\09MYR2.SGM
09MYR2
33860
99901
99901
13820
13820
99901
99901
11500
CBSA
urban/
rural
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Urban
2006
CBSAbased WI
0.8618
0.7446
0.7446
0.8959
0.8959
0.7446
0.7446
0.7682
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
01080
01090
01100
01110
01120
01130
01140
01150
01160
01170
01180
01190
01200
01210
01220
01230
01240
01250
01260
01270
01280
01290
01300
01310
01320
01330
01340
01350
01360
01370
01380
01390
01400
01410
01420
01430
01440
01450
01460
01470
01480
01490
01500
01510
01520
01530
01540
01550
01560
01570
01580
01590
01600
01610
01620
01630
01640
01650
01660
02013
02016
02020
02030
02040
02050
02060
02068
02070
02080
02090
02100
02110
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VerDate Aug<31>2005
County name
MSA No.
Chambers County, Alabama .................................................
Cherokee County, Alabama ..................................................
Chilton County, Alabama ......................................................
Choctaw County, Alabama ...................................................
Clarke County, Alabama .......................................................
Clay County, Alabama ..........................................................
Cleburne County, Alabama ...................................................
Coffee County, Alabama .......................................................
Colbert County, Alabama ......................................................
Conecuh County, Alabama ...................................................
Coosa County, Alabama .......................................................
Covington County, Alabama .................................................
Crenshaw County, Alabama .................................................
Cullman County, Alabama ....................................................
Dale County, Alabama ..........................................................
Dallas County, Alabama .......................................................
De Kalb County, Alabama ....................................................
Elmore County, Alabama ......................................................
Escambia County, Alabama ..................................................
Etowah County, Alabama .....................................................
Fayette County, Alabama .....................................................
Franklin County, Alabama .....................................................
Geneva County, Alabama .....................................................
Greene County, Alabama .....................................................
Hale County, Alabama ..........................................................
Henry County, Alabama ........................................................
Houston County, Alabama ....................................................
Jackson County, Alabama ....................................................
Jefferson County, Alabama ...................................................
Lamar County, Alabama .......................................................
Lauderdale County, Alabama ...............................................
Lawrence County, Alabama ..................................................
Lee County, Alabama ...........................................................
Limestone County, Alabama .................................................
Lowndes County, Alabama ...................................................
Macon County, Alabama .......................................................
Madison County, Alabama ....................................................
Marengo County, Alabama ...................................................
Marion County, Alabama ......................................................
Marshall County, Alabama ....................................................
Mobile County, Alabama .......................................................
Monroe County, Alabama .....................................................
Montgomery County, Alabama .............................................
Morgan County, Alabama .....................................................
Perry County, Alabama .........................................................
Pickens County, Alabama .....................................................
Pike County, Alabama ..........................................................
Randolph County, Alabama ..................................................
Russell County, Alabama ......................................................
St Clair County, Alabama .....................................................
Shelby County, Alabama ......................................................
Sumter County, Alabama ......................................................
Talladega County, Alabama ..................................................
Tallapoosa County, Alabama ................................................
Tuscaloosa County, Alabama ...............................................
Walker County, Alabama ......................................................
Washington County, Alabama ..............................................
Wilcox County, Alabama .......................................................
Winston County, Alabama ....................................................
Aleutians County East, Alaska ..............................................
Aleutians County West, Alaska .............................................
Anchorage County, Alaska ...................................................
Angoon County, Alaska ........................................................
Barrow-North Slope County, Alaska .....................................
Bethel County, Alaska ...........................................................
Bristol Bay Borough County, Alaska .....................................
Denali County, Alaska ...........................................................
Bristol Bay County, Alaska ...................................................
Cordova-Mc Carthy County, Alaska .....................................
Fairbanks County, Alaska .....................................................
Haines County, Alaska ..........................................................
Juneau County, Alaska .........................................................
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Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.7432
0.7432
0.7432
0.7432
0.7432
0.7432
0.7432
0.7432
0.8272
0.7432
0.7432
0.7432
0.7432
0.7432
0.7701
0.7432
0.7432
0.8618
0.7432
0.7938
0.7432
0.7432
0.7432
0.7432
0.7432
0.7432
0.7701
0.7432
0.9000
0.7432
0.8272
0.8469
0.8100
0.9146
0.7432
0.7432
0.9146
0.7432
0.7432
0.7432
0.7861
0.7432
0.8618
0.8469
0.7432
0.7432
0.7432
0.7432
0.8560
0.9000
0.9000
0.7432
0.7432
0.7432
0.8764
0.7432
0.7432
0.7432
0.7432
1.1888
1.1888
1.1784
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
E:\FR\FM\09MYR2.SGM
09MYR2
99901
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99901
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99901
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22520
99901
99901
99901
99901
99901
99901
99901
99901
33860
99901
23460
99901
99901
20020
46220
46220
20020
20020
99901
13820
99901
22520
19460
12220
26620
33860
99901
26620
99901
99901
99901
33660
99901
33860
19460
99901
99901
99901
99901
17980
13820
13820
99901
99901
99901
46220
13820
99901
99901
99901
99902
99902
11260
99902
99902
99902
99902
99902
99902
99902
21820
99902
99902
CBSA
urban/
rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
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Urban
Rural
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Rural
Rural
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
27089
2006
CBSAbased WI
0.7446
0.7446
0.8959
0.7446
0.7446
0.7446
0.7446
0.7446
0.8272
0.7446
0.7446
0.7446
0.7446
0.7446
0.7446
0.7446
0.7446
0.8618
0.7446
0.7938
0.7446
0.7446
0.7721
0.8645
0.8645
0.7721
0.7721
0.7446
0.8959
0.7446
0.8272
0.8469
0.8100
0.9146
0.8618
0.7446
0.9146
0.7446
0.7446
0.7446
0.7891
0.7446
0.8618
0.8469
0.7446
0.7446
0.7446
0.7446
0.8560
0.8959
0.8959
0.7446
0.7446
0.7446
0.8645
0.8959
0.7446
0.7446
0.7446
1.1977
1.1977
1.1895
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1408
1.1977
1.1977
27090
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
02120
02122
02130
02140
02150
02160
02164
02170
02180
02185
02188
02190
02200
02201
02210
02220
02230
02231
02232
02240
02250
02260
02261
02270
02280
02282
02290
03000
03010
03020
03030
03040
03050
03055
03060
03070
03080
03090
03100
03110
03120
03130
04000
04010
04020
04030
04040
04050
04060
04070
04080
04090
04100
04110
04120
04130
04140
04150
04160
04170
04180
04190
04200
04210
04220
04230
04240
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VerDate Aug<31>2005
County name
MSA No.
Kenai-Cook Inlet County, Alaska ..........................................
Kenai Peninsula Borough, Alaska ........................................
Ketchikan County, Alaska .....................................................
Kobuk County, Alaska ...........................................................
Kodiak County, Alaska ..........................................................
Kuskokwin County, Alaska ....................................................
Lake and Peninsula Borough, Alaska ...................................
Matanuska County, Alaska ...................................................
Nome County, Alaska ...........................................................
North Slope Borough, Alaska ...............................................
Northwest Arctic Borough, Alaska ........................................
Outer Ketchikan County, Alaska ...........................................
Prince Of Wales County, Alaska ..........................................
Prince of Wales-Outer Ketchikan Census Area, Alaska ......
Seward County, Alaska .........................................................
Sitka County, Alaska .............................................................
Skagway-Yakutat County, Alaska .........................................
Skagway-Yakutat-Angoon Census Area, Alaska ..................
Skagway-Hoonah-Angoon Census Area, Alaska .................
Southeast Fairbanks County, Alaska ....................................
Upper Yukon County, Alaska ................................................
Valdz-Chitna-Whitier County, Alaska ....................................
Valdex-Cordove Census Area, Alaska .................................
Wade Hampton County, Alaska ............................................
Wrangell-Petersburg County, Alaska ....................................
Yakutat Borough, Alaska ......................................................
Yukon-Koyukuk County, Alaska ............................................
Apache County, Arizona .......................................................
Cochise County, Arizona ......................................................
Coconino County, Arizona ....................................................
Gila County, Arizona .............................................................
Graham County, Arizona ......................................................
Greenlee County, Arizona .....................................................
La Paz County, Arizona ........................................................
Maricopa County, Arizona .....................................................
Mohave County, Arizona .......................................................
Navajo County, Arizona ........................................................
Pima County, Arizona ...........................................................
Pinal County, Arizona ...........................................................
Santa Cruz County, Arizona .................................................
Yavapai County, Arizona ......................................................
Yuma County, Arizona ..........................................................
Arkansas County, Arkansas ..................................................
Ashley County, Arkansas ......................................................
Baxter County, Arkansas ......................................................
Benton County, Arkansas .....................................................
Boone County, Arkansas ......................................................
Bradley County, Arkansas ....................................................
Calhoun County, Arkansas ...................................................
Carroll County, Arkansas ......................................................
Chicot County, Arkansas ......................................................
Clark County, Arkansas ........................................................
Clay County, Arkansas .........................................................
Cleburne County, Arkansas ..................................................
Cleveland County, Arkansas .................................................
Columbia County, Arkansas .................................................
Conway County, Arkansas ....................................................
Craighead County, Arkansas ................................................
Crawford County, Arkansas ..................................................
Crittenden County, Arkansas ................................................
Cross County, Arkansas .......................................................
Dallas County, Arkansas .......................................................
Desha County, Arkansas ......................................................
Drew County, Arkansas ........................................................
Faulkner County, Arkansas ...................................................
Franklin County, Arkansas ....................................................
Fulton County, Arkansas .......................................................
Garland County, Arkansas ....................................................
Grant County, Arkansas ........................................................
Greene County, Arkansas .....................................................
Hempstead County, Arkansas ..............................................
Hot Spring County, Arkansas ...............................................
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Rural
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Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
1.1888
0.9045
0.9045
1.1845
0.9045
0.9045
0.9045
0.9045
1.0127
1.1155
0.9045
0.9007
1.0127
0.9045
0.9045
0.9126
0.7744
0.7744
0.7744
0.8661
0.7744
0.7744
0.7744
0.7744
0.7744
0.7744
0.7744
0.7744
0.7744
0.7744
0.7744
0.7911
0.8246
0.9416
0.7744
0.7744
0.7744
0.7744
0.8747
0.7744
0.7744
0.7744
0.7744
0.7744
0.7744
0.7744
E:\FR\FM\09MYR2.SGM
09MYR2
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99902
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99902
99902
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99902
99902
99902
99902
99902
99902
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99902
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99902
99902
99902
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22380
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38060
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22220
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99904
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38220
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27860
22900
32820
99904
99904
99904
99904
30780
22900
99904
26300
30780
99904
99904
99904
CBSA
urban/
rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Rural
2006
CBSAbased WI
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1895
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
1.1977
0.8768
0.8768
1.2092
0.8768
0.8768
0.8768
0.8768
1.0127
0.8768
0.8768
0.9007
1.0127
0.8768
0.9869
0.9126
0.7466
0.7466
0.7466
0.8661
0.7466
0.7466
0.7466
0.7466
0.7466
0.7466
0.7466
0.7466
0.8680
0.7466
0.7466
0.7911
0.8230
0.9397
0.7466
0.7466
0.7466
0.7466
0.8747
0.8230
0.7466
0.9005
0.8747
0.7466
0.7466
0.7466
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
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04300
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04320
04330
04340
04350
04360
04370
04380
04390
04400
04410
04420
04430
04440
04450
04460
04470
04480
04490
04500
04510
04520
04530
04540
04550
04560
04570
04580
04590
04600
04610
04620
04630
04640
04650
04660
04670
04680
04690
04700
04710
04720
04730
04740
05000
05010
05020
05030
05040
05050
05060
05070
05080
05090
05100
05110
05120
05130
05140
05150
05160
05170
05200
05210
05300
05310
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VerDate Aug<31>2005
County name
MSA No.
Howard County, Arkansas ....................................................
Independence County, Arkansas ..........................................
Izard County, Arkansas .........................................................
Jackson County, Arkansas ...................................................
Jefferson County, Arkansas ..................................................
Johnson County, Arkansas ...................................................
Lafayette County, Arkansas ..................................................
Lawrence County, Arkansas .................................................
Lee County, Arkansas ...........................................................
Lincoln County, Arkansas .....................................................
Little River County, Arkansas ...............................................
Logan County, Arkansas .......................................................
Lonoke County, Arkansas .....................................................
Madison County, Arkansas ...................................................
Marion County, Arkansas ......................................................
Miller County, Arkansas ........................................................
Mississippi County, Arkansas ...............................................
Monroe County, Arkansas ....................................................
Montgomery County, Arkansas .............................................
Nevada County, Arkansas ....................................................
Newton County, Arkansas ....................................................
Ouachita County, Arkansas ..................................................
Perry County, Arkansas ........................................................
Phillips County, Arkansas .....................................................
Pike County, Arkansas ..........................................................
Poinsett County, Arkansas ....................................................
Polk County, Arkansas ..........................................................
Pope County, Arkansas ........................................................
Prairie County, Arkansas ......................................................
Pulaski County, Arkansas .....................................................
Randolph County, Arkansas .................................................
St Francis County, Arkansas ................................................
Saline County, Arkansas .......................................................
Scott County, Arkansas ........................................................
Searcy County, Arkansas .....................................................
Sebastian County, Arkansas .................................................
Sevier County, Arkansas ......................................................
Sharp County, Arkansas .......................................................
Stone County, Arkansas .......................................................
Union County, Arkansas .......................................................
Van Buren County, Arkansas ...............................................
Washington County, Arkansas ..............................................
White County, Arkansas .......................................................
Woodruff County, Arkansas ..................................................
Yell County, Arkansas ...........................................................
Alameda County, California ..................................................
Alpine County, California ......................................................
Amador County, California ....................................................
Butte County, California ........................................................
Calaveras County, California ................................................
Colusa County, California .....................................................
Contra Costa County, California ...........................................
Del Norte County, California .................................................
Eldorado County, California ..................................................
Fresno County, California .....................................................
Glenn County, California .......................................................
Humboldt County, California .................................................
Imperial County, California ....................................................
Inyo County, California ..........................................................
Kern County, California .........................................................
Kings County, California .......................................................
Lake County, California .........................................................
Lassen County, California .....................................................
Los Angeles County, California ............................................
Los Angeles County, California ............................................
Madera County, California ....................................................
Marin County, California .......................................................
Mariposa County, California ..................................................
Mendocino County, California ...............................................
Merced County, California ....................................................
Modoc County, California ......................................................
Mono County, California .......................................................
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Urban
Urban
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Rural
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Urban
Rural
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2006
MSAbased WI
CBSA
No.
0.7744
0.7744
0.7744
0.7744
0.8680
0.7744
0.7744
0.7744
0.7744
0.7744
0.7744
0.7744
0.8747
0.7744
0.7744
0.8283
0.7744
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0.7744
0.7744
0.7744
0.7744
0.8747
0.7744
0.7744
0.8747
0.7744
0.7744
0.8246
0.7744
0.7744
0.7744
0.7744
0.7744
0.8661
0.7744
0.7744
0.7744
1.5346
1.0775
1.0775
1.0511
1.0775
1.0775
1.5346
1.0775
1.3143
1.0428
1.0775
1.0775
1.0775
1.0775
1.0470
1.0775
1.0775
1.0775
1.1783
1.1783
1.0428
1.4994
1.0775
1.0775
1.1109
1.0775
1.0775
E:\FR\FM\09MYR2.SGM
09MYR2
99904
99904
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99904
38220
99904
99904
99904
99904
38220
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99904
30780
22220
99904
45500
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30780
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27860
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20940
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12540
25260
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31084
31084
31460
41884
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32900
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CBSA
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Urban
Urban
Rural
Rural
Urban
Urban
Urban
Urban
Rural
Rural
Urban
Rural
Rural
27091
2006
CBSAbased WI
0.7466
0.7466
0.7466
0.7466
0.8680
0.7466
0.7466
0.7466
0.7466
0.8680
0.7466
0.7466
0.8747
0.8661
0.7466
0.8283
0.7466
0.7466
0.7466
0.7466
0.7466
0.7466
0.8747
0.7466
0.7466
0.7911
0.7466
0.7466
0.7466
0.8747
0.7466
0.7466
0.8747
0.7466
0.7466
0.8230
0.7466
0.7466
0.7466
0.7466
0.7466
0.8661
0.7466
0.7466
0.7466
1.5346
1.1054
1.1054
1.0511
1.1054
1.1054
1.5346
1.1054
1.2969
1.0538
1.1054
1.1054
0.8906
1.1054
1.0470
1.0036
1.1054
1.1054
1.1783
1.1783
0.8713
1.4994
1.1054
1.1054
1.1109
1.1054
1.1054
27092
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
05370
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05390
05400
05410
05420
05430
05440
05450
05460
05470
05480
05490
05500
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County name
MSA No.
Monterey County, California .................................................
Napa County, California ........................................................
Nevada County, California ....................................................
Orange County, California ....................................................
Placer County, California ......................................................
Plumas County, California ....................................................
Riverside County, California .................................................
Sacramento County, California .............................................
San Benito County, California ...............................................
San Bernardino County, California .......................................
San Diego County, California ...............................................
San Francisco County, California .........................................
San Joaquin County, California ............................................
San Luis Obispo County, California ......................................
San Mateo County, California ...............................................
Santa Barbara County, California .........................................
Santa Clara County, California .............................................
Santa Cruz County, California ..............................................
Shasta County, California .....................................................
Sierra County, California .......................................................
Siskiyou County, California ...................................................
Solano County, California .....................................................
Sonoma County, California ...................................................
Stanislaus County, California ................................................
Sutter County, California .......................................................
Tehama County, California ...................................................
Trinity County, California .......................................................
Tulare County, California ......................................................
Tuolumne County, California ................................................
Ventura County, California ....................................................
Yolo County, California .........................................................
Yuba County, California ........................................................
Adams County, Colorado ......................................................
Alamosa County, Colorado ...................................................
Arapahoe County, Colorado .................................................
Archuleta County, Colorado ..................................................
Baca County, Colorado .........................................................
Bent County, Colorado ..........................................................
Boulder County, Colorado .....................................................
Chaffee County, Colorado ....................................................
Cheyenne County, Colorado .................................................
Clear Creek County, Colorado ..............................................
Conejos County, Colorado ....................................................
Costilla County, Colorado .....................................................
Crowley County, Colorado ....................................................
Custer County, Colorado ......................................................
Delta County, Colorado .........................................................
Denver County, Colorado .....................................................
Dolores County, Colorado .....................................................
Douglas County, Colorado ....................................................
Eagle County, Colorado ........................................................
Elbert County, Colorado ........................................................
El Paso County, Colorado ....................................................
Fremont County, Colorado ....................................................
Garfield County, Colorado ....................................................
Gilpin County, Colorado ........................................................
Grand County, Colorado .......................................................
Gunnison County, Colorado ..................................................
Hinsdale County, Colorado ...................................................
Huerfano County, Colorado ..................................................
Jackson County, Colorado ....................................................
Jefferson County, Colorado ..................................................
Kiowa County, Colorado .......................................................
Kit Carson County, Colorado ................................................
Lake County, Colorado .........................................................
La Plata County, Colorado ....................................................
Larimer County, Colorado .....................................................
Las Animas County, Colorado ..............................................
Lincoln County, Colorado ......................................................
Logan County, Colorado .......................................................
Mesa County, Colorado ........................................................
Mineral County, Colorado .....................................................
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2006
MSAbased WI
CBSA
No.
1.4128
1.3983
1.0775
1.1559
1.3143
1.0775
1.1027
1.3143
1.0775
1.1027
1.1413
1.4994
1.1307
1.1349
1.4994
1.1694
1.5118
1.5166
1.2203
1.0775
1.0775
1.3983
1.3493
1.1885
1.0921
1.0775
1.0775
1.0123
1.0775
1.1622
0.9950
1.0921
1.0723
0.9380
1.0723
0.9380
0.9380
0.9380
0.9734
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
1.0723
0.9380
1.0723
0.9380
0.9380
0.9468
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
1.0723
0.9380
0.9380
0.9380
0.9380
1.0122
0.9380
0.9380
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0.9550
0.9380
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Urban
Rural
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Rural
Urban
Rural
Rural
Rural
Urban
Rural
2006
CBSAbased WI
1.4128
1.2643
1.1054
1.1559
1.2969
1.1054
1.1027
1.2969
1.5099
1.1027
1.1413
1.4994
1.1307
1.1349
1.4994
1.1694
1.5099
1.5166
1.2203
1.1054
1.1054
1.4936
1.3493
1.1885
1.0921
1.1054
1.1054
1.0123
1.1054
1.1622
1.2969
1.0921
1.0723
0.9380
1.0723
0.9380
0.9380
0.9380
0.9734
0.9380
0.9380
1.0723
0.9380
0.9380
0.9380
0.9380
0.9380
1.0723
0.9380
1.0723
0.9380
1.0723
0.9468
0.9380
0.9380
1.0723
0.9380
0.9380
0.9380
0.9380
0.9380
1.0723
0.9380
0.9380
0.9380
0.9380
1.0122
0.9380
0.9380
0.9380
0.9550
0.9380
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
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SSA State/
County
Code
06400
06410
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06440
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06460
06470
06480
06490
06500
06510
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06530
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VerDate Aug<31>2005
County name
MSA No.
Moffat County, Colorado .......................................................
Montezuma County, Colorado ..............................................
Montrose County, Colorado ..................................................
Morgan County, Colorado .....................................................
Otero County, Colorado ........................................................
Ouray County, Colorado .......................................................
Park County, Colorado ..........................................................
Phillips County, Colorado ......................................................
Pitkin County, Colorado ........................................................
Prowers County, Colorado ....................................................
Pueblo County, Colorado ......................................................
Rio Blanco County, Colorado ...............................................
Rio Grande County, Colorado ..............................................
Routt County, Colorado ........................................................
Saguache County, Colorado .................................................
San Juan County, Colorado ..................................................
San Miguel County, Colorado ...............................................
Sedgwick County, Colorado ..................................................
Summit County, Colorado .....................................................
Teller County, Colorado ........................................................
Washington County, Colorado ..............................................
Weld County, Colorado .........................................................
Yuma County, Colorado ........................................................
Broomfield County, Colorado ................................................
Fairfield County, Connecticut ................................................
Hartford County, Connecticut ................................................
Litchfield County, Connecticut ..............................................
Middlesex County, Connecticut ............................................
New Haven County, Connecticut ..........................................
New London County, Connecticut ........................................
Tolland County, Connecticut .................................................
Windham County, Connecticut .............................................
Kent County, Delaware .........................................................
New Castle County, Delaware ..............................................
Sussex County, Delaware .....................................................
Washington Dc County, Dist Of Col .....................................
Alachua County, Florida ........................................................
Baker County, Florida ...........................................................
Bay County, Florida ..............................................................
Bradford County, Florida .......................................................
Brevard County, Florida ........................................................
Broward County, Florida .......................................................
Calhoun County, Florida .......................................................
Charlotte County, Florida ......................................................
Citrus County, Florida ...........................................................
Clay County, Florida .............................................................
Collier County, Florida ..........................................................
Columbia County, Florida .....................................................
Dade County, Florida ............................................................
De Soto County, Florida .......................................................
Dixie County, Florida .............................................................
Duval County, Florida ...........................................................
Escambia County, Florida .....................................................
Flagler County, Florida ..........................................................
Franklin County, Florida ........................................................
Gadsden County, Florida ......................................................
Gilchrist County, Florida ........................................................
Glades County, Florida .........................................................
Gulf County, Florida ..............................................................
Hamilton County, Florida ......................................................
Hardee County, Florida .........................................................
Hendry County, Florida .........................................................
Hernando County, Florida .....................................................
Highlands County, Florida .....................................................
Hillsborough County, Florida .................................................
Holmes County, Florida ........................................................
Indian River County, Florida .................................................
Jackson County, Florida .......................................................
Jefferson County, Florida ......................................................
Lafayette County, Florida ......................................................
Lake County, Florida .............................................................
Lee County, Florida ...............................................................
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Sfmt 4700
MSA
urban/
rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Urban
2006
MSAbased WI
CBSA
No.
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.8623
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9570
0.9380
1.0723
1.2196
1.1073
1.1073
1.1073
1.2196
1.1345
1.1073
1.1730
0.9776
1.0527
0.9579
1.0976
0.9388
0.8677
0.8005
0.8677
0.9839
1.0432
0.8677
0.9255
0.8677
0.9299
1.0139
0.8677
0.9750
0.8677
0.8677
0.9299
0.8096
0.9325
0.8677
0.8688
0.8677
0.8677
0.8677
0.8677
0.8677
0.8677
0.9233
0.8677
0.9233
0.8677
0.8677
0.8677
0.8677
0.8677
0.9464
0.9356
E:\FR\FM\09MYR2.SGM
09MYR2
99906
99906
99906
99906
99906
99906
19740
99906
99906
99906
39380
99906
99906
99906
99906
99906
99906
99906
99906
17820
99906
24540
99906
19740
14860
25540
25540
25540
35300
35980
25540
99907
20100
48864
99908
47894
23540
27260
37460
99910
37340
22744
99910
39460
99910
27260
34940
99910
33124
99910
99910
27260
37860
99910
99910
45220
23540
99910
99910
99910
99910
99910
45300
99910
45300
99910
42680
99910
45220
99910
36740
15980
CBSA
urban/
rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Urban
27093
2006
CBSAbased WI
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
1.0723
0.9380
0.9380
0.9380
0.8623
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9380
0.9468
0.9380
0.9570
0.9380
1.0723
1.2592
1.1073
1.1073
1.1073
1.1887
1.1345
1.1073
1.1730
0.9776
1.0471
0.9579
1.0926
0.9388
0.9290
0.8005
0.8568
0.9839
1.0432
0.8568
0.9255
0.8568
0.9290
1.0139
0.8568
0.9750
0.8568
0.8568
0.9290
0.8096
0.8568
0.8568
0.8688
0.9388
0.8568
0.8568
0.8568
0.8568
0.8568
0.9233
0.8568
0.9233
0.8568
0.9434
0.8568
0.8688
0.8568
0.9464
0.9356
27094
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
10360
10370
10380
10390
10400
10410
10420
10430
10440
10450
10460
10470
10480
10490
10500
10510
10520
10530
10540
10550
10560
10570
10580
10590
10600
10610
10620
10630
10640
10650
10660
11000
11010
11011
11020
11030
11040
11050
11060
11070
11080
11090
11100
11110
11120
11130
11140
11150
11160
11161
11170
11180
11190
11200
11210
11220
11230
11240
11250
11260
11270
11280
11281
11290
11291
11300
11310
11311
11320
11330
11340
11341
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VerDate Aug<31>2005
County name
MSA No.
Leon County, Florida .............................................................
Levy County, Florida .............................................................
Liberty County, Florida ..........................................................
Madison County, Florida .......................................................
Manatee County, Florida .......................................................
Marion County, Florida ..........................................................
Martin County, Florida ...........................................................
Monroe County, Florida ........................................................
Nassau County, Florida ........................................................
Okaloosa County, Florida .....................................................
Okeechobee County, Florida ................................................
Orange County, Florida .........................................................
Osceola County, Florida .......................................................
Palm Beach County, Florida .................................................
Pasco County, Florida ...........................................................
Pinellas County, Florida ........................................................
Polk County, Florida ..............................................................
Putnam County, Florida ........................................................
Johns County, Florida ...........................................................
St Lucie County, Florida .......................................................
Santa Rosa County, Florida ..................................................
Sarasota County, Florida ......................................................
Seminole County, Florida ......................................................
Sumter County, Florida .........................................................
Suwannee County, Florida ....................................................
Taylor County, Florida ...........................................................
Union County, Florida ...........................................................
Volusia County, Florida .........................................................
Wakulla County, Florida ........................................................
Walton County, Florida .........................................................
Washington County, Florida ..................................................
Appling County, Georgia .......................................................
Atkinson County, Georgia .....................................................
Bacon County, Georgia .........................................................
Baker County, Georgia .........................................................
Baldwin County, Georgia ......................................................
Banks County, Georgia .........................................................
Barrow County, Georgia .......................................................
Bartow County, Georgia ........................................................
Ben Hill County, Georgia ......................................................
Berrien County, Georgia .......................................................
Bibb County, Georgia ............................................................
Bleckley County, Georgia .....................................................
Brantley County, Georgia ......................................................
Brooks County, Georgia ........................................................
Bryan County, Georgia .........................................................
Bulloch County, Georgia .......................................................
Burke County, Georgia .........................................................
Butts County, Georgia ...........................................................
Calhoun County, Georgia .....................................................
Camden County, Georgia .....................................................
Candler County, Georgia ......................................................
Carroll County, Georgia ........................................................
Catoosa County, Georgia .....................................................
Charlton County, Georgia .....................................................
Chatham County, Georgia ....................................................
Chattahoochee County, Georgia ..........................................
Chattooga County, Georgia ..................................................
Cherokee County, Georgia ...................................................
Clarke County, Georgia ........................................................
Clay County, Georgia ............................................................
Clayton County, Georgia .......................................................
Clinch County, Georgia .........................................................
Cobb County, Georgia ..........................................................
Coffee County, Georgia ........................................................
Colquitt County, Georgia .......................................................
Columbia County, Georgia ....................................................
Cook County, Georgia ..........................................................
Coweta County, Georgia .......................................................
Crawford County, Georgia ....................................................
Crisp County, Georgia ..........................................................
Dade County, Georgia ..........................................................
00:49 May 09, 2006
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Urban
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Urban
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Urban
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Urban
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Urban
2006
MSAbased WI
CBSA
No.
0.8688
0.8677
0.8677
0.8677
0.9639
0.8925
1.0123
0.8677
0.9299
0.8872
0.8677
0.9464
0.9464
1.0067
0.9233
0.9233
0.8912
0.8677
0.9299
1.0123
0.8096
0.9639
0.9464
0.8677
0.8677
0.8677
0.8677
0.9325
0.8677
0.8677
0.8677
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.9793
0.9793
0.8166
0.8166
0.9277
0.8166
0.8166
0.8166
0.9461
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.9793
0.9088
0.8166
0.9461
0.8560
0.8166
0.9793
0.9855
0.8166
0.9793
0.8166
0.9793
0.8166
0.8166
0.9808
0.8166
0.9793
0.8166
0.8166
0.9088
E:\FR\FM\09MYR2.SGM
09MYR2
45220
99910
99910
99910
42260
36100
38940
99910
27260
23020
99910
36740
36740
48424
45300
45300
29460
99910
27260
38940
37860
42260
36740
99910
99910
99910
99910
19660
45220
99910
99910
99911
99911
99911
10500
99911
99911
12060
12060
99911
99911
31420
99911
15260
46660
42340
99911
12260
12060
99911
99911
99911
12060
16860
99911
42340
17980
99911
12060
12020
99911
12060
99911
12060
99911
99911
12260
99911
12060
31420
99911
16860
CBSA
urban/
rural
Urban
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Urban
2006
CBSAbased WI
0.8688
0.8568
0.8568
0.8568
0.9639
0.8925
1.0123
0.8568
0.9290
0.8872
0.8568
0.9464
0.9464
1.0067
0.9233
0.9233
0.8912
0.8568
0.9290
1.0123
0.8096
0.9639
0.9464
0.8568
0.8568
0.8568
0.8568
0.9299
0.8688
0.8568
0.8568
0.7662
0.7662
0.7662
0.8628
0.7662
0.7662
0.9793
0.9793
0.7662
0.7662
0.9443
0.7662
0.9311
0.8866
0.9461
0.7662
0.9748
0.9793
0.7662
0.7662
0.7662
0.9793
0.9088
0.7662
0.9461
0.8560
0.7662
0.9793
0.9855
0.7662
0.9793
0.7662
0.9793
0.7662
0.7662
0.9748
0.7662
0.9793
0.9443
0.7662
0.9088
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
11350
11360
11370
11380
11381
11390
11400
11410
11420
11421
11430
11440
11441
11450
11451
11460
11461
11462
11470
11471
11480
11490
11500
11510
11520
11530
11540
11550
11560
11570
11580
11581
11590
11591
11600
11601
11610
11611
11612
11620
11630
11640
11650
11651
11652
11660
11670
11680
11690
11691
11700
11701
11702
11703
11710
11720
11730
11740
11741
11750
11760
11770
11771
11772
11780
11790
11800
11801
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VerDate Aug<31>2005
County name
MSA No.
Dawson County, Georgia ......................................................
Decatur County, Georgia ......................................................
De Kalb County, Georgia ......................................................
Dodge County, Georgia ........................................................
Dooly County, Georgia ..........................................................
Dougherty County, Georgia ..................................................
Douglas County, Georgia ......................................................
Early County, Georgia ...........................................................
Echols County, Georgia ........................................................
Effingham County, Georgia ...................................................
Elbert County, Georgia .........................................................
Emanuel County, Georgia .....................................................
Evans County, Georgia .........................................................
Fannin County, Georgia ........................................................
Fayette County, Georgia .......................................................
Floyd County, Georgia ..........................................................
Forsyth County, Georgia .......................................................
Franklin County, Georgia ......................................................
Fulton County, Georgia .........................................................
Gilmer County, Georgia ........................................................
Glascock County, Georgia ....................................................
Glynn County, Georgia .........................................................
Gordon County, Georgia .......................................................
Grady County, Georgia .........................................................
Greene County, Georgia .......................................................
Gwinnett County, Georgia .....................................................
Habersham County, Georgia ................................................
Hall County, Georgia .............................................................
Hancock County, Georgia .....................................................
Haralson County, Georgia ....................................................
Harris County, Georgia .........................................................
Hart County, Georgia ............................................................
Heard County, Georgia .........................................................
Henry County, Georgia .........................................................
Houston County, Georgia .....................................................
Irwin County, Georgia ...........................................................
Jackson County, Georgia ......................................................
Jasper County, Georgia ........................................................
Jeff Davis County, Georgia ...................................................
Jefferson County, Georgia ....................................................
Jenkins County, Georgia .......................................................
Johnson County, Georgia .....................................................
Jones County, Georgia .........................................................
Lamar County, Georgia .........................................................
Lanier County, Georgia .........................................................
Laurens County, Georgia ......................................................
Lee County, Georgia .............................................................
Liberty County, Georgia ........................................................
Lincoln County, Georgia .......................................................
Long County, Georgia ...........................................................
Lowndes County, Georgia ....................................................
Lumpkin County, Georgia .....................................................
Mc Duffie County, Georgia ...................................................
Mc Intosh County, Georgia ...................................................
Macon County, Georgia ........................................................
Madison County, Georgia .....................................................
Marion County, Georgia ........................................................
Meriwether County, Georgia .................................................
Miller County, Georgia ..........................................................
Mitchell County, Georgia .......................................................
Monroe County, Georgia .......................................................
Montgomery County, Georgia ...............................................
Morgan County, Georgia .......................................................
Murray County, Georgia ........................................................
Muscogee County, Georgia ..................................................
Newton County, Georgia .......................................................
Oconee County, Georgia ......................................................
Oglethorpe County, Georgia .................................................
Paulding County, Georgia .....................................................
Peach County, Georgia .........................................................
Pickens County, Georgia ......................................................
Pierce County, Georgia .........................................................
00:49 May 09, 2006
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Rural
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Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Rural
2006
MSAbased WI
CBSA
No.
0.8166
0.8166
0.9793
0.8166
0.8166
0.8628
0.9793
0.8166
0.8166
0.9461
0.8166
0.8166
0.8166
0.8166
0.9793
0.8166
0.9793
0.8166
0.9793
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.9793
0.8166
0.8166
0.8166
0.8166
0.8560
0.8166
0.8166
0.9793
0.9277
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.9277
0.8166
0.8166
0.8166
0.8628
0.8166
0.8166
0.8166
0.8166
0.8166
0.9808
0.8166
0.8166
0.9855
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8560
0.9793
0.9855
0.8166
0.9793
0.9277
0.9793
0.8166
E:\FR\FM\09MYR2.SGM
09MYR2
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12060
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99911
19140
17980
12060
12020
12020
12060
99911
12060
99911
CBSA
urban/
rural
Urban
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Rural
27095
2006
CBSAbased WI
0.9793
0.7662
0.9793
0.7662
0.7662
0.8628
0.9793
0.7662
0.8866
0.9461
0.7662
0.7662
0.7662
0.7662
0.9793
0.9414
0.9793
0.7662
0.9793
0.7662
0.7662
0.9311
0.7662
0.7662
0.7662
0.9793
0.7662
0.8874
0.7662
0.9793
0.8560
0.7662
0.9793
0.9793
0.8645
0.7662
0.7662
0.9793
0.7662
0.7662
0.7662
0.7662
0.9443
0.9793
0.8866
0.7662
0.8628
1 0.91981
0.7662
1 0.91981
0.8866
0.7662
0.9748
0.9311
0.7662
0.9855
0.8560
0.9793
0.7662
0.7662
0.9443
0.7662
0.7662
0.9079
0.8560
0.9793
0.9855
0.9855
0.9793
0.7662
0.9793
0.7662
27096
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
11821
11830
11831
11832
11833
11834
11835
11840
11841
11842
11850
11851
11860
11861
11862
11870
11880
11881
11882
11883
11884
11885
11890
11900
11901
11902
11903
11910
11911
11912
11913
11920
11921
11930
11940
11941
11950
11960
11961
11962
11963
11970
11971
11972
11973
11980
12005
12010
12020
12040
12050
13000
13010
13020
13030
13040
13050
13060
13070
13080
13090
13100
13110
13120
13130
13140
13150
13160
13170
13180
13190
13200
.......
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VerDate Aug<31>2005
County name
MSA No.
Pike County, Georgia ............................................................
Polk County, Georgia ............................................................
Pulaski County, Georgia .......................................................
Putnam County, Georgia ......................................................
Quitman County, Georgia .....................................................
Rabun County, Georgia ........................................................
Randolph County, Georgia ...................................................
Richmond County, Georgia ...................................................
Rockdale County, Georgia ....................................................
Schley County, Georgia ........................................................
Screven County, Georgia ......................................................
Seminole County, Georgia ....................................................
Spalding County, Georgia .....................................................
Stephens County, Georgia ....................................................
Stewart County, Georgia .......................................................
Sumter County, Georgia .......................................................
Talbot County, Georgia .........................................................
Taliaferro County, Georgia ....................................................
Tattnall County, Georgia .......................................................
Taylor County, Georgia .........................................................
Telfair County, Georgia .........................................................
Terrell County, Georgia .........................................................
Thomas County, Georgia ......................................................
Tift County, Georgia ..............................................................
Toombs County, Georgia ......................................................
Towns County, Georgia ........................................................
Treutlen County, Georgia ......................................................
Troup County, Georgia .........................................................
Turner County, Georgia ........................................................
Twiggs County, Georgia .......................................................
Union County, Georgia .........................................................
Upson County, Georgia ........................................................
Walker County, Georgia ........................................................
Walton County, Georgia ........................................................
Ware County, Georgia ..........................................................
Warren County, Georgia .......................................................
Washington County, Georgia ................................................
Wayne County, Georgia ........................................................
Webster County, Georgia .....................................................
Wheeler County, Georgia .....................................................
White County, Georgia ..........................................................
Whitfield County, Georgia .....................................................
Wilcox County, Georgia ........................................................
Wilkes County, Georgia ........................................................
Wilkinson County, Georgia ...................................................
Worth County, Georgia .........................................................
Kalawao County, Hawaii .......................................................
Hawaii County, Hawaii ..........................................................
Honolulu County, Hawaii .......................................................
Kauai County, Hawaii ............................................................
Maui County, Hawaii .............................................................
Ada County, Idaho ................................................................
Adams County, Idaho ...........................................................
Bannock County, Idaho ........................................................
Bear Lake County, Idaho ......................................................
Benewah County, Idaho ........................................................
Bingham County, Idaho ........................................................
Blaine County, Idaho .............................................................
Boise County, Idaho .............................................................
Bonner County, Idaho ...........................................................
Bonneville County, Idaho ......................................................
Boundary County, Idaho .......................................................
Butte County, Idaho ..............................................................
Camas County, Idaho ...........................................................
Canyon County, Idaho ..........................................................
Caribou County, Idaho ..........................................................
Cassia County, Idaho ............................................................
Clark County, Idaho ..............................................................
Clearwater County, Idaho .....................................................
Custer County, Idaho ............................................................
Elmore County, Idaho ...........................................................
Franklin County, Idaho ..........................................................
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MSA
urban/
rural
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Rural
Rural
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Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.9808
0.9793
0.8166
0.8166
0.8166
0.9793
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.9277
0.8166
0.8166
0.9088
0.9793
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
0.8166
1.0551
1.0551
1.1214
1.0551
1.0551
0.9052
0.9097
0.9351
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9052
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
E:\FR\FM\09MYR2.SGM
09MYR2
12060
99911
99911
99911
99911
99911
99911
12260
12060
99911
99911
99911
12060
99911
99911
99911
99911
99911
99911
99911
99911
10500
99911
99911
99911
99911
99911
99911
99911
31420
99911
99911
16860
12060
99911
99911
99911
99911
99911
99911
99911
19140
99911
99911
99911
10500
99912
99912
26180
99912
99912
14260
99913
38540
99913
99913
99913
99913
14260
99913
26820
99913
99913
99913
14260
99913
99913
99913
99913
99913
99913
30860
CBSA
urban/
rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
2006
CBSAbased WI
0.9793
0.7662
0.7662
0.7662
0.7662
0.7662
0.7662
0.9748
0.9793
0.7662
0.7662
0.7662
0.9793
0.7662
0.7662
0.7662
0.7662
0.7662
0.7662
0.7662
0.7662
0.8628
0.7662
0.7662
0.7662
0.7662
0.7662
0.7662
0.7662
0.9443
0.7662
0.7662
0.9088
0.9793
0.7662
0.7662
0.7662
0.7662
0.7662
0.7662
0.7662
0.9079
0.7662
0.7662
0.7662
0.8628
1.0551
1.0551
1.1214
1.0551
1.0551
0.9052
0.8037
0.9351
0.8037
0.8037
0.8037
0.8037
0.9052
0.8037
0.9420
0.8037
0.8037
0.8037
0.9052
0.8037
0.8037
0.8037
0.8037
0.8037
0.8037
0.9164
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
13210
13220
13230
13240
13250
13260
13270
13280
13290
13300
13310
13320
13330
13340
13350
13360
13370
13380
13390
13400
13410
13420
13430
14000
14010
14020
14030
14040
14050
14060
14070
14080
14090
14100
14110
14120
14130
14140
14141
14150
14160
14170
14180
14190
14250
14310
14320
14330
14340
14350
14360
14370
14380
14390
14400
14410
14420
14421
14440
14450
14460
14470
14480
14490
14500
14510
14520
14530
14540
14550
14560
14570
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VerDate Aug<31>2005
County name
MSA No.
Fremont County, Idaho .........................................................
Gem County, Idaho ...............................................................
Gooding County, Idaho .........................................................
Idaho County, Idaho .............................................................
Jefferson County, Idaho ........................................................
Jerome County, Idaho ...........................................................
Kootenai County, Idaho ........................................................
Latah County, Idaho .............................................................
Lemhi County, Idaho .............................................................
Lewis County, Idaho .............................................................
Lincoln County, Idaho ...........................................................
Madison County, Idaho .........................................................
Minidoka County, Idaho ........................................................
Nez Perce County, Idaho ......................................................
Oneida County, Idaho ...........................................................
Owyhee County, Idaho .........................................................
Payette County, Idaho ..........................................................
Power County, Idaho ............................................................
Shoshone County, Idaho ......................................................
Teton County, Idaho .............................................................
Twin Falls County, Idaho ......................................................
Valley County, Idaho .............................................................
Washington County, Idaho ....................................................
Adams County, Illinois ..........................................................
Alexander County, Illinois .....................................................
Bond County, Illinois .............................................................
Boone County, Illinois ...........................................................
Brown County, Illinois ...........................................................
Bureau County, Illinois ..........................................................
Calhoun County, Illinois ........................................................
Carroll County, Illinois ...........................................................
Cass County, Illinois .............................................................
Champaign County, Illinois ...................................................
Christian County, Illinois .......................................................
Clark County, Illinois .............................................................
Clay County, Illinois ..............................................................
Clinton County, Illinois ..........................................................
Coles County, Illinois ............................................................
Cook County, Illinois .............................................................
Crawford County, Illinois .......................................................
Cumberland County, Illinois ..................................................
De Kalb County, Illinois .........................................................
De Witt County, Illinois ..........................................................
Douglas County, Illinois ........................................................
Du Page County, Illinois .......................................................
Edgar County, Illinois ............................................................
Edwards County, Illinois ........................................................
Effingham County, Illinois .....................................................
Fayette County, Illinois ..........................................................
Ford County, Illinois ..............................................................
Franklin County, Illinois .........................................................
Fulton County, Illinois ............................................................
Gallatin County, Illinois .........................................................
Greene County, Illinois ..........................................................
Grundy County, Illinois ..........................................................
Hamilton County, Illinois .......................................................
Hancock County, Illinois ........................................................
Hardin County, Illinois ...........................................................
Henderson County, Illinois ....................................................
Henry County, Illinois ............................................................
Iroquois County, Illinois .........................................................
Jackson County, Illinois ........................................................
Jasper County, Illinois ...........................................................
Jefferson County, Illinois .......................................................
Jersey County, Illinois ...........................................................
Jo Daviess County, Illinois ....................................................
Johnson County, Illinois ........................................................
Kane County, Illinois .............................................................
Kankakee County, Illinois ......................................................
Kendall County, Illinois ..........................................................
Knox County, Illinois .............................................................
Lake County, Illinois ..............................................................
00:49 May 09, 2006
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urban/
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Rural
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Rural
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Rural
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Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Urban
Rural
Urban
2006
MSAbased WI
CBSA
No.
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.9097
0.8301
0.8301
0.8301
0.9984
0.8301
0.8301
0.8301
0.8301
0.8301
0.9594
0.8301
0.8301
0.8301
0.8962
0.8301
1.0783
0.8301
0.8301
1.0783
0.8301
0.8301
1.0783
0.8301
0.8301
0.8301
0.8301
0.8301
0.8301
0.8301
0.8301
0.8301
1.0783
0.8301
0.8301
0.8301
0.8301
0.8724
0.8301
0.8301
0.8301
0.8301
0.8962
0.8301
0.8301
1.0783
1.0721
1.0783
0.8301
1.0783
E:\FR\FM\09MYR2.SGM
09MYR2
99913
14260
99913
99913
26820
99913
17660
99913
99913
99913
99913
99913
99913
30300
99913
14260
99913
38540
99913
99913
99913
99913
99913
99914
99914
41180
40420
99914
99914
41180
99914
99914
16580
99914
99914
99914
41180
99914
16974
99914
99914
16974
99914
99914
16974
99914
99914
99914
99914
16580
99914
99914
99914
99914
16974
99914
99914
99914
99914
19340
99914
99914
99914
99914
41180
99914
99914
16974
28100
16974
99914
29404
CBSA
urban/
rural
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Urban
Rural
Urban
27097
2006
CBSAbased WI
0.8037
0.9052
0.8037
0.8037
0.9420
0.8037
0.9647
0.8037
0.8037
0.8037
0.8037
0.8037
0.8037
0.9886
0.8037
0.9052
0.8037
0.9351
0.8037
0.8037
0.8037
0.8037
0.8037
0.8271
0.8271
0.8954
0.9984
0.8271
0.8271
0.8954
0.8271
0.8271
0.9594
0.8271
0.8271
0.8271
0.8954
0.8271
1.0790
0.8271
0.8271
1.0790
0.8271
0.8271
1.0790
0.8271
0.8271
0.8271
0.8271
0.9594
0.8271
0.8271
0.8271
0.8271
1.0790
0.8271
0.8271
0.8271
0.8271
0.8724
0.8271
0.8271
0.8271
0.8271
0.8954
0.8271
0.8271
1.0790
1.0721
1.0790
0.8271
1.0429
27098
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
14580
14590
14600
14610
14620
14630
14640
14650
14660
14670
14680
14690
14700
14710
14720
14730
14740
14750
14760
14770
14780
14790
14800
14810
14820
14830
14831
14850
14860
14870
14880
14890
14900
14910
14920
14921
14940
14950
14960
14970
14980
14981
14982
14983
14984
14985
14986
14987
14988
14989
14990
14991
14992
15000
15010
15020
15030
15040
15050
15060
15070
15080
15090
15100
15110
15120
15130
15140
15150
15160
15170
15180
.......
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VerDate Aug<31>2005
County name
MSA No.
La Salle County, Illinois ........................................................
Lawrence County, Illinois ......................................................
Lee County, Illinois ................................................................
Livingston County, Illinois .....................................................
Logan County, Illinois ............................................................
Mc Donough County, Illinois .................................................
Mc Henry County, Illinois ......................................................
Mclean County, Illinois ..........................................................
Macon County, Illinois ...........................................................
Macoupin County, Illinois ......................................................
Madison County, Illinois ........................................................
Marion County, Illinois ...........................................................
Marshall County, Illinois ........................................................
Mason County, Illinois ...........................................................
Massac County, Illinois .........................................................
Menard County, Illinois .........................................................
Mercer County, Illinois ..........................................................
Monroe County, Illinois .........................................................
Montgomery County, Illinois ..................................................
Morgan County, Illinois .........................................................
Moultrie County, Illinois .........................................................
Ogle County, Illinois ..............................................................
Peoria County, Illinois ...........................................................
Perry County, Illinois .............................................................
Piatt County, Illinois ..............................................................
Pike County, Illinois ...............................................................
Pope County, Illinois .............................................................
Pulaski County, Illinois ..........................................................
Putnam County, Illinois .........................................................
Randolph County, Illinois ......................................................
Richland County, Illinois ........................................................
Rock Island County, Illinois ...................................................
St Clair County, Illinois ..........................................................
Saline County, Illinois ............................................................
Sangamon County, Illinois ....................................................
Schuyler County, Illinois ........................................................
Scott County, Illinois .............................................................
Shelby County, Illinois ...........................................................
Stark County, Illinois .............................................................
Stephenson County, Illinois ..................................................
Tazewell County, Illinois .......................................................
Union County, Illinois ............................................................
Vermilion County, Illinois .......................................................
Wabash County, Illinois ........................................................
Warren County, Illinois ..........................................................
Washington County, Illinois ...................................................
Wayne County, Illinois ..........................................................
White County, Illinois ............................................................
Whiteside County, Illinois ......................................................
Will County, Illinois ................................................................
Williamson County, Illinois ....................................................
Winnebago County, Illinois ...................................................
Woodford County, Illinois ......................................................
Adams County, Indiana .........................................................
Allen County, Indiana ............................................................
Bartholomew County, Indiana ...............................................
Benton County, Indiana ........................................................
Blackford County, Indiana .....................................................
Boone County, Indiana .........................................................
Brown County, Indiana ..........................................................
Carroll County, Indiana .........................................................
Cass County, Indiana ............................................................
Clark County, Indiana ...........................................................
Clay County, Indiana .............................................................
Clinton County, Indiana .........................................................
Crawford County, Indiana .....................................................
Daviess County, Indiana .......................................................
Dearborn County, Indiana .....................................................
Decatur County, Indiana .......................................................
De Kalb County, Indiana .......................................................
Delaware County, Indiana .....................................................
Dubois County, Indiana .........................................................
00:49 May 09, 2006
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MSA
urban/
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Rural
Rural
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Urban
Urban
Rural
Urban
Rural
Rural
Rural
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Rural
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Rural
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Rural
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Urban
Rural
Rural
Rural
Rural
Rural
Rural
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Rural
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Urban
Rural
Urban
Rural
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Rural
Rural
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Urban
Rural
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Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Rural
Urban
Rural
Urban
Urban
Rural
2006
MSAbased WI
CBSA
No.
0.8301
0.8301
0.8301
0.8301
0.8301
0.8301
1.0783
0.9075
0.8067
0.8301
0.8962
0.8301
0.8301
0.8301
0.8301
0.8792
0.8301
0.8962
0.8301
0.8301
0.8301
0.9984
0.8870
0.8301
0.8301
0.8301
0.8301
0.8301
0.8301
0.8301
0.8301
0.8724
0.8962
0.8301
0.8792
0.8301
0.8301
0.8301
0.8301
0.8301
0.8870
0.8301
0.8301
0.8301
0.8301
0.8301
0.8301
0.8301
0.8301
1.0783
0.8301
0.9984
0.8870
0.9706
0.9706
0.8739
0.8739
0.8739
0.9865
0.8739
0.8739
0.8739
0.9293
0.8337
0.8736
0.8739
0.8739
0.9734
0.8739
0.9706
0.8930
0.8739
E:\FR\FM\09MYR2.SGM
09MYR2
99914
99914
99914
99914
99914
99914
16974
14060
19500
41180
41180
99914
37900
99914
99914
44100
19340
41180
99914
99914
99914
99914
37900
99914
16580
99914
99914
99914
99914
99914
99914
19340
41180
99914
44100
99914
99914
99914
37900
99914
37900
99914
19180
99914
99914
99914
99914
99914
99914
16974
99914
40420
37900
99915
23060
18020
29140
99915
26900
26900
29140
99915
31140
45460
99915
99915
99915
17140
99915
99915
34620
99915
CBSA
urban/
rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
2006
CBSAbased WI
0.8271
0.8271
0.8271
0.8271
0.8271
0.8271
1.0790
0.9075
0.8067
0.8954
0.8954
0.8271
0.8870
0.8271
0.8271
0.8792
0.8724
0.8954
0.8271
0.8271
0.8271
0.8271
0.8870
0.8271
0.9594
0.8271
0.8271
0.8271
0.8271
0.8271
0.8271
0.8724
0.8954
0.8271
0.8792
0.8271
0.8271
0.8271
0.8870
0.8271
0.8870
0.8271
0.9028
0.8271
0.8271
0.8271
0.8271
0.8271
0.8271
1.0790
0.8271
0.9984
0.8870
0.8624
0.9793
0.9588
0.8736
0.8624
0.9920
0.9920
0.8736
0.8624
0.9251
0.8304
0.8624
0.8624
0.8624
0.9615
0.8624
0.8624
0.8930
0.8624
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
15190
15200
15210
15220
15230
15240
15250
15260
15270
15280
15290
15300
15310
15320
15330
15340
15350
15360
15370
15380
15390
15400
15410
15420
15430
15440
15450
15460
15470
15480
15490
15500
15510
15520
15530
15540
15550
15560
15570
15580
15590
15600
15610
15620
15630
15640
15650
15660
15670
15680
15690
15700
15710
15720
15730
15740
15750
15760
15770
15780
15790
15800
15810
15820
15830
15840
15850
15860
15870
15880
15890
15900
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VerDate Aug<31>2005
County name
MSA No.
Elkhart County, Indiana .........................................................
Fayette County, Indiana ........................................................
Floyd County, Indiana ...........................................................
Fountain County, Indiana ......................................................
Franklin County, Indiana .......................................................
Fulton County, Indiana ..........................................................
Gibson County, Indiana ........................................................
Grant County, Indiana ...........................................................
Greene County, Indiana ........................................................
Hamilton County, Indiana ......................................................
Hancock County, Indiana ......................................................
Harrison County, Indiana ......................................................
Hendricks County, Indiana ....................................................
Henry County, Indiana ..........................................................
Howard County, Indiana .......................................................
Huntington County, Indiana ..................................................
Jackson County, Indiana .......................................................
Jasper County, Indiana .........................................................
Jay County, Indiana ..............................................................
Jefferson County, Indiana .....................................................
Jennings County, Indiana .....................................................
Johnson County, Indiana ......................................................
Knox County, Indiana ............................................................
Kosciusko County, Indiana ...................................................
Lagrange County, Indiana .....................................................
Lake County, Indiana ............................................................
La Porte County, Indiana ......................................................
Lawrence County, Indiana ....................................................
Madison County, Indiana ......................................................
Marion County, Indiana .........................................................
Marshall County, Indiana ......................................................
Martin County, Indiana ..........................................................
Miami County, Indiana ..........................................................
Monroe County, Indiana ........................................................
Montgomery County, Indiana ................................................
Morgan County, Indiana ........................................................
Newton County, Indiana ........................................................
Noble County, Indiana ..........................................................
Ohio County, Indiana ............................................................
Orange County, Indiana ........................................................
Owen County, Indiana ..........................................................
Parke County, Indiana ..........................................................
Perry County, Indiana ...........................................................
Pike County, Indiana .............................................................
Porter County, Indiana ..........................................................
Posey County, Indiana ..........................................................
Pulaski County, Indiana ........................................................
Putnam County, Indiana .......................................................
Randolph County, Indiana ....................................................
Ripley County, Indiana ..........................................................
Rush County, Indiana ...........................................................
St Joseph County, Indiana ....................................................
Scott County, Indiana ............................................................
Shelby County, Indiana .........................................................
Spencer County, Indiana ......................................................
Starke County, Indiana .........................................................
Steuben County, Indiana ......................................................
Sullivan County, Indiana .......................................................
Switzerland County, Indiana .................................................
Tippecanoe County, Indiana .................................................
Tipton County, Indiana ..........................................................
Union County, Indiana ..........................................................
Vanderburgh County, Indiana ...............................................
Vermillion County, Indiana ....................................................
Vigo County, Indiana .............................................................
Wabash County, Indiana .......................................................
Warren County, Indiana ........................................................
Warrick County, Indiana ........................................................
Washington County, Indiana .................................................
Wayne County, Indiana .........................................................
Wells County, Indiana ...........................................................
White County, Indiana ...........................................................
00:49 May 09, 2006
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Rural
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Urban
Urban
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Rural
Urban
Urban
Rural
Rural
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Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
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Urban
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Urban
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Rural
Urban
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
2006
MSAbased WI
CBSA
No.
0.9627
0.8739
0.9293
0.8739
0.8739
0.8739
0.8739
0.8739
0.8739
0.9865
0.9865
0.9293
0.9865
0.8739
0.9508
0.9706
0.8739
0.8739
0.8739
0.8739
0.8739
0.9865
0.8739
0.8739
0.8739
0.9395
0.8739
0.8739
0.9865
0.9865
0.8739
0.8739
0.8739
0.8447
0.8739
0.9865
0.8739
0.8739
0.9734
0.8739
0.8739
0.8739
0.8739
0.8739
0.9395
0.8713
0.8739
0.8739
0.8739
0.8739
0.8739
0.9788
0.9293
0.9865
0.8739
0.8739
0.8739
0.8739
0.8739
0.8736
0.9508
0.8739
0.8713
0.8337
0.8337
0.8739
0.8739
0.8713
0.8739
0.8739
0.9706
0.8739
E:\FR\FM\09MYR2.SGM
09MYR2
21140
99915
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99915
17140
99915
21780
99915
14020
26900
26900
31140
26900
99915
29020
99915
99915
23844
99915
99915
99915
26900
99915
99915
99915
23844
33140
99915
11300
26900
99915
99915
99915
14020
99915
26900
23844
99915
17140
99915
14020
99915
99915
99915
23844
21780
99915
26900
99915
99915
99915
43780
99915
26900
99915
99915
99915
45460
99915
29140
29020
99915
21780
45460
45460
99915
99915
21780
31140
99915
23060
99915
CBSA
urban/
rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Rural
Urban
Urban
Rural
Urban
Rural
27099
2006
CBSAbased WI
0.9627
0.8624
0.9251
0.8624
0.9615
0.8624
0.8713
0.8624
0.8447
0.9920
0.9920
0.9251
0.9920
0.8624
0.9508
0.8624
0.8624
0.9395
0.8624
0.8624
0.8624
0.9920
0.8624
0.8624
0.8624
0.9395
0.9399
0.8624
0.8586
0.9920
0.8624
0.8624
0.8624
0.8447
0.8624
0.9920
0.9395
0.8624
0.9615
0.8624
0.8447
0.8624
0.8624
0.8624
0.9395
0.8713
0.8624
0.9920
0.8624
0.8624
0.8624
0.9788
0.8624
0.9920
0.8624
0.8624
0.8624
0.8304
0.8624
0.8736
0.9508
0.8624
0.8713
0.8304
0.8304
0.8624
0.8624
0.8713
0.9251
0.8624
0.9793
0.8624
27100
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
15910
16000
16010
16020
16030
16040
16050
16060
16070
16080
16090
16100
16110
16120
16130
16140
16150
16160
16170
16180
16190
16200
16210
16220
16230
16240
16250
16260
16270
16280
16290
16300
16310
16320
16330
16340
16350
16360
16370
16380
16390
16400
16410
16420
16430
16440
16450
16460
16470
16480
16490
16500
16510
16520
16530
16540
16550
16560
16570
16580
16590
16600
16610
16620
16630
16640
16650
16660
16670
16680
16690
16700
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VerDate Aug<31>2005
County name
MSA No.
Whitley County, Indiana ........................................................
Adair County, Iowa ................................................................
Adams County, Iowa .............................................................
Allamakee County, Iowa .......................................................
Appanoose County, Iowa ......................................................
Audubon County, Iowa ..........................................................
Benton County, Iowa .............................................................
Black Hawk County, Iowa .....................................................
Boone County, Iowa .............................................................
Bremer County, Iowa ............................................................
Buchanan County, Iowa ........................................................
Buena Vista County, Iowa ....................................................
Butler County, Iowa ...............................................................
Calhoun County, Iowa ...........................................................
Carroll County, Iowa .............................................................
Cass County, Iowa ................................................................
Cedar County, Iowa ..............................................................
Cerro Gordo County, Iowa ....................................................
Cherokee County, Iowa ........................................................
Chickasaw County, Iowa .......................................................
Clarke County, Iowa ..............................................................
Clay County, Iowa .................................................................
Clayton County, Iowa ............................................................
Clinton County, Iowa .............................................................
Crawford County, Iowa .........................................................
Dallas County, Iowa ..............................................................
Davis County, Iowa ...............................................................
Decatur County, Iowa ...........................................................
Delaware County, Iowa .........................................................
Des Moines County, Iowa .....................................................
Dickinson County, Iowa ........................................................
Dubuque County, Iowa .........................................................
Emmet County, Iowa .............................................................
Fayette County, Iowa ............................................................
Floyd County, Iowa ...............................................................
Franklin County, Iowa ...........................................................
Fremont County, Iowa ...........................................................
Greene County, Iowa ............................................................
Grundy County, Iowa ............................................................
Guthrie County, Iowa ............................................................
Hamilton County, Iowa ..........................................................
Hancock County, Iowa ..........................................................
Hardin County, Iowa .............................................................
Harrison County, Iowa ..........................................................
Henry County, Iowa ..............................................................
Howard County, Iowa ............................................................
Humboldt County, Iowa .........................................................
Ida County, Iowa ...................................................................
Iowa County, Iowa ................................................................
Jackson County, Iowa ...........................................................
Jasper County, Iowa .............................................................
Jefferson County, Iowa .........................................................
Johnson County, Iowa ..........................................................
Jones County, Iowa ..............................................................
Keokuk County, Iowa ............................................................
Kossuth County, Iowa ...........................................................
Lee County, Iowa ..................................................................
Linn County, Iowa .................................................................
Louisa County, Iowa .............................................................
Lucas County, Iowa ..............................................................
Lyon County, Iowa ................................................................
Madison County, Iowa ..........................................................
Mahaska County, Iowa .........................................................
Marion County, Iowa .............................................................
Marshall County, Iowa ..........................................................
Mills County, Iowa .................................................................
Mitchell County, Iowa ............................................................
Monona County, Iowa ...........................................................
Monroe County, Iowa ............................................................
Montgomery County, Iowa ....................................................
Muscatine County, Iowa ........................................................
O Brien County, Iowa ............................................................
00:49 May 09, 2006
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urban/
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Rural
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Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
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Rural
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Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.9706
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8557
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.9669
0.8594
0.8594
0.8594
0.8594
0.8594
0.9024
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.9747
0.8594
0.8594
0.8594
0.8594
0.8825
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
E:\FR\FM\09MYR2.SGM
09MYR2
23060
99916
99916
99916
99916
99916
16300
47940
99916
47940
99916
99916
99916
99916
99916
99916
99916
99916
99916
99916
99916
99916
99916
99916
99916
19780
99916
99916
99916
99916
99916
20220
99916
99916
99916
99916
99916
99916
47940
19780
99916
99916
99916
36540
99916
99916
99916
99916
99916
99916
99916
99916
26980
16300
99916
99916
99916
16300
99916
99916
99916
19780
99916
99916
99916
36540
99916
99916
99916
99916
99916
99916
CBSA
urban/
rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
2006
CBSAbased WI
0.9793
0.8509
0.8509
0.8509
0.8509
0.8509
0.8825
0.8557
0.8509
0.8557
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.9669
0.8509
0.8509
0.8509
0.8509
0.8509
0.9024
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.8557
0.9669
0.8509
0.8509
0.8509
0.9560
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
0.9747
0.8825
0.8509
0.8509
0.8509
0.8825
0.8509
0.8509
0.8509
0.9669
0.8509
0.8509
0.8509
0.9560
0.8509
0.8509
0.8509
0.8509
0.8509
0.8509
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
16710
16720
16730
16740
16750
16760
16770
16780
16790
16800
16810
16820
16830
16840
16850
16860
16870
16880
16890
16900
16910
16920
16930
16940
16950
16960
16970
16980
17000
17010
17020
17030
17040
17050
17060
17070
17080
17090
17100
17110
17120
17130
17140
17150
17160
17170
17180
17190
17200
17210
17220
17230
17240
17250
17260
17270
17280
17290
17300
17310
17320
17330
17340
17350
17360
17370
17380
17390
17391
17410
17420
17430
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VerDate Aug<31>2005
County name
MSA No.
Osceola County, Iowa ...........................................................
Page County, Iowa ................................................................
Palo Alto County, Iowa .........................................................
Plymouth County, Iowa .........................................................
Pocahontas County, Iowa .....................................................
Polk County, Iowa .................................................................
Pottawattamie County, Iowa .................................................
Poweshiek County, Iowa .......................................................
Ringgold County, Iowa ..........................................................
Sac County, Iowa ..................................................................
Scott County, Iowa ................................................................
Shelby County, Iowa .............................................................
Sioux County, Iowa ...............................................................
Story County, Iowa ................................................................
Tama County, Iowa ...............................................................
Taylor County, Iowa ..............................................................
Union County, Iowa ...............................................................
Van Buren County, Iowa .......................................................
Wapello County, Iowa ...........................................................
Warren County, Iowa ............................................................
Washington County, Iowa .....................................................
Wayne County, Iowa .............................................................
Webster County, Iowa ...........................................................
Winnebago County, Iowa ......................................................
Winneshiek County, Iowa .....................................................
Woodbury County, Iowa ........................................................
Worth County, Iowa ..............................................................
Wright County, Iowa ..............................................................
Allen County, Kansas ............................................................
Anderson County, Kansas ....................................................
Atchison County, Kansas ......................................................
Barber County, Kansas .........................................................
Barton County, Kansas .........................................................
Bourbon County, Kansas ......................................................
Brown County, Kansas .........................................................
Butler County, Kansas ..........................................................
Chase County, Kansas .........................................................
Chautauqua County, Kansas ................................................
Cherokee County, Kansas ....................................................
Cheyenne County, Kansas ...................................................
Clark County, Kansas ...........................................................
Clay County, Kansas ............................................................
Cloud County, Kansas ..........................................................
Coffey County, Kansas .........................................................
Comanche County, Kansas ..................................................
Cowley County, Kansas ........................................................
Crawford County, Kansas .....................................................
Decatur County, Kansas .......................................................
Dickinson County, Kansas ....................................................
Doniphan County, Kansas ....................................................
Douglas County, Kansas ......................................................
Edwards County, Kansas ......................................................
Elk County, Kansas ...............................................................
Ellis County, Kansas .............................................................
Ellsworth County, Kansas .....................................................
Finney County, Kansas .........................................................
Ford County, Kansas ............................................................
Franklin County, Kansas .......................................................
Geary County, Kansas ..........................................................
Gove County, Kansas ...........................................................
Graham County, Kansas .......................................................
Grant County, Kansas ...........................................................
Gray County, Kansas ............................................................
Greeley County, Kansas .......................................................
Greenwood County, Kansas .................................................
Hamilton County, Kansas .....................................................
Harper County, Kansas .........................................................
Harvey County, Kansas ........................................................
Haskell County, Kansas ........................................................
Hodgeman County, Kansas ..................................................
Jackson County, Kansas ......................................................
Jefferson County, Kansas .....................................................
00:49 May 09, 2006
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urban/
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Rural
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Rural
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Rural
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Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.8594
0.8594
0.8594
0.8594
0.8594
0.9669
0.9560
0.8594
0.8594
0.8594
0.8724
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.8594
0.9669
0.8594
0.8594
0.8594
0.8594
0.8594
0.9416
0.8594
0.8594
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.9175
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8537
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.9175
0.8040
0.8040
0.8040
0.8040
E:\FR\FM\09MYR2.SGM
09MYR2
99916
99916
99916
99916
99916
19780
36540
99916
99916
99916
19340
99916
99916
11180
99916
99916
99916
99916
99916
19780
26980
99916
99916
99916
99916
43580
99916
99916
99917
99917
99917
99917
99917
99917
99917
48620
99917
99917
99917
99917
99917
99917
99917
99917
99917
99917
99917
99917
99917
41140
29940
99917
99917
99917
99917
99917
99917
28140
99917
99917
99917
99917
99917
99917
99917
99917
99917
48620
99917
99917
45820
45820
CBSA
urban/
rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
27101
2006
CBSAbased WI
0.8509
0.8509
0.8509
0.8509
0.8509
0.9669
0.9560
0.8509
0.8509
0.8509
0.8724
0.8509
0.8509
0.9536
0.8509
0.8509
0.8509
0.8509
0.8509
0.9669
0.9747
0.8509
0.8509
0.8509
0.8509
0.9381
0.8509
0.8509
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.9153
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.9519
0.8537
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.9476
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.9153
0.8035
0.8035
0.8920
0.8920
27102
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
17440
17450
17451
17470
17480
17490
17500
17510
17520
17530
17540
17550
17560
17570
17580
17590
17600
17610
17620
17630
17640
17650
17660
17670
17680
17690
17700
17710
17720
17730
17740
17750
17760
17770
17780
17790
17800
17810
17820
17830
17840
17841
17860
17870
17880
17890
17900
17910
17920
17921
17940
17950
17960
17970
17980
17981
17982
17983
17984
17985
17986
18000
18010
18020
18030
18040
18050
18060
18070
18080
18090
18100
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VerDate Aug<31>2005
County name
MSA No.
Jewell County, Kansas ..........................................................
Johnson County, Kansas ......................................................
Kearny County, Kansas ........................................................
Kingman County, Kansas .....................................................
Kiowa County, Kansas ..........................................................
Labette County, Kansas ........................................................
Lane County, Kansas ............................................................
Leavenworth County, Kansas ...............................................
Lincoln County, Kansas ........................................................
Linn County, Kansas .............................................................
Logan County, Kansas ..........................................................
Lyon County, Kansas ............................................................
Mc Pherson County, Kansas ................................................
Marion County, Kansas .........................................................
Marshall County, Kansas ......................................................
Meade County, Kansas .........................................................
Miami County, Kansas ..........................................................
Mitchell County, Kansas .......................................................
Montgomery County, Kansas ................................................
Morris County, Kansas ..........................................................
Morton County, Kansas ........................................................
Nemaha County, Kansas ......................................................
Neosho County, Kansas .......................................................
Ness County, Kansas ...........................................................
Norton County, Kansas .........................................................
Osage County, Kansas .........................................................
Osborne County, Kansas ......................................................
Ottawa County, Kansas ........................................................
Pawnee County, Kansas .......................................................
Phillips County, Kansas ........................................................
Pottawatomie County, Kansas ..............................................
Pratt County, Kansas ............................................................
Rawlins County, Kansas .......................................................
Reno County, Kansas ...........................................................
Republic County, Kansas ......................................................
Rice County, Kansas ............................................................
Riley County, Kansas ............................................................
Rooks County, Kansas .........................................................
Rush County, Kansas ...........................................................
Russell County, Kansas ........................................................
Saline County, Kansas ..........................................................
Scott County, Kansas ...........................................................
Sedgwick County, Kansas ....................................................
Seward County, Kansas .......................................................
Shawnee County, Kansas .....................................................
Sheridan County, Kansas .....................................................
Sherman County, Kansas .....................................................
Smith County, Kansas ..........................................................
Stafford County, Kansas .......................................................
Stanton County, Kansas .......................................................
Stevens County, Kansas .......................................................
Sumner County, Kansas .......................................................
Thomas County, Kansas .......................................................
Trego County, Kansas ..........................................................
Wabaunsee County, Kansas ................................................
Wallace County, Kansas .......................................................
Washington County, Kansas .................................................
Wichita County, Kansas ........................................................
Wilson County, Kansas .........................................................
Woodson County, Kansas ....................................................
Wyandotte County, Kansas ..................................................
Adair County, Kentucky ........................................................
Allen County, Kentucky .........................................................
Anderson County, Kentucky .................................................
Ballard County, Kentucky ......................................................
Barren County, Kentucky ......................................................
Bath County, Kentucky .........................................................
Bell County, Kentucky ...........................................................
Boone County, Kentucky ......................................................
Bourbon County, Kentucky ...................................................
Boyd County, Kentucky .........................................................
Boyle County, Kentucky ........................................................
00:49 May 09, 2006
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Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
2006
MSAbased WI
CBSA
No.
0.8040
0.9490
0.8040
0.8040
0.8040
0.8040
0.8040
0.9490
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.9490
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.9175
0.8040
0.8920
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.8040
0.9490
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.9734
0.8988
0.9477
0.7858
E:\FR\FM\09MYR2.SGM
09MYR2
99917
28140
99917
99917
99917
99917
99917
28140
99917
28140
99917
99917
99917
99917
99917
99917
28140
99917
99917
99917
99917
99917
99917
99917
99917
45820
99917
99917
99917
99917
99917
99917
99917
99917
99917
99917
99917
99917
99917
99917
99917
99917
48620
99917
45820
99917
99917
99917
99917
99917
99917
48620
99917
99917
45820
99917
99917
99917
99917
99917
28140
99918
99918
99918
99918
99918
99918
99918
17140
30460
26580
99918
CBSA
urban/
rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
2006
CBSAbased WI
0.8035
0.9476
0.8035
0.8035
0.8035
0.8035
0.8035
0.9476
0.8035
0.9476
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.9476
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8920
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.9153
0.8035
0.8920
0.8035
0.8035
0.8035
0.8035
0.8035
0.8035
0.9153
0.8035
0.8035
0.8920
0.8035
0.8035
0.8035
0.8035
0.8035
0.9476
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.9615
0.9075
0.9477
0.7766
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
18110
18120
18130
18140
18150
18160
18170
18180
18190
18191
18210
18220
18230
18240
18250
18260
18270
18271
18290
18291
18310
18320
18330
18340
18350
18360
18361
18362
18390
18400
18410
18420
18421
18440
18450
18460
18470
18480
18490
18500
18510
18511
18530
18540
18550
18560
18570
18580
18590
18600
18610
18620
18630
18640
18650
18660
18670
18680
18690
18700
18710
18720
18730
18740
18750
18760
18770
18780
18790
18800
18801
18802
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
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.......
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.......
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.......
.......
.......
.......
.......
.......
.......
.......
VerDate Aug<31>2005
County name
MSA No.
Bracken County, Kentucky ....................................................
Breathitt County, Kentucky ...................................................
Breckinridge County, Kentucky .............................................
Bullitt County, Kentucky ........................................................
Butler County, Kentucky .......................................................
Caldwell County, Kentucky ...................................................
Calloway County, Kentucky ..................................................
Campbell County, Kentucky ..................................................
Carlisle County, Kentucky .....................................................
Carroll County, Kentucky ......................................................
Carter County, Kentucky .......................................................
Casey County, Kentucky .......................................................
Christian County, Kentucky ...................................................
Clark County, Kentucky ........................................................
Clay County, Kentucky ..........................................................
Clinton County, Kentucky ......................................................
Crittenden County, Kentucky ................................................
Cumberland County, Kentucky .............................................
Daviess County, Kentucky ....................................................
Edmonson County, Kentucky ................................................
Elliott County, Kentucky ........................................................
Estill County, Kentucky .........................................................
Fayette County, Kentucky .....................................................
Fleming County, Kentucky ....................................................
Floyd County, Kentucky ........................................................
Franklin County, Kentucky ....................................................
Fulton County, Kentucky .......................................................
Gallatin County, Kentucky .....................................................
Garrard County, Kentucky ....................................................
Grant County, Kentucky ........................................................
Graves County, Kentucky .....................................................
Grayson County, Kentucky ...................................................
Green County, Kentucky .......................................................
Greenup County, Kentucky ...................................................
Hancock County, Kentucky ...................................................
Hardin County, Kentucky ......................................................
Harlan County, Kentucky ......................................................
Harrison County, Kentucky ...................................................
Hart County, Kentucky ..........................................................
Henderson County, Kentucky ...............................................
Henry County, Kentucky .......................................................
Hickman County, Kentucky ...................................................
Hopkins County, Kentucky ....................................................
Jackson County, Kentucky ....................................................
Jefferson County, Kentucky ..................................................
Jessamine County, Kentucky ................................................
Johnson County, Kentucky ...................................................
Kenton County, Kentucky .....................................................
Knott County, Kentucky ........................................................
Knox County, Kentucky .........................................................
Larue County, Kentucky ........................................................
Laurel County, Kentucky .......................................................
Lawrence County, Kentucky .................................................
Lee County, Kentucky ...........................................................
Leslie County, Kentucky .......................................................
Letcher County, Kentucky .....................................................
Lewis County, Kentucky ........................................................
Lincoln County, Kentucky .....................................................
Livingston County, Kentucky .................................................
Logan County, Kentucky .......................................................
Lyon County, Kentucky .........................................................
Mc Cracken County, Kentucky .............................................
Mc Creary County, Kentucky ................................................
Mc Lean County, Kentucky ...................................................
Madison County, Kentucky ...................................................
Magoffin County, Kentucky ...................................................
Marion County, Kentucky ......................................................
Marshall County, Kentucky ...................................................
Martin County, Kentucky .......................................................
Mason County, Kentucky ......................................................
Meade County, Kentucky ......................................................
Menifee County, Kentucky ....................................................
00:49 May 09, 2006
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18
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3400
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18
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1640
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MSA
urban/
rural
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Rural
Rural
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Urban
Rural
Rural
Urban
Rural
Urban
Urban
Rural
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Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.7858
0.7858
0.7858
0.9293
0.7858
0.7858
0.7858
0.9734
0.7858
0.7858
0.9477
0.7858
0.8284
0.8988
0.7858
0.7858
0.7858
0.7858
0.8780
0.7858
0.7858
0.7858
0.8988
0.7858
0.7858
0.7858
0.7858
0.9734
0.7858
0.9734
0.7858
0.7858
0.7858
0.9477
0.7858
0.7858
0.7858
0.7858
0.7858
0.8713
0.7858
0.7858
0.7858
0.7858
0.9293
0.8988
0.7858
0.9734
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.8988
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
E:\FR\FM\09MYR2.SGM
09MYR2
17140
99918
99918
31140
99918
99918
99918
17140
99918
99918
99918
99918
17300
30460
99918
99918
99918
99918
36980
14540
99918
99918
30460
99918
99918
99918
99918
17140
99918
17140
99918
99918
99918
26580
36980
21060
99918
99918
99918
21780
31140
99918
99918
99918
31140
30460
99918
17140
99918
99918
21060
99918
99918
99918
99918
99918
99918
99918
99918
99918
99918
99918
99918
36980
99918
99918
99918
99918
99918
99918
31140
99918
CBSA
urban/
rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
27103
2006
CBSAbased WI
0.9615
0.7766
0.7766
0.9251
0.7766
0.7766
0.7766
0.9615
0.7766
0.7766
0.7766
0.7766
0.8284
0.9075
0.7766
0.7766
0.7766
0.7766
0.8780
0.8211
0.7766
0.7766
0.9075
0.7766
0.7766
0.7766
0.7766
0.9615
0.7766
0.9615
0.7766
0.7766
0.7766
0.9477
0.8780
0.8802
0.7766
0.7766
0.7766
0.8713
0.9251
0.7766
0.7766
0.7766
0.9251
0.9075
0.7766
0.9615
0.7766
0.7766
0.8802
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.8780
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.9251
0.7766
27104
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
18830
18831
18850
18860
18861
18880
18890
18900
18910
18920
18930
18931
18932
18960
18970
18971
18972
18973
18974
18975
18976
18977
18978
18979
18980
18981
18982
18983
18984
18985
18986
18987
18988
18989
18990
18991
18992
19000
19010
19020
19030
19040
19050
19060
19070
19080
19090
19100
19110
19120
19130
19140
19150
19160
19170
19180
19190
19200
19210
19220
19230
19240
19250
19260
19270
19280
19290
19300
19310
19320
19330
19340
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
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.......
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.......
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.......
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.......
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.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
VerDate Aug<31>2005
County name
MSA No.
Mercer County, Kentucky ......................................................
Metcalfe County, Kentucky ...................................................
Monroe County, Kentucky .....................................................
Montgomery County, Kentucky .............................................
Morgan County, Kentucky .....................................................
Muhlenberg County, Kentucky ..............................................
Nelson County, Kentucky ......................................................
Nicholas County, Kentucky ...................................................
Ohio County, Kentucky .........................................................
Oldham County, Kentucky ....................................................
Owen County, Kentucky .......................................................
Owsley County, Kentucky .....................................................
Pendleton County, Kentucky .................................................
Perry County, Kentucky ........................................................
Pike County, Kentucky ..........................................................
Powell County, Kentucky ......................................................
Pulaski County, Kentucky .....................................................
Robertson County, Kentucky ................................................
Rockcastle County, Kentucky ...............................................
Rowan County, Kentucky ......................................................
Russell County, Kentucky .....................................................
Scott County, Kentucky .........................................................
Shelby County, Kentucky ......................................................
Simpson County, Kentucky ...................................................
Spencer County, Kentucky ...................................................
Taylor County, Kentucky .......................................................
Todd County, Kentucky .........................................................
Trigg County, Kentucky .........................................................
Trimble County, Kentucky .....................................................
Union County, Kentucky .......................................................
Warren County, Kentucky .....................................................
Washington County, Kentucky ..............................................
Wayne County, Kentucky ......................................................
Webster County, Kentucky ...................................................
Whitley County, Kentucky .....................................................
Wolfe County, Kentucky ........................................................
Woodford County, Kentucky .................................................
Acadia County, Louisiana .....................................................
Allen County, Louisiana ........................................................
Ascension County, Louisiana ................................................
Assumption County, Louisiana .............................................
Avoyelles County, Louisiana .................................................
Beauregard County, Louisiana .............................................
Bienville County, Louisiana ...................................................
Bossier County, Louisiana ....................................................
Caddo County, Louisiana ......................................................
Calcasieu County, Louisiana ................................................
Caldwell County, Louisiana ...................................................
Cameron County, Louisiana .................................................
Catahoula County, Louisiana ................................................
Claiborne County, Louisiana .................................................
Concordia County, Louisiana ................................................
De Soto County, Louisiana ...................................................
East Baton Rouge County, Louisiana ...................................
East Carroll County, Louisiana .............................................
East Feliciana County, Louisiana .........................................
Evangeline County, Louisiana ..............................................
Franklin County, Louisiana ...................................................
Grant County, Louisiana .......................................................
Iberia County, Louisiana .......................................................
Iberville County, Louisiana ....................................................
Jackson County, Louisiana ...................................................
Jefferson County, Louisiana .................................................
Jefferson Davis County, Louisiana .......................................
Lafayette County, Louisiana .................................................
Lafourche County, Louisiana ................................................
La Salle County, Louisiana ...................................................
Lincoln County, Louisiana .....................................................
Livingston County, Louisiana ................................................
Madison County, Louisiana ...................................................
Morehouse County, Louisiana ..............................................
Natchitoches County, Louisiana ...........................................
00:49 May 09, 2006
Jkt 208001
PO 00000
Frm 00066
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MSA
urban/
rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.9293
0.7858
0.7858
0.9734
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.8988
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.7858
0.8988
0.8251
0.7340
0.8643
0.7340
0.7340
0.7340
0.7340
0.8737
0.8737
0.7858
0.7340
0.7340
0.7340
0.7340
0.7340
0.7340
0.8643
0.7340
0.7340
0.7340
0.7340
0.7340
0.7340
0.7340
0.7340
0.8995
0.7340
0.8251
0.7894
0.7340
0.7340
0.8643
0.7340
0.7340
0.7340
E:\FR\FM\09MYR2.SGM
09MYR2
99918
99918
99918
99918
99918
99918
31140
99918
99918
31140
99918
99918
17140
99918
99918
99918
99918
99918
99918
99918
99918
30460
31140
99918
31140
99918
99918
17300
31140
99918
14540
99918
99918
21780
99918
99918
30460
99919
99919
12940
99919
99919
99919
99919
43340
43340
29340
99919
29340
99919
99919
99919
43340
12940
99919
12940
99919
99919
10780
99919
12940
99919
35380
99919
29180
26380
99919
99919
12940
99919
99919
99919
CBSA
urban/
rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Rural
2006
CBSAbased WI
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.9251
0.7766
0.7766
0.9251
0.7766
0.7766
0.9615
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.7766
0.9075
0.9251
0.7766
0.9251
0.7766
0.7766
0.8284
0.9251
0.7766
0.8211
0.7766
0.7766
0.8713
0.7766
0.7766
0.9075
0.7411
0.7411
0.8593
0.7411
0.7411
0.7411
0.7411
0.8760
0.8760
0.7833
0.7411
0.7833
0.7411
0.7411
0.7411
0.8760
0.8593
0.7411
0.8593
0.7411
0.7411
0.8033
0.7411
0.8593
0.7411
0.8995
0.7411
0.8428
0.7894
0.7411
0.7411
0.8593
0.7411
0.7411
0.7411
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
19350
19360
19370
19380
19390
19400
19410
19420
19430
19440
19450
19460
19470
19480
19490
19500
19510
19520
19530
19540
19550
19560
19570
19580
19590
19600
19610
19620
19630
20000
20010
20020
20030
20040
20050
20060
20070
20080
20090
20100
20110
20120
20130
20140
20150
21000
21010
21020
21030
21040
21050
21060
21070
21080
21090
21100
21110
21120
21130
21140
21150
21160
21170
21180
21190
21200
21210
21220
21230
22000
22010
22020
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VerDate Aug<31>2005
County name
MSA No.
Orleans County, Louisiana ....................................................
Ouachita County, Louisiana ..................................................
Plaquemines County, Louisiana ...........................................
Pointe Coupee County, Louisiana ........................................
Rapides County, Louisiana ...................................................
Red River County, Louisiana ................................................
Richland County, Louisiana ..................................................
Sabine County, Louisiana .....................................................
St Bernard County, Louisiana ...............................................
St Charles County, Louisiana ...............................................
St Helena County, Louisiana ................................................
St James County, Louisiana .................................................
St John Baptist County, Louisiana ........................................
St Landry County, Louisiana .................................................
St Martin County, Louisiana ..................................................
St Mary County, Louisiana ....................................................
St Tammany County, Louisiana ............................................
Tangipahoa County, Louisiana .............................................
Tensas County, Louisiana ....................................................
Terrebonne County, Louisiana ..............................................
Union County, Louisiana .......................................................
Vermilion County, Louisiana .................................................
Vernon County, Louisiana .....................................................
Washington County, Louisiana .............................................
Webster County, Louisiana ...................................................
West Baton Rouge County, Louisiana ..................................
West Carroll County, Louisiana ............................................
West Feliciana County, Louisiana ........................................
Winn County, Louisiana ........................................................
Androscoggin County, Maine ................................................
Aroostook County, Maine ......................................................
Cumberland County, Maine ..................................................
Franklin County, Maine .........................................................
Hancock County, Maine ........................................................
Kennebec County, Maine ......................................................
Knox County, Maine ..............................................................
Lincoln County, Maine ..........................................................
Oxford County, Maine ...........................................................
Penobscot County, Maine .....................................................
Piscataquis County, Maine ...................................................
Sagadahoc County, Maine ....................................................
Somerset County, Maine ......................................................
Waldo County, Maine ............................................................
Washington County, Maine ...................................................
York County, Maine ..............................................................
Allegany County, Maryland ...................................................
Anne Arundel County, Maryland ...........................................
Baltimore County, Maryland ..................................................
Baltimore City County, Maryland ..........................................
Calvert County, Maryland .....................................................
Caroline County, Maryland ...................................................
Carroll County, Maryland ......................................................
Cecil County, Maryland .........................................................
Charles County, Maryland ....................................................
Dorchester County, Maryland ...............................................
Frederick County, Maryland ..................................................
Garrett County, Maryland ......................................................
Harford County, Maryland .....................................................
Howard County, Maryland ....................................................
Kent County, Maryland .........................................................
Montgomery County, Maryland .............................................
Prince Georges County, Maryland ........................................
Queen Annes County, Maryland ...........................................
St Marys County, Maryland ..................................................
Somerset County, Maryland .................................................
Talbot County, Maryland .......................................................
Washington County, Maryland ..............................................
Wicomico County, Maryland .................................................
Worcester County, Maryland ................................................
Barnstable County, Massachusetts ......................................
Berkshire County, Massachusetts ........................................
Bristol County, Massachusetts ..............................................
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MSA
urban/
rural
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Urban
2006
MSAbased WI
CBSA
No.
0.8995
0.8044
0.8995
0.7340
0.8033
0.7340
0.7340
0.7340
0.8995
0.8995
0.7340
0.8995
0.8995
0.8251
0.8251
0.7340
0.8995
0.7340
0.7340
0.7894
0.7340
0.7340
0.7340
0.7340
0.8737
0.8643
0.7340
0.7340
0.7340
0.9331
0.8843
1.0382
0.8843
0.8843
0.8843
0.8843
0.8843
0.8843
0.9993
0.8843
1.0382
0.8843
0.8843
0.8843
1.0382
0.9317
0.9897
0.9897
0.9897
1.0976
0.9230
0.9897
1.0527
1.0976
0.9230
1.0976
0.9230
0.9897
0.9897
0.9230
1.0976
1.0976
0.9897
0.9230
0.9230
0.9230
0.9869
0.9230
0.9230
1.2600
1.0181
1.1178
E:\FR\FM\09MYR2.SGM
09MYR2
35380
33740
35380
12940
10780
99919
99919
99919
35380
35380
12940
99919
35380
99919
29180
99919
35380
99919
99919
26380
33740
99919
99919
99919
99919
12940
99919
12940
99919
30340
99920
38860
99920
99920
99920
99920
99920
99920
12620
99920
38860
99920
99920
99920
38860
19060
12580
12580
12580
47894
99921
12580
48864
47894
99921
13644
99921
12580
12580
99921
13644
47894
12580
99921
41540
99921
25180
41540
99921
12700
38340
39300
CBSA
urban/
rural
Urban
Urban
Urban
Urban
Urban
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
27105
2006
CBSAbased WI
0.8995
0.8031
0.8995
0.8593
0.8033
0.7411
0.7411
0.7411
0.8995
0.8995
0.8593
0.7411
0.8995
0.7411
0.8428
0.7411
0.8995
0.7411
0.7411
0.7894
0.8031
0.7411
0.7411
0.7411
0.7411
0.8593
0.7411
0.8593
0.7411
0.9331
0.8843
1.0382
0.8843
0.8843
0.8843
0.8843
0.8843
0.8843
0.9993
0.8843
1.0382
0.8843
0.8843
0.8843
1.0382
0.9317
0.9897
0.9897
0.9897
1.0926
0.9353
0.9897
1.0471
1.0926
0.9353
1.1483
0.9353
0.9897
0.9897
0.9353
1.1483
1.0926
0.9897
0.9353
0.9064
0.9353
0.9489
0.9064
0.9353
1.2600
1.0181
1.0966
27106
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
22030
22040
22060
22070
22080
22090
22120
22130
22150
22160
22170
23000
23010
23020
23030
23040
23050
23060
23070
23080
23090
23100
23110
23120
23130
23140
23150
23160
23170
23180
23190
23200
23210
23220
23230
23240
23250
23260
23270
23280
23290
23300
23310
23320
23330
23340
23350
23360
23370
23380
23390
23400
23410
23420
23430
23440
23450
23460
23470
23480
23490
23500
23510
23520
23530
23540
23550
23560
23570
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23600
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VerDate Aug<31>2005
County name
MSA No.
Dukes County, Massachusetts .............................................
Essex County, Massachusetts ..............................................
Franklin County, Massachusetts ...........................................
Hampden County, Massachusetts ........................................
Hampshire County, Massachusetts ......................................
Middlesex County, Massachusetts .......................................
Nantucket County, Massachusetts .......................................
Norfolk County, Massachusetts ............................................
Plymouth County, Massachusetts .........................................
Suffolk County, Massachusetts .............................................
Worcester County, Massachusetts .......................................
Alcona County, Michigan ......................................................
Alger County, Michigan .........................................................
Allegan County, Michigan .....................................................
Alpena County, Michigan ......................................................
Antrim County, Michigan .......................................................
Arenac County, Michigan ......................................................
Baraga County, Michigan ......................................................
Barry County, Michigan .........................................................
Bay County, Michigan ...........................................................
Benzie County, Michigan ......................................................
Berrien County, Michigan ......................................................
Branch County, Michigan ......................................................
Calhoun County, Michigan ....................................................
Cass County, Michigan .........................................................
Charlevoix County, Michigan ................................................
Cheboygan County, Michigan ...............................................
Chippewa County, Michigan .................................................
Clare County, Michigan .........................................................
Clinton County, Michigan ......................................................
Crawford County, Michigan ...................................................
Delta County, Michigan .........................................................
Dickinson County, Michigan ..................................................
Eaton County, Michigan ........................................................
Emmet County, Michigan ......................................................
Genesee County, Michigan ...................................................
Gladwin County, Michigan ....................................................
Gogebic County, Michigan ....................................................
Grand Traverse County, Michigan ........................................
Gratiot County, Michigan ......................................................
Hillsdale County, Michigan ....................................................
Houghton County, Michigan ..................................................
Huron County, Michigan .......................................................
Ingham County, Michigan .....................................................
Ionia County, Michigan .........................................................
Iosco County, Michigan .........................................................
Iron County, Michigan ...........................................................
Isabella County, Michigan .....................................................
Jackson County, Michigan ....................................................
Kalamazoo County, Michigan ...............................................
Kalkaska County, Michigan ...................................................
Kent County, Michigan ..........................................................
Keweenaw County, Michigan ................................................
Lake County, Michigan .........................................................
Lapeer County, Michigan ......................................................
Leelanau County, Michigan ..................................................
Lenawee County, Michigan ...................................................
Livingston County, Michigan .................................................
Luce County, Michigan .........................................................
Mackinac County, Michigan ..................................................
Macomb County, Michigan ...................................................
Manistee County, Michigan ...................................................
Marquette County, Michigan .................................................
Mason County, Michigan ......................................................
Mecosta County, Michigan ....................................................
Menominee County, Michigan ..............................................
Midland County, Michigan .....................................................
Missaukee County, Michigan ................................................
Monroe County, Michigan .....................................................
Montcalm County, Michigan ..................................................
Montmorency County, Michigan ...........................................
Muskegon County, Michigan .................................................
00:49 May 09, 2006
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MSA
urban/
rural
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Urban
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Urban
Urban
Urban
Urban
Rural
Rural
Urban
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Urban
Rural
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Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Urban
2006
MSAbased WI
CBSA
No.
1.0216
1.1178
1.0216
1.0263
1.0263
1.1178
1.0216
1.1178
1.1178
1.1178
1.1178
0.8824
0.8824
0.9445
0.8824
0.8824
0.8824
0.8824
0.8824
0.9241
0.8824
0.8879
0.8824
1.0143
0.8824
0.8824
0.8824
0.8824
0.8824
0.9794
0.8824
0.8824
0.8824
0.9794
0.8824
1.0655
0.8824
0.8824
0.8824
0.8824
0.8824
0.8824
0.8824
0.9794
0.8824
0.8824
0.8824
0.8824
0.9304
1.0143
0.8824
0.9445
0.8824
0.8824
1.0147
0.8824
1.0707
1.0707
0.8824
0.8824
1.0147
0.8824
0.8824
0.8824
0.8824
0.8824
0.9241
0.8824
1.0147
0.8824
0.8824
0.9445
E:\FR\FM\09MYR2.SGM
09MYR2
99922
21604
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44140
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15764
99922
14484
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14484
49340
99923
99923
99923
99923
99923
99923
99923
24340
13020
99923
35660
99923
12980
43780
99923
99923
99923
99923
29620
99923
99923
99923
29620
99923
22420
99923
99923
99923
99923
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29620
24340
99923
99923
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27100
28020
99923
24340
99923
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47644
99923
99923
47644
99923
99923
47644
99923
99923
99923
99923
99923
99923
99923
33780
99923
99923
34740
CBSA
urban/
rural
Rural
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
2006
CBSAbased WI
1.0216
1.0538
1.0248
1.0248
1.0248
1.1172
1.0216
1.1558
1.1558
1.1558
1.1028
0.8895
0.8895
0.8895
0.8895
0.8895
0.8895
0.8895
0.9390
0.9343
0.8895
0.8879
0.8895
0.9508
0.9788
0.8895
0.8895
0.8895
0.8895
0.9794
0.8895
0.8895
0.8895
0.9794
0.8895
1.0655
0.8895
0.8895
0.8895
0.8895
0.8895
0.8895
0.8895
0.9794
0.9390
0.8895
0.8895
0.8895
0.9304
1.0381
0.8895
0.9390
0.8895
0.8895
0.9871
0.8895
0.8895
0.9871
0.8895
0.8895
0.9871
0.8895
0.8895
0.8895
0.8895
0.8895
0.8895
0.8895
0.9468
0.8895
0.8895
0.9664
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
23610
23620
23630
23640
23650
23660
23670
23680
23690
23700
23710
23720
23730
23740
23750
23760
23770
23780
23790
23800
23810
23830
24000
24010
24020
24030
24040
24050
24060
24070
24080
24090
24100
24110
24120
24130
24140
24150
24160
24170
24180
24190
24200
24210
24220
24230
24240
24250
24260
24270
24280
24290
24300
24310
24320
24330
24340
24350
24360
24370
24380
24390
24400
24410
24420
24430
24440
24450
24460
24470
24480
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VerDate Aug<31>2005
County name
MSA No.
Newaygo County, Michigan ..................................................
Oakland County, Michigan ....................................................
Oceana County, Michigan .....................................................
Ogemaw County, Michigan ...................................................
Ontonagon County, Michigan ...............................................
Osceola County, Michigan ....................................................
Oscoda County, Michigan .....................................................
Otsego County, Michigan ......................................................
Ottawa County, Michigan ......................................................
Presque Isle County, Michigan .............................................
Roscommon County, Michigan .............................................
Saginaw County, Michigan ...................................................
St Clair County, Michigan .....................................................
St Joseph County, Michigan .................................................
Sanilac County, Michigan .....................................................
Schoolcraft County, Michigan ...............................................
Shiawassee County, Michigan ..............................................
Tuscola County, Michigan .....................................................
Van Buren County, Michigan ................................................
Washtenaw County, Michigan ..............................................
Wayne County, Michigan ......................................................
Wexford County, Michigan ....................................................
Aitkin County, Minnesota ......................................................
Anoka County, Minnesota .....................................................
Becker County, Minnesota ....................................................
Beltrami County, Minnesota ..................................................
Benton County, Minnesota ....................................................
Big Stone County, Minnesota ...............................................
Blue Earth County, Minnesota ..............................................
Brown County, Minnesota .....................................................
Carlton County, Minnesota ...................................................
Carver County, Minnesota ....................................................
Cass County, Minnesota .......................................................
Chippewa County, Minnesota ...............................................
Chisago County, Minnesota ..................................................
Clay County, Minnesota ........................................................
Clearwater County, Minnesota ..............................................
Cook County, Minnesota .......................................................
Cottonwood County, Minnesota ............................................
Crow Wing County, Minnesota .............................................
Dakota County, Minnesota ....................................................
Dodge County, Minnesota ....................................................
Douglas County, Minnesota ..................................................
Faribault County, Minnesota .................................................
Fillmore County, Minnesota ..................................................
Freeborn County, Minnesota ................................................
Goodhue County, Minnesota ................................................
Grant County, Minnesota ......................................................
Hennepin County, Minnesota ................................................
Houston County, Minnesota ..................................................
Hubbard County, Minnesota .................................................
Isanti County, Minnesota ......................................................
Itasca County, Minnesota .....................................................
Jackson County, Minnesota ..................................................
Kanabec County, Minnesota .................................................
Kandiyohi County, Minnesota ...............................................
Kittson County, Minnesota ....................................................
Koochiching County, Minnesota ...........................................
Lac Qui Parle County, Minnesota .........................................
Lake County, Minnesota .......................................................
Lake Of Woods County, Minnesota ......................................
Le Sueur County, Minnesota ................................................
Lincoln County, Minnesota ....................................................
Lyon County, Minnesota .......................................................
Mc Leod County, Minnesota .................................................
Mahnomen County, Minnesota .............................................
Marshall County, Minnesota .................................................
Martin County, Minnesota .....................................................
Meeker County, Minnesota ...................................................
Mille Lacs County, Minnesota ...............................................
Morrison County, Minnesota .................................................
Mower County, Minnesota ....................................................
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2006
MSAbased WI
CBSA
No.
0.8824
1.0147
0.8824
0.8824
0.8824
0.8824
0.8824
0.8824
0.9445
0.8824
0.8824
0.9241
1.0147
0.8824
0.8824
0.8824
0.8824
0.8824
1.0143
1.0707
1.0147
0.8824
0.9132
1.1075
0.9132
0.9132
0.9965
0.9132
0.9132
0.9132
0.9132
1.1075
0.9132
0.9132
1.1075
0.8486
0.9132
0.9132
0.9132
0.9132
1.1075
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
1.1075
0.9564
0.9132
1.1075
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
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99923
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26100
99923
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47644
99923
99923
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99923
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Rural
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Rural
Rural
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Rural
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27107
2006
CBSAbased WI
0.9390
0.9871
0.8895
0.8895
0.8895
0.8895
0.8895
0.8895
0.9055
0.8895
0.8895
0.9088
0.9871
0.8895
0.8895
0.8895
0.8895
0.8895
1.0381
1.0859
1.0424
0.8895
0.9132
1.1075
0.9132
0.9132
0.9965
0.9132
0.9132
0.9132
1.0213
1.1075
0.9132
0.9132
1.1075
0.8486
0.9132
0.9132
0.9132
0.9132
1.1075
1.1131
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
1.1075
0.9564
0.9132
1.1075
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
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27108
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
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Murray County, Minnesota ....................................................
Nicollet County, Minnesota ...................................................
Nobles County, Minnesota ....................................................
Norman County, Minnesota ..................................................
Olmsted County, Minnesota ..................................................
Otter Tail County, Minnesota ................................................
Pennington County, Minnesota .............................................
Pine County, Minnesota ........................................................
Pipestone County, Minnesota ...............................................
Polk County, Minnesota ........................................................
Pope County, Minnesota .......................................................
Ramsey County, Minnesota ..................................................
Red Lake County, Minnesota ...............................................
Redwood County, Minnesota ................................................
Renville County, Minnesota ..................................................
Rice County, Minnesota ........................................................
Rock County, Minnesota .......................................................
Roseau County, Minnesota ...................................................
St Louis County, Minnesota ..................................................
Scott County, Minnesota .......................................................
Sherburne County, Minnesota ..............................................
Sibley County, Minnesota .....................................................
Stearns County, Minnesota ...................................................
Steele County, Minnesota .....................................................
Stevens County, Minnesota ..................................................
Swift County, Minnesota .......................................................
Todd County, Minnesota .......................................................
Traverse County, Minnesota .................................................
Wabasha County, Minnesota ................................................
Wadena County, Minnesota ..................................................
Waseca County, Minnesota ..................................................
Washington County, Minnesota ............................................
Watonwan County, Minnesota ..............................................
Wilkin County, Minnesota .....................................................
Winona County, Minnesota ...................................................
Wright County, Minnesota .....................................................
Yellow Medicine County, Minnesota .....................................
Adams County, Mississippi ...................................................
Alcorn County, Mississippi ....................................................
Amite County, Mississippi .....................................................
Attala County, Mississippi .....................................................
Benton County, Mississippi ...................................................
Bolivar County, Mississippi ...................................................
Calhoun County, Mississippi .................................................
Carroll County, Mississippi ....................................................
Chickasaw County, Mississippi .............................................
Choctaw County, Mississippi ................................................
Claiborne County, Mississippi ...............................................
Clarke County, Mississippi ....................................................
Clay County, Mississippi .......................................................
Coahoma County, Mississippi ...............................................
Copiah County, Mississippi ...................................................
Covington County, Mississippi ..............................................
Desoto County, Mississippi ...................................................
Forrest County, Mississippi ...................................................
Franklin County, Mississippi .................................................
George County, Mississippi ..................................................
Greene County, Mississippi ..................................................
Grenada County, Mississippi ................................................
Hancock County, Mississippi ................................................
Harrison County, Mississippi .................................................
Hinds County, Mississippi .....................................................
Holmes County, Mississippi ..................................................
Humphreys County, Mississippi ............................................
Issaquena County, Mississippi ..............................................
Itawamba County, Mississippi ...............................................
Jackson County, Mississippi .................................................
Jasper County, Mississippi ...................................................
Jefferson County, Mississippi ...............................................
Jefferson Davis County, Mississippi .....................................
Jones County, Mississippi .....................................................
Kemper County, Mississippi ..................................................
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2006
MSAbased WI
CBSA
No.
0.9132
0.9132
0.9132
0.9132
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0.9132
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0.9132
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0.9132
1.1075
0.9132
0.9132
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0.9132
0.9132
0.9132
0.9132
1.1075
0.9132
0.9132
0.9132
1.1075
0.9132
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
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0.7634
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0.7634
0.7634
0.7634
0.7634
0.9416
0.7601
0.7634
0.7634
0.7634
0.7634
0.8706
0.8706
0.8382
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2006
CBSAbased WI
0.9132
0.9132
0.9132
0.9132
1.1131
0.9132
0.9132
0.9132
0.9132
0.7901
0.9132
1.1075
0.9132
0.9132
0.9132
0.9132
0.9132
0.9132
1.0213
1.1075
1.1075
0.9132
0.9965
0.9132
0.9132
0.9132
0.9132
0.9132
1.1131
0.9132
0.9132
1.1075
0.9132
0.9132
0.9132
1.1075
0.9132
0.7674
0.7674
0.7674
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0.7674
0.7674
0.7674
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0.7674
0.7674
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0.7674
0.8311
0.7674
0.9397
0.7601
0.7674
0.8156
0.7674
0.7674
0.8929
0.8929
0.8311
0.7674
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0.8156
0.7674
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Lafayette County, Mississippi ...............................................
Lamar County, Mississippi ....................................................
Lauderdale County, Mississippi ............................................
Lawrence County, Mississippi ...............................................
Leake County, Mississippi ....................................................
Lee County, Mississippi ........................................................
Leflore County, Mississippi ...................................................
Lincoln County, Mississippi ...................................................
Lowndes County, Mississippi ................................................
Madison County, Mississippi .................................................
Marion County, Mississippi ...................................................
Marshall County, Mississippi .................................................
Monroe County, Mississippi ..................................................
Montgomery County, Mississippi ..........................................
Neshoba County, Mississippi ................................................
Newton County, Mississippi ..................................................
Noxubee County, Mississippi ................................................
Oktibbeha County, Mississippi ..............................................
Panola County, Mississippi ...................................................
Pearl River County, Mississippi ............................................
Perry County, Mississippi ......................................................
Pike County, Mississippi .......................................................
Pontotoc County, Mississippi ................................................
Prentiss County, Mississippi .................................................
Quitman County, Mississippi .................................................
Rankin County, Mississippi ...................................................
Scott County, Mississippi ......................................................
Sharkey County, Mississippi .................................................
Simpson County, Mississippi ................................................
Smith County, Mississippi .....................................................
Stone County, Mississippi .....................................................
Sunflower County, Mississippi ..............................................
Tallahatchie County, Mississippi ...........................................
Tate County, Mississippi .......................................................
Tippah County, Mississippi ...................................................
Tishomingo County, Mississippi ............................................
Tunica County, Mississippi ...................................................
Union County, Mississippi .....................................................
Walthall County, Mississippi .................................................
Warren County, Mississippi ..................................................
Washington County, Mississippi ...........................................
Wayne County, Mississippi ...................................................
Webster County, Mississippi .................................................
Wilkinson County, Mississippi ...............................................
Winston County, Mississippi .................................................
Yalobusha County, Mississippi .............................................
Yazoo County, Mississippi ....................................................
Adair County, Missouri ..........................................................
Andrew County, Missouri ......................................................
Atchison County, Missouri ....................................................
Audrain County, Missouri ......................................................
Barry County, Missouri ..........................................................
Barton County, Missouri ........................................................
Bates County, Missouri .........................................................
Benton County, Missouri .......................................................
Bollinger County, Missouri ....................................................
Boone County, Missouri ........................................................
Buchanan County, Missouri ..................................................
Butler County, Missouri .........................................................
Caldwell County, Missouri .....................................................
Callaway County, Missouri ....................................................
Camden County, Missouri .....................................................
Cape Girardeau County, Missouri ........................................
Carroll County, Missouri ........................................................
Carter County, Missouri ........................................................
Cass County, Missouri ..........................................................
Cedar County, Missouri ........................................................
Chariton County, Missouri .....................................................
Christian County, Missouri ....................................................
Clark County, Missouri ..........................................................
Clay County, Missouri ...........................................................
Clinton County, Missouri .......................................................
00:49 May 09, 2006
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Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Urban
2006
MSAbased WI
CBSA
No.
0.7634
0.7601
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.8382
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.8382
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7634
0.7959
0.9519
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.8345
0.9519
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.9490
0.7959
0.7959
0.8250
0.7959
0.9490
0.9490
E:\FR\FM\09MYR2.SGM
09MYR2
99925
25620
99925
99925
99925
99925
99925
99925
99925
27140
99925
32820
99925
99925
99925
99925
99925
99925
99925
99925
25620
99925
99925
99925
99925
27140
99925
99925
27140
99925
25060
99925
99925
32820
99925
99925
32820
99925
99925
99925
99925
99925
99925
99925
99925
99925
99925
99926
41140
99926
99926
99926
99926
28140
99926
99926
17860
41140
99926
28140
27620
99926
99926
99926
99926
28140
99926
99926
44180
99926
28140
28140
CBSA
urban/
rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Urban
27109
2006
CBSAbased WI
0.7674
0.7601
0.7674
0.7674
0.7674
0.7674
0.7674
0.7674
0.7674
0.8311
0.7674
0.9397
0.7674
0.7674
0.7674
0.7674
0.7674
0.7674
0.7674
0.7674
0.7601
0.7674
0.7674
0.7674
0.7674
0.8311
0.7674
0.7674
0.8311
0.7674
0.8929
0.7674
0.7674
0.9397
0.7674
0.7674
0.9397
0.7674
0.7674
0.7674
0.7674
0.7674
0.7674
0.7674
0.7674
0.7674
0.7674
0.7900
0.9519
0.7900
0.7900
0.7900
0.7900
0.9476
0.7900
0.7900
0.8345
0.9519
0.7900
0.9476
0.8387
0.7900
0.7900
0.7900
0.7900
0.9476
0.7900
0.7900
0.8237
0.7900
0.9476
0.9476
27110
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
26250
26260
26270
26280
26290
26300
26310
26320
26330
26340
26350
26360
26370
26380
26390
26400
26410
26411
26412
26440
26450
26460
26470
26480
26490
26500
26510
26520
26530
26540
26541
26560
26570
26580
26590
26600
26601
26620
26630
26631
26650
26660
26670
26680
26690
26700
26710
26720
26730
26740
26750
26751
26770
26780
26790
26800
26810
26820
26821
26840
26850
26860
26870
26880
26881
26900
26910
26911
26930
26940
26950
26960
.......
.......
.......
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.......
.......
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VerDate Aug<31>2005
County name
MSA No.
Cole County, Missouri ...........................................................
Cooper County, Missouri ......................................................
Crawford County, Missouri ....................................................
Dade County, Missouri ..........................................................
Dallas County, Missouri ........................................................
Daviess County, Missouri .....................................................
De Kalb County, Missouri .....................................................
Dent County, Missouri ...........................................................
Douglas County, Missouri .....................................................
Dunklin County, Missouri ......................................................
Franklin County, Missouri .....................................................
Gasconade County, Missouri ................................................
Gentry County, Missouri .......................................................
Greene County, Missouri ......................................................
Grundy County, Missouri ......................................................
Harrison County, Missouri .....................................................
Henry County, Missouri .........................................................
Hickory County, Missouri ......................................................
Holt County, Missouri ............................................................
Howard County, Missouri ......................................................
Howell County, Missouri .......................................................
Iron County, Missouri ............................................................
Jackson County, Missouri .....................................................
Jasper County, Missouri .......................................................
Jefferson County, Missouri ...................................................
Johnson County, Missouri .....................................................
Knox County, Missouri ..........................................................
Laclede County, Missouri ......................................................
Lafayette County, Missouri ...................................................
Lawrence County, Missouri ...................................................
Lewis County, Missouri .........................................................
Lincoln County, Missouri .......................................................
Linn County, Missouri ...........................................................
Livingston County, Missouri ..................................................
Mc Donald County, Missouri .................................................
Macon County, Missouri .......................................................
Madison County, Missouri .....................................................
Maries County, Missouri .......................................................
Marion County, Missouri .......................................................
Mercer County, Missouri .......................................................
Miller County, Missouri ..........................................................
Mississippi County, Missouri .................................................
Moniteau County, Missouri ...................................................
Monroe County, Missouri ......................................................
Montgomery County, Missouri ..............................................
Morgan County, Missouri ......................................................
New Madrid County, Missouri ...............................................
Newton County, Missouri ......................................................
Nodaway County, Missouri ...................................................
Oregon County, Missouri ......................................................
Osage County, Missouri ........................................................
Ozark County, Missouri .........................................................
Pemiscot County, Missouri ...................................................
Perry County, Missouri ..........................................................
Pettis County, Missouri .........................................................
Phelps County, Missouri .......................................................
Pike County, Missouri ...........................................................
Platte County, Missouri .........................................................
Polk County, Missouri ...........................................................
Pulaski County, Missouri .......................................................
Putnam County, Missouri ......................................................
Ralls County, Missouri ..........................................................
Randolph County, Missouri ...................................................
Ray County, Missouri ............................................................
Reynolds County, Missouri ...................................................
Ripley County, Missouri ........................................................
St Charles County, Missouri .................................................
St Clair County, Missouri ......................................................
St Francois County, Missouri ................................................
St Louis County, Missouri .....................................................
St Louis City County, Missouri ..............................................
Ste Genevieve County, Missouri ..........................................
00:49 May 09, 2006
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Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
2006
MSAbased WI
CBSA
No.
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.8962
0.7959
0.7959
0.8250
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.9490
0.8582
0.8962
0.7959
0.7959
0.7959
0.9490
0.7959
0.7959
0.8962
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.8582
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.9490
0.7959
0.7959
0.7959
0.7959
0.7959
0.9490
0.7959
0.7959
0.8962
0.7959
0.7959
0.8962
0.8962
0.7959
E:\FR\FM\09MYR2.SGM
09MYR2
27620
99926
41180
99926
44180
99926
41140
99926
99926
99926
41180
99926
99926
44180
99926
99926
99926
99926
99926
17860
99926
99926
28140
27900
41180
99926
99926
99926
28140
99926
99926
41180
99926
99926
22220
99926
99926
99926
99926
99926
99926
99926
27620
99926
99926
99926
99926
27900
99926
99926
27620
99926
99926
99926
99926
99926
99926
28140
44180
99926
99926
99926
99926
28140
99926
99926
41180
99926
99926
41180
41180
99926
CBSA
urban/
rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
2006
CBSAbased WI
0.8387
0.7900
0.8954
0.7900
0.8237
0.7900
0.9519
0.7900
0.7900
0.7900
0.8954
0.7900
0.7900
0.8237
0.7900
0.7900
0.7900
0.7900
0.7900
0.8345
0.7900
0.7900
0.9476
0.8582
0.8954
0.7900
0.7900
0.7900
0.9476
0.7900
0.7900
0.8954
0.7900
0.7900
0.8661
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.8387
0.7900
0.7900
0.7900
0.7900
0.8582
0.7900
0.7900
0.8387
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.9476
0.8237
0.7900
0.7900
0.7900
0.7900
0.9476
0.7900
0.7900
0.8954
0.7900
0.7900
0.8954
0.8954
0.7900
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
26970
26980
26981
26982
26983
26984
26985
26986
26987
26988
26989
26990
26991
26992
26993
26994
26995
26996
27000
27010
27020
27030
27040
27050
27060
27070
27080
27090
27100
27110
27113
27120
27130
27140
27150
27160
27170
27180
27190
27200
27210
27220
27230
27240
27250
27260
27270
27280
27290
27300
27310
27320
27330
27340
27350
27360
27370
27380
27390
27400
27410
27420
27430
27440
27450
27460
27470
27480
27490
27500
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27520
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VerDate Aug<31>2005
County name
MSA No.
Saline County, Missouri ........................................................
Schuyler County, Missouri ....................................................
Scotland County, Missouri ....................................................
Scott County, Missouri ..........................................................
Shannon County, Missouri ....................................................
Shelby County, Missouri .......................................................
Stoddard County, Missouri ....................................................
Stone County, Missouri .........................................................
Sullivan County, Missouri ......................................................
Taney County, Missouri ........................................................
Texas County, Missouri ........................................................
Vernon County, Missouri .......................................................
Warren County, Missouri ......................................................
Washington County, Missouri ...............................................
Wayne County, Missouri .......................................................
Webster County, Missouri .....................................................
Worth County, Missouri .........................................................
Wright County, Missouri ........................................................
Beaverhead County, Montana ..............................................
Big Horn County, Montana ...................................................
Blaine County, Montana ........................................................
Broadwater County, Montana ...............................................
Carbon County, Montana ......................................................
Carter County, Montana ........................................................
Cascade County, Montana ...................................................
Chouteau County, Montana ..................................................
Custer County, Montana .......................................................
Daniels County, Montana ......................................................
Dawson County, Montana .....................................................
Deer Lodge County, Montana ...............................................
Yellowstone National Park, Montana ....................................
Fallon County, Montana ........................................................
Fergus County, Montana ......................................................
Flathead County, Montana ....................................................
Gallatin County, Montana .....................................................
Garfield County, Montana .....................................................
Glacier County, Montana ......................................................
Golden Valley County, Montana ...........................................
Granite County, Montana ......................................................
Hill County, Montana .............................................................
Jefferson County, Montana ...................................................
Judith Basin County, Montana ..............................................
Lake County, Montana ..........................................................
Lewis And Clark County, Montana .......................................
Liberty County, Montana .......................................................
Lincoln County, Montana ......................................................
Mc Cone County, Montana ...................................................
Madison County, Montana ....................................................
Meagher County, Montana ...................................................
Mineral County, Montana ......................................................
Missoula County, Montana ...................................................
Musselshell County, Montana ...............................................
Park County, Montana ..........................................................
Petroleum County, Montana .................................................
Phillips County, Montana ......................................................
Pondera County, Montana ....................................................
Powder River County, Montana ............................................
Powell County, Montana .......................................................
Prairie County, Montana .......................................................
Ravalli County, Montana .......................................................
Richland County, Montana ....................................................
Roosevelt County, Montana ..................................................
Rosebud County, Montana ...................................................
Sanders County, Montana ....................................................
Sheridan County, Montana ...................................................
Silver Bow County, Montana ................................................
Stillwater County, Montana ...................................................
Sweet Grass County, Montana .............................................
Teton County, Montana ........................................................
Toole County, Montana .........................................................
Treasure County, Montana ...................................................
Valley County, Montana ........................................................
00:49 May 09, 2006
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MSA
urban/
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Rural
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Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.7959
0.8962
0.7959
0.7959
0.8250
0.7959
0.7959
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.9052
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.9473
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
E:\FR\FM\09MYR2.SGM
09MYR2
99926
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99926
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99926
99926
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99926
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41180
41180
99926
44180
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13740
99927
24500
99927
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Urban
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Urban
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Urban
Rural
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Rural
Rural
Rural
Rural
Rural
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Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
27111
2006
CBSAbased WI
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.8954
0.8954
0.7900
0.8237
0.7900
0.7900
0.8762
0.8762
0.8762
0.8762
0.8834
0.8762
0.9052
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.9473
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
27112
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
27530
27540
27550
28000
28010
28020
28030
28040
28050
28060
28070
28080
28090
28100
28110
28120
28130
28140
28150
28160
28170
28180
28190
28200
28210
28220
28230
28240
28250
28260
28270
28280
28290
28300
28310
28320
28330
28340
28350
28360
28370
28380
28390
28400
28410
28420
28430
28440
28450
28460
28470
28480
28490
28500
28510
28520
28530
28540
28550
28560
28570
28580
28590
28600
28610
28620
28630
28640
28650
28660
28670
28680
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VerDate Aug<31>2005
County name
MSA No.
Wheatland County, Montana ................................................
Wibaux County, Montana ......................................................
Yellowstone County, Montana ..............................................
Adams County, Nebraska .....................................................
Antelope County, Nebraska ..................................................
Arthur County, Nebraska ......................................................
Banner County, Nebraska .....................................................
Blaine County, Nebraska ......................................................
Boone County, Nebraska ......................................................
Box Butte County, Nebraska ................................................
Boyd County, Nebraska ........................................................
Brown County, Nebraska ......................................................
Buffalo County, Nebraska .....................................................
Burt County, Nebraska ..........................................................
Butler County, Nebraska .......................................................
Cass County, Nebraska ........................................................
Cedar County, Nebraska ......................................................
Chase County, Nebraska ......................................................
Cherry County, Nebraska .....................................................
Cheyenne County, Nebraska ................................................
Clay County, Nebraska .........................................................
Colfax County, Nebraska ......................................................
Cuming County, Nebraska ....................................................
Custer County, Nebraska ......................................................
Dakota County, Nebraska .....................................................
Dawes County, Nebraska .....................................................
Dawson County, Nebraska ...................................................
Deuel County, Nebraska .......................................................
Dixon County, Nebraska .......................................................
Dodge County, Nebraska ......................................................
Douglas County, Nebraska ...................................................
Dundy County, Nebraska ......................................................
Fillmore County, Nebraska ...................................................
Franklin County, Nebraska ...................................................
Frontier County, Nebraska ....................................................
Furnas County, Nebraska .....................................................
Gage County, Nebraska .......................................................
Garden County, Nebraska ....................................................
Garfield County, Nebraska ....................................................
Gosper County, Nebraska ....................................................
Grant County, Nebraska .......................................................
Greeley County, Nebraska ....................................................
Hall County, Nebraska ..........................................................
Hamilton County, Nebraska ..................................................
Harlan County, Nebraska ......................................................
Hayes County, Nebraska ......................................................
Hitchcock County, Nebraska .................................................
Holt County, Nebraska ..........................................................
Hooker County, Nebraska .....................................................
Howard County, Nebraska ....................................................
Jefferson County, Nebraska .................................................
Johnson County, Nebraska ...................................................
Kearney County, Nebraska ...................................................
Keith County, Nebraska ........................................................
Keya Paha County, Nebraska ..............................................
Kimball County, Nebraska ....................................................
Knox County, Nebraska ........................................................
Lancaster County, Nebraska ................................................
Lincoln County, Nebraska .....................................................
Logan County, Nebraska ......................................................
Loup County, Nebraska ........................................................
Mc Pherson County, Nebraska .............................................
Madison County, Nebraska ...................................................
Merrick County, Nebraska ....................................................
Morrill County, Nebraska ......................................................
Nance County, Nebraska ......................................................
Nemaha County, Nebraska ...................................................
Nuckolls County, Nebraska ...................................................
Otoe County, Nebraska ........................................................
Pawnee County, Nebraska ...................................................
Perkins County, Nebraska ....................................................
Phelps County, Nebraska .....................................................
00:49 May 09, 2006
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Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.8762
0.8762
0.8834
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.9560
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.9416
0.8657
0.8657
0.8657
0.8657
0.8657
0.9560
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
1.0214
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
E:\FR\FM\09MYR2.SGM
09MYR2
99927
99927
13740
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
36540
99928
99928
99928
99928
99928
99928
99928
99928
43580
99928
99928
99928
43580
99928
36540
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
30700
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
99928
CBSA
urban/
rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
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Rural
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Rural
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Rural
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Rural
Rural
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Rural
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Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
2006
CBSAbased WI
0.8762
0.8762
0.8834
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.9560
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.9381
0.8657
0.8657
0.8657
0.9381
0.8657
0.9560
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
1.0214
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
28690
28700
28710
28720
28730
28740
28750
28760
28770
28780
28790
28800
28810
28820
28830
28840
28850
28860
28870
28880
28890
28900
28910
28920
29000
29010
29020
29030
29040
29050
29060
29070
29080
29090
29100
29110
29120
29130
29140
29150
29160
30000
30010
30020
30030
30040
30050
30060
30070
30080
30090
31000
31100
31150
31160
31180
31190
31200
31220
31230
31250
31260
31270
31290
31300
31310
31320
31340
31350
31360
31370
31390
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VerDate Aug<31>2005
County name
MSA No.
Pierce County, Nebraska ......................................................
Platte County, Nebraska .......................................................
Polk County, Nebraska .........................................................
Redwillow County, Nebraska ................................................
Richardson County, Nebraska ..............................................
Rock County, Nebraska ........................................................
Saline County, Nebraska ......................................................
Sarpy County, Nebraska .......................................................
Saunders County, Nebraska .................................................
Scotts Bluff County, Nebraska ..............................................
Seward County, Nebraska ....................................................
Sheridan County, Nebraska ..................................................
Sherman County, Nebraska ..................................................
Sioux County, Nebraska .......................................................
Stanton County, Nebraska ....................................................
Thayer County, Nebraska .....................................................
Thomas County, Nebraska ...................................................
Thurston County, Nebraska ..................................................
Valley County, Nebraska ......................................................
Washington County, Nebraska .............................................
Wayne County, Nebraska .....................................................
Webster County, Nebraska ...................................................
Wheeler County, Nebraska ...................................................
York County, Nebraska .........................................................
Churchill County, Nevada .....................................................
Clark County, Nevada ...........................................................
Douglas County, Nevada ......................................................
Elko County, Nevada ............................................................
Esmeralda County, Nevada ..................................................
Eureka County, Nevada ........................................................
Humboldt County, Nevada ....................................................
Lander County, Nevada ........................................................
Lincoln County, Nevada ........................................................
Lyon County, Nevada ...........................................................
Mineral County, Nevada .......................................................
Nye County, Nevada .............................................................
Carson City County, Nevada ................................................
Pershing County, Nevada .....................................................
Storey County, Nevada .........................................................
Washoe County, Nevada ......................................................
White Pine County, Nevada ..................................................
Belknap County, New Hampshire .........................................
Carroll County, New Hampshire ...........................................
Cheshire County, New Hampshire .......................................
Coos County, New Hampshire .............................................
Grafton County, New Hampshire ..........................................
Hillsboro County, New Hampshire ........................................
Merrimack County, New Hampshire .....................................
Rockingham County, New Hampshire ..................................
Strafford County, New Hampshire ........................................
Sullivan County, New Hampshire .........................................
Atlantic County, New Jersey .................................................
Bergen County, New Jersey .................................................
Burlington County, New Jersey ............................................
Camden County, New Jersey ...............................................
Cape May County, New Jersey ............................................
Cumberland County, New Jersey .........................................
Essex County, New Jersey ...................................................
Gloucester County, New Jersey ...........................................
Hudson County, New Jersey ................................................
Hunterdon County, New Jersey ............................................
Mercer County, New Jersey .................................................
Middlesex County, New Jersey ............................................
Monmouth County, New Jersey ............................................
Morris County, New Jersey ...................................................
Ocean County, New Jersey ..................................................
Passaic County, New Jersey ................................................
Salem County, New Jersey ..................................................
Somerset County, New Jersey .............................................
Sussex County, New Jersey .................................................
Union County, New Jersey ...................................................
Warren County, New Jersey .................................................
00:49 May 09, 2006
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Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
2006
MSAbased WI
CBSA
No.
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.9560
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.9560
0.8657
0.8657
0.8657
0.8657
0.9687
1.1155
0.9687
0.9687
0.9687
0.9687
0.9687
0.9687
0.9687
0.9687
0.9687
1.1155
0.9687
0.9687
0.9687
1.0982
0.9687
1.0817
1.0817
1.0817
1.0817
1.0817
1.1178
1.1178
1.1178
1.1178
1.0817
1.1496
1.1651
1.0922
1.0922
1.1496
0.9827
1.1834
1.0922
1.1338
1.1167
1.0834
1.1167
1.1260
1.1834
1.1260
1.1651
1.0922
1.1167
1.1834
1.1834
1.1834
E:\FR\FM\09MYR2.SGM
09MYR2
99928
99928
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99928
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35084
15804
35644
35084
45940
20764
20764
35084
20764
35644
48864
20764
35084
35084
10900
CBSA
urban/
rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
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Rural
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Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
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Rural
Rural
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
27113
2006
CBSAbased WI
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.9560
0.9560
0.8657
1.0214
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.8657
0.9560
0.8657
0.8657
0.8657
0.8657
0.9065
1.1437
0.9065
0.9065
0.9065
0.9065
0.9065
0.9065
0.9065
0.9065
0.9065
0.9065
1.0234
0.9065
1.0982
1.0982
0.9065
1.0817
1.0817
1.0817
1.0817
1.0817
1.0354
1.0354
1.0374
1.0374
1.0817
1.1615
1.3188
1.0517
1.0517
1.1011
0.9827
1.1883
1.0517
1.3188
1.1883
1.0834
1.1249
1.1249
1.1883
1.1249
1.3188
1.0471
1.1249
1.1883
1.1883
0.9818
27114
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
32000
32010
32020
32025
32030
32040
32050
32060
32070
32080
32090
32100
32110
32120
32130
32131
32140
32150
32160
32170
32180
32190
32200
32210
32220
32230
32240
32250
32260
32270
32280
32290
32300
33000
33010
33020
33030
33040
33050
33060
33070
33080
33090
33200
33210
33220
33230
33240
33260
33270
33280
33290
33300
33310
33320
33330
33331
33340
33350
33360
33370
33380
33400
33420
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VerDate Aug<31>2005
County name
MSA No.
Bernalillo County, New Mexico .............................................
Catron County, New Mexico .................................................
Chaves County, New Mexico ................................................
Cibola County, New Mexico ..................................................
Colfax County, New Mexico ..................................................
Curry County, New Mexico ...................................................
De Baca County, New Mexico ..............................................
Dona Ana County, New Mexico ............................................
Eddy County, New Mexico ....................................................
Grant County, New Mexico ...................................................
Guadalupe County, New Mexico ..........................................
Harding County, New Mexico ...............................................
Hidalgo County, New Mexico ................................................
Lea County, New Mexico ......................................................
Lincoln County, New Mexico ................................................
Los Alamos County, New Mexico .........................................
Luna County, New Mexico ....................................................
Mc Kinley County, New Mexico ............................................
Mora County, New Mexico ....................................................
Otero County, New Mexico ...................................................
Quay County, New Mexico ...................................................
Rio Arriba County, New Mexico ............................................
Roosevelt County, New Mexico ............................................
Sandoval County, New Mexico .............................................
San Juan County, New Mexico ............................................
San Miguel County, New Mexico ..........................................
Santa Fe County, New Mexico .............................................
Sierra County, New Mexico ..................................................
Socorro County, New Mexico ...............................................
Taos County, New Mexico ....................................................
Torrance County, New Mexico .............................................
Union County, New Mexico ..................................................
Valencia County, New Mexico ..............................................
Albany County, New York .....................................................
Allegany County, New York ..................................................
Bronx County, New York ......................................................
Broome County, New York ...................................................
Cattaraugus County, New York ............................................
Cayuga County, New York ...................................................
Chautauqua County, New York ............................................
Chemung County, New York ................................................
Chenango County, New York ...............................................
Clinton County, New York .....................................................
Columbia County, New York .................................................
Cortland County, New York ..................................................
Delaware County, New York .................................................
Dutchess County, New York .................................................
Erie County, New York .........................................................
Essex County, New York ......................................................
Franklin County, New York ...................................................
Fulton County, New York ......................................................
Genesee County, New York .................................................
Greene County, New York ....................................................
Hamilton County, New York ..................................................
Herkimer County, New York .................................................
Jefferson County, New York .................................................
Kings County, New York .......................................................
Lewis County, New York .......................................................
Livingston County, New York ................................................
Madison County, New York ..................................................
Monroe County, New York ....................................................
Montgomery County, New York ............................................
Nassau County, New York ....................................................
New York County, New York ................................................
Niagara County, New York ...................................................
Oneida County, New York ....................................................
Onondaga County, New York ...............................................
Ontario County, New York ....................................................
Orange County, New York ....................................................
Orleans County, New York ...................................................
Oswego County, New York ...................................................
Otsego County, New York ....................................................
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Rural
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Rural
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Rural
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Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Rural
2006
MSAbased WI
CBSA
No.
0.9684
0.8563
0.8563
0.8563
0.8563
0.8563
0.8563
0.8467
0.8563
0.8563
0.8563
0.8563
0.8563
0.8563
0.8563
1.0748
0.8563
0.8563
0.8563
0.8563
0.8563
0.8563
0.8563
0.9684
0.8563
0.8563
1.0748
0.8563
0.8563
0.8563
0.8563
0.8563
0.9684
0.8559
0.8395
1.3464
0.8562
0.8395
0.9492
0.7544
0.8250
0.8395
0.8395
0.8395
0.8395
0.8395
1.0475
0.9511
0.8395
0.8395
0.8395
0.9049
0.8395
0.8395
0.8358
0.8395
1.3464
0.8395
0.9049
0.9492
0.9049
0.8559
1.2719
1.3464
0.9511
0.8358
0.9492
0.9049
1.1207
0.9049
0.9492
0.8395
E:\FR\FM\09MYR2.SGM
09MYR2
10740
99932
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29740
99932
99932
99932
99932
99932
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99932
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10740
22140
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35644
13780
99933
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39100
15380
99933
99933
99933
99933
99933
99933
46540
99933
35644
99933
40380
45060
40380
99933
35004
35644
15380
46540
45060
40380
39100
40380
45060
99933
CBSA
urban/
rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Rural
2006
CBSAbased WI
0.9684
0.8635
0.8635
0.8635
0.8635
0.8635
0.8635
0.8467
0.8635
0.8635
0.8635
0.8635
0.8635
0.8635
0.8635
0.8635
0.8635
0.8635
0.8635
0.8635
0.8635
0.8635
0.8635
0.9684
0.8509
0.8635
1.0920
0.8635
0.8635
0.8635
0.9684
0.8635
0.9684
0.8589
0.8154
1.3188
0.8562
0.8154
0.8154
0.8154
0.8250
0.8154
0.8154
0.8154
0.8154
0.8154
1.0891
0.9511
0.8154
0.8154
0.8154
0.8154
0.8154
0.8154
0.8358
0.8154
1.3188
0.8154
0.9121
0.9574
0.9121
0.8154
1.2719
1.3188
0.9511
0.8358
0.9574
0.9121
1.0891
0.9121
0.9574
0.8154
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
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SSA State/
County
Code
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33680
33690
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33750
33760
33770
33800
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33910
34000
34010
34020
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34050
34060
34070
34080
34090
34100
34110
34120
34130
34140
34150
34160
34170
34180
34190
34200
34210
34220
34230
34240
34250
34251
34270
34280
34290
34300
34310
34320
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VerDate Aug<31>2005
County name
MSA No.
Putnam County, New York ...................................................
Queens County, New York ...................................................
Rensselaer County, New York ..............................................
Richmond County, New York ................................................
Rockland County, New York .................................................
St Lawrence County, New York ............................................
Saratoga County, New York .................................................
Schenectady County, New York ...........................................
Schoharie County, New York ................................................
Schuyler County, New York ..................................................
Seneca County, New York ....................................................
Steuben County, New York ..................................................
Suffolk County, New York .....................................................
Sullivan County, New York ...................................................
Tioga County, New York .......................................................
Tompkins County, New York ................................................
Ulster County, New York ......................................................
Warren County, New York ....................................................
Washington County, New York .............................................
Wayne County, New York .....................................................
Westchester County, New York ............................................
Wyoming County, New York .................................................
Yates County, New York .......................................................
Alamance County, N Carolina ..............................................
Alexander County, N Carolina ..............................................
Alleghany County, N Carolina ...............................................
Anson County, N Carolina ....................................................
Ashe County, N Carolina ......................................................
Avery County, N Carolina .....................................................
Beaufort County, N Carolina .................................................
Bertie County, N Carolina .....................................................
Bladen County, N Carolina ...................................................
Brunswick County, N Carolina ..............................................
Buncombe County, N Carolina .............................................
Burke County, N Carolina .....................................................
Cabarrus County, N Carolina ................................................
Caldwell County, N Carolina .................................................
Camden County, N Carolina .................................................
Carteret County, N Carolina .................................................
Caswell County, N Carolina ..................................................
Catawba County, N Carolina ................................................
Chatham County, N Carolina ................................................
Cherokee County, N Carolina ...............................................
Chowan County, N Carolina .................................................
Clay County, N Carolina .......................................................
Cleveland County, N Carolina ..............................................
Columbus County, N Carolina ..............................................
Craven County, N Carolina ...................................................
Cumberland County, N Carolina ...........................................
Currituck County, N Carolina ................................................
Dare County, N Carolina .......................................................
Davidson County, N Carolina ...............................................
Davie County, N Carolina .....................................................
Duplin County, N Carolina ....................................................
Durham County, N Carolina ..................................................
Edgecombe County, N Carolina ...........................................
Forsyth County, N Carolina ..................................................
Franklin County, N Carolina ..................................................
Gaston County, N Carolina ...................................................
Gates County, N Carolina .....................................................
Graham County, N Carolina .................................................
Granville County, N Carolina ................................................
Greene County, N Carolina ..................................................
Guilford County, N Carolina ..................................................
Halifax County, N Carolina ...................................................
Harnett County, N Carolina ...................................................
Haywood County, N Carolina ...............................................
Henderson County, N Carolina .............................................
Hertford County, N Carolina .................................................
Hoke County, N Carolina ......................................................
Hyde County, N Carolina ......................................................
Iredell County, N Carolina .....................................................
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Rural
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Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
1.3464
1.3464
0.8559
1.3464
1.3464
0.8395
0.8559
0.8559
0.8559
0.8395
0.8395
0.8395
1.2719
0.8395
0.8562
0.8395
0.8395
0.8559
0.8559
0.9049
1.3464
0.8395
0.8395
0.9018
0.8921
0.8462
0.8462
0.8462
0.8462
0.8462
0.8462
0.8462
0.9582
0.9737
0.8921
0.9715
0.8921
0.8462
0.8462
0.8462
0.8921
1.0034
0.8462
0.8462
0.8462
0.8462
0.8462
0.8462
0.9416
0.8799
0.8462
0.9018
0.9018
0.8462
1.0034
0.8915
0.9018
1.0034
0.9715
0.8462
0.8462
0.8462
0.8462
0.9018
0.8462
0.8462
0.8462
0.8462
0.8462
0.8462
0.8462
0.8462
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09MYR2
35644
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35644
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99933
10580
10580
10580
99933
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35004
99933
13780
27060
28740
24020
24020
40380
35644
99933
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15500
25860
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99934
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99934
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49180
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40580
49180
39580
16740
99934
99934
99934
24780
24660
99934
99934
11700
11700
99934
22180
99934
99934
CBSA
urban/
rural
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Urban
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Urban
Rural
Urban
Urban
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Urban
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
27115
2006
CBSAbased WI
1.3188
1.3188
0.8589
1.3188
1.3188
0.8154
0.8589
0.8589
0.8589
0.8154
0.8154
0.8154
1.2719
0.8154
0.8562
0.9793
0.9255
0.8559
0.8559
0.9121
1.3188
0.8154
0.8154
0.8905
0.8921
0.8540
0.9750
0.8540
0.8540
0.8540
0.8540
0.8540
0.9582
0.9285
0.8921
0.9750
0.8921
0.8540
0.8540
0.8540
0.8921
1.0244
0.8540
0.8540
0.8540
0.8540
0.8540
0.8540
0.9416
0.8799
0.8540
0.8540
0.8944
0.8540
1.0244
0.8915
0.8944
0.9691
0.9750
0.8540
0.8540
0.8540
0.9425
0.9104
0.8540
0.8540
0.9285
0.9285
0.8540
0.9416
0.8540
0.8540
27116
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
34490
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34510
34520
34530
34540
34550
34560
34570
34580
34590
34600
34610
34620
34630
34640
34650
34660
34670
34680
34690
34700
34710
34720
34730
34740
34750
34760
34770
34780
34790
34800
34810
34820
34830
34840
34850
34860
34870
34880
34890
34900
34910
34920
34930
34940
34950
34960
34970
34980
34981
35000
35010
35020
35030
35040
35050
35060
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VerDate Aug<31>2005
County name
MSA No.
Jackson County, N Carolina .................................................
Johnston County, N Carolina ................................................
Jones County, N Carolina .....................................................
Lee County, N Carolina ........................................................
Lenoir County, N Carolina ....................................................
Lincoln County, N Carolina ...................................................
Mc Dowell County, N Carolina ..............................................
Macon County, N Carolina ....................................................
Madison County, N Carolina .................................................
Martin County, N Carolina ....................................................
Mecklenburg County, N Carolina ..........................................
Mitchell County, N Carolina ..................................................
Montgomery County, N Carolina ..........................................
Moore County, N Carolina ....................................................
Nash County, N Carolina ......................................................
New Hanover County, N Carolina ........................................
Northampton County, N Carolina ..........................................
Onslow County, N Carolina ..................................................
Orange County, N Carolina ..................................................
Pamlico County, N Carolina ..................................................
Pasquotank County, N Carolina ...........................................
Pender County, N Carolina ...................................................
Perquimans County, N Carolina ...........................................
Person County, N Carolina ...................................................
Pitt County, N Carolina .........................................................
Polk County, N Carolina .......................................................
Randolph County, N Carolina ...............................................
Richmond County, N Carolina ..............................................
Robeson County, N Carolina ................................................
Rockingham County, N Carolina ..........................................
Rowan County, N Carolina ...................................................
Rutherford County, N Carolina .............................................
Sampson County, N Carolina ...............................................
Scotland County, N Carolina ................................................
Stanly County, N Carolina ....................................................
Stokes County, N Carolina ...................................................
Surry County, N Carolina ......................................................
Swain County, N Carolina .....................................................
Transylvania County, N Carolina ..........................................
Tyrrell County, N Carolina ....................................................
Union County, N Carolina .....................................................
Vance County, N Carolina ....................................................
Wake County, N Carolina .....................................................
Warren County, N Carolina ...................................................
Washington County, N Carolina ...........................................
Watauga County, N Carolina ................................................
Wayne County, N Carolina ...................................................
Wilkes County, N Carolina ....................................................
Wilson County, N Carolina ....................................................
Yadkin County, N Carolina ...................................................
Yancey County, N Carolina ..................................................
Adams County, N Dakota .....................................................
Barnes County, N Dakota .....................................................
Benson County, N Dakota ....................................................
Billings County, N Dakota .....................................................
Bottineau County, N Dakota .................................................
Bowman County, N Dakota ..................................................
Burke County, N Dakota .......................................................
Burleigh County, N Dakota ...................................................
Cass County, N Dakota ........................................................
Cavalier County, N Dakota ...................................................
Dickey County, N Dakota ......................................................
Divide County, N Dakota ......................................................
Dunn County, N Dakota ........................................................
Eddy County, N Dakota ........................................................
Emmons County, N Dakota ..................................................
Foster County, N Dakota ......................................................
Golden Valley County, N Dakota ..........................................
Grand Forks County, N Dakota ............................................
Grant County, N Dakota .......................................................
Griggs County, N Dakota ......................................................
Hettinger County, N Dakota ..................................................
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urban/
rural
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Rural
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Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Rural
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Urban
Rural
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Rural
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Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.8462
1.0034
0.8462
0.8462
0.8462
0.9715
0.8462
0.8462
0.9737
0.8462
0.9715
0.8462
0.8462
0.8462
0.8915
0.9582
0.8462
0.8236
1.0034
0.8462
0.8462
0.8462
0.8462
0.8462
0.9425
0.8462
0.9018
0.8462
0.8462
0.8462
0.9715
0.8462
0.8462
0.8462
0.8462
0.9018
0.8462
0.8462
0.8462
0.8462
0.9715
0.8462
1.0034
0.8462
0.8462
0.8462
0.8775
0.8462
0.8462
0.9018
0.8462
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7574
0.8486
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7901
0.7261
0.7261
0.7261
E:\FR\FM\09MYR2.SGM
09MYR2
99934
39580
99934
99934
99934
99934
99934
99934
11700
99934
16740
99934
99934
99934
40580
48900
99934
27340
20500
99934
99934
48900
99934
20500
24780
99934
24660
99934
99934
24660
99934
99934
99934
99934
99934
49180
99934
99934
99934
99934
16740
99934
39580
99934
99934
99934
24140
99934
99934
49180
99934
99935
99935
99935
99935
99935
99935
99935
13900
22020
99935
99935
99935
99935
99935
99935
99935
99935
24220
99935
99935
99935
CBSA
urban/
rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
2006
CBSAbased WI
0.8540
0.9691
0.8540
0.8540
0.8540
0.8540
0.8540
0.8540
0.9285
0.8540
0.9750
0.8540
0.8540
0.8540
0.8915
0.9582
0.8540
0.8236
1.0244
0.8540
0.8540
0.9582
0.8540
1.0244
0.9425
0.8540
0.9104
0.8540
0.8540
0.9104
0.8540
0.8540
0.8540
0.8540
0.8540
0.8944
0.8540
0.8540
0.8540
0.8540
0.9750
0.8540
0.9691
0.8540
0.8540
0.8540
0.8775
0.8540
0.8540
0.8944
0.8540
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7574
0.8486
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7901
0.7261
0.7261
0.7261
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
35210
35220
35230
35240
35250
35260
35270
35280
35290
35300
35310
35320
35330
35340
35350
35360
35370
35380
35390
35400
35410
35420
35430
35440
35450
35460
35470
35480
35490
35500
35510
35520
36000
36010
36020
36030
36040
36050
36060
36070
36080
36090
36100
36110
36120
36130
36140
36150
36160
36170
36190
36200
36210
36220
36230
36240
36250
36260
36270
36280
36290
36300
36310
36330
36340
36350
36360
36370
36380
36390
36400
36410
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VerDate Aug<31>2005
County name
MSA No.
Kidder County, N Dakota ......................................................
La Moure County, N Dakota .................................................
Logan County, N Dakota ......................................................
Mc Henry County, N Dakota .................................................
Mc Intosh County, N Dakota .................................................
Mc Kenzie County, N Dakota ...............................................
Mc Lean County, N Dakota ..................................................
Mercer County, N Dakota .....................................................
Morton County, N Dakota .....................................................
Mountrail County, N Dakota ..................................................
Nelson County, N Dakota .....................................................
Oliver County, N Dakota .......................................................
Pembina County, N Dakota ..................................................
Pierce County, N Dakota ......................................................
Ramsey County, N Dakota ...................................................
Ransom County, N Dakota ...................................................
Renville County, N Dakota ....................................................
Richland County, N Dakota ..................................................
Rolette County, N Dakota .....................................................
Sargent County, N Dakota ....................................................
Sheridan County, N Dakota ..................................................
Sioux County, N Dakota .......................................................
Slope County, N Dakota .......................................................
Stark County, N Dakota ........................................................
Steele County, N Dakota ......................................................
Stutsman County, N Dakota .................................................
Towner County, N Dakota ....................................................
Traill County, N Dakota .........................................................
Walsh County, N Dakota ......................................................
Ward County, N Dakota ........................................................
Wells County, N Dakota ........................................................
Williams County, N Dakota ...................................................
Adams County, Ohio .............................................................
Allen County, Ohio ................................................................
Ashland County, Ohio ...........................................................
Ashtabula County, Ohio ........................................................
Athens County, Ohio .............................................................
Auglaize County, Ohio ..........................................................
Belmont County, Ohio ...........................................................
Brown County, Ohio ..............................................................
Butler County, Ohio ...............................................................
Carroll County, Ohio .............................................................
Champaign County, Ohio ......................................................
Clark County, Ohio ................................................................
Clermont County, Ohio .........................................................
Clinton County, Ohio .............................................................
Columbiana County, Ohio .....................................................
Coshocton County, Ohio .......................................................
Crawford County, Ohio .........................................................
Cuyahoga County, Ohio ........................................................
Darke County, Ohio ..............................................................
Defiance County, Ohio ..........................................................
Delaware County, Ohio .........................................................
Erie County, Ohio ..................................................................
Fairfield County, Ohio ...........................................................
Fayette County, Ohio ............................................................
Franklin County, Ohio ...........................................................
Fulton County, Ohio ..............................................................
Gallia County, Ohio ...............................................................
Geauga County, Ohio ...........................................................
Greene County, Ohio ............................................................
Guernsey County, Ohio ........................................................
Hamilton County, Ohio ..........................................................
Hancock County, Ohio ..........................................................
Hardin County, Ohio .............................................................
Harrison County, Ohio ..........................................................
Henry County, Ohio ..............................................................
Highland County, Ohio ..........................................................
Hocking County, Ohio ...........................................................
Holmes County, Ohio ............................................................
Huron County, Ohio ..............................................................
Jackson County, Ohio ...........................................................
00:49 May 09, 2006
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urban/
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Rural
Rural
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Rural
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Urban
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7574
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.8921
0.9119
0.8921
0.9183
0.8921
0.9119
0.7161
0.9734
0.8951
0.8935
0.8921
0.8980
0.9734
0.8921
0.8848
0.8921
0.9891
0.9183
0.8921
0.8921
0.9874
0.8921
0.9874
0.8921
0.9874
0.9574
0.8921
0.9183
0.8980
0.8921
0.9734
0.8921
0.8921
0.8921
0.8921
0.8921
0.8921
0.8921
0.8921
0.8921
E:\FR\FM\09MYR2.SGM
09MYR2
99935
99935
99935
99935
99935
99935
99935
99935
13900
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99935
99936
30620
99936
99936
99936
99936
48540
17140
17140
15940
99936
44220
17140
99936
99936
99936
99936
17460
99936
99936
18140
41780
18140
99936
18140
45780
99936
17460
19380
99936
17140
99936
99936
99936
99936
99936
99936
99936
99936
99936
CBSA
urban/
rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
27117
2006
CBSAbased WI
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7574
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.7261
0.8826
0.9225
0.8826
0.8826
0.8826
0.8826
0.7161
0.9615
0.9615
0.8935
0.8826
0.8396
0.9615
0.8826
0.8826
0.8826
0.8826
0.9213
0.8826
0.8826
0.9860
0.9019
0.9860
0.8826
0.9860
0.9574
0.8826
0.9213
0.9064
0.8826
0.9615
0.8826
0.8826
0.8826
0.8826
0.8826
0.8826
0.8826
0.8826
0.8826
27118
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
36420
36430
36440
36450
36460
36470
36480
36490
36500
36510
36520
36530
36540
36550
36560
36570
36580
36590
36600
36610
36620
36630
36640
36650
36660
36670
36680
36690
36700
36710
36720
36730
36740
36750
36760
36770
36780
36790
36800
36810
36820
36830
36840
36850
36860
36870
36880
36890
37000
37010
37020
37030
37040
37050
37060
37070
37080
37090
37100
37110
37120
37130
37140
37150
37160
37170
37180
37190
37200
37210
37220
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VerDate Aug<31>2005
County name
MSA No.
Jefferson County, Ohio .........................................................
Knox County, Ohio ................................................................
Lake County, Ohio ................................................................
Lawrence County, Ohio ........................................................
Licking County, Ohio .............................................................
Logan County, Ohio ..............................................................
Lorain County, Ohio ..............................................................
Lucas County, Ohio ..............................................................
Madison County, Ohio ..........................................................
Mahoning County, Ohio ........................................................
Marion County, Ohio .............................................................
Medina County, Ohio ............................................................
Meigs County, Ohio ..............................................................
Mercer County, Ohio .............................................................
Miami County, Ohio ..............................................................
Monroe County, Ohio ............................................................
Montgomery County, Ohio ....................................................
Morgan County, Ohio ............................................................
Morrow County, Ohio ............................................................
Muskingum County, Ohio ......................................................
Noble County, Ohio ...............................................................
Ottawa County, Ohio .............................................................
Paulding County, Ohio ..........................................................
Perry County, Ohio ...............................................................
Pickaway County, Ohio .........................................................
Pike County, Ohio .................................................................
Portage County, Ohio ...........................................................
Preble County, Ohio ..............................................................
Putnam County, Ohio ............................................................
Richland County, Ohio ..........................................................
Ross County, Ohio ................................................................
Sandusky County, Ohio ........................................................
Scioto County, Ohio ..............................................................
Seneca County, Ohio ............................................................
Shelby County, Ohio .............................................................
Stark County, Ohio ................................................................
Summit County, Ohio ............................................................
Trumbull County, Ohio ..........................................................
Tuscarawas County, Ohio .....................................................
Union County, Ohio ...............................................................
Van Wert County, Ohio .........................................................
Vinton County, Ohio ..............................................................
Warren County, Ohio ............................................................
Washington County, Ohio .....................................................
Wayne County, Ohio .............................................................
Williams County, Ohio ...........................................................
Wood County, Ohio ...............................................................
Wyandot County, Ohio ..........................................................
Adair County, Oklahoma .......................................................
Alfalfa County, Oklahoma .....................................................
Atoka County, Oklahoma ......................................................
Beaver County, Oklahoma ....................................................
Beckham County, Oklahoma ................................................
Blaine County, Oklahoma .....................................................
Bryan County, Oklahoma ......................................................
Caddo County, Oklahoma .....................................................
Canadian County, Oklahoma ................................................
Carter County, Oklahoma .....................................................
Cherokee County, Oklahoma ................................................
Choctaw County, Oklahoma .................................................
Cimarron County, Oklahoma ................................................
Cleveland County, Oklahoma ...............................................
Coal County, Oklahoma ........................................................
Comanche County, Oklahoma ..............................................
Cotton County, Oklahoma .....................................................
Craig County, Oklahoma .......................................................
Creek County, Oklahoma ......................................................
Custer County, Oklahoma .....................................................
Delaware County, Oklahoma ................................................
Dewey County, Oklahoma ....................................................
Ellis County, Oklahoma .........................................................
Garfield County, Oklahoma ...................................................
00:49 May 09, 2006
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PO 00000
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MSA
urban/
rural
Urban
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Urban
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Urban
Rural
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Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
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Urban
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Rural
Rural
Rural
Urban
Rural
Urban
Rural
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Urban
Rural
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Rural
Rural
Rural
Urban
Urban
Urban
Rural
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Rural
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Urban
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Rural
Urban
Rural
Rural
Rural
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Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
2006
MSAbased WI
CBSA
No.
0.7819
0.8921
0.9183
0.9477
0.9874
0.8921
0.9183
0.9574
0.9874
0.8848
0.8921
0.9183
0.8921
0.8921
0.8980
0.8921
0.8980
0.8921
0.8921
0.8921
0.8921
0.8921
0.8921
0.8921
0.9874
0.8921
0.8982
0.8921
0.8921
0.9891
0.8921
0.8921
0.8921
0.8921
0.8921
0.8935
0.8982
0.8848
0.8921
0.8921
0.8921
0.8921
0.9734
0.8270
0.8921
0.8921
0.9574
0.8921
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.9025
0.7442
0.7442
0.7442
0.7442
0.9025
0.7442
0.7872
0.7442
0.7442
0.8587
0.7442
0.7442
0.7442
0.7442
0.8666
E:\FR\FM\09MYR2.SGM
09MYR2
48260
99936
17460
26580
18140
99936
17460
45780
18140
49660
99936
17460
99936
99936
19380
99936
19380
99936
18140
99936
99936
45780
99936
99936
18140
99936
10420
19380
99936
31900
99936
99936
99936
99936
99936
15940
10420
49660
99936
18140
99936
99936
17140
37620
99936
99936
45780
99936
99937
99937
99937
99937
99937
99937
99937
99937
36420
99937
99937
99937
99937
36420
99937
30020
99937
99937
46140
99937
99937
99937
99937
99937
CBSA
urban/
rural
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
2006
CBSAbased WI
0.7819
0.8826
0.9213
0.9477
0.9860
0.8826
0.9213
0.9574
0.9860
0.8603
0.8826
0.9213
0.8826
0.8826
0.9064
0.8826
0.9064
0.8826
0.9860
0.8826
0.8826
0.9574
0.8826
0.8826
0.9860
0.8826
0.8982
0.9064
0.8826
0.9891
0.8826
0.8826
0.8826
0.8826
0.8826
0.8935
0.8982
0.8603
0.8826
0.9860
0.8826
0.8826
0.9615
0.8270
0.8826
0.8826
0.9574
0.8826
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.9031
0.7581
0.7581
0.7581
0.7581
0.9031
0.7581
0.7872
0.7581
0.7581
0.8543
0.7581
0.7581
0.7581
0.7581
0.7581
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
37240
37250
37260
37270
37280
37290
37300
37310
37320
37330
37340
37350
37360
37370
37380
37390
37400
37410
37420
37430
37440
37450
37460
37470
37480
37490
37500
37510
37520
37530
37540
37550
37560
37570
37580
37590
37600
37610
37620
37630
37640
37650
37660
37670
37680
37690
37700
37710
37720
37730
37740
37750
37760
38000
38010
38020
38030
38040
38050
38060
38070
38080
38090
38100
38110
38120
38130
38140
38150
38160
38170
38180
.......
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VerDate Aug<31>2005
County name
MSA No.
Garvin County, Oklahoma .....................................................
Grady County, Oklahoma .....................................................
Grant County, Oklahoma ......................................................
Greer County, Oklahoma ......................................................
Harmon County, Oklahoma ..................................................
Harper County, Oklahoma ....................................................
Haskell County, Oklahoma ...................................................
Hughes County, Oklahoma ...................................................
Jackson County, Oklahoma ..................................................
Jefferson County, Oklahoma ................................................
Johnston County, Oklahoma .................................................
Kay County, Oklahoma .........................................................
Kingfisher County, Oklahoma ...............................................
Kiowa County, Oklahoma .....................................................
Latimer County, Oklahoma ...................................................
Le Flore County, Oklahoma ..................................................
Lincoln County, Oklahoma ....................................................
Logan County, Oklahoma .....................................................
Love County, Oklahoma .......................................................
Mc Clain County, Oklahoma .................................................
Mc Curtain County, Oklahoma ..............................................
Mc Intosh County, Oklahoma ...............................................
Major County, Oklahoma ......................................................
Marshall County, Oklahoma ..................................................
Mayes County, Oklahoma .....................................................
Murray County, Oklahoma ....................................................
Muskogee County, Oklahoma ...............................................
Noble County, Oklahoma ......................................................
Nowata County, Oklahoma ...................................................
Okfuskee County, Oklahoma ................................................
Oklahoma County, Oklahoma ...............................................
Okmulgee County, Oklahoma ...............................................
Osage County, Oklahoma .....................................................
Ottawa County, Oklahoma ....................................................
Pawnee County, Oklahoma ..................................................
Payne County, Oklahoma .....................................................
Pittsburg County, Oklahoma .................................................
Pontotoc County, Oklahoma .................................................
Pottawatomie County, Oklahoma .........................................
Pushmataha County, Oklahoma ...........................................
Roger Mills County, Oklahoma .............................................
Rogers County, Oklahoma ....................................................
Seminole County, Oklahoma ................................................
Sequoyah County, Oklahoma ...............................................
Stephens County, Oklahoma ................................................
Texas County, Oklahoma .....................................................
Tillman County, Oklahoma ....................................................
Tulsa County, Oklahoma ......................................................
Wagoner County, Oklahoma .................................................
Washington County, Oklahoma ............................................
Washita County, Oklahoma ..................................................
Woods County, Oklahoma ....................................................
Woodward County, Oklahoma ..............................................
Baker County, Oregon ..........................................................
Benton County, Oregon ........................................................
Clackamas County, Oregon ..................................................
Clatsop County, Oregon .......................................................
Columbia County, Oregon ....................................................
Coos County, Oregon ...........................................................
Crook County, Oregon ..........................................................
Curry County, Oregon ...........................................................
Deschutes County, Oregon ...................................................
Douglas County, Oregon ......................................................
Gilliam County, Oregon .........................................................
Grant County, Oregon ...........................................................
Harney County, Oregon ........................................................
Hood River County, Oregon .................................................
Jackson County, Oregon ......................................................
Jefferson County, Oregon .....................................................
Josephine County, Oregon ...................................................
Klamath County, Oregon ......................................................
Lake County, Oregon ............................................................
00:49 May 09, 2006
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MSA
urban/
rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
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Urban
Rural
Urban
Rural
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Rural
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Urban
Rural
Urban
Rural
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Urban
Rural
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Rural
Urban
Rural
Rural
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Urban
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.9025
0.7442
0.9025
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.7442
0.9025
0.7442
0.8587
0.7442
0.7442
0.7442
0.7442
0.7442
0.9025
0.7442
0.7442
0.8587
0.7442
0.8246
0.7442
0.7442
0.7442
0.8587
0.8587
0.7442
0.7442
0.7442
0.7442
1.0052
1.0729
1.1266
1.0052
1.1266
1.0052
1.0052
1.0052
1.0052
1.0052
1.0052
1.0052
1.0052
1.0052
1.0225
1.0052
1.0052
1.0052
1.0052
E:\FR\FM\09MYR2.SGM
09MYR2
99937
36420
99937
99937
99937
99937
99937
99937
99937
99937
99937
99937
99937
99937
99937
22900
36420
36420
99937
36420
99937
99937
99937
99937
99937
99937
99937
99937
99937
99937
36420
46140
46140
99937
46140
99937
99937
99937
99937
99937
99937
46140
99937
22900
99937
99937
99937
46140
46140
99937
99937
99937
99937
99938
18700
38900
99938
38900
99938
99938
99938
13460
99938
99938
99938
99938
99938
32780
99938
99938
99938
99938
CBSA
urban/
rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
27119
2006
CBSAbased WI
0.7581
0.9031
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.8230
0.9031
0.9031
0.7581
0.9031
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.9031
0.8543
0.8543
0.7581
0.8543
0.7581
0.7581
0.7581
0.7581
0.7581
0.7581
0.8543
0.7581
0.8230
0.7581
0.7581
0.7581
0.8543
0.8543
0.7581
0.7581
0.7581
0.7581
0.9826
1.0729
1.1266
0.9826
1.1266
0.9826
0.9826
0.9826
1.0786
0.9826
0.9826
0.9826
0.9826
0.9826
1.0225
0.9826
0.9826
0.9826
0.9826
27120
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
38190
38200
38210
38220
38230
38240
38250
38260
38270
38280
38290
38300
38310
38320
38330
38340
38350
39000
39010
39070
39080
39100
39110
39120
39130
39140
39150
39160
39180
39190
39200
39210
39220
39230
39240
39250
39260
39270
39280
39290
39310
39320
39330
39340
39350
39360
39370
39380
39390
39400
39410
39420
39440
39450
39460
39470
39480
39510
39520
39530
39540
39550
39560
39580
39590
39600
39610
39620
39630
39640
39650
39670
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.......
VerDate Aug<31>2005
County name
MSA No.
Lane County, Oregon ............................................................
Lincoln County, Oregon ........................................................
Linn County, Oregon .............................................................
Malheur County, Oregon .......................................................
Marion County, Oregon .........................................................
Morrow County, Oregon ........................................................
Multnomah County, Oregon ..................................................
Polk County, Oregon .............................................................
Sherman County, Oregon .....................................................
Tillamook County, Oregon ....................................................
Umatilla County, Oregon .......................................................
Union County, Oregon ..........................................................
Wallowa County, Oregon ......................................................
Wasco County, Oregon .........................................................
Washington County, Oregon .................................................
Wheeler County, Oregon ......................................................
Yamhill County, Oregon ........................................................
Adams County, Pennsylvania ...............................................
Allegheny County, Pennsylvania ..........................................
Armstrong County, Pennsylvania ..........................................
Beaver County, Pennsylvania ...............................................
Bedford County, Pennsylvania ..............................................
Berks County, Pennsylvania .................................................
Blair County, Pennsylvania ...................................................
Bradford County, Pennsylvania ............................................
Bucks County, Pennsylvania ................................................
Butler County, Pennsylvania .................................................
Cambria County, Pennsylvania .............................................
Cameron County, Pennsylvania ...........................................
Carbon County, Pennsylvania ..............................................
Centre County, Pennsylvania ...............................................
Chester County, Pennsylvania ..............................................
Clarion County, Pennsylvania ...............................................
Clearfield County, Pennsylvania ...........................................
Clinton County, Pennsylvania ...............................................
Columbia County, Pennsylvania ...........................................
Crawford County, Pennsylvania ............................................
Cumberland County, Pennsylvania .......................................
Dauphin County, Pennsylvania .............................................
Delaware County, Pennsylvania ...........................................
Elk County, Pennsylvania .....................................................
Erie County, Pennsylvania ....................................................
Fayette County, Pennsylvania ..............................................
Forest County, Pennsylvania ................................................
Franklin County, Pennsylvania .............................................
Fulton County, Pennsylvania ................................................
Greene County, Pennsylvania ..............................................
Huntingdon County, Pennsylvania ........................................
Indiana County, Pennsylvania ..............................................
Jefferson County, Pennsylvania ...........................................
Juniata County, Pennsylvania ...............................................
Lackawanna County, Pennsylvania ......................................
Lancaster County, Pennsylvania ..........................................
Lawrence County, Pennsylvania ...........................................
Lebanon County, Pennsylvania ............................................
Lehigh County, Pennsylvania ...............................................
Luzerne County, Pennsylvania .............................................
Lycoming County, Pennsylvania ...........................................
Mc Kean County, Pennsylvania ............................................
Mercer County, Pennsylvania ...............................................
Mifflin County, Pennsylvania .................................................
Monroe County, Pennsylvania ..............................................
Montgomery County, Pennsylvania ......................................
Montour County, Pennsylvania .............................................
Northampton County, Pennsylvania .....................................
Northumberland County, Pennsylvania ................................
Perry County, Pennsylvania ..................................................
Philadelphia County, Pennsylvania .......................................
Pike County, Pennsylvania ...................................................
Potter County, Pennsylvania .................................................
Schuylkill County, Pennsylvania ...........................................
Snyder County, Pennsylvania ...............................................
00:49 May 09, 2006
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urban/
rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Urban
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
1.0818
1.0052
1.0052
1.0052
1.0442
1.0052
1.1266
1.0442
1.0052
1.0052
1.0052
1.0052
1.0052
1.0052
1.1266
1.0052
1.1266
0.8319
0.8860
0.8319
0.8860
0.8319
0.9686
0.8944
0.8319
1.0922
0.8860
0.8086
0.8319
0.9845
0.8356
1.0922
0.8319
0.8319
0.8319
0.8524
0.8319
0.9233
0.9233
1.0922
0.8319
0.8737
0.8860
0.8319
0.8319
0.8319
0.8319
0.8319
0.8319
0.8319
0.8319
0.8524
0.9694
0.8319
0.9233
0.9845
0.8524
0.8364
0.8319
0.7793
0.8319
0.8319
1.0922
0.8319
0.9845
0.8319
0.9233
1.0922
1.1207
0.8319
0.8319
0.8319
E:\FR\FM\09MYR2.SGM
09MYR2
21660
99938
99938
99938
41420
99938
38900
41420
99938
99938
99938
99938
99938
99938
38900
99938
38900
99939
38300
38300
38300
99939
39740
11020
99939
37964
38300
27780
99939
10900
44300
37964
99939
99939
99939
99939
99939
25420
25420
37964
99939
21500
38300
99939
99939
99939
99939
99939
99939
99939
99939
42540
29540
99939
30140
10900
42540
48700
99939
49660
99939
99939
37964
99939
10900
99939
25420
37964
35084
99939
99939
99939
CBSA
urban/
rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Urban
Rural
Rural
Rural
2006
CBSAbased WI
1.0818
0.9826
0.9826
0.9826
1.0442
0.9826
1.1266
1.0442
0.9826
0.9826
0.9826
0.9826
0.9826
0.9826
1.1266
0.9826
1.1266
0.8291
0.8845
0.8845
0.8845
0.8291
0.9686
0.8944
0.8291
1.1038
0.8845
0.8354
0.8291
0.9818
0.8356
1.1038
0.8291
0.8291
0.8291
0.8291
0.8291
0.9313
0.9313
1.1038
0.8291
0.8737
0.8845
0.8291
0.8291
0.8291
0.8291
0.8291
0.8291
0.8291
0.8291
0.8540
0.9694
0.8291
0.8459
0.9818
0.8540
0.8364
0.8291
0.8603
0.8291
0.8291
1.1038
0.8291
0.9818
0.8291
0.9313
1.1038
1.1883
0.8291
0.8291
0.8291
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
39680
39690
39700
39710
39720
39730
39740
39750
39760
39770
39790
39800
40010
40020
40030
40040
40050
40060
40070
40080
40090
40100
40110
40120
40130
40140
40145
40150
40160
40170
40180
40190
40200
40210
40220
40230
40240
40250
40260
40265
40270
40280
40290
40300
40310
40320
40330
40340
40350
40360
40370
40380
40390
40400
40410
40420
40430
40440
40450
40460
40470
40480
40490
40500
40510
40520
40530
40540
40550
40560
40570
40580
.......
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VerDate Aug<31>2005
County name
MSA No.
Somerset County, Pennsylvania ...........................................
Sullivan County, Pennsylvania ..............................................
Susquehanna County, Pennsylvania ....................................
Tioga County, Pennsylvania .................................................
Union County, Pennsylvania .................................................
Venango County, Pennsylvania ............................................
Warren County, Pennsylvania ..............................................
Washington County, Pennsylvania .......................................
Wayne County, Pennsylvania ...............................................
Westmoreland County, Pennsylvania ...................................
Wyoming County, Pennsylvania ...........................................
York County, Pennsylvania ...................................................
Adjuntas County, Puerto Rico ...............................................
Aguada County, Puerto Rico ................................................
Aguadilla County, Puerto Rico ..............................................
Aguas Buenas County, Puerto Rico .....................................
Aibonito County, Puerto Rico ................................................
Anasco County, Puerto Rico .................................................
Arecibo County, Puerto Rico ................................................
Arroyo County, Puerto Rico ..................................................
Barceloneta County, Puerto Rico .........................................
Barranquitas County, Puerto Rico ........................................
Bayamon County, Puerto Rico .............................................
Cabo Rojo County, Puerto Rico ...........................................
Caguas County, Puerto Rico ................................................
Camuy County, Puerto Rico .................................................
Canovanas County, Puerto Rico ..........................................
Carolina County, Puerto Rico ...............................................
Catano County, Puerto Rico .................................................
Cayey County, Puerto Rico ..................................................
Ceiba County, Puerto Rico ...................................................
Ciales County, Puerto Rico ...................................................
Cidra County, Puerto Rico ....................................................
Coamo County, Puerto Rico .................................................
Comerio County, Puerto Rico ...............................................
Corozal County, Puerto Rico ................................................
Culebra County, Puerto Rico ................................................
Dorado County, Puerto Rico .................................................
Fajardo County, Puerto Rico ................................................
Florida County, Puerto Rico ..................................................
Guanica County, Puerto Rico ...............................................
Guayama County, Puerto Rico .............................................
Guayanilla County, Puerto Rico ............................................
Guaynabo County, Puerto Rico ............................................
Gurabo County, Puerto Rico .................................................
Hatillo County, Puerto Rico ...................................................
Hormigueros County, Puerto Rico ........................................
Humacao County, Puerto Rico .............................................
Isabela County, Puerto Rico .................................................
Jayuya County, Puerto Rico .................................................
Juana Diaz County, Puerto Rico ..........................................
Juncos County, Puerto Rico .................................................
Lajas County, Puerto Rico ....................................................
Lares County, Puerto Rico ....................................................
Las Marias County, Puerto Rico ...........................................
Las Piedras County, Puerto Rico .........................................
Loiza County, Puerto Rico ....................................................
Luquillo County, Puerto Rico ................................................
Manati County, Puerto Rico ..................................................
Maricao County, Puerto Rico ................................................
Maunabo County, Puerto Rico ..............................................
Mayaguez County, Puerto Rico ............................................
Moca County, Puerto Rico ....................................................
Morovis County, Puerto Rico ................................................
Naguabo County, Puerto Rico ..............................................
Naranjito County, Puerto Rico ..............................................
Orocovis County, Puerto Rico ..............................................
Patillas County, Puerto Rico .................................................
Penuelas County, Puerto Rico ..............................................
Ponce County, Puerto Rico ..................................................
Quebradillas County, Puerto Rico ........................................
Rincon County, Puerto Rico .................................................
00:49 May 09, 2006
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MSA
urban/
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Rural
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Rural
Rural
Rural
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Urban
Urban
Urban
Rural
Rural
Urban
Urban
Urban
Urban
Urban
Rural
Rural
Urban
Urban
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.8086
0.8319
0.8319
0.8319
0.8319
0.8319
0.8319
0.8860
0.8319
0.8860
0.8524
0.9347
0.3604
0.4876
0.4876
0.4752
0.3604
0.4243
0.4112
0.3604
0.4752
0.3604
0.4752
0.4243
0.4120
0.4112
0.4752
0.4752
0.4752
0.4120
0.4752
0.3604
0.4120
0.3604
0.4752
0.4752
0.3604
0.4752
0.4752
0.4752
0.3604
0.3604
0.4881
0.4752
0.4120
0.4112
0.4243
0.4752
0.3604
0.3604
0.4881
0.4752
0.3604
0.3604
0.3604
0.4752
0.4752
0.4752
0.4752
0.3604
0.3604
0.4243
0.4876
0.4752
0.4752
0.4752
0.3604
0.3604
0.4881
0.4881
0.3604
0.3604
E:\FR\FM\09MYR2.SGM
09MYR2
99939
99939
99939
99939
99939
99939
99939
38300
99939
38300
42540
49620
99940
10380
10380
41980
41980
10380
41980
25020
41980
41980
41980
41900
41980
41980
41980
41980
41980
41980
21940
41980
41980
99940
41980
41980
99940
41980
21940
41980
49500
25020
49500
41980
41980
41980
32420
41980
10380
99940
38660
41980
41900
10380
99940
41980
41980
21940
41980
99940
41980
32420
10380
41980
41980
41980
41980
25020
49500
38660
41980
10380
CBSA
urban/
rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
27121
2006
CBSAbased WI
0.8291
0.8291
0.8291
0.8291
0.8291
0.8291
0.8291
0.8845
0.8291
0.8845
0.8540
0.9347
0.4047
0.4738
0.4738
0.4621
0.4621
0.4738
0.4621
0.3181
0.4621
0.4621
0.4621
0.4650
0.4621
0.4621
0.4621
0.4621
0.4621
0.4621
0.4153
0.4621
0.4621
0.4047
0.4621
0.4621
0.4047
0.4621
0.4153
0.4621
0.4408
0.3181
0.4408
0.4621
0.4621
0.4621
0.4020
0.4621
0.4738
0.4047
0.4939
0.4621
0.4650
0.4738
0.4047
0.4621
0.4621
0.4153
0.4621
0.4047
0.4621
0.4020
0.4738
0.4621
0.4621
0.4621
0.4621
0.3181
0.4408
0.4939
0.4621
0.4738
27122
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
40590
40610
40620
40630
40640
40650
40660
40670
40680
40690
40700
40710
40720
40730
40740
40750
40760
40770
41000
41010
41020
41030
41050
42000
42010
42020
42030
42040
42050
42060
42070
42080
42090
42100
42110
42120
42130
42140
42150
42160
42170
42180
42190
42200
42210
42220
42230
42240
42250
42260
42270
42280
42290
42300
42310
42320
42330
42340
42350
42360
42370
42380
42390
42400
42410
42420
42430
42440
42450
43010
43020
43030
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VerDate Aug<31>2005
County name
MSA No.
Rio Grande County, Puerto Rico ..........................................
Sabana Grande County, Puerto Rico ...................................
Salinas County, Puerto Rico .................................................
San German County, Puerto Rico ........................................
San Juan County, Puerto Rico .............................................
San Lorenzo County, Puerto Rico ........................................
San Sebastian County, Puerto Rico .....................................
Santa Isabel County, Puerto Rico ........................................
Toa Alta County, Puerto Rico ...............................................
Toa Baja County, Puerto Rico ..............................................
Trujillo Alto County, Puerto Rico ...........................................
Utuado County, Puerto Rico .................................................
Vega Alta County, Puerto Rico .............................................
Vega Baja County, Puerto Rico ............................................
Vieques County, Puerto Rico ................................................
Villalba County, Puerto Rico .................................................
Yabucoa County, Puerto Rico ..............................................
Yauco County, Puerto Rico ..................................................
Bristol County, Rhode Island ................................................
Kent County, Rhode Island ...................................................
Newport County, Rhode Island .............................................
Providence County, Rhode Island ........................................
Washington County, Rhode Island .......................................
Abbeville County, S Carolina ................................................
Aiken County, S Carolina ......................................................
Allendale County, S Carolina ................................................
Anderson County, S Carolina ...............................................
Bamberg County, S Carolina ................................................
Barnwell County, S Carolina .................................................
Beaufort County, S Carolina .................................................
Berkeley County, S Carolina .................................................
Calhoun County, S Carolina .................................................
Charleston County, S Carolina .............................................
Cherokee County, S Carolina ...............................................
Chester County, S Carolina ..................................................
Chesterfield County, S Carolina ...........................................
Clarendon County, S Carolina ..............................................
Colleton County, S Carolina .................................................
Darlington County, S Carolina ..............................................
Dillon County, S Carolina ......................................................
Dorchester County, S Carolina .............................................
Edgefield County, S Carolina ................................................
Fairfield County, S Carolina ..................................................
Florence County, S Carolina .................................................
Georgetown County, S Carolina ...........................................
Greenville County, S Carolina ..............................................
Greenwood County, S Carolina ............................................
Hampton County, S Carolina ................................................
Horry County, S Carolina ......................................................
Jasper County, S Carolina ....................................................
Kershaw County, S Carolina .................................................
Lancaster County, S Carolina ...............................................
Laurens County, S Carolina ..................................................
Lee County, S Carolina .........................................................
Lexington County, S Carolina ...............................................
Mc Cormick County, S Carolina ...........................................
Marion County, S Carolina ....................................................
Marlboro County, S Carolina ................................................
Newberry County, S Carolina ...............................................
Oconee County, S Carolina ..................................................
Orangeburg County, S Carolina ...........................................
Pickens County, S Carolina ..................................................
Richland County, S Carolina .................................................
Saluda County, S Carolina ...................................................
Spartanburg County, S Carolina ...........................................
Sumter County, S Carolina ...................................................
Union County, S Carolina .....................................................
Williamsburg County, S Carolina ..........................................
York County, S Carolina .......................................................
Aurora County, S Dakota ......................................................
Beadle County, S Dakota .....................................................
Bennett County, S Dakota ....................................................
00:49 May 09, 2006
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Urban
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Urban
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Urban
Rural
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Rural
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.4752
0.4243
0.3604
0.4243
0.4752
0.4120
0.3604
0.3604
0.4752
0.4752
0.4752
0.3604
0.4752
0.4752
0.3604
0.4881
0.4752
0.4881
1.1058
1.1058
1.1058
1.1058
1.1058
0.8631
0.9808
0.8631
0.9615
0.8631
0.8631
0.8631
0.9245
0.8631
0.9245
0.9615
0.8631
0.8631
0.8631
0.8631
0.8631
0.8631
0.9245
0.9808
0.8631
0.9042
0.8631
0.9615
0.8631
0.8631
0.8934
0.8631
0.8631
0.8631
0.8631
0.8631
0.9082
0.8631
0.8631
0.8631
0.8631
0.8631
0.8631
0.9615
0.9082
0.8631
0.9615
0.8377
0.8631
0.8631
0.9715
0.8551
0.8551
0.8551
E:\FR\FM\09MYR2.SGM
09MYR2
41980
41900
99940
41900
41980
41980
10380
99940
41980
41980
41980
99940
41980
41980
99940
38660
41980
49500
39300
39300
39300
39300
39300
99942
12260
99942
11340
99942
99942
99942
16700
17900
16700
99942
99942
99942
99942
99942
22500
99942
16700
12260
17900
22500
99942
24860
99942
99942
34820
99942
17900
99942
24860
99942
17900
99942
99942
99942
99942
99942
99942
24860
17900
17900
43900
44940
99942
99942
16740
99943
99943
99943
CBSA
urban/
rural
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Rural
2006
CBSAbased WI
0.4621
0.4650
0.4047
0.4650
0.4621
0.4621
0.4738
0.4047
0.4621
0.4621
0.4621
0.4047
0.4621
0.4621
0.4047
0.4939
0.4621
0.4408
1.0966
1.0966
1.0966
1.0966
1.0966
0.8638
0.9748
0.8638
0.8997
0.8638
0.8638
0.8638
0.9245
0.9057
0.9245
0.8638
0.8638
0.8638
0.8638
0.8638
0.8947
0.8638
0.9245
0.9748
0.9057
0.8947
0.8638
1.0027
0.8638
0.8638
0.8934
0.8638
0.9057
0.8638
1.0027
0.8638
0.9057
0.8638
0.8638
0.8638
0.8638
0.8638
0.8638
1.0027
0.9057
0.9057
0.9172
0.8377
0.8638
0.8638
0.9750
0.8560
0.8560
0.8560
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
43040
43050
43060
43070
43080
43090
43100
43110
43120
43130
43140
43150
43160
43170
43180
43190
43200
43210
43220
43230
43240
43250
43260
43270
43280
43290
43300
43310
43320
43330
43340
43350
43360
43370
43380
43390
43400
43410
43420
43430
43440
43450
43460
43470
43480
43490
43500
43510
43520
43530
43540
43550
43560
43570
43580
43590
43600
43610
43620
43630
43640
43650
43670
43680
44000
44010
44020
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VerDate Aug<31>2005
County name
MSA No.
Bon Homme County, S Dakota ............................................
Brookings County, S Dakota .................................................
Brown County, S Dakota ......................................................
Brule County, S Dakota ........................................................
Buffalo County, S Dakota .....................................................
Butte County, S Dakota ........................................................
Campbell County, S Dakota .................................................
Charles Mix County, S Dakota .............................................
Clark County, S Dakota ........................................................
Clay County, S Dakota .........................................................
Codington County, S Dakota ................................................
Corson County, S Dakota .....................................................
Custer County, S Dakota ......................................................
Davison County, S Dakota ....................................................
Day County, S Dakota ..........................................................
Deuel County, S Dakota .......................................................
Dewey County, S Dakota ......................................................
Douglas County, S Dakota ...................................................
Edmunds County, S Dakota .................................................
Fall River County, S Dakota .................................................
Faulk County, S Dakota ........................................................
Grant County, S Dakota ........................................................
Gregory County, S Dakota ....................................................
Haakon County, S Dakota ....................................................
Hamlin County, S Dakota .....................................................
Hand County, S Dakota ........................................................
Hanson County, S Dakota ....................................................
Harding County, S Dakota ....................................................
Hughes County, S Dakota ....................................................
Hutchinson County, S Dakota ...............................................
Hyde County, S Dakota ........................................................
Jackson County, S Dakota ...................................................
Jerauld County, S Dakota .....................................................
Jones County, S Dakota .......................................................
Kingsbury County, S Dakota .................................................
Lake County, S Dakota .........................................................
Lawrence County, S Dakota .................................................
Lincoln County, S Dakota .....................................................
Lyman County, S Dakota ......................................................
Mc Cook County, S Dakota ..................................................
Mc Pherson County, S Dakota .............................................
Marshall County, S Dakota ...................................................
Meade County, S Dakota ......................................................
Mellette County, S Dakota ....................................................
Miner County, S Dakota ........................................................
Minnehaha County, S Dakota ...............................................
Moody County, S Dakota ......................................................
Pennington County, S Dakota ..............................................
Perkins County, S Dakota .....................................................
Potter County, S Dakota .......................................................
Roberts County, S Dakota ....................................................
Sanborn County, S Dakota ...................................................
Shannon County, S Dakota ..................................................
Spink County, S Dakota ........................................................
Stanley County, S Dakota .....................................................
Sully County, S Dakota .........................................................
Todd County, S Dakota ........................................................
Tripp County, S Dakota ........................................................
Turner County, S Dakota ......................................................
Union County, S Dakota .......................................................
Walworth County, S Dakota ..................................................
Washabaugh County, S Dakota ...........................................
Yankton County, S Dakota ...................................................
Ziebach County, S Dakota ....................................................
Anderson County, Tennessee ..............................................
Bedford County, Tennessee .................................................
Benton County, Tennessee ..................................................
Bledsoe County, Tennessee .................................................
Blount County, Tennessee ....................................................
Bradley County, Tennessee ..................................................
Campbell County, Tennessee ...............................................
Cannon County, Tennessee .................................................
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2006
MSAbased WI
CBSA
No.
0.8551
0.8551
0.8551
0.8551
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0.8551
0.8551
0.8551
0.9635
0.8551
0.8551
0.8551
0.8551
0.8551
0.8551
0.8551
0.9635
0.8551
0.8987
0.8551
0.8551
0.8551
0.8551
0.8551
0.8551
0.8551
0.8551
0.8551
0.8551
0.8551
0.8551
0.8551
0.8551
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0.8551
0.8397
0.7935
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0.7935
0.8397
0.7935
0.7935
0.7935
E:\FR\FM\09MYR2.SGM
09MYR2
99943
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43620
43580
99943
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99943
28940
99944
99944
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28940
17420
99944
34980
CBSA
urban/
rural
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Rural
Rural
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Rural
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Rural
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Urban
27123
2006
CBSAbased WI
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.9635
0.8560
0.9635
0.8560
0.8560
0.8987
0.8560
0.8560
0.9635
0.8560
0.8987
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.8560
0.9635
0.9381
0.8560
0.8560
0.8560
0.8560
0.8441
0.7895
0.7895
0.7895
0.8441
0.8139
0.7895
0.9790
27124
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
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44130
44140
44150
44160
44170
44180
44190
44200
44210
44220
44230
44240
44250
44260
44270
44280
44290
44300
44310
44320
44330
44340
44350
44360
44370
44380
44390
44400
44410
44420
44430
44440
44450
44460
44470
44480
44490
44500
44510
44520
44530
44540
44550
44560
44570
44580
44590
44600
44610
44620
44630
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MSA No.
Carroll County, Tennessee ...................................................
Carter County, Tennessee ....................................................
Cheatham County, Tennessee .............................................
Chester County, Tennessee .................................................
Claiborne County, Tennessee ..............................................
Clay County, Tennessee .......................................................
Cocke County, Tennessee ....................................................
Coffee County, Tennessee ...................................................
Crockett County, Tennessee ................................................
Cumberland County, Tennessee ..........................................
Davidson County, Tennessee ...............................................
Decatur County, Tennessee .................................................
De Kalb County, Tennessee .................................................
Dickson County, Tennessee .................................................
Dyer County, Tennessee ......................................................
Fayette County, Tennessee ..................................................
Fentress County, Tennessee ................................................
Franklin County, Tennessee .................................................
Gibson County, Tennessee ..................................................
Giles County, Tennessee ......................................................
Grainger County, Tennessee ................................................
Greene County, Tennessee ..................................................
Grundy County, Tennessee ..................................................
Hamblen County, Tennessee ...............................................
Hamilton County, Tennessee ................................................
Hancock County, Tennessee ................................................
Hardeman County, Tennessee .............................................
Hardin County, Tennessee ...................................................
Hawkins County, Tennessee ................................................
Haywood County, Tennessee ...............................................
Henderson County, Tennessee ............................................
Henry County, Tennessee ....................................................
Hickman County, Tennessee ................................................
Houston County, Tennessee ................................................
Humphreys County, Tennessee ...........................................
Jackson County, Tennessee .................................................
Jefferson County, Tennessee ...............................................
Johnson County, Tennessee ................................................
Knox County, Tennessee ......................................................
Lake County, Tennessee ......................................................
Lauderdale County, Tennessee ............................................
Lawrence County, Tennessee ..............................................
Lewis County, Tennessee .....................................................
Lincoln County, Tennessee ..................................................
Loudon County, Tennessee ..................................................
Mc Minn County, Tennessee ................................................
Mc Nairy County, Tennessee ...............................................
Macon County, Tennessee ...................................................
Madison County, Tennessee ................................................
Marion County, Tennessee ...................................................
Marshall County, Tennessee ................................................
Maury County, Tennessee ....................................................
Meigs County, Tennessee ....................................................
Monroe County, Tennessee ..................................................
Montgomery County, Tennessee ..........................................
Moore County, Tennessee ....................................................
Morgan County, Tennessee ..................................................
Obion County, Tennessee ....................................................
Overton County, Tennessee .................................................
Perry County, Tennessee .....................................................
Pickett County, Tennessee ...................................................
Polk County, Tennessee .......................................................
Putnam County, Tennessee .................................................
Rhea County, Tennessee .....................................................
Roane County, Tennessee ...................................................
Robertson County, Tennessee .............................................
Rutherford County, Tennessee .............................................
Scott County, Tennessee ......................................................
Sequatchie County, Tennessee ............................................
Sevier County, Tennessee ....................................................
Shelby County, Tennessee ...................................................
Smith County, Tennessee .....................................................
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2006
MSAbased WI
CBSA
No.
0.7935
0.8007
0.9808
0.8964
0.7935
0.7935
0.7935
0.7935
0.7935
0.7935
0.9808
0.7935
0.7935
0.9808
0.7935
0.9416
0.7935
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0.9088
0.7935
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0.7935
0.8007
0.7935
0.7935
0.7935
0.7935
0.7935
0.7935
0.7935
0.7935
0.7935
0.8397
0.7935
0.7935
0.7935
0.7935
0.7935
0.8397
0.7935
0.7935
0.7935
0.8964
0.9088
0.7935
0.7935
0.7935
0.7935
0.8284
0.7935
0.7935
0.7935
0.7935
0.7935
0.7935
0.7935
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2006
CBSAbased WI
0.7895
0.7937
0.9790
0.8964
0.7895
0.7895
0.7895
0.7895
0.7895
0.7895
0.9790
0.7895
0.7895
0.9790
0.7895
0.9397
0.7895
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0.7961
0.7895
0.7895
0.7961
0.9088
0.7895
0.7895
0.7895
0.8054
0.7895
0.7895
0.7895
0.9790
0.7895
0.7895
0.7895
0.7961
0.7895
0.8441
0.7895
0.7895
0.7895
0.7895
0.7895
0.8441
0.7895
0.7895
0.9790
0.8964
0.9088
0.7895
0.7895
0.7895
0.7895
0.8284
0.7895
0.7895
0.7895
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0.7895
0.7895
0.8139
0.7895
0.7895
0.7895
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0.9790
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
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County
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45130
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45223
45224
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45260
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Stewart County, Tennessee ..................................................
Sullivan County, Tennessee .................................................
Sumner County, Tennessee .................................................
Tipton County, Tennessee ....................................................
Trousdale County, Tennessee ..............................................
Unicoi County, Tennessee ....................................................
Union County, Tennessee ....................................................
Van Buren County, Tennessee .............................................
Warren County, Tennessee ..................................................
Washington County, Tennessee ...........................................
Wayne County, Tennessee ...................................................
Weakley County, Tennessee ................................................
White County, Tennessee .....................................................
Williamson County, Tennessee ............................................
Wilson County, Tennessee ...................................................
Anderson County, Texas ......................................................
Andrews County, Texas ........................................................
Angelina County, Texas ........................................................
Aransas County, Texas .........................................................
Archer County, Texas ...........................................................
Armstrong County, Texas .....................................................
Atascosa County, Texas .......................................................
Austin County, Texas ............................................................
Bailey County, Texas ............................................................
Bandera County, Texas ........................................................
Bastrop County, Texas .........................................................
Baylor County, Texas ............................................................
Bee County, Texas ...............................................................
Bell County, Texas ................................................................
Bexar County, Texas ............................................................
Blanco County, Texas ...........................................................
Borden County, Texas ..........................................................
Bosque County, Texas ..........................................................
Bowie County, Texas ............................................................
Brazoria County, Texas ........................................................
Brazos County, Texas ...........................................................
Brewster County, Texas ........................................................
qBriscoe County, Texas ........................................................
Brooks County, Texas ...........................................................
Brown County, Texas ............................................................
Burleson County, Texas ........................................................
Burnet County, Texas ...........................................................
Caldwell County, Texas ........................................................
Calhoun County, Texas ........................................................
Callahan County, Texas ........................................................
Cameron County, Texas .......................................................
Camp County, Texas ............................................................
Carson County, Texas ..........................................................
Cass County, Texas ..............................................................
Castro County, Texas ...........................................................
Chambers County, Texas .....................................................
Cherokee County, Texas ......................................................
Childress County, Texas .......................................................
Clay County, Texas ...............................................................
Cochran County, Texas ........................................................
Coke County, Texas .............................................................
Coleman County, Texas .......................................................
Collin County, Texas .............................................................
Collingsworth County, Texas ................................................
Colorado County, Texas .......................................................
Comal County, Texas ...........................................................
Comanche County, Texas ....................................................
Concho County, Texas .........................................................
Cooke County, Texas ...........................................................
Coryell County, Texas ...........................................................
Cottle County, Texas ............................................................
Crane County, Texas ............................................................
Crockett County, Texas ........................................................
Crosby County, Texas ..........................................................
Culberson County, Texas .....................................................
Dallam County, Texas ...........................................................
Dallas County, Texas ............................................................
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Rural
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Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
2006
MSAbased WI
CBSA
No.
0.7935
0.8007
0.9808
0.9416
0.7935
0.8007
0.8397
0.7935
0.7935
0.8007
0.7935
0.7935
0.7935
0.9808
0.9808
0.7931
0.7931
0.7931
0.7931
0.8365
0.7931
0.7931
0.7931
0.7931
0.7931
0.9437
0.7931
0.7931
0.8526
0.8984
0.7931
0.7931
0.7931
0.8283
0.8563
0.8900
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.9437
0.7931
0.7931
0.9804
0.7931
0.7931
0.7931
0.7931
1.0091
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
1.0205
0.7931
0.7931
0.8984
0.7931
0.7931
0.7931
0.8526
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
1.0205
E:\FR\FM\09MYR2.SGM
09MYR2
17300
28700
34980
32820
34980
27740
28940
99944
99944
27740
99944
99944
99944
34980
34980
99945
99945
99945
18580
48660
11100
41700
26420
99945
41700
12420
99945
99945
28660
41700
99945
99945
99945
45500
26420
17780
99945
99945
99945
99945
17780
99945
12420
47020
10180
15180
99945
11100
99945
99945
26420
99945
99945
48660
99945
99945
99945
19124
99945
99945
41700
99945
99945
99945
28660
99945
99945
99945
31180
99945
99945
19124
CBSA
urban/
rural
Urban
Urban
Urban
Urban
Urban
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
27125
2006
CBSAbased WI
0.8284
0.8054
0.9790
0.9397
0.9790
0.7937
0.8441
0.7895
0.7895
0.7937
0.7895
0.7895
0.7895
0.9790
0.9790
0.8003
0.8003
0.8003
0.8550
0.8285
0.9156
0.8980
0.9996
0.8003
0.8980
0.9437
0.8003
0.8003
0.8526
0.8980
0.8003
0.8003
0.8003
0.8283
0.9996
0.8900
0.8003
0.8003
0.8003
0.8003
0.8900
0.8003
0.9437
0.8160
0.7896
0.9804
0.8003
0.9156
0.8003
0.8003
0.9996
0.8003
0.8003
0.8285
0.8003
0.8003
0.8003
1.0228
0.8003
0.8003
0.8980
0.8003
0.8003
0.8003
0.8526
0.8003
0.8003
0.8003
0.8783
0.8003
0.8003
1.0228
27126
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
45391
45392
45400
45410
45420
45421
45430
45431
45440
45450
45451
45460
45470
45480
45490
45500
45510
45511
45520
45521
45522
45530
45531
45540
45541
45542
45550
45551
45552
45560
45561
45562
45563
45564
45570
45580
45581
45582
45583
45590
45591
45592
45600
45610
45620
45621
45630
45631
45632
45640
45650
45651
45652
45653
45654
45660
45661
45662
45670
45671
45672
45680
45681
45690
45691
45700
45710
45711
45720
45721
45722
45730
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VerDate Aug<31>2005
County name
MSA No.
Dawson County, Texas .........................................................
Deaf Smith County, Texas ....................................................
Delta County, Texas .............................................................
Denton County, Texas ..........................................................
De Witt County, Texas ..........................................................
Dickens County, Texas .........................................................
Dimmit County, Texas ...........................................................
Donley County, Texas ...........................................................
Duval County, Texas .............................................................
Eastland County, Texas ........................................................
Ector County, Texas .............................................................
Edwards County, Texas ........................................................
Ellis County, Texas ...............................................................
El Paso County, Texas .........................................................
Erath County, Texas .............................................................
Falls County, Texas ..............................................................
Fannin County, Texas ...........................................................
Fayette County, Texas ..........................................................
Fisher County, Texas ............................................................
Floyd County, Texas .............................................................
Foard County, Texas ............................................................
Fort Bend County, Texas ......................................................
Franklin County, Texas .........................................................
Freestone County, Texas ......................................................
Frio County, Texas ................................................................
Gaines County, Texas ..........................................................
Galveston County, Texas ......................................................
Garza County, Texas ............................................................
Gillespie County, Texas ........................................................
Glasscock County, Texas .....................................................
Goliad County, Texas ...........................................................
Gonzales County, Texas .......................................................
Gray County, Texas ..............................................................
Grayson County, Texas ........................................................
Gregg County, Texas ............................................................
Grimes County, Texas ..........................................................
Guadaloupe County, Texas ..................................................
Hale County, Texas ..............................................................
Hall County, Texas ................................................................
Hamilton County, Texas ........................................................
Hansford County, Texas .......................................................
Hardeman County, Texas .....................................................
Hardin County, Texas ...........................................................
Harris County, Texas ............................................................
Harrison County, Texas ........................................................
Hartley County, Texas ..........................................................
Haskell County, Texas ..........................................................
Hays County, Texas ..............................................................
Hemphill County, Texas ........................................................
Henderson County, Texas ....................................................
Hidalgo County, Texas ..........................................................
Hill County, Texas .................................................................
Hockley County, Texas .........................................................
Hood County, Texas .............................................................
Hopkins County, Texas .........................................................
Houston County, Texas ........................................................
Howard County, Texas .........................................................
Hudspeth County, Texas ......................................................
Hunt County, Texas ..............................................................
Hutchinson County, Texas ....................................................
Irion County, Texas ...............................................................
Jack County, Texas ..............................................................
Jackson County, Texas .........................................................
Jasper County, Texas ...........................................................
Jeff Davis County, Texas ......................................................
Jefferson County, Texas .......................................................
Jim Hogg County, Texas ......................................................
Jim Wells County, Texas ......................................................
Johnson County, Texas ........................................................
Jones County, Texas ............................................................
Karnes County, Texas ..........................................................
Kaufman County, Texas .......................................................
00:49 May 09, 2006
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urban/
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Rural
Rural
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Rural
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Rural
Urban
Rural
Urban
Urban
Rural
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Urban
Rural
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Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
2006
MSAbased WI
CBSA
No.
0.7931
0.7931
0.7931
1.0205
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.9741
0.7931
1.0205
0.8977
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
1.0091
0.7931
0.7931
0.7931
0.7931
0.9635
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.9507
0.8888
0.7931
0.8984
0.7931
0.7931
0.7931
0.7931
0.7931
0.8412
1.0091
0.8888
0.7931
0.7931
0.9437
0.7931
1.0205
0.8934
0.7931
0.7931
0.9522
0.7931
0.7931
0.7931
0.7931
1.0205
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.8412
0.7931
0.7931
0.9522
0.7931
0.7931
1.0205
E:\FR\FM\09MYR2.SGM
09MYR2
99945
99945
19124
19124
99945
99945
99945
99945
99945
99945
36220
99945
19124
21340
99945
99945
99945
99945
99945
99945
99945
26420
99945
99945
99945
99945
26420
99945
99945
99945
47020
99945
99945
43300
30980
99945
41700
99945
99945
99945
99945
99945
13140
26420
99945
99945
99945
12420
99945
99945
32580
99945
99945
99945
99945
99945
99945
99945
19124
99945
41660
99945
99945
99945
99945
13140
99945
99945
23104
10180
99945
19124
CBSA
urban/
rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Urban
2006
CBSAbased WI
0.8003
0.8003
1.0228
1.0228
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.9884
0.8003
1.0228
0.8977
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.9996
0.8003
0.8003
0.8003
0.8003
0.9996
0.8003
0.8003
0.8003
0.8160
0.8003
0.8003
0.9507
0.8730
0.8003
0.8980
0.8003
0.8003
0.8003
0.8003
0.8003
0.8412
0.9996
0.8003
0.8003
0.8003
0.9437
0.8003
0.8003
0.8934
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
1.0228
0.8003
0.8271
0.8003
0.8003
0.8003
0.8003
0.8412
0.8003
0.8003
0.9486
0.7896
0.8003
1.0228
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
45731
45732
45733
45734
45740
45741
45742
45743
45744
45750
45751
45752
45753
45754
45755
45756
45757
45758
45759
45760
45761
45762
45770
45771
45772
45780
45781
45782
45783
45784
45785
45790
45791
45792
45793
45794
45795
45796
45797
45800
45801
45802
45803
45804
45810
45820
45821
45822
45830
45831
45832
45840
45841
45842
45843
45844
45845
45850
45860
45861
45870
45871
45872
45873
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45879
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VerDate Aug<31>2005
County name
MSA No.
Kendall County, Texas ..........................................................
Kenedy County, Texas ..........................................................
Kent County, Texas ..............................................................
Kerr County, Texas ...............................................................
Kimble County, Texas ...........................................................
King County, Texas ...............................................................
Kinney County, Texas ...........................................................
Kleberg County, Texas .........................................................
Knox County, Texas ..............................................................
Lamar County, Texas ............................................................
Lamb County, Texas .............................................................
Lampasas County, Texas .....................................................
La Salle County, Texas .........................................................
Lavaca County, Texas ..........................................................
Lee County, Texas ................................................................
Leon County, Texas ..............................................................
Liberty County, Texas ...........................................................
Limestone County, Texas .....................................................
Lipscomb County, Texas ......................................................
Live Oak County, Texas .......................................................
Llano County, Texas .............................................................
Loving County, Texas ...........................................................
Lubbock County, Texas ........................................................
Lynn County, Texas ..............................................................
Mc Culloch County, Texas ....................................................
Mc Lennan County, Texas ....................................................
Mc Mullen County, Texas .....................................................
Madison County, Texas ........................................................
Marion County, Texas ...........................................................
Martin County, Texas ............................................................
Mason County, Texas ...........................................................
Matagorda County, Texas .....................................................
Maverick County, Texas .......................................................
Medina County, Texas ..........................................................
Menard County, Texas ..........................................................
Midland County, Texas .........................................................
Milam County, Texas ............................................................
Mills County, Texas ...............................................................
Mitchell County, Texas ..........................................................
Montague County, Texas ......................................................
Montgomery County, Texas ..................................................
Moore County, Texas ............................................................
Morris County, Texas ............................................................
Motley County, Texas ...........................................................
Nacogdoches County, Texas ................................................
Navarro County, Texas .........................................................
Newton County, Texas ..........................................................
Nolan County, Texas ............................................................
Nueces County, Texas ..........................................................
Ochiltree County, Texas .......................................................
Oldham County, Texas .........................................................
Orange County, Texas ..........................................................
Palo Pinto County, Texas .....................................................
Panola County, Texas ...........................................................
Parker County, Texas ...........................................................
Parmer County, Texas ..........................................................
Pecos County, Texas ............................................................
Polk County, Texas ...............................................................
Potter County, Texas ............................................................
Presidio County, Texas .........................................................
Rains County, Texas .............................................................
Randall County, Texas ..........................................................
Reagan County, Texas .........................................................
Real County, Texas ..............................................................
Red River County, Texas ......................................................
Reeves County, Texas ..........................................................
Refugio County, Texas .........................................................
Roberts County, Texas .........................................................
Robertson County, Texas .....................................................
Rockwall County, Texas .......................................................
Runnels County, Texas .........................................................
Rusk County, Texas ..............................................................
00:49 May 09, 2006
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Urban
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Rural
Rural
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Rural
Rural
Rural
Urban
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
1.0091
0.7931
0.7931
0.7931
0.7931
0.7931
0.8783
0.7931
0.7931
0.8518
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.9741
0.7931
0.7931
0.7931
0.7931
1.0091
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.8550
0.7931
0.7931
0.8412
0.7931
0.7931
0.9522
0.7931
0.7931
0.7931
0.9156
0.7931
0.7931
0.9156
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
1.0205
0.7931
0.7931
E:\FR\FM\09MYR2.SGM
09MYR2
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Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
27127
2006
CBSAbased WI
0.8980
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8526
0.8003
0.8003
0.8003
0.8003
0.9996
0.8003
0.8003
0.8003
0.8003
0.8003
0.8783
0.8003
0.8003
0.8518
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8980
0.8003
0.9514
0.8003
0.8003
0.8003
0.8003
0.9996
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8550
0.8003
0.8003
0.8412
0.8003
0.8003
0.9486
0.8003
0.8003
0.8003
0.9156
0.8003
0.8003
0.9156
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8900
1.0228
0.8003
0.8730
27128
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
45882
45883
45884
45885
45886
45887
45888
45889
45890
45891
45892
45893
45900
45901
45902
45903
45904
45905
45910
45911
45912
45913
45920
45921
45930
45940
45941
45942
45943
45944
45945
45946
45947
45948
45949
45950
45951
45952
45953
45954
45955
45960
45961
45962
45970
45971
45972
45973
45974
45980
45981
45982
45983
46000
46010
46020
46030
46040
46050
46060
46070
46080
46090
46100
46110
46120
46130
46140
46150
46160
46170
46180
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VerDate Aug<31>2005
County name
MSA No.
Sabine County, Texas ...........................................................
San Augustine County, Texas ..............................................
San Jacinto County, Texas ...................................................
San Patricio County, Texas ..................................................
San Saba County, Texas ......................................................
Schleicher County, Texas .....................................................
Scurry County, Texas ...........................................................
Shackelford County, Texas ...................................................
Shelby County, Texas ...........................................................
Sherman County, Texas .......................................................
Smith County, Texas .............................................................
Somervell County, Texas ......................................................
Starr County, Texas ..............................................................
Stephens County, Texas .......................................................
Sterling County, Texas ..........................................................
Stonewall County, Texas ......................................................
Sutton County, Texas ...........................................................
Swisher County, Texas .........................................................
Tarrant County, Texas ..........................................................
Taylor County, Texas ............................................................
Terrell County, Texas ............................................................
Terry County, Texas .............................................................
Throckmorton County, Texas ................................................
Titus County, Texas ..............................................................
Tom Green County, Texas ...................................................
Travis County, Texas ............................................................
Trinity County, Texas ............................................................
Tyler County, Texas ..............................................................
Upshur County, Texas ..........................................................
Upton County, Texas ............................................................
Uvalde County, Texas ...........................................................
Val Verde County, Texas ......................................................
Van Zandt County, Texas .....................................................
Victoria County, Texas ..........................................................
Walker County, Texas ...........................................................
Waller County, Texas ............................................................
Ward County, Texas .............................................................
Washington County, Texas ...................................................
Webb County, Texas ............................................................
Wharton County, Texas ........................................................
Wheeler County, Texas ........................................................
Wichita County, Texas ..........................................................
Wilbarger County, Texas ......................................................
Willacy County, Texas ..........................................................
Williamson County, Texas ....................................................
Wilson County, Texas ...........................................................
Winkler County, Texas ..........................................................
Wise County, Texas ..............................................................
Wood County, Texas ............................................................
Yoakum County, Texas .........................................................
Young County, Texas ...........................................................
Zapata County, Texas ...........................................................
Zavala County, Texas ...........................................................
Beaver County, Utah .............................................................
Box Elder County, Utah ........................................................
Cache County, Utah ..............................................................
Carbon County, Utah ............................................................
Daggett County, Utah ...........................................................
Davis County, Utah ...............................................................
Duchesne County, Utah ........................................................
Emery County, Utah ..............................................................
Garfield County, Utah ...........................................................
Grand County, Utah ..............................................................
Iron County, Utah ..................................................................
Juab County, Utah ................................................................
Kane County, Utah ................................................................
Millard County, Utah .............................................................
Morgan County, Utah ............................................................
Piute County, Utah ................................................................
Rich County, Utah .................................................................
Salt Lake County, Utah .........................................................
San Juan County, Utah .........................................................
00:49 May 09, 2006
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urban/
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Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
2006
MSAbased WI
CBSA
No.
0.7931
0.7931
0.7931
0.8550
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.9168
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.9522
0.8054
0.7931
0.7931
0.7931
0.7931
0.8271
0.9437
0.7931
0.7931
0.8888
0.7931
0.7931
0.7931
0.7931
0.8160
0.7931
1.0091
0.7931
0.7931
0.8068
0.7931
0.7931
0.8365
0.7931
0.7931
0.9437
0.8984
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.7931
0.8762
0.8762
0.8762
0.8762
0.8762
0.9340
0.8762
0.8762
0.8762
0.8762
0.8762
0.8762
1.1845
0.8762
0.8762
0.8762
0.8762
0.9340
0.8762
E:\FR\FM\09MYR2.SGM
09MYR2
99945
99945
26420
18580
99945
99945
99945
99945
99945
99945
46340
99945
99945
99945
99945
99945
99945
99945
23104
10180
99945
99945
99945
99945
41660
12420
99945
99945
30980
99945
99945
99945
99945
47020
99945
26420
99945
99945
29700
99945
99945
48660
99945
99945
12420
41700
99945
23104
99945
99945
99945
99945
99945
99946
99946
30860
99946
99946
36260
99946
99946
99946
99946
99946
39340
99946
99946
36260
99946
99946
41620
99946
CBSA
urban/
rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Rural
Urban
Rural
2006
CBSAbased WI
0.8003
0.8003
0.9996
0.8550
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.9168
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.8003
0.9486
0.7896
0.8003
0.8003
0.8003
0.8003
0.8271
0.9437
0.8003
0.8003
0.8730
0.8003
0.8003
0.8003
0.8003
0.8160
0.8003
0.9996
0.8003
0.8003
0.8068
0.8003
0.8003
0.8285
0.8003
0.8003
0.9437
0.8980
0.8003
0.9486
0.8003
0.8003
0.8003
0.8003
0.8003
0.8118
0.8118
0.9164
0.8118
0.8118
0.9029
0.8118
0.8118
0.8118
0.8118
0.8118
0.9500
0.8118
0.8118
0.9029
0.8118
0.8118
0.9421
0.8118
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
46190
46200
46210
46220
46230
46240
46250
46260
46270
46280
47000
47010
47020
47030
47040
47050
47060
47070
47080
47090
47100
47110
47120
47130
48010
48020
49000
49010
49011
49020
49030
49040
49050
49060
49070
49080
49088
49090
49100
49110
49111
49120
49130
49140
49141
49150
49160
49170
49180
49190
49191
49194
49200
49210
49211
49212
49213
49220
49230
49240
49241
49250
49260
49270
49280
49288
49290
49291
49300
49310
49320
49328
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VerDate Aug<31>2005
County name
MSA No.
Sanpete County, Utah ...........................................................
Sevier County, Utah ..............................................................
Summit County, Utah ............................................................
Tooele County, Utah .............................................................
Uintah County, Utah ..............................................................
Utah County, Utah ................................................................
Wasatch County, Utah ..........................................................
Washington County, Utah .....................................................
Wayne County, Utah .............................................................
Weber County, Utah .............................................................
Addison County, Vermont .....................................................
Bennington County, Vermont ................................................
Caledonia County, Vermont ..................................................
Chittenden County, Vermont .................................................
Essex County, Vermont ........................................................
Franklin County, Vermont .....................................................
Grand Isle County, Vermont .................................................
Lamoille County, Vermont .....................................................
Orange County, Vermont ......................................................
Orleans County, Vermont .....................................................
Rutland County, Vermont ......................................................
Washington County, Vermont ...............................................
Windham County, Vermont ...................................................
Windsor County, Vermont .....................................................
St Croix County, Virgin Islands .............................................
St Thomas-John County, Virgin Islands ...............................
Accomack County, Virginia ...................................................
Albemarle County, Virginia ...................................................
Alexandria City County, Virginia ...........................................
Alleghany County, Virginia ....................................................
Amelia County, Virginia .........................................................
Amherst County, Virginia ......................................................
Appomattox County, Virginia ................................................
Arlington County, Virginia .....................................................
Augusta County, Virginia ......................................................
Bath County, Virginia ............................................................
Bedford City County, Virginia ................................................
Bedford County, Virginia .......................................................
Bland County, Virginia ..........................................................
Botetourt County, Virginia .....................................................
Bristol City County, Virginia ..................................................
Brunswick County, Virginia ...................................................
Buchanan County, Virginia ...................................................
Buckingham County, Virginia ................................................
Buena Vista City County, Virginia .........................................
Campbell County, Virginia ....................................................
Caroline County, Virginia ......................................................
Carroll County, Virginia .........................................................
Charles City County, Virginia ................................................
Charlotte County, Virginia .....................................................
Charlottesville City County, Virginia ......................................
Chesapeake County, Virginia ...............................................
Chesterfield County, Virginia ................................................
Clarke County, Virginia .........................................................
Clifton Forge City County, Virginia .......................................
Colonial Heights County, Virginia .........................................
Covington City County, Virginia ............................................
Craig County, Virginia ...........................................................
Culpeper County, Virginia .....................................................
Cumberland County, Virginia ................................................
Danville City County, Virginia ...............................................
Dickenson County, Virginia ...................................................
Dinniddie County, Virginia .....................................................
Emporia County, Virginia ......................................................
Essex County, Virginia ..........................................................
Fairfax City County, Virginia .................................................
Fairfax County, Virginia .........................................................
Falls Church City County, Virginia ........................................
Fauquier County, Virginia .....................................................
Floyd County, Virginia ...........................................................
Fluvanna County, Virginia .....................................................
Franklin City County, Virginia ...............................................
00:49 May 09, 2006
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Urban
Rural
Urban
Rural
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Rural
2006
MSAbased WI
CBSA
No.
0.8762
0.8762
0.8762
0.8762
0.8762
0.9500
0.8762
0.8762
0.8762
0.9340
0.9830
0.9830
0.9830
0.9410
0.9830
0.9410
0.9410
0.9830
0.9830
0.9830
0.9830
0.9830
0.9830
0.9830
0.7615
0.7615
0.8417
1.0187
1.0976
0.8417
0.8417
0.8691
0.8417
1.0976
0.8417
0.8417
0.8691
0.8691
0.8417
0.8387
0.8007
0.8417
0.8417
0.8417
0.8417
0.8691
0.8417
0.8417
0.9328
0.8417
1.0187
0.8799
0.9328
1.0976
0.8417
0.9328
0.8417
0.8417
1.0976
0.8417
0.8489
0.8417
0.9328
0.8417
0.8417
1.0976
1.0976
1.0976
1.0976
0.8417
1.0187
0.8417
E:\FR\FM\09MYR2.SGM
09MYR2
99946
99946
41620
41620
99946
39340
99946
41100
99946
36260
99947
99947
99947
15540
99947
15540
15540
99947
99947
99947
99947
99947
99947
99947
99948
99948
99949
16820
47894
99949
40060
31340
31340
47894
99949
99949
31340
31340
99949
40220
28700
99949
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99949
99949
31340
40060
99949
40060
99949
16820
47260
40060
47894
99949
40060
99949
40220
99949
40060
19260
99949
40060
99949
99949
47894
47894
47894
47894
99949
16820
99949
CBSA
urban/
rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Rural
27129
2006
CBSAbased WI
0.8118
0.8118
0.9421
0.9421
0.8118
0.9500
0.8118
0.9392
0.8118
0.9029
0.9830
0.9830
0.9830
0.9410
0.9830
0.9410
0.9410
0.9830
0.9830
0.9830
0.9830
0.9830
0.9830
0.9830
0.7615
0.7615
0.8013
1.0187
1.0926
0.8013
0.9328
0.8691
0.8691
1.0926
0.8013
0.8013
0.8691
0.8691
0.8013
0.8374
0.8054
0.8013
0.8013
0.8013
0.8013
0.8691
0.9328
0.8013
0.9328
0.8013
1.0187
0.8799
0.9328
1.0926
0.8013
0.9328
0.8013
0.8374
0.8013
0.9328
0.8489
0.8013
0.9328
0.8013
0.8013
1.0926
1.0926
1.0926
1.0926
0.8013
1.0187
0.8013
27130
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
49330
49340
49342
49343
49350
49360
49370
49380
49390
49400
49410
49411
49420
49421
49430
49440
49450
49451
49460
49470
49480
49490
49500
49510
49520
49522
49530
49540
49550
49551
49560
49561
49563
49565
49570
49580
49590
49600
49610
49620
49621
49622
49641
49650
49660
49661
49670
49680
49690
49700
49701
49710
49711
49712
49720
49730
49740
49750
49770
49771
49780
49790
49791
49800
49801
49810
49820
49830
49838
49840
49850
49860
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VerDate Aug<31>2005
County name
MSA No.
Franklin County, Virginia .......................................................
Frederick County, Virginia .....................................................
Fredericksburg City County, Virginia ....................................
Galax City County, Virginia ...................................................
Giles County, Virginia ...........................................................
Gloucester County, Virginia ..................................................
Goochland County, Virginia ..................................................
Grayson County, Virginia ......................................................
Greene County, Virginia ........................................................
Greensville County, Virginia ..................................................
Halifax County, Virginia .........................................................
Hampton City County, Virginia ..............................................
Hanover County, Virginia ......................................................
Harrisonburg City County, Virginia .......................................
Henrico County, Virginia .......................................................
Henry County, Virginia ..........................................................
Highland County, Virginia .....................................................
Hopewell City County, Virginia .............................................
Isle Of Wight County, Virginia ...............................................
James City Co County, Virginia ............................................
King And Queen County, Virginia .........................................
King George County, Virginia ...............................................
King William County, Virginia ................................................
Lancaster County, Virginia ....................................................
Lee County, Virginia ..............................................................
Lexington County, Virginia ....................................................
Loudoun County, Virginia ......................................................
Louisa County, Virginia .........................................................
Lunenburg County, Virginia ..................................................
Lynchburg City County, Virginia ...........................................
Madison County, Virginia ......................................................
Martinsville City County, Virginia ..........................................
Manassas City County, Virginia ............................................
Manassas Park City County, Virginia ...................................
Mathews County, Virginia .....................................................
Mecklenburg County, Virginia ...............................................
Middlesex County, Virginia ...................................................
Montgomery County, Virginia ................................................
Nansemond County, Virginia ................................................
Nelson County, Virginia ........................................................
New Kent County, Virginia ....................................................
Newport News City County, Virginia .....................................
Norfolk City County, Virginia .................................................
Northampton County, Virginia ...............................................
Northumberland County, Virginia ..........................................
Norton City County, Virginia .................................................
Nottoway County, Virginia .....................................................
Orange County, Virginia ........................................................
Page County, Virginia ...........................................................
Patrick County, Virginia .........................................................
Petersburg City County, Virginia ...........................................
Pittsylvania County, Virginia .................................................
Portsmouth City County, Virginia ..........................................
Poquoson City County, Virginia ............................................
Powhatan County, Virginia ....................................................
Prince Edward County, Virginia ............................................
Prince George County, Virginia ............................................
Prince William County, Virginia .............................................
Pulaski County, Virginia ........................................................
Radford City County, Virginia ...............................................
Rappahannock County, Virginia ...........................................
Richmond County, Virginia ...................................................
Richmond City County, Virginia ............................................
Roanoke County, Virginia .....................................................
Roanoke City County, Virginia ..............................................
Rockbridge County, Virginia .................................................
Rockingham County, Virginia ................................................
Russell County, Virginia ........................................................
Salem County, Virginia .........................................................
Scott County, Virginia ...........................................................
Shenandoah County, Virginia ...............................................
Smyth County, Virginia .........................................................
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Urban
Urban
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Urban
Urban
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Rural
Rural
Rural
Rural
Urban
Urban
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.8417
0.8417
1.0976
0.8417
0.8417
0.8799
0.9328
0.8417
1.0187
0.8417
0.8417
0.8799
0.9328
0.8417
0.9328
0.8417
0.8417
0.9328
0.8799
0.8799
0.8417
1.0976
0.8417
0.8417
0.8417
0.8417
1.0976
0.8417
0.8417
0.8691
0.8417
0.8417
1.0976
1.0976
0.8799
0.8417
0.8417
0.8417
0.8417
0.8417
0.9328
0.8799
0.8799
0.8417
0.8417
0.8417
0.8417
0.8417
0.8417
0.8417
0.9328
0.8489
0.8799
0.8799
0.9328
0.8417
0.9328
1.0976
0.8417
0.8417
0.8417
0.8417
0.9328
0.8387
0.8387
0.8417
0.8417
0.8417
0.8387
0.8007
0.8417
0.8417
E:\FR\FM\09MYR2.SGM
09MYR2
40220
49020
47894
99949
13980
47260
40060
99949
16820
99949
99949
47260
40060
25500
40060
99949
99949
40060
47260
47260
40060
99949
40060
99949
99949
99949
47894
40060
99949
31340
99949
99949
47894
47894
47260
99949
99949
13980
99949
16820
40060
47260
47260
99949
99949
99949
99949
99949
99949
99949
40060
19260
47260
47260
40060
99949
40060
47894
13980
13980
99949
99949
40060
40220
40220
99949
25500
99949
40220
28700
99949
99949
CBSA
urban/
rural
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Urban
Urban
Urban
Rural
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Urban
Urban
Rural
Rural
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Rural
2006
CBSAbased WI
0.8374
1.0214
1.0926
0.8013
0.7954
0.8799
0.9328
0.8013
1.0187
0.8013
0.8013
0.8799
0.9328
0.9088
0.9328
0.8013
0.8013
0.9328
0.8799
0.8799
0.9328
0.8013
0.9328
0.8013
0.8013
0.8013
1.0926
0.9328
0.8013
0.8691
0.8013
0.8013
1.0926
1.0926
0.8799
0.8013
0.8013
0.7954
0.8013
1.0187
0.9328
0.8799
0.8799
0.8013
0.8013
0.8013
0.8013
0.8013
0.8013
0.8013
0.9328
0.8489
0.8799
0.8799
0.9328
0.8013
0.9328
1.0926
0.7954
0.7954
0.8013
0.8013
0.9328
0.8374
0.8374
0.8013
0.9088
0.8013
0.8374
0.8054
0.8013
0.8013
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
49867
49870
49880
49890
49891
49892
49900
49910
49920
49921
49930
49950
49951
49960
49961
49962
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49981
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50010
50020
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50080
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50100
50110
50120
50130
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50150
50160
50170
50180
50190
50200
50210
50220
50230
50240
50250
50260
50270
50280
50290
50300
50310
50320
50330
50340
50350
50360
50370
50380
51000
51010
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VerDate Aug<31>2005
County name
MSA No.
South Boston City County, Virginia ......................................
Southampton County, Virginia ..............................................
Spotsylvania County, Virginia ...............................................
Stafford County, Virginia .......................................................
Staunton City County, Virginia ..............................................
Suffolk City County, Virginia .................................................
Surry County, Virginia ...........................................................
Sussex County, Virginia ........................................................
Tazewell County, Virginia .....................................................
Virginia Beach City County, Virginia .....................................
Warren County, Virginia ........................................................
Washington County, Virginia .................................................
Waynesboro City County, Virginia ........................................
Westmoreland County, Virginia ............................................
Williamsburg City County, Virginia ........................................
Winchester City County, Virginia ..........................................
Wise County, Virginia ............................................................
Wythe County, Virginia .........................................................
York County, Virginia ............................................................
Adams County, Washington .................................................
Asotin County, Washington ...................................................
Benton County, Washington .................................................
Chelan County, Washington .................................................
Clallam County, Washington .................................................
Clark County, Washington ....................................................
Columbia County, Washington .............................................
Cowlitz County, Washington .................................................
Douglas County, Washington ...............................................
Ferry County, Washington ....................................................
Franklin County, Washington ................................................
Garfield County, Washington ................................................
Grant County, Washington ....................................................
Grays Harbor County, Washington .......................................
Island County, Washington ...................................................
Jefferson County, Washington ..............................................
King County, Washington .....................................................
Kitsap County, Washington ...................................................
Kittitas County, Washington ..................................................
Klickitat County, Washington ................................................
Lewis County, Washington ...................................................
Lincoln County, Washington .................................................
Mason County, Washington ..................................................
Okanogan County, Washington ............................................
Pacific County, Washington ..................................................
Pend Oreille County, Washington .........................................
Pierce County, Washington ..................................................
San Juan County, Washington .............................................
Skagit County, Washington ...................................................
Skamania County, Washington .............................................
Snohomish County, Washington ...........................................
Spokane County, Washington ..............................................
Stevens County, Washington ................................................
Thurston County, Washington ..............................................
Wahkiakum County, Washington ..........................................
Walla Walla County, Washington .........................................
Whatcom County, Washington .............................................
Whitman County, Washington ..............................................
Yakima County, Washington .................................................
Barbour County, W Virginia ..................................................
Berkeley County, W Virginia .................................................
Boone County, W Virginia .....................................................
Braxton County, W Virginia ...................................................
Brooke County, W Virginia ....................................................
Cabell County, W Virginia .....................................................
Calhoun County, W Virginia ..................................................
Clay County, W Virginia ........................................................
Doddridge County, W Virginia ..............................................
Fayette County, W Virginia ...................................................
Gilmer County, W Virginia ....................................................
Grant County, W Virginia ......................................................
Greenbrier County, W Virginia ..............................................
Hampshire County, W Virginia ..............................................
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Rural
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2006
MSAbased WI
CBSA
No.
0.8417
0.8417
1.0976
1.0976
0.8417
0.8799
0.8417
0.8417
0.8417
0.8799
1.0976
0.8007
0.8417
0.8417
0.8799
0.8417
0.8417
0.8417
0.8799
1.0217
1.0217
1.0619
1.0217
1.0217
1.1266
1.0217
1.0217
1.0217
1.0217
1.0619
1.0217
1.0217
1.0217
1.1567
1.0217
1.1567
1.0675
1.0217
1.0217
1.0217
1.0217
1.0217
1.0217
1.0217
1.0217
1.0742
1.0217
1.0217
1.0217
1.1567
1.0905
1.0217
1.0927
1.0217
1.0217
1.1731
1.0217
1.0155
0.7900
1.0976
0.7900
0.7900
0.7819
0.9477
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
E:\FR\FM\09MYR2.SGM
09MYR2
99949
99949
47894
47894
99949
47260
47260
40060
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47260
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28700
99949
99949
47260
49020
99949
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30300
28420
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99950
38900
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31020
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99950
28420
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42644
14740
99950
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45104
99950
34580
38900
42644
44060
99950
36500
99950
99950
13380
99950
49420
99951
25180
16620
99951
48260
26580
99951
16620
99951
99951
99951
99951
99951
49020
CBSA
urban/
rural
Rural
Rural
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Urban
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Urban
Rural
Urban
Urban
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Urban
Urban
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Urban
27131
2006
CBSAbased WI
0.8013
0.8013
1.0926
1.0926
0.8013
0.8799
0.8799
0.9328
0.8013
0.8799
1.0926
0.8054
0.8013
0.8013
0.8799
1.0214
0.8013
0.8013
0.8799
1.0510
0.9886
1.0619
1.0070
1.0510
1.1266
1.0510
0.9579
1.0070
1.0510
1.0619
1.0510
1.0510
1.0510
1.0510
1.0510
1.1577
1.0675
1.0510
1.0510
1.0510
1.0510
1.0510
1.0510
1.0510
1.0510
1.0742
1.0510
1.0454
1.1266
1.1577
1.0905
1.0510
1.0927
1.0510
1.0510
1.1731
1.0510
1.0155
0.7717
0.9489
0.8445
0.7717
0.7819
0.9477
0.7717
0.8445
0.7717
0.7717
0.7717
0.7717
0.7717
1.0214
27132
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
51140
51150
51160
51170
51180
51190
51200
51210
51220
51230
51240
51250
51260
51270
51280
51290
51300
51310
51320
51330
51340
51350
51360
51370
51380
51390
51400
51410
51420
51430
51440
51450
51460
51470
51480
51490
51500
51510
51520
51530
51540
52000
52010
52020
52030
52040
52050
52060
52070
52080
52090
52100
52110
52120
52130
52140
52150
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County name
MSA No.
Hancock County, W Virginia .................................................
Hardy County, W Virginia .....................................................
Harrison County, W Virginia .................................................
Jackson County, W Virginia ..................................................
Jefferson County, W Virginia ................................................
Kanawha County, W Virginia ................................................
Lewis County, W Virginia ......................................................
Lincoln County, W Virginia ....................................................
Logan County, W Virginia .....................................................
Mc Dowell County, W Virginia ..............................................
Marion County, W Virginia ....................................................
Marshall County, W Virginia .................................................
Mason County, W Virginia ....................................................
Mercer County, W Virginia ....................................................
Mineral County, W Virginia ...................................................
Mingo County, W Virginia .....................................................
Monongalia County, W Virginia ............................................
Monroe County, W Virginia ...................................................
Morgan County, W Virginia ...................................................
Nicholas County, W Virginia .................................................
Ohio County, W Virginia .......................................................
Pendleton County, W Virginia ...............................................
Pleasants County, W Virginia ...............................................
Pocahontas County, W Virginia ............................................
Preston County, W Virginia ...................................................
Putnam County, W Virginia ...................................................
Raleigh County, W Virginia ...................................................
Randolph County, W Virginia ................................................
Ritchie County, W Virginia ....................................................
Roane County, W Virginia ....................................................
Summers County, W Virginia ................................................
Taylor County, W Virginia .....................................................
Tucker County, W Virginia ....................................................
Tyler County, W Virginia .......................................................
Upshur County, W Virginia ...................................................
Wayne County, W Virginia ....................................................
Webster County, W Virginia ..................................................
Wetzel County, W Virginia ....................................................
Wirt County, W Virginia .........................................................
Wood County, W Virginia ......................................................
Wyoming County, W Virginia ................................................
Adams County, Wisconsin ....................................................
Ashland County, Wisconsin ..................................................
Barron County, Wisconsin ....................................................
Bayfield County, Wisconsin ..................................................
Brown County, Wisconsin .....................................................
Buffalo County, Wisconsin ....................................................
Burnett County, Wisconsin ....................................................
Calumet County, Wisconsin ..................................................
Chippewa County, Wisconsin ...............................................
Clark County, Wisconsin .......................................................
Columbia County, Wisconsin ................................................
Crawford County, Wisconsin .................................................
Dane County, Wisconsin .......................................................
Dodge County, Wisconsin .....................................................
Door County, Wisconsin .......................................................
Douglas County, Wisconsin ..................................................
Dunn County, Wisconsin .......................................................
Eau Claire County, Wisconsin ..............................................
Florence County, Wisconsin .................................................
Fond Du Lac County, Wisconsin ..........................................
Forest County, Wisconsin .....................................................
Grant County, Wisconsin ......................................................
Green County, Wisconsin .....................................................
Green Lake County, Wisconsin ............................................
Iowa County, Wisconsin ........................................................
Iron County, Wisconsin .........................................................
Jackson County, Wisconsin ..................................................
Jefferson County, Wisconsin ................................................
Juneau County, Wisconsin ...................................................
Kenosha County, Wisconsin .................................................
Kewaunee County, Wisconsin ..............................................
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urban/
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Rural
Urban
Rural
Rural
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Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
2006
MSAbased WI
CBSA
No.
0.7819
0.7900
0.7900
0.7900
1.0976
0.8445
0.7900
0.7900
0.7900
0.7900
0.7900
0.7161
0.7900
0.7900
0.9317
0.7900
0.7900
0.7900
0.7900
0.7900
0.7161
0.7900
0.7900
0.7900
0.7900
0.8445
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.7900
0.9477
0.7900
0.7900
0.7900
0.8270
0.7900
0.9478
0.9478
0.9478
0.9478
0.9483
0.9478
0.9478
0.9239
0.9201
0.9478
0.9478
0.9478
1.0754
0.9478
0.9478
1.0213
0.9478
0.9201
0.9478
0.9478
0.9478
0.9478
0.9478
0.9478
0.9478
0.9478
0.9478
0.9478
0.9478
0.9760
0.9478
E:\FR\FM\09MYR2.SGM
09MYR2
48260
99951
99951
99951
47894
16620
99951
16620
99951
99951
99951
48540
99951
99951
19060
99951
34060
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25180
99951
48540
99951
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99951
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16620
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24580
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99952
20740
99952
22540
99952
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31540
99952
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99952
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29404
24580
CBSA
urban/
rural
Urban
Rural
Rural
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Rural
Rural
Rural
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Rural
Rural
Urban
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Urban
Urban
2006
CBSAbased WI
0.7819
0.7717
0.7717
0.7717
1.0926
0.8445
0.7717
0.8445
0.7717
0.7717
0.7717
0.7161
0.7717
0.7717
0.9317
0.7717
0.8420
0.7717
0.9489
0.7717
0.7161
0.7717
0.8270
0.7717
0.8420
0.8445
0.7717
0.7717
0.7717
0.7717
0.7717
0.7717
0.7717
0.7717
0.7717
0.9477
0.7717
0.7717
0.8270
0.8270
0.7717
0.9509
0.9509
0.9509
0.9509
0.9483
0.9509
0.9509
0.9288
0.9201
0.9509
1.0659
0.9509
1.0659
0.9509
0.9509
1.0213
0.9509
0.9201
0.9509
0.9640
0.9509
0.9509
0.9509
0.9509
1.0659
0.9509
0.9509
0.9509
0.9509
1.0429
0.9483
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
mmaher on PROD1PC60 with RULES2
SSA State/
County
Code
52310
52320
52330
52340
52350
52360
52370
52380
52381
52390
52400
52410
52420
52430
52440
52450
52460
52470
52480
52490
52500
52510
52520
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52550
52560
52570
52580
52590
52600
52610
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52670
52680
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52700
53000
53010
53020
53030
53040
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53060
53070
53080
53090
53100
53110
53120
53130
53140
53150
53160
53170
53180
53190
53200
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65010
65020
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VerDate Aug<31>2005
County name
MSA No.
La Crosse County, Wisconsin ...............................................
Lafayette County, Wisconsin ................................................
Langlade County, Wisconsin ................................................
Lincoln County, Wisconsin ....................................................
Manitowoc County, Wisconsin ..............................................
Marathon County, Wisconsin ................................................
Marinette County, Wisconsin ................................................
Marquette County, Wisconsin ...............................................
Menominee County, Wisconsin ............................................
Milwaukee County, Wisconsin ..............................................
Monroe County, Wisconsin ...................................................
Oconto County, Wisconsin ....................................................
Oneida County, Wisconsin ....................................................
Outagamie County, Wisconsin ..............................................
Ozaukee County, Wisconsin .................................................
Pepin County, Wisconsin ......................................................
Pierce County, Wisconsin .....................................................
Polk County, Wisconsin ........................................................
Portage County, Wisconsin ...................................................
Price County, Wisconsin .......................................................
Racine County, Wisconsin ....................................................
Richland County, Wisconsin .................................................
Rock County, Wisconsin .......................................................
Rusk County, Wisconsin .......................................................
St Croix County, Wisconsin ..................................................
Sauk County, Wisconsin .......................................................
Sawyer County, Wisconsin ...................................................
Shawano County, Wisconsin ................................................
Sheboygan County, Wisconsin .............................................
Taylor County, Wisconsin .....................................................
Trempealeau County, Wisconsin ..........................................
Vernon County, Wisconsin ....................................................
Vilas County, Wisconsin .......................................................
Walworth County, Wisconsin ................................................
Washburn County, Wisconsin ...............................................
Washington County, Wisconsin ............................................
Waukesha County, Wisconsin ..............................................
Waupaca County, Wisconsin ................................................
Waushara County, Wisconsin ...............................................
Winnebago County, Wisconsin .............................................
Wood County, Wisconsin ......................................................
Albany County, Wyoming ......................................................
Big Horn County, Wyoming ..................................................
Campbell County, Wyoming .................................................
Carbon County, Wyoming .....................................................
Converse County, Wyoming .................................................
Crook County, Wyoming .......................................................
Fremont County, Wyoming ...................................................
Goshen County, Wyoming ....................................................
Hot Springs County, Wyoming ..............................................
Johnson County, Wyoming ...................................................
Laramie County, Wyoming ....................................................
Lincoln County, Wyoming .....................................................
Natrona County, Wyoming ....................................................
Niobrara County, Wyoming ...................................................
Park County, Wyoming .........................................................
Platte County, Wyoming .......................................................
Sheridan County, Wyoming ..................................................
Sublette County, Wyoming ...................................................
Sweetwater County, Wyoming ..............................................
Teton County, Wyoming .......................................................
Uinta County, Wyoming ........................................................
Washakie County, Wyoming .................................................
Weston County, Wyoming ....................................................
Agana County, Guam ...........................................................
Agana Heights County, Guam ..............................................
Agat County, Guam ..............................................................
Asan County, Guam ..............................................................
Barrigada County, Guam ......................................................
Chalan Pago County, Guam .................................................
Dededo County, Guam .........................................................
Inarajan County, Guam .........................................................
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Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.9564
0.9478
0.9478
0.9478
0.9478
0.9590
0.9478
0.9478
0.9478
1.0146
0.9478
0.9478
0.9478
0.9239
1.0146
0.9478
1.1075
0.9478
0.9478
0.9478
0.8997
0.9478
0.9538
0.9478
1.1075
0.9478
0.9478
0.9478
0.8911
0.9478
0.9478
0.9478
0.9478
0.9478
0.9478
1.0146
1.0146
0.9478
0.9478
0.9239
0.9478
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.8775
0.9257
0.9026
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
E:\FR\FM\09MYR2.SGM
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99965
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CBSA
urban/
rural
Urban
Rural
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Urban
Rural
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Urban
Rural
Urban
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
27133
2006
CBSAbased WI
0.9564
0.9509
0.9509
0.9509
0.9509
0.9590
0.9509
0.9509
0.9509
1.0146
0.9509
0.9483
0.9509
0.9288
1.0146
0.9509
1.1075
0.9509
0.9509
0.9509
0.8997
0.9509
0.9538
0.9509
1.1075
0.9509
0.9509
0.9509
0.8911
0.9509
0.9509
0.9509
0.9509
0.9509
0.9509
1.0146
1.0146
0.9509
0.9509
0.9183
0.9509
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.8775
0.9257
0.9026
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9257
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
27134
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
SSA State/
County
Code
65090
65100
65110
65120
65130
65140
65150
65160
65170
65180
65190
65200
65210
65220
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
.......
County name
MSA No.
Maite County, Guam .............................................................
Mangilao County, Guam .......................................................
Merizo County, Guam ...........................................................
Mongmong County, Guam ....................................................
Ordot County, Guam .............................................................
Piti County, Guam .................................................................
Santa Rita County, Guam .....................................................
Sinajana County, Guam ........................................................
Talofofo County, Guam .........................................................
Tamuning County, Guam ......................................................
Toto County, Guam ...............................................................
Umatac County, Guam .........................................................
Yigo County, Guam ...............................................................
Yona County, Guam .............................................................
65
65
65
65
65
65
65
65
65
65
65
65
65
65
MSA
urban/
rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
2006
MSAbased WI
CBSA
No.
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
99965
99965
99965
99965
99965
99965
99965
99965
99965
99965
99965
99965
99965
99965
CBSA
urban/
rural
2006
CBSAbased WI
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
Rural
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
0.9611
1 At this time, there are no hospitals located in these CBSA-based urban areas on which to base a wage index. Therefore, the wage index
value is based on the average wage index for all urban areas within the state.
Addendum C—Wage Index Tables
In this addendum, we provide the
tables referred to throughout the
preamble in this final rule. Tables 1 and
2 below provide the CBSA-based wage
index values for urban and rural
providers.
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS
CBSA
code
Urban area (constituent counties)
Wage
index
10180 .......
Abilene, TX ................................................................................................................................................................................
Callahan County, TX.
Jones County, TX.
Taylor County, TX.
´
Aguadilla-Isabela-San Sebastian, PR .......................................................................................................................................
Aguada Municipio, PR.
Aguadilla Municipio, PR.
˜
Anasco Municipio, PR.
Isabela Municipio, PR.
Lares Municipio, PR.
Moca Municipio, PR.
´
Rincon Municipio, PR.
˘
San Sebastia≤n Municipio, PR.
Akron, OH ..................................................................................................................................................................................
Portage County, OH.
Summit County, OH.
Albany, GA ................................................................................................................................................................................
Baker County, GA.
Dougherty County, GA.
Lee County, GA.
Terrell County, GA.
Worth County, GA.
Albany-Schenectady-Troy, NY ..................................................................................................................................................
Albany County, NY.
Rensselaer County, NY.
Saratoga County, NY.
Schenectady County, NY.
Schoharie County, NY.
Albuquerque, NM ......................................................................................................................................................................
Bernalillo County, NM.
Sandoval County, NM.
Torrance County, NM.
Valencia County, NM.
Alexandria, LA ...........................................................................................................................................................................
Grant Parish, LA.
Rapides Parish, LA.
Allentown-Bethlehem-Easton, PA-NJ ........................................................................................................................................
Warren County, NJ.
Carbon County, PA.
Lehigh County, PA.
Northampton County, PA.
Altoona, PA ...............................................................................................................................................................................
Blair County, PA.
Amarillo, TX ...............................................................................................................................................................................
0.7896
10380 .......
10420 .......
10500 .......
10580 .......
10740 .......
10780 .......
mmaher on PROD1PC60 with RULES2
10900 .......
11020 .......
11100 .......
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0.8628
0.8589
0.9684
0.8033
0.9818
0.8944
0.9156
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
27135
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
11180 .......
11260 .......
11300 .......
11340 .......
11460 .......
11500 .......
11540 .......
11700 .......
12020 .......
12060 .......
12100 .......
12220 .......
mmaher on PROD1PC60 with RULES2
12260 .......
12420 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Armstrong County, TX.
Carson County, TX.
Potter County, TX.
Randall County, TX.
Ames, IA ....................................................................................................................................................................................
Story County, IA.
Anchorage, AK ..........................................................................................................................................................................
Anchorage Municipality, AK.
Matanuska-Susitna Borough, AK.
Anderson, IN .............................................................................................................................................................................
Madison County, IN.
Anderson, SC ............................................................................................................................................................................
Anderson County, SC.
Ann Arbor, MI ............................................................................................................................................................................
Washtenaw County, MI.
Anniston-Oxford, AL ..................................................................................................................................................................
Calhoun County, AL.
Appleton, WI ..............................................................................................................................................................................
Calumet County, WI.
Outagamie County, WI.
Asheville, NC .............................................................................................................................................................................
Buncombe County, NC.
Haywood County, NC.
Henderson County, NC.
Madison County, NC.
Athens-Clarke County, GA ........................................................................................................................................................
Clarke County, GA.
Madison County, GA.
Oconee County, GA.
Oglethorpe County, GA.
Atlanta-Sandy Springs-Marietta, GA .........................................................................................................................................
Barrow County, GA.
Bartow County, GA.
Butts County, GA.
Carroll County, GA.
Cherokee County, GA.
Clayton County, GA.
Cobb County, GA.
Coweta County, GA.
Dawson County, GA.
DeKalb County, GA.
Douglas County, GA.
Fayette County, GA.
Forsyth County, GA.
Fulton County, GA.
Gwinnett County, GA.
Haralson County, GA.
Heard County, GA.
Henry County, GA.
Jasper County, GA.
Lamar County, GA.
Meriwether County, GA.
Newton County, GA.
Paulding County, GA.
Pickens County, GA.
Pike County, GA.
Rockdale County, GA.
Spalding County, GA.
Walton County, GA.
Atlantic City, NJ .........................................................................................................................................................................
Atlantic County, NJ.
Auburn-Opelika, AL ...................................................................................................................................................................
Lee County, AL.
Augusta-Richmond County, GA-SC ..........................................................................................................................................
Burke County, GA.
Columbia County, GA.
McDuffie County, GA.
Richmond County, GA.
Aiken County, SC.
Edgefield County, SC.
Austin-Round Rock, TX .............................................................................................................................................................
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09MYR2
0.9536
1.1895
0.8586
0.8997
1.0859
0.7682
0.9288
0.9285
0.9855
0.9793
1.1615
0.8100
0.9748
0.9437
27136
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
12540 .......
12580 .......
12620 .......
12700 .......
12940 .......
12980 .......
13020 .......
13140 .......
13380 .......
13460 .......
13644 .......
13740 .......
13780 .......
13820 .......
13900 .......
mmaher on PROD1PC60 with RULES2
13980 .......
14020 .......
14060 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Bastrop County, TX.
Caldwell County, TX.
Hays County, TX.
Travis County, TX.
Williamson County, TX.
Bakersfield, CA ..........................................................................................................................................................................
Kern County, CA.
Baltimore-Towson, MD ..............................................................................................................................................................
Anne Arundel County, MD.
Baltimore County, MD.
Carroll County, MD.
Harford County, MD.
Howard County, MD.
Queen Anne’s County, MD.
Baltimore City, MD.
Bangor, ME ...............................................................................................................................................................................
Penobscot County, ME.
Barnstable Town, MA ................................................................................................................................................................
Barnstable County, MA.
Baton Rouge, LA .......................................................................................................................................................................
Ascension Parish, LA.
East Baton Rouge Parish, LA.
East Feliciana Parish, LA.
Iberville Parish, LA.
Livingston Parish, LA.
Pointe Coupee Parish, LA.
St. Helena Parish, LA.
West Baton Rouge Parish, LA.
West Feliciana Parish, LA.
Battle Creek, MI ........................................................................................................................................................................
Calhoun County, MI.
Bay City, MI ...............................................................................................................................................................................
Bay County, MI.
Beaumont-Port Arthur, TX .........................................................................................................................................................
Hardin County, TX.
Jefferson County, TX.
Orange County, TX.
Bellingham, WA .........................................................................................................................................................................
Whatcom County, WA.
Bend, OR ...................................................................................................................................................................................
Deschutes County, OR.
Bethesda-Gaithersburg-Frederick, MD .....................................................................................................................................
Frederick County, MD.
Montgomery County, MD.
Billings, MT ................................................................................................................................................................................
Carbon County, MT.
Yellowstone County, MT.
Binghamton, NY ........................................................................................................................................................................
Broome County, NY.
Tioga County, NY.
Birmingham-Hoover, AL ............................................................................................................................................................
Bibb County, AL.
Blount County, AL.
Chilton County, AL.
Jefferson County, AL.
St. Clair County, AL.
Shelby County, AL.
Walker County, AL.
Bismarck, ND ............................................................................................................................................................................
Burleigh County, ND.
Morton County, ND.
Blacksburg-Christiansburg-Radford, VA ...................................................................................................................................
Giles County, VA.
Montgomery County, VA.
Pulaski County, VA.
Radford City, VA.
Bloomington, IN .........................................................................................................................................................................
Greene County, IN.
Monroe County, IN.
Owen County, IN.
Bloomington-Normal, IL .............................................................................................................................................................
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09MYR2
1.0470
0.9897
0.9993
1.2600
0.8593
0.9508
0.9343
0.8412
1.1731
1.0786
1.1483
0.8834
0.8562
0.8959
0.7574
0.7954
0.8447
0.9075
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
27137
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
14260 .......
14484 .......
14500 .......
14540 .......
14740 .......
14860 .......
15180 .......
15260 .......
15380 .......
15500 .......
15540 .......
15764 .......
15804 .......
15940 .......
15980 .......
16180 .......
16220 .......
16300 .......
16580 .......
16620 .......
mmaher on PROD1PC60 with RULES2
16700 .......
16740 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
McLean County, IL.
Boise City-Nampa, ID ................................................................................................................................................................
Ada County, ID.
Boise County, ID.
Canyon County, ID.
Gem County, ID.
Owyhee County, ID.
Boston-Quincy, MA ...................................................................................................................................................................
Norfolk County, MA.
Plymouth County, MA.
Suffolk County, MA.
Boulder, CO ...............................................................................................................................................................................
Boulder County, CO.
Bowling Green, KY ....................................................................................................................................................................
Edmonson County, KY.
Warren County, KY.
Bremerton-Silverdale, WA .........................................................................................................................................................
Kitsap County, WA.
Bridgeport-Stamford-Norwalk, CT .............................................................................................................................................
Fairfield County, CT.
Brownsville-Harlingen, TX .........................................................................................................................................................
Cameron County, TX.
Brunswick, GA ...........................................................................................................................................................................
Brantley County, GA.
Glynn County, GA.
McIntosh County, GA.
Buffalo-Niagara Falls, NY ..........................................................................................................................................................
Erie County, NY.
Niagara County, NY.
Burlington, NC ...........................................................................................................................................................................
Alamance County, NC.
Burlington-South Burlington, VT ................................................................................................................................................
Chittenden County, VT.
Franklin County, VT.
Grand Isle County, VT.
Cambridge-Newton-Framingham, MA .......................................................................................................................................
Middlesex County, MA.
Camden, NJ ..............................................................................................................................................................................
Burlington County, NJ.
Camden County, NJ.
Gloucester County, NJ.
Canton-Massillon, OH ...............................................................................................................................................................
Carroll County, OH.
Stark County, OH.
Cape Coral-Fort Myers, FL .......................................................................................................................................................
Lee County, FL.
Carson City, NV ........................................................................................................................................................................
Carson City, NV.
Casper, WY ...............................................................................................................................................................................
Natrona County, WY.
Cedar Rapids, IA .......................................................................................................................................................................
Benton County, IA.
Jones County, IA.
Linn County, IA.
Champaign-Urbana, IL ..............................................................................................................................................................
Champaign County, IL.
Ford County, IL.
Piatt County, IL.
Charleston, WV .........................................................................................................................................................................
Boone County, WV.
Clay County, WV.
Kanawha County, WV.
Lincoln County, WV.
Putnam County, WV.
Charleston-North Charleston, SC .............................................................................................................................................
Berkeley County, SC.
Charleston County, SC.
Dorchester County, SC.
Charlotte-Gastonia-Concord, NC-SC ........................................................................................................................................
Anson County, NC.
Cabarrus County, NC.
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09MYR2
0.9052
1.1558
0.9734
0.8211
1.0675
1.2592
0.9804
0.9311
0.9511
0.8905
0.9410
1.1172
1.0517
0.8935
0.9356
1.0234
0.9026
0.8825
0.9594
0.8445
0.9245
0.9750
27138
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
16820 .......
16860 .......
16940 .......
16974 .......
17020 .......
17140 .......
17300 .......
17420 .......
17460 .......
17660 .......
mmaher on PROD1PC60 with RULES2
17780 .......
17820 .......
17860 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Gaston County, NC.
Mecklenburg County, NC.
Union County, NC.
York County, SC.
Charlottesville, VA .....................................................................................................................................................................
Albemarle County, VA.
Fluvanna County, VA.
Greene County, VA.
Nelson County, VA.
Charlottesville City, VA.
Chattanooga, TN-GA .................................................................................................................................................................
Catoosa County, GA.
Dade County, GA.
Walker County, GA.
Hamilton County, TN.
Marion County, TN.
Sequatchie County, TN.
Cheyenne, WY ..........................................................................................................................................................................
Laramie County, WY.
Chicago-Naperville-Joliet, IL .....................................................................................................................................................
Cook County, IL.
DeKalb County, IL.
DuPage County, IL.
Grundy County, IL.
Kane County, IL.
Kendall County, IL.
McHenry County, IL.
Will County, IL.
Chico, CA ..................................................................................................................................................................................
Butte County, CA.
Cincinnati-Middletown, OH-KY-IN .............................................................................................................................................
Dearborn County, IN.
Franklin County, IN.
Ohio County, IN.
Boone County, KY.
Bracken County, KY.
Campbell County, KY.
Gallatin County, KY.
Grant County, KY.
Kenton County, KY.
Pendleton County, KY.
Brown County, OH.
Butler County, OH.
Clermont County, OH.
Hamilton County, OH.
Warren County, OH.
Clarksville, TN-KY .....................................................................................................................................................................
Christian County, KY.
Trigg County, KY.
Montgomery County, TN.
Stewart County, TN.
Cleveland, TN ............................................................................................................................................................................
Bradley County, TN.
Polk County, TN.
Cleveland-Elyria-Mentor, OH ....................................................................................................................................................
Cuyahoga County, OH.
Geauga County, OH.
Lake County, OH.
Lorain County, OH.
Medina County, OH.
Coeur d’Alene, ID ......................................................................................................................................................................
Kootenai County, ID.
College Station-Bryan, TX .........................................................................................................................................................
Brazos County, TX.
Burleson County, TX.
Robertson County, TX.
Colorado Springs, CO ...............................................................................................................................................................
El Paso County, CO.
Teller County, CO.
Columbia, MO ...........................................................................................................................................................................
Boone County, MO.
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09MYR2
1.0187
0.9088
0.8775
1.0790
1.0511
0.9615
0.8284
0.8139
0.9213
0.9647
0.8900
0.9468
0.8345
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
27139
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
17900 .......
17980 .......
18020 .......
18140 .......
18580 .......
18700 .......
19060 .......
19124 .......
19140 .......
19180 .......
19260 .......
19340 .......
19380 .......
19460 .......
mmaher on PROD1PC60 with RULES2
19500 .......
19660 .......
19740 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Howard County, MO.
Columbia, SC ............................................................................................................................................................................
Calhoun County, SC.
Fairfield County, SC.
Kershaw County, SC.
Lexington County, SC.
Richland County, SC.
Saluda County, SC.
Columbus, GA-AL .....................................................................................................................................................................
Russell County, AL.
Chattahoochee County, GA.
Harris County, GA.
Marion County, GA.
Muscogee County, GA.
Columbus, IN .............................................................................................................................................................................
Bartholomew County, IN.
Columbus, OH ...........................................................................................................................................................................
Delaware County, OH.
Fairfield County, OH.
Franklin County, OH.
Licking County, OH.
Madison County, OH.
Morrow County, OH.
Pickaway County, OH.
Union County, OH.
Corpus Christi, TX .....................................................................................................................................................................
Aransas County, TX.
Nueces County, TX.
San Patricio County, TX.
Corvallis, OR .............................................................................................................................................................................
Benton County, OR.
Cumberland, MD-WV ................................................................................................................................................................
Allegany County, MD.
Mineral County, WV.
Dallas-Plano-Irving, TX .............................................................................................................................................................
Collin County, TX.
Dallas County, TX.
Delta County, TX.
Denton County, TX.
Ellis County, TX.
Hunt County, TX.
Kaufman County, TX.
Rockwall County, TX.
Dalton, GA .................................................................................................................................................................................
Murray County, GA.
Whitfield County, GA.
Danville, IL .................................................................................................................................................................................
Vermilion County, IL.
Danville, VA ...............................................................................................................................................................................
Pittsylvania County, VA.
Danville City, VA.
Davenport-Moline-Rock Island, IA-IL ........................................................................................................................................
Henry County, IL.
Mercer County, IL.
Rock Island County, IL.
Scott County, IA.
Dayton, OH ................................................................................................................................................................................
Greene County, OH.
Miami County, OH.
Montgomery County, OH.
Preble County, OH.
Decatur, AL ...............................................................................................................................................................................
Lawrence County, AL.
Morgan County, AL.
Decatur, IL .................................................................................................................................................................................
Macon County, IL.
Deltona-Daytona Beach-Ormond Beach, FL ............................................................................................................................
Volusia County, FL.
Denver-Aurora, CO ...................................................................................................................................................................
Adams County, CO.
Arapahoe County, CO.
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09MYR2
0.9057
0.8560
0.9588
0.9860
0.8550
1.0729
0.9317
1.0228
0.9079
0.9028
0.8489
0.8724
0.9064
0.8469
0.8067
0.9299
1.0723
27140
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
19780 .......
19804 .......
20020 .......
20100 .......
20220 .......
20260 .......
20500 .......
20740 .......
20764 .......
20940 .......
21060 .......
21140 .......
21300 .......
21340 .......
21500 .......
21604 .......
21660 .......
mmaher on PROD1PC60 with RULES2
21780 .......
21820 .......
21940 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Broomfield County, CO.
Clear Creek County, CO.
Denver County, CO.
Douglas County, CO.
Elbert County, CO.
Gilpin County, CO.
Jefferson County, CO.
Park County, CO.
Des Moines-West Des Moines, IA ............................................................................................................................................
Dallas County, IA.
Guthrie County, IA.
Madison County, IA.
Polk County, IA.
Warren County, IA.
Detroit-Livonia-Dearborn, MI .....................................................................................................................................................
Wayne County, MI.
Dothan, AL ................................................................................................................................................................................
Geneva County, AL.
Henry County, AL.
Houston County, AL.
Dover, DE ..................................................................................................................................................................................
Kent County, DE.
Dubuque, IA ..............................................................................................................................................................................
Dubuque County, IA.
Duluth, MN-WI ...........................................................................................................................................................................
Carlton County, MN.
St. Louis County, MN.
Douglas County, WI.
Durham, NC ..............................................................................................................................................................................
Chatham County, NC.
Durham County, NC.
Orange County, NC.
Person County, NC.
Eau Claire, WI ...........................................................................................................................................................................
Chippewa County, WI.
Eau Claire County, WI.
Edison, NJ .................................................................................................................................................................................
Middlesex County, NJ.
Monmouth County, NJ.
Ocean County, NJ.
Somerset County, NJ.
El Centro, CA ............................................................................................................................................................................
Imperial County, CA.
Elizabethtown, KY .....................................................................................................................................................................
Hardin County, KY.
Larue County, KY.
Elkhart-Goshen, IN ....................................................................................................................................................................
Elkhart County, IN.
Elmira, NY .................................................................................................................................................................................
Chemung County, NY.
El Paso, TX ...............................................................................................................................................................................
El Paso County, TX.
Erie, PA .....................................................................................................................................................................................
Erie County, PA.
Essex County, MA .....................................................................................................................................................................
Essex County, MA.
Eugene-Springfield, OR ............................................................................................................................................................
Lane County, OR.
Evansville, IN-KY .......................................................................................................................................................................
Gibson County, IN.
Posey County, IN.
Vanderburgh County, IN.
Warrick County, IN.
Henderson County, KY.
Webster County, KY.
Fairbanks, AK ............................................................................................................................................................................
Fairbanks North Star Borough, AK.
Fajardo, PR ...............................................................................................................................................................................
Ceiba Municipio, PR.
Fajardo Municipio, PR.
Luquillo Municipio, PR.
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09MYR2
0.9669
1.0424
0.7721
0.9776
0.9024
1.0213
1.0244
0.9201
1.1249
0.8906
0.8802
0.9627
0.8250
0.8977
0.8737
1.0538
1.0818
0.8713
1.1408
0.4153
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
27141
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
Urban area (constituent counties)
Wage
index
22020 .......
Fargo, ND-MN ...........................................................................................................................................................................
Cass County, ND.
Clay County, MN.
Farmington, NM .........................................................................................................................................................................
San Juan County, NM.
Fayetteville, NC .........................................................................................................................................................................
Cumberland County, NC.
Hoke County, NC.
Fayetteville-Springdale-Rogers, AR-MO ...................................................................................................................................
Benton County, AR.
Madison County, AR.
Washington County, AR.
McDonald County, MO.
Flagstaff, AZ ..............................................................................................................................................................................
Coconino County, AZ.
Flint, MI ......................................................................................................................................................................................
Genesee County, MI.
Florence, SC .............................................................................................................................................................................
Darlington County, SC.
Florence County, SC.
Florence-Muscle Shoals, AL .....................................................................................................................................................
Colbert County, AL.
Lauderdale County, AL.
Fond du Lac, WI ........................................................................................................................................................................
Fond du Lac County, WI.
Fort Collins-Loveland, CO .........................................................................................................................................................
Larimer County, CO.
Fort Lauderdale-Pompano Beach-Deerfield Beach, FL ............................................................................................................
Broward County, FL.
Fort Smith, AR-OK ....................................................................................................................................................................
Crawford County, AR.
Franklin County, AR.
Sebastian County, AR.
Le Flore County, OK.
Sequoyah County, OK.
Fort Walton Beach-Crestview-Destin, FL ..................................................................................................................................
Okaloosa County, FL.
Fort Wayne, IN ..........................................................................................................................................................................
Allen County, IN.
Wells County, IN.
Whitley County, IN.
Fort Worth-Arlington, TX ...........................................................................................................................................................
Johnson County, TX.
Parker County, TX.
Tarrant County, TX.
Wise County, TX.
Fresno, CA ................................................................................................................................................................................
Fresno County, CA.
Gadsden, AL .............................................................................................................................................................................
Etowah County, AL.
Gainesville, FL ...........................................................................................................................................................................
Alachua County, FL.
Gilchrist County, FL.
Gainesville, GA ..........................................................................................................................................................................
Hall County, GA.
Gary, IN .....................................................................................................................................................................................
Jasper County, IN.
Lake County, IN.
Newton County, IN.
Porter County, IN.
Glens Falls, NY .........................................................................................................................................................................
Warren County, NY.
Washington County, NY.
Goldsboro, NC ...........................................................................................................................................................................
Wayne County, NC.
Grand Forks, ND-MN ................................................................................................................................................................
Polk County, MN.
Grand Forks County, ND.
Grand Junction, CO ..................................................................................................................................................................
Mesa County, CO.
Grand Rapids-Wyoming, MI ......................................................................................................................................................
0.8486
22140 .......
22180 .......
22220 .......
22380 .......
22420 .......
22500 .......
22520 .......
22540 .......
22660 .......
22744 .......
22900 .......
23020 .......
23060 .......
23104 .......
23420 .......
23460 .......
23540 .......
23580 .......
23844 .......
24020 .......
mmaher on PROD1PC60 with RULES2
24140 .......
24220 .......
24300 .......
24340 .......
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0.8509
0.9416
0.8661
1.2092
1.0655
0.8947
0.8272
0.9640
1.0122
1.0432
0.8230
0.8872
0.9793
0.9486
1.0538
0.7938
0.9388
0.8874
0.9395
0.8559
0.8775
0.7901
0.9550
0.9390
27142
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
24500 .......
24540 .......
24580 .......
24660 .......
24780 .......
24860 .......
25020 .......
25060 .......
25180 .......
25260 .......
25420 .......
25500 .......
25540 .......
25620 .......
25860 .......
25980 .......
26100 .......
mmaher on PROD1PC60 with RULES2
26180 .......
26300 .......
26380 .......
26420 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Barry County, MI.
Ionia County, MI.
Kent County, MI.
Newaygo County, MI.
Great Falls, MT .........................................................................................................................................................................
Cascade County, MT.
Greeley, CO ..............................................................................................................................................................................
Weld County, CO.
Green Bay, WI ...........................................................................................................................................................................
Brown County, WI.
Kewaunee County, WI.
Oconto County, WI.
Greensboro-High Point, NC ......................................................................................................................................................
Guilford County, NC.
Randolph County, NC.
Rockingham County, NC.
Greenville, NC ...........................................................................................................................................................................
Greene County, NC.
Pitt County, NC.
Greenville, SC ...........................................................................................................................................................................
Greenville County, SC.
Laurens County, SC.
Pickens County, SC.
Guayama, PR ............................................................................................................................................................................
Arroyo Municipio, PR.
Guayama Municipio, PR.
Patillas Municipio, PR.
Gulfport-Biloxi, MS ....................................................................................................................................................................
Hancock County, MS.
Harrison County, MS.
Stone County, MS.
Hagerstown-Martinsburg, MD-WV ............................................................................................................................................
Washington County, MD.
Berkeley County, WV.
Morgan County, WV.
Hanford-Corcoran, CA ...............................................................................................................................................................
Kings County, CA.
Harrisburg-Carlisle, PA ..............................................................................................................................................................
Cumberland County, PA.
Dauphin County, PA.
Perry County, PA.
Harrisonburg, VA .......................................................................................................................................................................
Rockingham County, VA.
Harrisonburg City, VA.
Hartford-West Hartford-East Hartford, CT ................................................................................................................................
Hartford County, CT.
Litchfield County, CT.
Middlesex County, CT.
Tolland County, CT.
Hattiesburg, MS .........................................................................................................................................................................
Forrest County, MS.
Lamar County, MS.
Perry County, MS.
Hickory-Lenoir-Morganton, NC ..................................................................................................................................................
Alexander County, NC.
Burke County, NC.
Caldwell County, NC.
Catawba County, NC.
Hinesville-Fort Stewart, GA1 .....................................................................................................................................................
Liberty County, GA.
Long County, GA.
Holland-Grand Haven, MI .........................................................................................................................................................
Ottawa County, MI.
Honolulu, HI ...............................................................................................................................................................................
Honolulu County, HI.
Hot Springs, AR ........................................................................................................................................................................
Garland County, AR.
Houma-Bayou Cane-Thibodaux, LA .........................................................................................................................................
Lafourche Parish, LA.
Terrebonne Parish, LA.
Houston-Sugar Land-Baytown, TX ...........................................................................................................................................
00:49 May 09, 2006
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09MYR2
0.9052
0.9570
0.9483
0.9104
0.9425
1.0027
0.3181
0.8929
0.9489
1.0036
0.9313
0.9088
1.1073
0.7601
0.8921
0.9198
0.9055
1.1214
0.9005
0.7894
0.9996
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
27143
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
26580 .......
26620 .......
26820 .......
26900 .......
26980 .......
27060 .......
27100 .......
27140 .......
27180 .......
27260 .......
27340 .......
27500 .......
27620 .......
mmaher on PROD1PC60 with RULES2
27740 .......
27780 .......
27860 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Austin County, TX.
Brazoria County, TX.
Chambers County, TX.
Fort Bend County, TX.
Galveston County, TX.
Harris County, TX.
Liberty County, TX.
Montgomery County, TX.
San Jacinto County, TX.
Waller County, TX.
Huntington-Ashland, WV-KY-OH ..............................................................................................................................................
Boyd County, KY.
Greenup County, KY.
Lawrence County, OH.
Cabell County, WV.
Wayne County, WV.
Huntsville, AL ............................................................................................................................................................................
Limestone County, AL.
Madison County, AL.
Idaho Falls, ID ...........................................................................................................................................................................
Bonneville County, ID.
Jefferson County, ID.
Indianapolis-Carmel, IN .............................................................................................................................................................
Boone County, IN.
Brown County, IN.
Hamilton County, IN.
Hancock County, IN.
Hendricks County, IN.
Johnson County, IN.
Marion County, IN.
Morgan County, IN.
Putnam County, IN.
Shelby County, IN.
Iowa City, IA ..............................................................................................................................................................................
Johnson County, IA.
Washington County, IA.
Ithaca, NY ..................................................................................................................................................................................
Tompkins County, NY.
Jackson, MI ...............................................................................................................................................................................
Jackson County, MI.
Jackson, MS ..............................................................................................................................................................................
Copiah County, MS.
Hinds County, MS.
Madison County, MS.
Rankin County, MS.
Simpson County, MS.
Jackson, TN ..............................................................................................................................................................................
Chester County, TN.
Madison County, TN.
Jacksonville, FL .........................................................................................................................................................................
Baker County, FL.
Clay County, FL.
Duval County, FL.
Nassau County, FL.
St. Johns County, FL.
Jacksonville, NC ........................................................................................................................................................................
Onslow County, NC.
Janesville, WI ............................................................................................................................................................................
Rock County, WI.
Jefferson City, MO ....................................................................................................................................................................
Callaway County, MO.
Cole County, MO.
Moniteau County, MO.
Osage County, MO.
Johnson City, TN .......................................................................................................................................................................
Carter County, TN.
Unicoi County, TN.
Washington County, TN.
Johnstown, PA ..........................................................................................................................................................................
Cambria County, PA.
Jonesboro, AR ...........................................................................................................................................................................
00:49 May 09, 2006
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09MYR2
0.9477
0.9146
0.9420
0.9920
0.9747
0.9793
0.9304
0.8311
0.8964
0.9290
0.8236
0.9538
0.8387
0.7937
0.8354
0.7911
27144
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
27900 .......
28020 .......
28100 .......
28140 .......
28420 .......
28660 .......
28700 .......
28740 .......
28940 .......
29020 .......
29100 .......
29140 .......
29180 .......
29340 .......
mmaher on PROD1PC60 with RULES2
29404 .......
29460 .......
29540 .......
29620 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Craighead County, AR.
Poinsett County, AR.
Joplin, MO .................................................................................................................................................................................
Jasper County, MO.
Newton County, MO.
Kalamazoo-Portage, MI .............................................................................................................................................................
Kalamazoo County, MI.
Van Buren County, MI.
Kankakee-Bradley, IL ................................................................................................................................................................
Kankakee County, IL.
Kansas City, MO-KS .................................................................................................................................................................
Franklin County, KS.
Johnson County, KS.
Leavenworth County, KS.
Linn County, KS.
Miami County, KS.
Wyandotte County, KS.
Bates County, MO.
Caldwell County, MO.
Cass County, MO.
Clay County, MO.
Clinton County, MO.
Jackson County, MO.
Lafayette County, MO.
Platte County, MO.
Ray County, MO.
Kennewick-Richland-Pasco, WA ...............................................................................................................................................
Benton County, WA.
Franklin County, WA.
Killeen-Temple-Fort Hood, TX ..................................................................................................................................................
Bell County, TX.
Coryell County, TX.
Lampasas County, TX.
Kingsport-Bristol-Bristol, TN-VA ................................................................................................................................................
Hawkins County, TN.
Sullivan County, TN.
Bristol City, VA.
Scott County, VA.
Washington County, VA.
Kingston, NY .............................................................................................................................................................................
Ulster County, NY.
Knoxville, TN .............................................................................................................................................................................
Anderson County, TN.
Blount County, TN.
Knox County, TN.
Loudon County, TN.
Union County, TN.
Kokomo, IN ................................................................................................................................................................................
Howard County, IN.
Tipton County, IN.
La Crosse, WI-MN .....................................................................................................................................................................
Houston County, MN.
La Crosse County, WI.
Lafayette, IN ..............................................................................................................................................................................
Benton County, IN.
Carroll County, IN.
Tippecanoe County, IN.
Lafayette, LA .............................................................................................................................................................................
Lafayette Parish, LA.
St. Martin Parish, LA.
Lake Charles, LA .......................................................................................................................................................................
Calcasieu Parish, LA.
Cameron Parish, LA.
Lake County-Kenosha County, IL-WI .......................................................................................................................................
Lake County, IL.
Kenosha County, WI.
Lakeland, FL ..............................................................................................................................................................................
Polk County, FL.
Lancaster, PA ............................................................................................................................................................................
Lancaster County, PA.
Lansing-East Lansing, MI ..........................................................................................................................................................
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09MYR2
0.8582
1.0381
1.0721
0.9476
1.0619
0.8526
0.8054
0.9255
0.8441
0.9508
0.9564
0.8736
0.8428
0.7833
1.0429
0.8912
0.9694
0.9794
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
27145
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
29700 .......
29740 .......
29820 .......
29940 .......
30020 .......
30140 .......
30300 .......
30340 .......
30460 .......
30620 .......
30700 .......
30780 .......
30860 .......
30980 .......
31020 .......
31084 .......
31140 .......
mmaher on PROD1PC60 with RULES2
31180 .......
31340 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Clinton County, MI.
Eaton County, MI.
Ingham County, MI.
Laredo, TX .................................................................................................................................................................................
Webb County, TX.
Las Cruces, NM ........................................................................................................................................................................
Dona Ana County, NM.
Las Vegas-Paradise, NV ...........................................................................................................................................................
Clark County, NV.
Lawrence, KS ............................................................................................................................................................................
Douglas County, KS.
Lawton, OK ................................................................................................................................................................................
Comanche County, OK.
Lebanon, PA ..............................................................................................................................................................................
Lebanon County, PA.
Lewiston, ID-WA ........................................................................................................................................................................
Nez Perce County, ID.
Asotin County, WA.
Lewiston-Auburn, ME ................................................................................................................................................................
Androscoggin County, ME.
Lexington-Fayette, KY ...............................................................................................................................................................
Bourbon County, KY.
Clark County, KY.
Fayette County, KY.
Jessamine County, KY.
Scott County, KY.
Woodford County, KY.
Lima, OH ...................................................................................................................................................................................
Allen County, OH.
Lincoln, NE ................................................................................................................................................................................
Lancaster County, NE.
Seward County, NE.
Little Rock-North Little Rock, AR ..............................................................................................................................................
Faulkner County, AR.
Grant County, AR.
Lonoke County, AR.
Perry County, AR.
Pulaski County, AR.
Saline County, AR.
Logan, UT-ID .............................................................................................................................................................................
Franklin County, ID.
Cache County, UT.
Longview, TX .............................................................................................................................................................................
Gregg County, TX.
Rusk County, TX.
Upshur County, TX.
Longview, WA ...........................................................................................................................................................................
Cowlitz County, WA.
Los Angeles-Long Beach-Glendale, CA ...................................................................................................................................
Los Angeles County, CA.
Louisville-Jefferson County, KY-IN ...........................................................................................................................................
Clark County, IN.
Floyd County, IN.
Harrison County, IN.
Washington County, IN.
Bullitt County, KY.
Henry County, KY.
Jefferson County, KY.
Meade County, KY.
Nelson County, KY.
Oldham County, KY.
Shelby County, KY.
Spencer County, KY.
Trimble County, KY.
Lubbock, TX ..............................................................................................................................................................................
Crosby County, TX.
Lubbock County, TX.
Lynchburg, VA ...........................................................................................................................................................................
Amherst County, VA.
Appomattox County, VA.
Bedford County, VA.
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09MYR2
0.8068
0.8467
1.1437
0.8537
0.7872
0.8459
0.9886
0.9331
0.9075
0.9225
1.0214
0.8747
0.9164
0.8730
0.9579
1.1783
0.9251
0.8783
0.8691
27146
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
31420 .......
31460 .......
31540 .......
31700 .......
31900 .......
32420 .......
32580 .......
32780 .......
32820 .......
32900 .......
33124 .......
33140 .......
33260 .......
33340 .......
33460 .......
mmaher on PROD1PC60 with RULES2
33540 .......
33660 .......
33700 .......
33740 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Campbell County, VA.
Bedford City, VA.
Lynchburg City, VA.
Macon, GA ................................................................................................................................................................................
Bibb County, GA.
Crawford County, GA.
Jones County, GA.
Monroe County, GA.
Twiggs County, GA.
Madera, CA ...............................................................................................................................................................................
Madera County, CA.
Madison, WI ..............................................................................................................................................................................
Columbia County, WI.
Dane County, WI.
Iowa County, WI.
Manchester-Nashua, NH ...........................................................................................................................................................
Hillsborough County, NH.
Merrimack County, NH.
Mansfield, OH ............................................................................................................................................................................
Richland County, OH.
¨
Mayaguez, PR ...........................................................................................................................................................................
Hormigueros Municipio, PR.
¨
Mayaguez Municipio, PR.
McAllen-Edinburg-Mission, TX ..................................................................................................................................................
Hidalgo County, TX.
Medford, OR ..............................................................................................................................................................................
Jackson County, OR.
Memphis, TN-MS-AR ................................................................................................................................................................
Crittenden County, AR.
DeSoto County, MS.
Marshall County, MS.
Tate County, MS.
Tunica County, MS.
Fayette County, TN.
Shelby County, TN.
Tipton County, TN.
Merced, CA ...............................................................................................................................................................................
Merced County, CA.
Miami-Miami Beach-Kendall, FL ...............................................................................................................................................
Miami-Dade County, FL.
Michigan City-La Porte, IN ........................................................................................................................................................
LaPorte County, IN.
Midland, TX ...............................................................................................................................................................................
Midland County, TX.
Milwaukee-Waukesha-West Allis, WI ........................................................................................................................................
Milwaukee County, WI.
Ozaukee County, WI.
Washington County, WI.
Waukesha County, WI.
Minneapolis-St. Paul-Bloomington, MN-WI ...............................................................................................................................
Anoka County, MN.
Carver County, MN.
Chisago County, MN.
Dakota County, MN.
Hennepin County, MN.
Isanti County, MN.
Ramsey County, MN.
Scott County, MN.
Sherburne County, MN.
Washington County, MN.
Wright County, MN.
Pierce County, WI.
St. Croix County, WI.
Missoula, MT .............................................................................................................................................................................
Missoula County, MT.
Mobile, AL .................................................................................................................................................................................
Mobile County, AL.
Modesto, CA ..............................................................................................................................................................................
Stanislaus County, CA.
Monroe, LA ................................................................................................................................................................................
Ouachita Parish, LA.
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09MYR2
0.9443
0.8713
1.0659
1.0354
0.9891
0.4020
0.8934
1.0225
0.9397
1.1109
0.9750
0.9399
0.9514
1.0146
1.1075
0.9473
0.7891
1.1885
0.8031
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
27147
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
33780 .......
33860 .......
34060 .......
34100 .......
34580 .......
34620 .......
34740 .......
34820 .......
34900 .......
34940 .......
34980 .......
35004 .......
35084 .......
35300 .......
35380 .......
mmaher on PROD1PC60 with RULES2
35644 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Union Parish, LA.
Monroe, MI ................................................................................................................................................................................
Monroe County, MI.
Montgomery, AL ........................................................................................................................................................................
Autauga County, AL.
Elmore County, AL.
Lowndes County, AL.
Montgomery County, AL.
Morgantown, WV .......................................................................................................................................................................
Monongalia County, WV.
Preston County, WV.
Morristown, TN ..........................................................................................................................................................................
Grainger County, TN.
Hamblen County, TN.
Jefferson County, TN.
Mount Vernon-Anacortes, WA ..................................................................................................................................................
Skagit County, WA.
Muncie, IN .................................................................................................................................................................................
Delaware County, IN.
Muskegon-Norton Shores, MI ...................................................................................................................................................
Muskegon County, MI.
Myrtle Beach-Conway-North Myrtle Beach, SC ........................................................................................................................
Horry County, SC.
Napa, CA ...................................................................................................................................................................................
Napa County, CA.
Naples-Marco Island, FL ...........................................................................................................................................................
Collier County, FL.
Nashville-Davidson--Murfreesboro, TN .....................................................................................................................................
Cannon County, TN.
Cheatham County, TN.
Davidson County, TN.
Dickson County, TN.
Hickman County, TN.
Macon County, TN.
Robertson County, TN.
Rutherford County, TN.
Smith County, TN.
Sumner County, TN.
Trousdale County, TN.
Williamson County, TN.
Wilson County, TN.
Nassau-Suffolk, NY ...................................................................................................................................................................
Nassau County, NY.
Suffolk County, NY.
Newark-Union, NJ-PA ...............................................................................................................................................................
Essex County, NJ.
Hunterdon County, NJ.
Morris County, NJ.
Sussex County, NJ.
Union County, NJ.
Pike County, PA.
New Haven-Milford, CT .............................................................................................................................................................
New Haven County, CT.
New Orleans-Metairie-Kenner, LA ............................................................................................................................................
Jefferson Parish, LA.
Orleans Parish, LA.
Plaquemines Parish, LA.
St. Bernard Parish, LA.
St. Charles Parish, LA.
St. John the Baptist Parish, LA.
St. Tammany Parish, LA.
New York-White Plains-Wayne, NY-NJ ....................................................................................................................................
Bergen County, NJ.
Hudson County, NJ.
Passaic County, NJ.
Bronx County, NY.
Kings County, NY.
New York County, NY.
Putnam County, NY.
Queens County, NY.
Richmond County, NY.
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09MYR2
0.9468
0.8618
0.8420
0.7961
1.0454
0.8930
0.9664
0.8934
1.2643
1.0139
0.9790
1.2719
1.1883
1.1887
0.8995
1.3188
27148
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
35660 .......
35980 .......
36084 .......
36100 .......
36140 .......
36220 .......
36260 .......
36420 .......
36500 .......
36540 .......
36740 .......
36780 .......
36980 .......
37100 .......
37340 .......
37460 .......
37620 .......
37700 .......
mmaher on PROD1PC60 with RULES2
37860 .......
37900 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Rockland County, NY.
Westchester County, NY.
Niles-Benton Harbor, MI ............................................................................................................................................................
Berrien County, MI.
Norwich-New London, CT .........................................................................................................................................................
New London County, CT.
Oakland-Fremont-Hayward, CA ................................................................................................................................................
Alameda County, CA.
Contra Costa County, CA.
Ocala, FL ...................................................................................................................................................................................
Marion County, FL.
Ocean City, NJ ..........................................................................................................................................................................
Cape May County, NJ.
Odessa, TX ...............................................................................................................................................................................
Ector County, TX.
Ogden-Clearfield, UT ................................................................................................................................................................
Davis County, UT.
Morgan County, UT.
Weber County, UT.
Oklahoma City, OK ...................................................................................................................................................................
Canadian County, OK.
Cleveland County, OK.
Grady County, OK.
Lincoln County, OK.
Logan County, OK.
McClain County, OK.
Oklahoma County, OK.
Olympia, WA .............................................................................................................................................................................
Thurston County, WA.
Omaha-Council Bluffs, NE-IA ....................................................................................................................................................
Harrison County, IA.
Mills County, IA.
Pottawattamie County, IA.
Cass County, NE.
Douglas County, NE.
Sarpy County, NE.
Saunders County, NE.
Washington County, NE.
Orlando-Kissimmee, FL .............................................................................................................................................................
Lake County, FL.
Orange County, FL.
Osceola County, FL.
Seminole County, FL.
Oshkosh-Neenah, WI ................................................................................................................................................................
Winnebago County, WI.
Owensboro, KY .........................................................................................................................................................................
Daviess County, KY.
Hancock County, KY.
McLean County, KY.
Oxnard-Thousand Oaks-Ventura, CA .......................................................................................................................................
Ventura County, CA.
Palm Bay-Melbourne-Titusville, FL ...........................................................................................................................................
Brevard County, FL.
Panama City-Lynn Haven, FL ...................................................................................................................................................
Bay County, FL.
Parkersburg-Marietta-Vienna, WV-OH ......................................................................................................................................
Washington County, OH.
Pleasants County, WV.
Wirt County, WV.
Wood County, WV.
Pascagoula, MS ........................................................................................................................................................................
George County, MS.
Jackson County, MS.
Pensacola-Ferry Pass-Brent, FL ...............................................................................................................................................
Escambia County, FL.
Santa Rosa County, FL.
Peoria, IL ...................................................................................................................................................................................
Marshall County, IL.
Peoria County, IL.
Stark County, IL.
Tazewell County, IL.
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09MYR2
0.8879
1.1345
1.5346
0.8925
1.1011
0.9884
0.9029
0.9031
1.0927
0.9560
0.9464
0.9183
0.8780
1.1622
0.9839
0.8005
0.8270
0.8156
0.8096
0.8870
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
27149
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
37964 .......
38060 .......
38220 .......
38300 .......
38340 .......
38540 .......
38660 .......
38860 .......
38900 .......
38940 .......
39100 .......
39140 .......
39300 .......
39340 .......
39380 .......
mmaher on PROD1PC60 with RULES2
39460 .......
39540 .......
39580 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Woodford County, IL.
Philadelphia, PA ........................................................................................................................................................................
Bucks County, PA.
Chester County, PA.
Delaware County, PA.
Montgomery County, PA.
Philadelphia County, PA.
Phoenix-Mesa-Scottsdale, AZ ...................................................................................................................................................
Maricopa County, AZ.
Pinal County, AZ.
Pine Bluff, AR ............................................................................................................................................................................
Cleveland County, AR.
Jefferson County, AR.
Lincoln County, AR.
Pittsburgh, PA ...........................................................................................................................................................................
Allegheny County, PA.
Armstrong County, PA.
Beaver County, PA.
Butler County, PA.
Fayette County, PA.
Washington County, PA.
Westmoreland County, PA.
Pittsfield, MA .............................................................................................................................................................................
Berkshire County, MA.
Pocatello, ID ..............................................................................................................................................................................
Bannock County, ID.
Power County, ID.
Ponce, PR .................................................................................................................................................................................
´
Juana Dıaz Municipio, PR.
Ponce Municipio, PR.
Villalba Municipio, PR.
Portland-South Portland-Biddeford, ME ....................................................................................................................................
Cumberland County, ME.
Sagadahoc County, ME.
York County, ME.
Portland-Vancouver-Beaverton, OR-WA ...................................................................................................................................
Clackamas County, OR.
Columbia County, OR.
Multnomah County, OR.
Washington County, OR.
Yamhill County, OR.
Clark County, WA.
Skamania County, WA.
Port St. Lucie-Fort Pierce, FL ...................................................................................................................................................
Martin County, FL.
St. Lucie County, FL.
Poughkeepsie-Newburgh-Middletown, NY ................................................................................................................................
Dutchess County, NY.
Orange County, NY.
Prescott, AZ ...............................................................................................................................................................................
Yavapai County, AZ.
Providence-New Bedford-Fall River, RI-MA .............................................................................................................................
Bristol County, MA.
Bristol County, RI.
Kent County, RI.
Newport County, RI.
Providence County, RI.
Washington County, RI.
Provo-Orem, UT ........................................................................................................................................................................
Juab County, UT.
Utah County, UT.
Pueblo, CO ................................................................................................................................................................................
Pueblo County, CO.
Punta Gorda, FL ........................................................................................................................................................................
Charlotte County, FL.
Racine, WI .................................................................................................................................................................................
Racine County, WI.
Raleigh-Cary, NC ......................................................................................................................................................................
Franklin County, NC.
Johnston County, NC.
Wake County, NC.
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09MYR2
1.1038
1.0127
0.8680
0.8845
1.0181
0.9351
0.4939
1.0382
1.1266
1.0123
1.0891
0.9869
1.0966
0.9500
0.8623
0.9255
0.8997
0.9691
27150
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
Urban area (constituent counties)
Wage
index
39660 .......
Rapid City, SD ...........................................................................................................................................................................
Meade County, SD.
Pennington County, SD.
Reading, PA ..............................................................................................................................................................................
Berks County, PA.
Redding, CA ..............................................................................................................................................................................
Shasta County, CA.
Reno-Sparks, NV ......................................................................................................................................................................
Storey County, NV.
Washoe County, NV.
Richmond, VA ...........................................................................................................................................................................
Amelia County, VA.
Caroline County, VA.
Charles City County, VA.
Chesterfield County, VA.
Cumberland County, VA.
Dinwiddie County, VA.
Goochland County, VA.
Hanover County, VA.
Henrico County, VA.
King and Queen County, VA.
King William County, VA.
Louisa County, VA.
New Kent County, VA.
Powhatan County, VA.
Prince George County, VA.
Sussex County, VA.
Colonial Heights City, VA.
Hopewell City, VA.
Petersburg City, VA.
Richmond City, VA.
Riverside-San Bernardino-Ontario, CA .....................................................................................................................................
Riverside County, CA.
San Bernardino County, CA.
Roanoke, VA .............................................................................................................................................................................
Botetourt County, VA.
Craig County, VA.
Franklin County, VA.
Roanoke County, VA.
Roanoke City, VA.
Salem City, VA.
Rochester, MN ..........................................................................................................................................................................
Dodge County, MN.
Olmsted County, MN.
Wabasha County, MN.
Rochester, NY ...........................................................................................................................................................................
Livingston County, NY.
Monroe County, NY.
Ontario County, NY.
Orleans County, NY.
Wayne County, NY.
Rockford, IL ...............................................................................................................................................................................
Boone County, IL.
Winnebago County, IL.
Rockingham County-Strafford County, NH ...............................................................................................................................
Rockingham County, NH.
Strafford County, NH.
Rocky Mount, NC ......................................................................................................................................................................
Edgecombe County, NC.
Nash County, NC.
Rome, GA ..................................................................................................................................................................................
Floyd County, GA.
Sacramento—Arden-Arcade—Roseville, CA ............................................................................................................................
El Dorado County, CA.
Placer County, CA.
Sacramento County, CA.
Yolo County, CA.
Saginaw-Saginaw Township North, MI .....................................................................................................................................
Saginaw County, MI.
St. Cloud, MN ............................................................................................................................................................................
Benton County, MN.
0.8987
39740 .......
39820 .......
39900 .......
40060 .......
40140 .......
40220 .......
40340 .......
40380 .......
40420 .......
40484 .......
40580 .......
40660 .......
mmaher on PROD1PC60 with RULES2
40900 .......
40980 .......
41060 .......
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00:49 May 09, 2006
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09MYR2
0.9686
1.2203
1.0982
0.9328
1.1027
0.8374
1.1131
0.9121
0.9984
1.0374
0.8915
0.9414
1.2969
0.9088
0.9965
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
27151
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
41100 .......
41140 .......
41180 .......
41420 .......
41500 .......
41540 .......
41620 .......
41660 .......
41700 .......
41740 .......
41780 .......
41884 .......
41900 .......
mmaher on PROD1PC60 with RULES2
41940 .......
41980 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Stearns County, MN.
St. George, UT ..........................................................................................................................................................................
Washington County, UT.
St. Joseph, MO-KS ...................................................................................................................................................................
Doniphan County, KS.
Andrew County, MO.
Buchanan County, MO.
DeKalb County, MO.
St. Louis, MO-IL ........................................................................................................................................................................
Bond County, IL.
Calhoun County, IL.
Clinton County, IL.
Jersey County, IL.
Macoupin County, IL.
Madison County, IL.
Monroe County, IL.
St. Clair County, IL.
Crawford County, MO.
Franklin County, MO.
Jefferson County, MO.
Lincoln County, MO.
St. Charles County, MO.
St. Louis County, MO.
Warren County, MO.
Washington County, MO.
St. Louis City, MO.
Salem, OR .................................................................................................................................................................................
Marion County, OR.
Polk County, OR.
Salinas, CA ................................................................................................................................................................................
Monterey County, CA.
Salisbury, MD ............................................................................................................................................................................
Somerset County, MD.
Wicomico County, MD.
Salt Lake City, UT .....................................................................................................................................................................
Salt Lake County, UT.
Summit County, UT.
Tooele County, UT.
San Angelo, TX .........................................................................................................................................................................
Irion County, TX.
Tom Green County, TX.
San Antonio, TX ........................................................................................................................................................................
Atascosa County, TX.
Bandera County, TX.
Bexar County, TX.
Comal County, TX.
Guadalupe County, TX.
Kendall County, TX.
Medina County, TX.
Wilson County, TX.
San Diego-Carlsbad-San Marcos, CA ......................................................................................................................................
San Diego County, CA.
Sandusky, OH ...........................................................................................................................................................................
Erie County, OH.
San Francisco-San Mateo-Redwood City, CA ..........................................................................................................................
Marin County, CA.
San Francisco County, CA.
San Mateo County, CA.
´
San German-Cabo Rojo, PR ....................................................................................................................................................
Cabo Rojo Municipio, PR.
Lajas Municipio, PR.
Sabana Grande Municipio, PR.
´
San German Municipio, PR.
San Jose-Sunnyvale-Santa Clara, CA ......................................................................................................................................
San Benito County, CA.
Santa Clara County, CA.
San Juan-Caguas-Guaynabo, PR .............................................................................................................................................
Aguas Buenas Municipio, PR.
Aibonito Municipio, PR.
Arecibo Municipio, PR.
Barceloneta Municipio, PR.
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09MYR2
0.9392
0.9519
0.8954
1.0442
1.4128
0.9064
0.9421
0.8271
0.8980
1.1413
0.9019
1.4994
0.4650
1.5099
0.4621
27152
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
42020 .......
42044 .......
42060 .......
42100 .......
42140 .......
42220 .......
42260 .......
42340 .......
42540 .......
42644 .......
42680 .......
mmaher on PROD1PC60 with RULES2
43100 .......
43300 .......
43340 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Barranquitas Municipio, PR.
´
Bayamon Municipio, PR.
Caguas Municipio, PR.
Camuy Municipio, PR.
´
Canovanas Municipio, PR.
Carolina Municipio, PR.
˜
Catano Municipio, PR.
Cayey Municipio, PR.
Ciales Municipio, PR.
Cidra Municipio, PR.
´
Comerıo Municipio, PR.
Corozal Municipio, PR.
Dorado Municipio, PR.
Florida Municipio, PR.
Guaynabo Municipio, PR.
Gurabo Municipio, PR.
Hatillo Municipio, PR.
Humacao Municipio, PR.
Juncos Municipio, PR.
Las Piedras Municipio, PR.
´
Loıza Municipio, PR.
´
Manatı Municipio, PR.
Maunabo Municipio, PR.
Morovis Municipio, PR.
Naguabo Municipio, PR.
Naranjito Municipio, PR.
Orocovis Municipio, PR.
Quebradillas Municipio, PR.
´
Rıo Grande Municipio, PR.
San Juan Municipio, PR.
San Lorenzo Municipio, PR.
Toa Alta Municipio, PR.
Toa Baja Municipio, PR.
Trujillo Alto Municipio, PR.
Vega Alta Municipio, PR.
Vega Baja Municipio, PR.
Yabucoa Municipio, PR.
San Luis Obispo-Paso Robles, CA ...........................................................................................................................................
San Luis Obispo County, CA.
Santa Ana-Anaheim-Irvine, CA .................................................................................................................................................
Orange County, CA.
Santa Barbara-Santa Maria, CA ...............................................................................................................................................
Santa Barbara County, CA.
Santa Cruz-Watsonville, CA ......................................................................................................................................................
Santa Cruz County, CA.
Santa Fe, NM ............................................................................................................................................................................
Santa Fe County, NM.
Santa Rosa-Petaluma, CA ........................................................................................................................................................
Sonoma County, CA.
Sarasota-Bradenton-Venice, FL ................................................................................................................................................
Manatee County, FL.
Sarasota County, FL.
Savannah, GA ...........................................................................................................................................................................
Bryan County, GA.
Chatham County, GA.
Effingham County, GA.
Scranton-Wilkes-Barre, PA .......................................................................................................................................................
Lackawanna County, PA.
Luzerne County, PA.
Wyoming County, PA.
Seattle-Bellevue-Everett, WA ....................................................................................................................................................
Sebastian-Vero Beach, FL ........................................................................................................................................................
Indian River County, FL.
Sheboygan, WI ..........................................................................................................................................................................
Sheboygan County, WI.
Sherman-Denison, TX ...............................................................................................................................................................
Grayson County, TX.
Shreveport-Bossier City, LA ......................................................................................................................................................
Bossier Parish, LA.
Caddo Parish, LA.
De Soto Parish, LA.
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E:\FR\FM\09MYR2.SGM
09MYR2
1.1349
1.1559
1.1694
1.5166
1.0920
1.3493
0.9639
0.9461
0.8540
1.1577
0.9434
0.8911
0.9507
0.8760
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
27153
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
Urban area (constituent counties)
Wage
index
43580 .......
Sioux City, IA-NE-SD ................................................................................................................................................................
Woodbury County, IA.
Dakota County, NE.
Dixon County, NE.
Union County, SD.
Sioux Falls, SD ..........................................................................................................................................................................
Lincoln County, SD.
McCook County, SD.
Minnehaha County, SD.
Turner County, SD.
South Bend-Mishawaka, IN-MI .................................................................................................................................................
St. Joseph County, IN.
Cass County, MI.
Spartanburg, SC ........................................................................................................................................................................
Spartanburg County, SC.
Spokane, WA ............................................................................................................................................................................
Spokane County, WA.
Springfield, IL ............................................................................................................................................................................
Menard County, IL.
Sangamon County, IL.
Springfield, MA ..........................................................................................................................................................................
Franklin County, MA.
Hampden County, MA.
Hampshire County, MA.
Springfield, MO ..........................................................................................................................................................................
Christian County, MO.
Dallas County, MO.
Greene County, MO.
Polk County, MO.
Webster County, MO.
Springfield, OH ..........................................................................................................................................................................
Clark County, OH.
State College, PA ......................................................................................................................................................................
Centre County, PA.
Stockton, CA .............................................................................................................................................................................
San Joaquin County, CA.
Sumter, SC ................................................................................................................................................................................
Sumter County, SC.
Syracuse, NY ............................................................................................................................................................................
Madison County, NY.
Onondaga County, NY.
Oswego County, NY.
Tacoma, WA ..............................................................................................................................................................................
Pierce County, WA.
Tallahassee, FL .........................................................................................................................................................................
Gadsden County, FL.
Jefferson County, FL.
Leon County, FL.
Wakulla County, FL.
Tampa-St. Petersburg-Clearwater, FL ......................................................................................................................................
Hernando County, FL.
Hillsborough County, FL.
Pasco County, FL.
Pinellas County, FL.
Terre Haute, IN .........................................................................................................................................................................
Clay County, IN.
Sullivan County, IN.
Vermillion County, IN.
Vigo County, IN.
Texarkana, TX-Texarkana, AR .................................................................................................................................................
Miller County, AR.
Bowie County, TX.
Toledo, OH ................................................................................................................................................................................
Fulton County, OH.
Lucas County, OH.
Ottawa County, OH.
Wood County, OH.
Topeka, KS ................................................................................................................................................................................
Jackson County, KS.
Jefferson County, KS.
Osage County, KS.
0.9381
43620 .......
43780 .......
43900 .......
44060 .......
44100 .......
44140 .......
44180 .......
44220 .......
44300 .......
44700 .......
44940 .......
45060 .......
45104 .......
45220 .......
45300 .......
45460 .......
45500 .......
mmaher on PROD1PC60 with RULES2
45780 .......
45820 .......
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09MYR2
0.9635
0.9788
0.9172
1.0905
0.8792
1.0248
0.8237
0.8396
0.8356
1.1307
0.8377
0.9574
1.0742
0.8688
0.9233
0.8304
0.8283
0.9574
0.8920
27154
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
45940 .......
46060 .......
46140 .......
46220 .......
46340 .......
46540 .......
46660 .......
46700 .......
47020 .......
47220 .......
47260 .......
47300 .......
47380 .......
47580 .......
mmaher on PROD1PC60 with RULES2
47644 .......
47894 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Shawnee County, KS.
Wabaunsee County, KS.
Trenton-Ewing, NJ .....................................................................................................................................................................
Mercer County, NJ.
Tucson, AZ ................................................................................................................................................................................
Pima County, AZ.
Tulsa, OK ..................................................................................................................................................................................
Creek County, OK.
Okmulgee County, OK.
Osage County, OK.
Pawnee County, OK.
Rogers County, OK.
Tulsa County, OK.
Wagoner County, OK.
Tuscaloosa, AL ..........................................................................................................................................................................
Greene County, AL.
Hale County, AL.
Tuscaloosa County, AL.
Tyler, TX ....................................................................................................................................................................................
Smith County, TX.
Utica-Rome, NY ........................................................................................................................................................................
Herkimer County, NY.
Oneida County, NY.
Valdosta, GA .............................................................................................................................................................................
Brooks County, GA.
Echols County, GA.
Lanier County, GA.
Lowndes County, GA.
Vallejo-Fairfield, CA ...................................................................................................................................................................
Solano County, CA.
Victoria, TX ................................................................................................................................................................................
Calhoun County, TX.
Goliad County, TX.
Victoria County, TX.
Vineland-Millville-Bridgeton, NJ .................................................................................................................................................
Cumberland County, NJ.
Virginia Beach-Norfolk-Newport News, VA-NC ........................................................................................................................
Currituck County, NC.
Gloucester County, VA.
Isle of Wight County, VA.
James City County, VA.
Mathews County, VA.
Surry County, VA.
York County, VA.
Chesapeake City, VA.
Hampton City, VA.
Newport News City, VA.
Norfolk City, VA.
Poquoson City, VA.
Portsmouth City, VA.
Suffolk City, VA.
Virginia Beach City, VA.
Williamsburg City, VA.
Visalia-Porterville, CA ................................................................................................................................................................
Tulare County, CA.
Waco, TX ...................................................................................................................................................................................
McLennan County, TX.
Warner Robins, GA ...................................................................................................................................................................
Houston County, GA.
Warren-Troy-Farmington Hills, MI .............................................................................................................................................
Lapeer County, MI.
Livingston County, MI.
Macomb County, MI.
Oakland County, MI.
St. Clair County, MI.
Washington-Arlington-Alexandria, DC-VA-MD-WV ...................................................................................................................
District of Columbia, DC.
Calvert County, MD.
Charles County, MD.
Prince George’s County, MD.
Arlington County, VA.
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09MYR2
1.0834
0.9007
0.8543
0.8645
0.9168
0.8358
0.8866
1.4936
0.8160
0.9827
0.8799
1.0123
0.8518
0.8645
0.9871
1.0926
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
27155
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
47940 .......
48140 .......
48260 .......
48300 .......
48424 .......
48540 .......
48620 .......
48660 .......
48700 .......
48864 .......
48900 .......
49020 .......
49180 .......
49340 .......
mmaher on PROD1PC60 with RULES2
49420 .......
49500 .......
VerDate Aug<31>2005
Wage
index
Urban area (constituent counties)
Clarke County, VA.
Fairfax County, VA.
Fauquier County, VA.
Loudoun County, VA.
Prince William County, VA.
Spotsylvania County, VA.
Stafford County, VA.
Warren County, VA.
Alexandria City, VA.
Fairfax City, VA.
Falls Church City, VA.
Fredericksburg City, VA.
Manassas City, VA.
Manassas Park City, VA.
Jefferson County, WV.
Waterloo-Cedar Falls, IA ...........................................................................................................................................................
Black Hawk County, IA.
Bremer County, IA.
Grundy County, IA.
Wausau, WI ...............................................................................................................................................................................
Marathon County, WI.
Weirton-Steubenville, WV-OH ...................................................................................................................................................
Jefferson County, OH.
Brooke County, WV.
Hancock County, WV.
Wenatchee, WA ........................................................................................................................................................................
Chelan County, WA.
Douglas County, WA.
West Palm Beach-Boca Raton-Boynton Beach, FL .................................................................................................................
Palm Beach County, FL.
Wheeling, WV-OH .....................................................................................................................................................................
Belmont County, OH.
Marshall County, WV.
Ohio County, WV.
Wichita, KS ................................................................................................................................................................................
Butler County, KS.
Harvey County, KS.
Sedgwick County, KS.
Sumner County, KS.
Wichita Falls, TX .......................................................................................................................................................................
Archer County, TX.
Clay County, TX.
Wichita County, TX.
Williamsport, PA ........................................................................................................................................................................
Lycoming County, PA.
Wilmington, DE-MD-NJ .............................................................................................................................................................
New Castle County, DE.
Cecil County, MD.
Salem County, NJ.
Wilmington, NC .........................................................................................................................................................................
Brunswick County, NC.
New Hanover County, NC.
Pender County, NC.
Winchester, VA-WV ...................................................................................................................................................................
Frederick County, VA.
Winchester City, VA.
Hampshire County, WV.
Winston-Salem, NC ...................................................................................................................................................................
Davie County, NC.
Forsyth County, NC.
Stokes County, NC.
Yadkin County, NC.
Worcester, MA ...........................................................................................................................................................................
Worcester County, MA.
Yakima, WA ...............................................................................................................................................................................
Yakima County, WA.
Yauco, PR .................................................................................................................................................................................
˘
Gua≤nica Municipio, PR.
Guayanilla Municipio, PR.
˜
Penuelas Municipio, PR.
Yauco Municipio, PR.
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E:\FR\FM\09MYR2.SGM
09MYR2
0.8557
0.9590
0.7819
1.0070
1.0067
0.7161
0.9153
0.8285
0.8364
1.0471
0.9582
1.0214
0.8944
1.1028
1.0155
0.4408
27156
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and Regulations
TABLE 1.—PROPOSED WAGE INDEX FOR URBAN AREAS BASED ON CBSA LABOR MARKET AREAS—Continued
CBSA
code
Urban area (constituent counties)
Wage
index
49620 .......
York-Hanover, PA .....................................................................................................................................................................
York County, PA.
Youngstown-Warren-Boardman, OH-PA ..................................................................................................................................
Mahoning County, OH.
Trumbull County, OH.
Mercer County, PA.
Yuba City, CA ............................................................................................................................................................................
Sutter County, CA.
Yuba County, CA.
Yuma, AZ ..................................................................................................................................................................................
Yuma County, AZ.
0.9347
49660 .......
49700 .......
49740 .......
0.8603
1.0921
0.9126
1 At this time, there are no hospitals located in this urban area on which to base a wage index. Therefore, the urban wage index value is based
on the average wage index for all urban areas within the State.
TABLE 2.—PROPOSED WAGE INDEX
BASED ON CBSA LABOR MARKET
AREAS FOR RURAL AREAS
CBSA
code
mmaher on PROD1PC60 with RULES2
01
02
03
04
05
06
07
08
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
Wage
Index
Nonurban
Alabama ..........................
Alaska .............................
Arizona ............................
Arkansas .........................
California .........................
Colorado .........................
Connecticut .....................
Delaware .........................
Florida .............................
Georgia ...........................
Hawaii .............................
Idaho ...............................
Illinois ..............................
Indiana ............................
Iowa ................................
Kansas ............................
Kentucky .........................
Louisiana ........................
Maine ..............................
Maryland .........................
Massachusetts 1 ..............
Michigan .........................
Minnesota .......................
Mississippi ......................
Missouri ..........................
Montana ..........................
Nebraska ........................
Nevada ...........................
New Hampshire ..............
New Jersey 1 ...................
VerDate Aug<31>2005
00:49 May 09, 2006
0.7446
1.1977
0.8768
0.7466
1.1054
0.9380
1.1730
0.9579
0.8568
0.7662
1.0551
0.8037
0.8271
0.8624
0.8509
0.8035
0.7766
0.7411
0.8843
0.9353
1.0216
0.8895
0.9132
0.7674
0.7900
0.8762
0.8657
0.9065
1.0817
............
Jkt 208001
TABLE 2.—PROPOSED WAGE INDEX
BASED ON CBSA LABOR MARKET
AREAS FOR RURAL AREAS—Continued
CBSA
code
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
50
51
52
53
PO 00000
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
........
TABLE 2.—PROPOSED WAGE INDEX
BASED ON CBSA LABOR MARKET
AREAS FOR RURAL AREAS—Continued
Nonurban
Wage
Index
CBSA
code
Nonurban
Wage
Index
New Mexico ....................
New York ........................
North Carolina ................
North Dakota ..................
Ohio ................................
Oklahoma .......................
Oregon ............................
Pennsylvania ..................
Puerto Rico 1 ...................
Rhode Island 1 ................
South Carolina ................
South Dakota ..................
Tennessee ......................
Texas ..............................
Utah ................................
Vermont ..........................
Virginia ............................
Washington .....................
West Virginia ..................
Wisconsin .......................
Wyoming .........................
0.8635
0.8154
0.8540
0.7261
0.8826
0.7581
0.9826
0.8291
0.4047
............
0.8638
0.8560
0.7895
0.8003
0.8118
0.9830
0.8013
1.0510
0.7717
0.9509
0.9257
65 ........
Guam ..............................
0.9611
Frm 00118
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1 All
counties within the State are classified
as urban, with the exception of Massachusetts
and Puerto Rico. Massachusetts and Puerto
Rico have areas designated as rural, however,
no short-term, acute care hospitals are located
in the area(s) for FY 2006. Because more recent data is not available for those areas, we
are using last year’s wage index value.
[FR Doc. 06–4202 Filed 5–1–06; 4:00 pm]
BILLING CODE 4120–01–P
E:\FR\FM\09MYR2.SGM
09MYR2
]]>Agencies
[Federal Register Volume 71, Number 89 (Tuesday, May 9, 2006)]
[Rules and Regulations]
[Pages 27040-27156]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 06-4202]
[[Page 27039]]
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Part II
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 412 and 424
Medicare Program; Inpatient Psychiatric Facilities Prospective Payment
System Payment Update for Rate Year Beginning July 1, 2006 (RY 2007);
Final Rule
Federal Register / Vol. 71, No. 89 / Tuesday, May 9, 2006 / Rules and
Regulations
[[Page 27040]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 412 and 424
[CMS-1306-F]
RIN 0938-AN82
Medicare Program; Inpatient Psychiatric Facilities Prospective
Payment System Payment Update for Rate Year Beginning July 1, 2006 (RY
2007)
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
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SUMMARY: This final rule updates the prospective payment rates for
Medicare inpatient hospital services provided by inpatient psychiatric
facilities (IPFs). These changes are applicable to IPF discharges
occurring during the rate year beginning July 1, 2006 through June 30,
2007. In addition, we are adopting the new Office of Management and
Budget (OMB) labor market area definitions for the purpose of
geographic classification and the wage index. We are also making
revisions to existing policies and implementing new polices.
DATES: Effective Date: These regulations are effective on July 1, 2006.
FOR FURTHER INFORMATION CONTACT: Dorothy Colbert, (410) 786-4533 for
general information. Mary Lee Seifert, (410) 786-0030 for information
regarding the market basket and labor-related share. Theresa Bean,
(410) 786-2287 for information regarding the regulatory impact
analysis. Matthew Quarrick, (410) 786-9867 for information on the wage
index.
SUPPLEMENTARY INFORMATION:
Table of Contents
To assist readers in referencing sections contained in this
document, we are providing the following table of contents.
I. Background
A. General and Legislative History
B. Overview of the Establishment of the IPF PPS
C. Applicability of the IPF PPS
II. Overview for Updating the IPF PPS
A. Requirements for Updating the IPF PPS
B. Transition Period for Implementation of the IPF PPS
III. Provisions of the Proposed Regulation
IV. Analysis of and Responses to Public Comments
V. Updates to the IPF PPS for RY Beginning July 1, 2006
A. Calculation of the Average Per Diem Cost
B. Determining the Standardized Budget-Neutral Federal Per Diem
Base Rate
1. Standardization of the Federal Per Diem Base Rate
2. Calculation of the Budget Neutrality Adjustment
a. Outlier Adjustment
b. Stop-Loss Provision Adjustment
c. Behavioral Offset
3. Revision of Standardization Factor
C. Update of the Federal Per Diem Base Rate
1. Market Basket for IPFs Reimbursed Under the IPF PPS
a. Market Basket Index for IPF PPS
b. Overview of the RPL Market Basket
2. Methodology for Operating Portion of the RPL Market Basket
3. Methodology for Capital Portion of the RPL Market Basket
4. Labor-Related Share
VI. Update of the IPF PPS Adjustment Factors
A. Overview of the IPF PPS Adjustment Factors
B. Patient-Level Adjustments
1. Adjustment for DRG Assignment
2. Payment for Comorbid Conditions
3. Patient Age Adjustments
4. Variable Per Diem Adjustments
C. Facility-Level Adjustments
1. Wage Index Adjustment
a. Revisions of IPF PPS Geographic Classifications
b. Current IPF PPS Labor Market Areas Based on MSAs
c. Core-Based Statistical Areas
d. Revision of the IPF PPS Labor Market Areas
i. New England MSAs
ii. Metropolitan Divisions
iii. Micropolitan Areas
e. Implementation of the Revised Labor Market Areas Under the
IPF PPS
f. Wage Index Budget Neutrality
2. Adjustment for Rural Location
3. Teaching Adjustment
4. Cost of Living Adjustment for IPFs Located in Alaska and
Hawaii
5. Adjustment for IPFs With a Qualifying Emergency Department
(ED)
a. New Source of Admission Code To Implement the ED Adjustment
b. Applicability of the ED Adjustment to IPFs in Critical Access
Hospitals
D. Other Payment Adjustments and Policies
1. Outlier Payments
a. Update to the Outlier Fixed Dollar Loss Threshold Amount
b. Statistical Accuracy of Cost-to-Charge Ratios
2. Stop-Loss Provision
3. Patients Who Receive Electroconvulsive Therapy (ECT)
4. Physician Certification and Recertification Requirements
5. Provision of Therapeutic Recreation in IPFs
6. Same Day Transfers
VII. Miscellaneous Public Comments Within the Scope of the Proposed
Rule
VIII. Provisions of the Final Rule
IX. Collection of Information Requirements
X. Regulatory Impact Analysis
Acronyms
Because of the many terms to which we refer by acronym in this
final rule, we are listing the acronyms used and their corresponding
terms in alphabetical order below:
BBA Balanced Budget Act of 1997, (Pub. L. 105-33)
BBRA Medicare, Medicaid and SCHIP [State Children's Health Insurance
Program] Balanced Budget Refinement Act of 1999, (Pub. L. 106-113)
BIPA Medicare, Medicaid, and SCHIP [State Children's Health
Insurance Program] Benefits Improvement and Protection Act of 2000,
(Pub. L. 106-554)
CBSA Core-Based Statistical Area
CCR Cost-to-charge ratio
CMS Centers for Medicare & Medicaid Services
CMSA Consolidated Metropolitan Statistical Area
DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders
Fourth Edition--Text Revision
DRGs Diagnosis-related groups
FY Federal fiscal year
HCRIS Hospital Cost Report Information System
ICD-9-CM International Classification of Diseases, 9th Revision,
Clinical Modification
IPFs Inpatient psychiatric facilities
IRFs Inpatient rehabilitation facilities
LTCHs Long-term care hospitals
MedPAR Medicare provider analysis and review file
MMA Medicare Prescription Drug, Improvement and Modernization Act of
2003, (Pub. L. 108-173)
MSA Metropolitan Statistical Area
NECMA New England County Metropolitan Area
OMB Office of Management and Budget
PIP Periodic Interim Payments
RY Rate Year (July 1 through June 30)
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, (Pub. L. 97-
248)
I. Background
A. General and Legislative History
The Congress directed implementation of a prospective payment
system (PPS) for acute care hospitals with the enactment of Pub. L. 98-
21. Section 601 of the Social Security Amendments of 1983 (Pub. L. 98-
21) added a new section 1886(d) to the Social Security Act (the Act)
that replaced the reasonable cost-based payment system for most
hospital inpatient services with a PPS.
Although most hospital inpatient services became subject to the
PPS, certain hospitals, including IPFs, inpatient rehabilitation
facilities (IRFs), long term care hospitals (LTCHs), and children's
hospitals were excluded from the PPS for acute care hospitals. These
hospitals and units were paid their reasonable costs for inpatient
services,
[[Page 27041]]
subject to a per discharge limitation or target amount under the
authority of the Tax Equity and Fiscal Responsibility Act of 1982
(TEFRA), Pub. L. 97-248. The regulations implementing the TEFRA
(reasonable cost-based) payment provisions are located at 42 CFR part
413. Cancer hospitals were added to the list of excluded hospitals by
section 6004(a) of the Omnibus Budget Reconciliation Act of 1989, (Pub.
L. 101-239).
The Congress enacted various provisions in the Balanced Budget Act
of 1997 (BBA) (Pub. L. 105-33), the Medicare, Medicaid, and SCHIP
(State Children's Health Insurance Program) Balanced Budget Refinement
Act of 1999 (BBRA) (Pub. L. 106-113), and the Medicare, Medicaid, and
SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Pub. L.
106-554) to replace the reasonable cost-based method of reimbursement
with a PPS for IRFs, LTCHs, and IPFs. Section 124 of the BBRA required
implementation of the IPF PPS.
Section 124 of the BBRA mandated that the Secretary--(1) Develop a
per diem PPS for inpatient hospital services furnished in psychiatric
hospitals and psychiatric units; (2) include in the PPS an adequate
patient classification system that reflects the differences in patient
resource use and costs among psychiatric hospitals and psychiatric
units; (3) maintain budget neutrality; (4) permit the Secretary to
require psychiatric hospitals and psychiatric units to submit
information necessary for the development of the PPS; and (5) submit a
report to the Congress describing the development of the PPS. Section
124 of the BBRA also required that the IPF PPS be implemented for cost
reporting periods beginning on or after October 1, 2002.
Section 405(g)(2) of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (MMA) (Pub. L. 108-173) extended the IPF
PPS to distinct part psychiatric units of critical access hospitals
(CAHs).
To implement these provisions, the following were published: a
proposed rule in the Federal Register on November 28, 2003 (68 FR
66920); a final rule on November 15, 2004 (69 FR 66922); and a
correction notice to the final rule on April 1, 2005 (70 FR 16724). For
more detail, see the program memorandum Web site, https://
www.cms.hhs.gov/transmittals/01_overview.asp.
B. Overview of the Establishment of the IPF PPS
The November 2004 IPF PPS final rule established regulations for
the IPF PPS under 42 CFR 412, subpart N.
The IPF PPS established the Federal per diem base rate for each
patient day in an IPF derived from the national average daily routine
operating, ancillary, and capital costs in IPFs in FY 2002. The average
per diem cost was updated to the midpoint of the first year under the
IPF PPS, standardized to account for the overall positive effects of
the IPF PPS payment adjustments, and adjusted for budget neutrality.
The Federal per diem payment under the IPF PPS is comprised of the
Federal per diem base rate described above and certain patient and
facility payment adjustments that were found in the regression analysis
to be associated with statistically significant per diem cost
differences (see 69 FR 66933 through 66936 for a description of the
regression analysis). The patient-level adjustments include age, DRG
assignment, comorbidities, and variable per diem adjustments to reflect
the higher cost incurred in the early days of a psychiatric stay.
Facility-level adjustments include adjustments for the IPF's wage
index, rural location, teaching status, a cost of living adjustment for
IPFs located in Alaska and Hawaii, and presence of a qualifying
emergency department (ED). The IPF PPS provides additional payments for
outlier cases, stop-loss protection which is applicable only during the
IPF PPS transition period, includes special payment provisions for
interrupted stays, and a per treatment adjustment for patients who
undergo electroconvulsive therapy (ECT). We refer readers to the
November 2004 IPF PPS final rule for a comprehensive discussion of the
research and data that supported the establishment of the IPF PPS.
We established a CMS Web site that contains useful information
regarding the IPF PPS including the proposed rules, final rules, and
the correction notices. The Web site URL is https://www.cms.hhs.gov/
InpatientPsychFacilPPS/ and may be accessed to download or view
publications and other information pertinent to the IPF PPS.
C. Applicability of the IPF PPS
The IPF PPS is applicable to freestanding psychiatric hospitals,
including government-operated psychiatric hospitals, and distinct part
psychiatric units of acute care hospitals and CAHs.
The regulations at Sec. 412.402 define an IPF as a hospital that
meets the requirements specified in Sec. 412.22, Sec. 412.23(a),
Sec. 482.60, Sec. 482.61, and Sec. 482.62, and units that meet the
requirements specified in Sec. 412.22, Sec. 412.25, and Sec. 412.27.
However, the following hospitals are paid under a special payment
provision, as described in Sec. 412.22(c) and, therefore, are not
subject to the IPF PPS rules:
Veterans Administration hospitals.
Hospitals that are reimbursed under State cost control
systems approved under 42 CFR part 403.
Hospitals that are reimbursed in accordance with
demonstration projects specified in section 402(a) of Pub. L. 90-248
(42 U.S.C. 1395b-1) or section 222(a) of Pub. L. 92-603 (42 U.S.C.
1395b-1(note)).
Non-participating hospitals furnishing emergency services
to Medicare beneficiaries.
II. Overview for Updating the IPF PPS
A. Requirements for Updating the IPF PPS
Section 124 of the BBRA does not specify an update strategy for the
IPF PPS and is broadly written to give the Secretary discretion in
establishing an update methodology. Therefore, we reviewed the update
approach used in other hospital PPSs (specifically, the IRF and LTCH
PPS update methodologies). As a result of this analysis, we stated in
the November 2004 IPF PPS final rule (69 FR 66966) that we would
implement the IPF PPS using the following update strategy--(1)
Calculate the final Federal per diem base rate to be budget neutral for
the 18-month period (that is, January 1, 2005 through June 30, 2006);
(2) use a July 1 through June 30 annual update cycle; and (3) allow the
IPF PPS first update to be effective for discharges July 1, 2006
through June 30, 2007.
As explained in the November 2004 IPF PPS final rule, we believe it
is important to delay updating the adjustment factors derived from the
regression analysis until we have IPF PPS data that include as much
information as possible regarding the patient-level characteristics of
the population that each IPF serves. For this reason, we do not intend
to update the regression analysis and recalculate the Federal per diem
base rate until we analyze IPF PPS data (that is, no earlier than FY
2008). Until that analysis is complete, we stated our intention to
publish a notice in the Federal Register each spring to update the IPF
PPS as specified in Sec. 412.428.
[[Page 27042]]
However, since the implementation of the IPF PPS, a new market
basket index was announced in the August 2005 IPPS final rule. We
believe that this new market basket should be implemented in the IPF
PPS as well in order to update the system using the best data
available. Therefore, rather than publish a notice to update the IPF
PPS in 2006, we published a proposed rule in the Federal Register on
January 23, 2006 (71 FR 3616) to allow interested parties an
opportunity to comment on the proposed changes.
Updates to the IPF PPS as specified in Sec. 412.428 include:
A description of the methodology and data used to
calculate the updated Federal per diem base payment amount.
The rate of increase factor as described in Sec.
412.424(a)(2)(iii), which is based on the excluded hospital with
capital market basket under the update methodology of 1886(b)(3)(B)(ii)
of the Act for each year.
The best available hospital wage index and information
regarding whether an adjustment to the Federal per diem base rate is
needed to maintain budget neutrality.
Updates to the fixed dollar loss amount in order to
maintain the appropriate outlier percentage.
Describe the ICD-9-CM coding and DRG classification
changes discussed in the annual update to the hospital IPPS
regulations.
Update the ECT adjustment by a factor specified by CMS.
B. Transition Period for Implementation of the IPF PPS
In the November 2004 IPF PPS final rule, we established Sec.
412.426 to provide for a 3-year transition period from reasonable cost-
based reimbursement to full prospective payment for IPFs. New IPFs, as
defined in Sec. 412.426(c), are paid 100 percent of the Federal per
diem rate. However, for those IPFs that are transitioning to the new
system, during the 3-year period as specified in the November 2004 IPF
PPS final rule, payment is based on an increasing percentage of the PPS
payment and a decreasing percentage of each IPF's facility-specific
TEFRA reimbursement rate. The blend percentages are as follows:
Table 1.--IPF PPS Final Rule Transition Blend Factors
------------------------------------------------------------------------
Cost reporting IPF PPS
Transition year periods beginning TEFRA rate Federal rate
on or after percentage percentage
------------------------------------------------------------------------
1................... January 1, 2005... 75 25
2................... January 1, 2006... 50 50
3................... January 1, 2007... 25 75
January 1, 2008... 0 100
------------------------------------------------------------------------
Changes to the blend percentages occur at the beginning of an IPF's
cost reporting period. We note that we are currently in year two of the
transition period. As a result, for discharges occurring during IPF
cost reporting periods beginning in calendar year (CY) 2006, IPFs would
receive a blended payment consisting of 50 percent of the facility-
specific TEFRA payment and 50 percent of the IPF PPS payment amount.
However, regardless of when an IPF's cost reporting year begins, the
payment update will be effective for discharges occurring on or after
July 1, 2006 through June 30, 2007. We note that we are not making any
changes to the transition approach established in the November 2004 IPF
PPS final rule.
III. Provisions of the Proposed Regulation
In January 2006, we published a proposed rule that appeared in the
Federal Register at (71 FR 3616), and on February 24, 2006, a
correction notice appeared in the Federal Register (71 FR 9505) to
correct technical errors in the proposed rule and to extend the comment
period for our policy concerning Electroconvulsive Therapy (ECT). The
January 2006 proposed rule (hereinafter referred to as the Rate Year
(RY) 2007 proposed rule) set forth the proposed annual update to the
proposed prospective payment for IPFs for discharges occurring during
the RY beginning July 1, 2006. As part of the update, we proposed to
incorporate OMB's revised definitions for MSAs and its new definitions
of Micropolitan Statistical Areas and Core-Based Statistical Areas
(CBSAs). In addition, we proposed the following----
Update payments for IPFs using a market basket reflecting
the operating and capital cost structures of IRFs, IPFs, and LTCHs.
Develop cost weights for benefits, contract labor, and
blood and blood products using the FY 2002-based IPPS market basket.
Provide weights and proxies for the FY 2002-based RPL
market basket.
Indicate the methodology for the capital portion of the FY
2002-based RPL market basket.
Update the outlier threshold amount to maintain total
estimated outlier payments at 2 percent of total estimated payments.
Use source code ``D'' to identify IPF patients who have
been transferred to the IPF from the same hospital or CAH.
Retain the 17 percent adjustment for IPFs located in rural
areas, the 1.31 adjustment for IPFs with a qualifying ED, the 0.5150
teaching adjustment to the Federal per diem base rate, and the DRG
adjustment factors currently being paid to IPFs for discharges
occurring during RY 2007.
Update the payment rate for ECT.
Update the DRG listing and comorbidity categories to
reflect the ICD-9-CM revisions effective October 1, 2005.
In addition to addressing these issues in the proposed rule for RY
2007, we also proposed making the following specific revisions to the
existing text of the regulations. We proposed to make conforming
changes in 42 CFR parts 412 and 424, as discussed throughout this
preamble.
In Sec. 412.27, we proposed to revise paragraph (b) to remove the
reference to recreational therapy.
In Sec. 412.402, we proposed to revise the heading of ``Fixed
dollar loss-threshold'' to ``Fixed dollar loss threshold amount'' and
revise the definitions of ``Fixed dollar loss threshold amount'',
``Qualifying emergency department'', ``Rural area'' and ``Urban area.''
For consistency, we proposed to make conforming changes to these
terminologies wherever they appear in the regulations text.
In Sec. 412.424, we proposed to add paragraph (d)(1)(iii)(E) to
clarify that the teaching adjustment is made on a claim basis as an
interim payment and the final payment in full is made during the final
settlement of the cost report. For clarity, we also proposed to revise
paragraph (d)(2) introductory text. The current language in (d)(2)(iii)
would become the introductory text for paragraph (d)(2) and paragraph
[[Page 27043]]
(d)(2)(iii) would be removed. In addition, we proposed to revise Sec.
412.424(d)(3)(i)(A) to clarify that an outlier payment is made if an
IPF's estimated total cost for a case exceeds a fixed dollar loss
threshold amount plus the Federal payment amount for the case.
In Sec. 412.426(a), we proposed to correct the cross reference to
the Federal per diem payment amount. We incorrectly referenced the
Federal per diem base rate as Sec. 412.424(c). The correct cross
reference to the Federal per diem payment amount is Sec. 412.424(d).
In Sec. 412.428, we proposed to revise paragraph (b) to specify
that for discharges occurring on or after January 1, 2005 but before
July 1, 2006 the rate of increase factor for the Federal portion of the
payment is based on the FY 1997-based excluded hospital with capital
market basket and for discharges occurring on or after July 1, 2006,
the rate of increase factor for the Federal portion of the payment is
based on the FY 2002-based Rehabilitation, Psychiatric, and Long-Term
Care (RPL) market basket.
In addition, we proposed to add a new paragraph (g) to state that
we would update the national urban and rural cost to charge ratio
medians and ceilings. Paragraph (1) through (3) would specify the types
of IPFs in which to apply the national cost to charge ratio.
Furthermore, we proposed to add a new paragraph (h) to update the cost
of living adjustment factors, if appropriate.
In Sec. 424.14, we proposed to revise the title to read,
``Requirements for inpatient services of inpatient psychiatric
facilities,'' to ensure consistency in compliance with the requirements
among all IPFs. We also proposed to add a new paragraph (c)(3) to
clarify for purposes of payment under the IPF PPS, that the physician
would also recertify that the patient continues to need, on a daily
basis, active inpatient psychiatric care (furnished directly by or
requiring the supervision of inpatient psychiatric facility personnel)
or other professional services that can only be provided on an
inpatient basis.
In addition, we proposed to revise paragraph (d)(2) to state that
the first recertification is required as of the 12th day of
hospitalization. Subsequent recertifications would be required at
intervals established by the hospital's utilization review committee
(on a case-by-case basis if it so chooses), but no less frequently than
every 30 days.
IV. Analysis of and Responses to Public Comments
We provided for a 60 day comment period on the RY 2007 proposed
rule. The correction notice to correct technical errors that appeared
in the RY 2007 proposed rule appeared in the Federal Register on
February 24, 2006. The correction notice extended the public comment
period on the ECT policy, to allow the public an opportunity to comment
on the corrected policy.
We received approximately 32 public comments from hospital
associations, psychiatric hospitals and units, and acute care
hospitals. In general, commenters expressed some concern about a few of
our proposals and suggested that we wait to implement specific updates
to the IPF PPS until we can analyze 2005 claims data. A few commenters
requested that we provide the provider impact files that are comparable
to the files prepared for the Inpatient Prospective Payment System
(IPPS). In addition, several commenters requested that we retain the
rural adjustment or provide a 3-year hold harmless provision for IPFs
that would lose their rural adjustment if we adopted the proposed CBSA
definitions. Several commenters supported the proposed changes to the
IPF PPS.
Summaries of the public comments received and our responses to
those comments are provided in the appropriate sections in the preamble
of this final rule.
V. Updates to the IPF PPS for RY Beginning July 1, 2006
The IPF PPS is based on a standardized Federal per diem base rate
calculated from IPF average per diem costs and adjusted for budget-
neutrality in the implementation year. The Federal per diem base rate
is used as the standard payment per day under the IPF PPS and is
adjusted by the applicable wage index factor and the patient-level and
facility-level adjustments that are applicable to the IPF stay.
The following is an explanation of how we calculated the Federal
per diem base rate and the standardization and budget neutrality
factors as described in the November 2004 IPF PPS final rule.
A. Calculation of the Average Per Diem Cost
As indicated in the November 2004 IPF PPS final rule, to calculate
the Federal per diem base rate, we estimated the average cost per day
for-- (1) routine services from FY 2002 cost reports (supplemented with
FY 2001 cost reports if the FY 2002 cost report was missing); and (2)
ancillary services using data from the FY 2002 Medicare claims and
corresponding data from facility cost reports.
For routine services, the per diem operating and capital costs were
used to develop the average per diem cost amount. The per diem routine
costs were obtained from each facility's Medicare cost report. To
estimate the costs for routine services included in the Federal per
diem base rate calculation, we added the total routine costs (including
costs for capital) submitted on the cost report for each provider and
divided it by the total Medicare days.
Some average routine costs per day were determined to be aberrant,
that is, the costs were extraordinarily high or low and most likely
contained data errors. We provided a detailed discussion in the
November 2004 IPF PPS final rule (69 FR 66926 through 66927) of the
method used to trim extraordinarily high or low cost values from the
per diem rate development file in order to improve the accuracy of our
results. For ancillary services, we calculated the costs by converting
charges from the FY 2002 Medicare claims into costs using facility-
specific, cost-center specific cost-to-charge ratios obtained from each
provider's applicable cost reports. We matched each provider's
departmental cost-to-charge ratios from their Medicare cost report to
each charge on their claims reported in the MedPAR file. Multiplying
the total charges for each type of ancillary service by the
corresponding cost-to-charge ratio provided an estimate of the costs
for all ancillary services received by the patient during the stay. We
determined the average ancillary amount per day by dividing the total
ancillary costs for all stays by the total number of covered Medicare
days.
Adding the average ancillary costs per day and the average routine
costs per day including capital costs provided the estimated average
per diem cost for each patient day of inpatient psychiatric care in FY
2002.
B. Determining the Standardized Budget-Neutral Federal Per Diem Base
Rate
Section 124(a)(1) of the BBRA requires that the implementing IPF
PPS be budget neutral. In other words, the amount of total payments
under the IPF PPS, including any payment adjustments, must be projected
to be equal to the amount of total payments that would have been made
if the IPF PPS were not implemented. Therefore, in the November 2004
IPF PPS final
[[Page 27044]]
rule, we calculated the budget neutrality factor by setting the total
estimated IPF PPS payments to be equal to the total estimated payments
that would have been made under the TEFRA methodology had the IPF PPS
not been implemented.
The November 2004 IPF PPS final rule includes a step-by-step
description of the methodology we used to estimate payments under the
TEFRA payment system (69 FR 66930). For the IPF PPS methodology, we
calculated the final Federal per diem base rate to be budget neutral
during the implementation period under the IPF PPS using a July 1
update cycle. Thus, the implementation period for the IPF PPS is the
18-month period January 1, 2005 through June 30, 2006.
We updated the average cost per day to the midpoint of the IPF PPS
implementation period (that is, October 1, 2005). We used the most
recent projection of the full percentage increase in the 1997-based
excluded hospital with capital market basket index for FY 2003 and
later in accordance with Sec. 413.40(c)(3)(viii). The updated average
cost per day was used in the payment model to establish the budget
neutrality adjustment.
Public comments and our responses on changes for determining the
standardized budget neutral federal per diem base rate are summarized
below.
Comment: We received several comments regarding the determination
of the target amount and the temporary caps on the facility-specific
TEFRA payments which expired in FY 2002. Specifically, the commenters
stated that even though the temporary caps on the facility-specific
(TEFRA) payments expired in FY 2002, the capped payment amounts which
were used to establish the baseline for budget neutrality purposes,
were inflated by the market basket rate for each year until the PPS
began in 2005.
The commenters believe that CMS should have used what would have
been spent, absent the expired temporary caps inflated using the market
basket rate, to establish the baseline rather than capped payments. The
commenters stated that using the capped payments could have
inappropriately reduced the allowed aggregate spending under the PPS
each year.
Response: We are aware that there have been concerns over the
method we used for calculating the target amount for cost reporting
periods beginning after FY 2002 for those hospitals and units that were
subject to the ``payment caps'' in accordance with section
1886(b)(3)(H) of the Act and regulations at Sec. 413.40(c)(4)(iii). We
have addressed this issue several times, but most recently in the FY
2006 IPPS final rule (70 FR 47278 and 70 FR 47464). Specifically, we
addressed the issue of whether Sec. 413.40(c)(4)(iii) (specifically
paragraph (c)(4)(iii)(A)) continues to apply beyond FY 2002. In that
rule, we stated that Sec. 413.40(c)(4)(iii) applies only to cost
reporting periods beginning on or after October 1, 1997 through
September 30, 2002, for IPFs, IRFs, and LTCHs. In addition, we clarify
that once the 75th percentile cap provision in paragraph (c)(4)(iii) of
Sec. 413.40 expired, the target amount is then determined based on
Sec. 413.40(c)(4)(ii) which states that, ``Subject to the provisions
of [Sec. 413.40] paragraph (c)(4)(iii) of this section, for subsequent
cost reporting periods, the target amount equals the hospital's target
amount for the previous cost reporting period increased by the update
factor for the subject cost reporting period'' unless the provisions of
paragraph (c)(5)(ii) of this section apply. Thus, under the
requirements of Sec. 413.40 (c)(4)(ii), in this instance, the previous
cost reporting period's target amount would be increased by the
applicable update factor to arrive at the target amount for FY 2003.
Similarly, for cost reporting periods beginning in years subsequent to
FY 2003, we calculate a hospital's target amount by taking its previous
year's target amount and updating it by the updated factor for the
subject cost reporting period unless the provision of paragraph
(c)(5)(ii) of this section apply. We followed the methodology in Sec.
413.40(c)(4)(ii) and therefore our projections of what would have been
spent under TEFRA and the budget neutrality adjustment are correct.
Final Rule Action: To clarify, in order to calculate the target
amounts for cost reporting periods beginning in FY 2003, our policy is
that the target amounts for cost reporting periods beginning in FY 2002
are updated as described in Sec. 413.40(c)(4)(ii). Similarly, for cost
reporting periods beginning in years subsequent to FY 2003, we
calculate target amounts by taking the previous year's target amount
and updating it, consistent with Sec. 413.40(c)(4)(ii).
1. Standardization of the Federal Per Diem Base Rate
In the November 2004 IPF PPS final rule, we standardized the IPF
PPS Federal per diem base rate in order to account for the overall
positive effects of the IPF PPS payment adjustment factors. To
standardize the IPF PPS payments, we compared the IPF PPS payment
amounts calculated from the FY 2002 MedPAR file to the projected TEFRA
payments from the FY 2002 cost report file updated to the midpoint of
the IPF PPS implementation period (that is, October 2005). The
standardization factor was calculated by dividing total estimated
payments under the TEFRA payment system by estimated payments under the
IPF PPS. The standardization factor was calculated to be 0.8367. As a
result, in the November 2004 IPF PPS final rule, the $724.43 average
cost per day was reduced by 16.33 percent (100 percent minus 83.67
percent).
2. Calculation of the Budget Neutrality Adjustment
To compute the budget neutrality adjustment for the IPF PPS, we
separately identified each component of the adjustment, that is, the
outlier adjustment, stop-loss adjustment, and behavioral offset.
a. Outlier Adjustment
Since the IPF PPS payment amount for each IPF includes applicable
outlier amounts, we reduced the standardized Federal per diem base rate
to account for aggregate IPF PPS payments estimated to be made as
outlier payments. The appropriate outlier amount was determined by
comparing the adjusted prospective payment for the entire stay to the
computed cost per case. If costs were above the prospective payment
plus the adjusted fixed dollar loss threshold amount, an outlier
payment was computed using the applicable risk-sharing percentages (see
section VI.D.1 of this final rule). The outlier amount was computed for
all stays, and the total outlier amount was added to the final IPF PPS
payment. The outlier adjustment was calculated to be 2 percent. As a
result, the standardized Federal per diem base rate was reduced by 2
percent to account for projected outlier payments.
b. Stop-Loss Provision Adjustment
As explained in the November 2004 IPF PPS final rule, we provide a
stop-loss payment to ensure that an IPF's total PPS payments are no
less than a minimum percentage of their TEFRA payment, had the IPF PPS
not been implemented. We reduced the standardized Federal per diem base
rate by the percentage of aggregate IPF PPS payments estimated to be
made for stop-loss payments.
The stop-loss payment amount was determined by comparing aggregate
prospective payments that the provider would receive under the IPF PPS
to aggregate TEFRA payments that the provider would have otherwise
received without implementation of the IPF PPS. If an IPF's aggregate
IPF PPS payments are less than 70 percent of its aggregate
[[Page 27045]]
payments under TEFRA, a stop-loss payment was computed for that IPF.
The stop-loss payment amounts were computed for those IPFs that were
projected to receive the payments, and the total amount was added to
the final IPF PPS payment amount. As a result, the standardized Federal
per diem base rate was reduced by 0.39 percent to account for stop-loss
payments.
c. Behavioral Offset
As explained in the November 2004 IPF PPS final rule,
implementation of the IPF PPS may result in certain changes in IPF
practices especially with respect to coding for comorbid medical
conditions. As a result, Medicare may incur higher payments than
assumed in our calculations. Accounting for these effects through an
adjustment is commonly known as a behavioral offset.
Based on accepted actuarial practices and consistent with the
assumptions made in other prospective payment systems, we assumed in
determining the behavioral offset that IPFs would regain 15 percent of
potential ``losses'' and augment payment increases by 5 percent. We
applied this actuarial assumption, which is based on our historical
experience with new payment systems, to the estimated ``losses'' and
``gains'' among the IPFs. The behavioral offset for the IPF PPS was
calculated to be 2.66 percent. As a result, we reduced the standardized
Federal per diem base rate by 2.66 percent to account for behavioral
changes.
To summarize, the $724.43 updated average per diem cost was reduced
by 16.33 percent to account for standardization to projected TEFRA
payments for the implementation period, by 2 percent to account for
outlier payments, by 0.39 percent to account for stop-loss payments,
and by 2.66 percent reduction to account for the behavioral offset. The
final standardized budget-neutral Federal per diem base rate for the
IPF PPS implementation year was calculated to be $575.95. We discuss
the Federal per diem base rate for RY 2007 below.
Public comments and our responses on the behavioral offset are
summarized below.
Comment: Several commenters expressed concern that CMS continues to
maintain the behavioral offset which is intended to account for changes
in provider practice patterns as a result of movement to prospective
payment which could result in higher Medicare payments. A few
commenters stated that accurate coding is already a high priority in
distinct part units and freestanding facilities. Therefore, coding
practices in these facilities should not undergo major changes. The
commenters suggested that because the PPS is being phased in, and only
50 percent of the payment in the second year would be based on the IPF
PPS, the incentive for behavior change is diminished.
Several commenters recommended that CMS analyze the preliminary
2005 claims data and adjust the calculations for the behavioral offset
to maintain IPF spending at appropriate levels. A few commenters
expressed concern that CMS did not indicate whether an analysis was
conducted to determine if continuing the adjustment for behavioral
offset is warranted. They believe the assumptions made for both the
proposed RY and the implementation year of the IPF PPS overestimated
the likely impact of changes in hospital behavior.
Response: We explained in the November 2004 IPF PPS final rule and
the RY 2007 proposed rule that we believe it is reasonable to expect
changes in IPFs' practices especially with respect to coding for
comorbid medical conditions and changes in length of stay (LOS), as a
result of the implementation of the IPF PPS.
In addition, based on accepted actuarial practices and consistent
with the assumptions made in implementing other prospective payment
systems, we assumed in determining the behavioral offset, that IPFs
would regain 15 percent of potential ``losses'' and augment payment
increases by 5 percent. We applied this actuarial assumption, which is
based on our historical experience with new payment systems, to the
estimated ``losses'' and ``gains'' among the IPFs.
As indicated in the RY 2007 proposed rule, we do not plan to change
adjustment factors or projections, including the behavioral offset,
until we analyze IPF PPS data. At that time, we will re-assess the
accuracy of the behavioral offset along with the other factors
impacting budget neutrality. We anticipate analyzing 2005 IPF PPS
claims and cost report data in the future.
Comment: Several commenters inquired why CMS is continuing to
include budget neutrality factors in the Federal per diem base rate
(behavioral offset, stop-loss adjustment, and outlier adjustment),
effectively lowering the base rate. Since the PPS is only budget
neutral for the implementation year, the commenters believe the base
rate should not reflect budget neutrality factors that effectively
lower the amount.
Response: We acknowledge that the PPS is only budget neutral for
the implementation year. The standardization factor, behavioral offset,
stop-loss adjustment, and outlier adjustment were included in the 2005
Federal per diem base rate of $575.95. In implementing the RY 2007
final rule, we adjust the standardization factor (see section V.B.3 of
this final rule), and apply the market basket update and the wage index
budget neutrality factor to the base rate. As indicated above, we do
not plan to change any adjustment factors or projections, including the
budget neutrality factors (behavioral offset, stop-loss adjustment, and
outlier adjustment), until we analyze IPF PPS data. We will revisit all
assumptions used to calculate the budget neutrality adjustment and make
any necessary prospective changes to the Federal per diem base rate. In
section VI.D.3 of this final rule, we address these comments with
respect to the calculation of the ECT rate.
Final Rule Action: In summary, for future RYs, we will reassess the
appropriateness of the behavior offset along with the other factors
impacting budget neutrality. For the RY 2007 IPF PPS, we will continue
to adjust the standardization factor and apply the market basket
updates and the wage index budget neutrality factors.
3. Revision of the Standardization Factor
In reviewing the methodology used to simulate the IPF PPS payments
used for the November 2004 IPF PPS final rule, we discovered that the
computer code incorrectly assigned non-teaching status to most teaching
facilities. As a result, total IPF PPS payments were underestimated by
about 1.36 percent. The underestimated IPF PPS payment total was used
in calculating the IPF PPS standardization factor. The standardization
factor represents the amount by which the IPF PPS per diem payment rate
and the ECT rate must be reduced in order to make total IPF PPS
payments equal to estimated total TEFRA payments assuming IPFs
continued to be paid solely under TEFRA for the first PPS payment year.
The standardization factor is calculated as the ratio of estimated
total TEFRA payments to estimated total IPF PPS payments assuming no
reduction to the per diem and ECT payment rates. Since the IPF PPS
payment total should have been larger than the estimated figure, the
standardization factor should have been smaller (0.8254 vs. 0.8367). In
turn, the Federal per diem base rate and the ECT rate should have been
reduced by 0.8254 instead of 0.8367.
To resolve this issue, we proposed to amend the Federal per diem
base rate and the ECT payment rate prospectively. Using the
standardization
[[Page 27046]]
factor of 0.8254, the base rate should have been $568.17 for the
implementation year of the IPF PPS. It is this base rate that we
proposed to update using the market basket rate of increase of 4.3
percent and the budget-neutral wage index factor of 1.0042 (see section
VI.C.1.f of this final rule). Applying these factors yields a proposed
Federal per diem base rate of $595.09 for the RY beginning July 1, 2006
through June 30, 2007.
Public comments and our responses on the revision of the
standardization factor are summarized below.
Comment: One commenter asked whether the overall increase in the
base rate is appropriately calculated and sufficient.
Response: As explained above and in the RY 2007 proposed rule, the
correction of the standardization factor reveals that last year's per
diem rate should have been $568.17, and not $575.95. To correct this
error prospectively, we apply the market basket increase of 4.3 percent
to $568.17, and then apply the wage index budget neutrality factor to
compute the Federal per diem base rate.
Final Rule Action: In summary, we are finalizing our decision to
revise the standardization factor prospectively, and the Federal per
diem base rate for RY 2007 is $595.09.
C. Update of the Federal Per Diem Base Rate
1. Market Basket for IPFs Reimbursed Under the IPF PPS
a. Market Basket Index for IPF PPS
The market basket index used to develop the IPF PPS is the excluded
hospital with capital market basket. This market basket was based on
1997 Medicare cost report data and includes data for Medicare
participating IPFs, IRFs, LTCHs, cancer, and children's hospitals.
We are presently unable to create a separate market basket
specifically for psychiatric hospitals due to the small number of
facilities and the limited data that are provided (for instance,
approximately 4 percent of psychiatric facilities reported contract
labor cost data for FY 2002). However, since all IRFs, LTCHs, and IPFs
are now paid under a PPS, we are updating PPS payments made under the
IRF PPS, the LTCH PPS, and the IPF PPS using a market basket reflecting
the operating and capital cost structures for IRFs, IPFs, and LTCHs
(hereafter referred to as the rehabilitation, psychiatric, long-term
care (RPL) market basket). We have excluded children's and cancer
hospitals from the RPL market basket because their payments are based
entirely on reasonable costs subject to rate-of-increase limits
established under the authority of section 1886(b) of the Act, which is
implemented in regulations at Sec. 413.40. They are not reimbursed
under a PPS. Also, the FY 2002 cost structures for children's and
cancer hospitals are noticeably different than the cost structures of
the IRFs, IPFs, and LTCHs.
The services offered in IRFs, IPFs, and LTCHs are typically more
labor-intensive than those offered in cancer and children's hospitals.
Therefore, the compensation cost weights for IRFs, IPFs, and LTCHs are
larger than those in cancer and children's hospitals. In addition, the
depreciation cost weights for IRFs, IPFs, and LTCHs are noticeably
smaller than those for children's and cancer hospitals.
In the following discussion, we provide an overview on the market
basket and describe the methodologies we are using for purposes of
determining the operating and capital portions of the FY 2002-based RPL
market basket.
b. Overview of the RPL Market Basket
The RPL market basket is a fixed weight, Laspeyres-type price index
that was constructed in three steps. First, a base period was selected
(in this case, FY 2002) and total base period expenditures were
estimated for a set of mutually exclusive and exhaustive spending
categories based upon type of expenditure. Then the proportion of total
costs that each category represents was determined. These proportions
are called cost or expenditure weights. Second, each expenditure
category was matched to an appropriate price or wage variable, referred
to as a price proxy. In nearly every instance, these price proxies are
price levels derived from publicly available statistical series that
are published on a consistent schedule, preferably at least on a
quarterly basis.
Finally, the expenditure weight for each cost category was
multiplied by the level of its respective price proxy for a given
period. The sum of these products (that is, the expenditure weights
multiplied by their price levels) for all cost categories yields the
composite index level of the market basket in a given period. Repeating
this step for other periods produces a series of market basket levels
over time. Dividing an index level for a given period by an index level
for an earlier period produces a rate of growth in the input price
index over that time period.
A market basket is described as a fixed-weight index because it
answers the question of how much it would cost, at another time, to
purchase the same mix of goods and services purchased to provide
hospital services in a base period. The effects on total expenditures
resulting from changes in the quantity or mix of goods and services
(intensity) purchased subsequent to the base period are not measured.
In this manner, the market basket measures only pure price change. Only
when the index is rebased would the quantity and intensity effects be
captured in the cost weights. Therefore, we rebase the market basket
periodically so that cost weights reflect changes in the mix of goods
and services that hospitals purchase (hospital inputs) to furnish
patient care between base periods.
The terms rebasing and revising, while often used interchangeably,
actually denote different activities. Rebasing means moving the base
year for the structure of costs of an input price index (for example,
shifting the base year cost structure from FY 1997 to FY 2002).
Revising means changing data sources, methodology, or price proxies
used in the input price index. We have rebased and revised the market
basket used to update the IPF PPS.
2. Methodology for Operating Portion of the RPL Market Basket
The operating portion of the FY 2002-based RPL market basket
consists of several major cost categories derived from the FY 2002
Medicare cost reports for IRFs, IPFs, and LTCHs: wages, drugs,
professional liability insurance, and a residual. We chose to use FY
2002 as the base year because we believe this is the most recent,
complete year of Medicare cost reports. Due to insufficient Medicare
cost report data for IRFs, IPFs, and LTCHs, we have developed cost
weights for benefits, contract labor, and blood and blood products
using the FY 2002-based IPPS market basket (70 FR 23384), which we
explain in more detail later in this section. For example, less than 30
percent of IRFs, IPFs, and LTCHs reported benefit cost data in FY 2002.
We have noticed an increase in cost data for these expense categories
over the last 4 years. The next time we rebase the RPL market basket
there may be sufficient IRF, IPF, and LTCH cost report data to develop
the weights for these expenditure categories.
Since the cost weights for the RPL market basket are based on
facility costs, as proposed and for this final rule, we are limiting
our sample to hospitals with a Medicare average LOS within a comparable
range of the total facility average LOS. We believe this provides a
more accurate reflection of the structure of costs for Medicare covered
[[Page 27047]]
days. Our goal is to measure cost shares that are reflective of case
mix and practice patterns associated with providing services to
Medicare beneficiaries.
As proposed and for this final rule, we are using those cost
reports for IRFs and LTCHs whose Medicare average LOS is within 15
percent (that is, 15 percent higher or lower) of the total facility
average LOS for the hospital. This is the same edit applied to the FY
1992-based and FY 1997-based excluded hospital with capital market
basket. We are using 15 percent because it includes those LTCHs and
IRFs whose Medicare LOS is within approximately 5 days of the facility
LOS.
As proposed and for this final rule, we use a less stringent
measure of Medicare LOS for IPFs whose average LOS is within 30 or 50
percent (depending on the total facility average LOS) of the total
facility average LOS. Using this less stringent edit allows us to
increase our sample size by over 150 cost reports and produce a cost
weight more consistent with the overall facility. The edit we applied
to IPFs when developing the FY 1997-based excluded hospital with
capital market basket was based on the best available data at the time.
Public comments and our responses on the proposed changes for
implementing the methodology for the operating portion of the RPL
market basket are summarized below.
Comment: One commenter disagreed with our proposed LOS methodology,
which included those cost reports for IRFs and LTCHs whose Medicare
average LOS is within 15 percent (that is, 15 percent higher or lower)
of the total facility average LOS and those cost reports for IPFs whose
average LOS is within 30 or 50 percent (depending on the total facility
average LOS) of the total facility average LOS.
A commenter stated that the LOS methodology appears to factor into
the calculation a disproportionate share of psychiatric facilities with
a longer LOS. In addition, the commenter indicated that the RY 2007
proposed rule stated that costs decrease further into a patient's stay
and that CMS assumes that IPFs have an incompatible cost per discharge
when grouped with the lower LOS in the IRFs and LTCHs.
Response: As stated previously, since the cost weights for the RPL
market basket are based on facility costs, we limited our sample to
hospitals with a Medicare average LOS within a comparable range of the
total facility average LOS. We believe this provides a more accurate
reflection of the structure of costs for Medicare treatments.
We disagree with the commenter that the IPF LOS edit includes a
disproportionate share of IPFs with a longer LOS. For clarity, we are
providing below a table that compares the distribution of the Medicare
and facility LOSs for IPFs using no edit and the proposed 30/50 edit.
Table 2.--IPFs FY 2002 Medicare and Facility LOS Distributions
----------------------------------------------------------------------------------------------------------------
Medicare length of stay Facility length of stay
---------------------------------------------------------------
No trim 30/50 trim No trim 30/50 trim
----------------------------------------------------------------------------------------------------------------
100% Max........................................ 93 70 5334 75
99%............................................. 86 54 822 63
95%............................................. 59 36 333 39
90%............................................. 49 23 227 26
75% Q3.......................................... 28 15 57 15
50% Median...................................... 13 11 13 10
25% Q1.......................................... 10 9 8 8
10%............................................. 8 7 6 6
5%.............................................. 7 7 6 5
1%.............................................. 4 5 5 5
0% Min.......................................... 1 3 1 3
----------------------------------------------------------------------------------------------------------------
The Medicare and facility LOS distributions are consistent when the
proposed edit is applied. However, not applying the edit would include
in the market basket those IPFs whose facility LOS are dramatically
different from their Medicare LOS. In addition, the Medicare LOS
distribution with the 30/50 edit is similar to the Medicare LOS
distribution with no edit. Therefore, we believe that the proposed edit
does not include a disproportionate share of IPFs with a longer LOS in
the market basket.
Applying these LOS edits left us with a sample of hospitals whose
average Medicare utilization was approximately 50 percent, while those
excluded from the market basket had a Medicare utilization of
approximately 10 percent. Given this, we firmly believe that these LOS
edits help us meet our goal to measure cost shares that are reflective
of case mix and practice patterns associated with providing services to
Medicare beneficiaries.
The detailed cost categories under the residual (that is, the
remaining portion of the market basket after excluding wages and
salaries, drugs, and professional liability cost weights) are derived
from the FY 2002-based IPPS market basket and the 1997 Benchmark Input-
Output (I-O) Tables published by the Bureau of Economic Analysis, U.S.
Department of Commerce. The FY 2002-based IPPS market basket was
developed using FY 2002 Medicare hospital cost reports with the most
recent and detailed cost data (see the August 12, 2005 IPPS final rule
(70 FR 47388)). The 1997 Benchmark I-O is the most recent,
comprehensive source of cost data for all hospitals. The RPL cost
weights for benefits, contract labor, and blood and blood products were
derived using the FY 2002-based IPPS market basket. For example, the
ratio of the benefit cost weight to the wages and salaries cost weight
in the FY 2002-based IPPS market basket was applied to the RPL wages
and salaries cost weight to derive a benefit cost weight for the RPL
market basket. As proposed and for this final rule, the remaining RPL
operating cost categories were derived using the 1997 Benchmark I-O
Tables, aged to 2002 using relative price changes. (The methodology we
used to age the data involves applying the annual price changes from
the price proxies to the appropriate cost categories. We repeated this
practice for each year.) Therefore, using this methodology, roughly 59
percent of the RPL market basket was accounted for by wages, drugs, and
professional liability insurance data from FY 2002 Medicare cost report
data for IRFs, LTCHs, and IPFs.
Additional comments and our responses on the methodology for
[[Page 27048]]
operating portion of the RPL market basket are summarized below.
Comment: Several commenters proposed that CMS regularly re-analyze
the RPL cost report data, which are the basis of the RPL market basket.
The commenters indicated that the methodology used for the RPL market
basket includes data from the IPPS hospital market basket rather than
relying solely on IPF, IRF, and LTCH data.
The commenters recommended that CMS work with providers to improve
the cost reports from rehabilitation, psychiatric, and LTCHs in order
to ensure that the data used for the market basket represent only the
types of excluded hospitals for which the RPL market basket was
developed. The commenters believe that improving the data reported on
the RPL cost reports would not only refine the RPL market basket but
also improve the accuracy of the labor-related share to which the wage
index is applied.
Response: We rely on the IPPS cost report data to supplement the
IRF, IPF, and LTCH Medicare cost report data for benefits, contract
labor, and blood and blood products. For example, the ratio of the
benefit cost weight to the wages and salaries cost weight in the FY
2002-based IPPS market basket was applied to the RPL wages and salaries
cost weight to derive a benefit cost weight for the RPL market basket.
We did not use expenditure levels from the IPPS data directly but, as
explained, we developed and used the ratios from IPPS data to determine
these RPL cost weights.
The wages and salaries cost weight was derived using the IRF, IPF,
and LTCH Medicare cost reports and accounts for 50 percent of the RPL
market basket. Due to data limitations, this was the best methodology
for developing the latter cost weights.
We agree with the commenters that improving the data reported on
the RPL cost reports could improve the RPL market basket and labor-
related share. We have noticed this data improvement on other provider-
type cost reports and encourage IRF, IPF, and LTCH providers to fully
complete their cost reports. We believe that this would help us develop
the most complete and accurate market basket possible. We will analyze
RPL cost report data on a regular basis and continue to consider the
possibility of provider-specific market basket indices.
Comment: One commenter requested that CMS explain how it computes
cost category weights based on Medicare cost report data. The commenter
stated that if they understood which data elements were used and how
they were used, CMS could develop educational programs to improve their
member hospitals' reporting.
Response: The RPL market basket cost weights are based on
freestanding Medicare cost report data for IRFs, IPFs, and LTCHs. We
mainly rely on data from worksheets A through G to derive the cost
weights. Worksheet S-3, part II is the only worksheet which allows for
the reporting of benefits and contract labor data; however, it is not a
required worksheet for IRFs, IPFs, and LTCHs. As stated previously, we
relied on the IPPS Medicare cost report worksheet S-3, part II data to
derive the relationships for benefits and contract labor to wages and
salaries.
Additionally, capital cost weights are derived using worksheet A-7.
The estimates generated using this worksheet, as well as worksheet G,
could be enhanced with higher reporting rates. Again, we encourage IRF,
IPF, and LTCH providers to fully complete their cost reports to help us
in developing the most complete and accurate market basket.
Table 3 below sets forth the complete 2002-based RPL market basket
including cost categories, weights, and price proxies. For comparison
purposes, the corresponding FY 1997-based excluded hospital with
capital market basket is listed as well.
As proposed and for this final rule, wages and salaries are 52.895
percent of total costs in the FY 2002-based RPL market basket compared
to 47.335 percent for the FY 1997-based excluded hospital with capital
market basket. Employee benefits are 12.982 percent in the FY 2002-
based RPL market basket compared to 10.244 percent for the FY 1997-
based excluded hospital with capital market basket. As a result,
compensation costs (wages and salaries plus employee benefits) for the
FY 2002-based RPL market basket are 65.877 percent of costs compared to
57.579 percent for the FY 1997-based excluded hospital with capital
market basket. Of the 8 percentage-point difference between the
compensation shares, approximately 3 percentage points were due to the
new base year (FY 2002 instead of FY 1997), 3 percentage points were
due to the revised LOS edit, and the remaining 2 percentage points were
due to the exclusion of other hospitals (that is, only including IPFs,
IRFs, and LTCHs in the market basket).
Following the table is a summary outlining the choice of the
proxies we chose to use for the operating portion of the market basket.
The price proxies for the capital portion are described in more detail
in the capital methodology section (see section V.C.3 of this final
rule).
Table 3.--FY 2002-Based RPL Market Basket Cost Categories, Weights, and Proxies With FY 1997-Based Excluded
Hospital With Capital Market Basket Used for Comparison
----------------------------------------------------------------------------------------------------------------
FY 1997-based
excluded hospital FY 2002-based RPL FY 2002 market basket price
Expense categories with capital market basket proxies
market basket
----------------------------------------------------------------------------------------------------------------
Total................................... 100.000 100.000
Compensation............................ 57.579 65.877
Wages and Salaries *................ 47.335 52.895 ECI--Wages and Salaries,
