Medicare Program; Proposed Hospice Wage Index for Fiscal Year 2009, 24000-24035 [08-1198]

Download as PDF 24000 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules maintenance plan and 2002 base-year inventory for the Warren County Area because it meets the requirements of section 110(a)(1) of the CAA. EPA is soliciting public comments on the issues discussed in this document. These comments will be considered before taking final action. rfrederick on PROD1PC67 with PROPOSALS IV. Statutory and Executive Order Reviews Under the CAA, the Administrator is required to approve a SIP submission that complies with the provisions of the Act and applicable Federal regulations. 42 U.S.C. 7410(k); 40 CFR 52.02(a). Thus, in reviewing SIP submissions, EPA’s role is to approve state choices, provided that they meet the criteria of the CAA. Accordingly, this action merely proposes to approve state law as meeting Federal requirements and does not impose additional requirements beyond those imposed by state law. For that reason, this proposed • Is not a ‘‘significant regulatory action’’ subject to review by the Office of Management and Budget under Executive Order 12866 (58 FR 51735, October 4, 1993); • Does not impose an information collection burden under the provisions of the Paperwork Reduction Act (44 U.S.C. 3501 et seq.); • Is certified as not having a significant economic impact on a substantial number of small entities under the Regulatory Flexibility Act (5 U.S.C. 601 et seq.); • Does not contain any unfunded mandate or significantly or uniquely affect small governments, as described in the Unfunded Mandates Reform Act of 1995 (Pub. L. 104–4); • Does not have Federalism implications as specified in Executive Order 13132 (64 FR 43255, August 10, 1999); • Is not an economically significant regulatory action based on health or safety risks subject to Executive Order 13045 (62 FR 19885, April 23, 1997); • Is not a significant regulatory action subject to Executive Order 13211 (66 FR 28355, May 22, 2001); • Is not subject to requirements of Section 12(d) of the National Technology Transfer and Advancement Act of 1995 (15 U.S.C. 272 note) because application of those requirements would be inconsistent with the CAA; and • Does not provide EPA with the discretionary authority to address, as appropriate, disproportionate human health or environmental effects, using practicable and legally permissible methods, under Executive Order 12898 (59 FR 7629, February 16, 1994). VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 In addition, this proposed rule to approve the maintenance plan and the 2002 base-year inventory for the Warren County Area in the Commonwealth of Pennsylvania does not have tribal implications as specified by Executive Order 13175 (65 FR 67249, November 9, 2000), because the SIP is not approved to apply in Indian country located in the state, and EPA notes that it will not impose substantial direct costs on tribal governments or preempt tribal law. List of Subjects in 40 CFR Part 52 Environmental protection, Air pollution control, Nitrogen dioxide, Ozone, Reporting and recordkeeping requirements, Volatile organic compounds. Authority: 42 U.S.C. 7401 et seq. Dated: April 24, 2008. William T. Wisniewski, Acting Regional Administrator, Region III. [FR Doc. E8–9613 Filed 4–30–08; 8:45 am] BILLING CODE 6560–50–P DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 418 [CMS–1548–P] RIN 0938–AP14 Medicare Program; Proposed Hospice Wage Index for Fiscal Year 2009 Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Proposed rule. AGENCY: SUMMARY: This proposed rule proposes the hospice wage index for fiscal year 2009. This proposed rule also proposes to phase-out the Medicare hospice budget neutrality adjustment factor and clarify two wage index issues, pertaining to the definition of rural and urban areas and to multi-campus hospital facilities. DATES: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on June 27, 2008. ADDRESSES: In commenting, please refer to file code CMS–1548–P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission. You may submit comments in one of four ways (please choose only one of the ways listed): 1. Electronically. You may submit electronic comments on this regulation PO 00000 Frm 00019 Fmt 4702 Sfmt 4702 to https://www.regulations.gov. Follow the instructions for ‘‘Comment or Submission’’ and enter the filecode to find the document accepting comments. 2. By regular mail. You may mail written comments (one original and two copies) to the following address only: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–1548– P, P.O. Box 8012, Baltimore, MD 21244– 1850. Please allow sufficient time for mailed comments to be received before the close of the comment period. 3. By express or overnight mail. You may send written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS–1548–P, Mail Stop C4–26–05, 7500 Security Boulevard, Baltimore, MD 21244–1850. 4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to either of the following addresses: a. Room 445–G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201. (Because access to the interior of the HHH Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.) b. 7500 Security Boulevard, Baltimore, MD 21244–1850. If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786– 9994 in advance to schedule your arrival with one of our staff members. Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period. For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section. FOR FURTHER INFORMATION CONTACT: Randy Throndset (410) 786–0131 or Katie Lucas (410) 786–7723. SUPPLEMENTARY INFORMATION: Submitting Comments: We welcome comments from the public on all issues set forth in this rule to assist us in fully considering issues and developing policies. You can assist us by E:\FR\FM\01MYP1.SGM 01MYP1 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules referencing the file code CMS–1548–P and the specific ‘‘issue identifier’’ that precedes the section on which you choose to comment. Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: https:// www.regulations.gov. Follow the search instructions on that Web site to view public comments. Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1–800–743–3951. rfrederick on PROD1PC67 with PROPOSALS Table of Contents I. Background A. General 1. Hospice Care 2. Medicare Payment for Hospice Care B. Hospice Wage Index 1. Raw Wage Index Values (Pre-Floor, PreReclassified Hospital Wage Index) 2. Changes to Core-Based Statistical Area (CBSA) Designations 3. Definition of Urban and Rural Areas 4. Areas Without Hospital Wage Data 5. CBSA Nomenclature Changes 6. Hospice Payment Rates II. Provisions of the Proposed Rule A. Clarification of New England Deemed Counties B. Wage Data for Multi-Campus Hospitals C. FY 2009 Proposed Hospice Wage Index With Phase-Out of the Budget Neutrality Adjustment Factor (BNAF) 1. Background 2. Areas Without Hospital Wage Data 3. Phase-Out of the BNAF a. Effects of phasing-out the BNAF using the published FY 2008 Hospice Wage Index Data b. Effects of phasing-out the BNAF using the Updated Pre-floor, Pre-reclassified Hospital Wage Index Data (FY 2009 proposal) D. Summary of the Provisions of the Proposed Rule III. Collection of Information Requirements IV. Regulatory Impact Analysis A. Overall Impact B. Anticipated Effects 1. Hospice Size 2. Geographic Location 3. Type of Ownership 4. Hospice Base C. Accounting Statement VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 Part 418—Hospice Care I. Background A. General 1. Hospice Care Hospice care is an approach to treatment that recognizes that the impending death of an individual warrants a change in the focus from curative care to palliative care for relief of pain and for symptom management. The goal of hospice care is to help terminally ill individuals continue life with minimal disruption to normal activities while remaining primarily in the home environment. A hospice uses an interdisciplinary approach to deliver medical, nursing, social, psychological, emotional, and spiritual services through use of a broad spectrum of professional and other caregivers, with the goal of making the individual as physically and emotionally comfortable as possible. Counseling services and inpatient respite services are available to the family of the hospice patient. Hospice programs consider both the patient and the family as a unit of care. Section 1861(dd) of the Social Security Act (the Act) provides for coverage of hospice care for terminally ill Medicare beneficiaries who elect to receive care from a participating hospice. Section 1814(i) of the Act provides payment for Medicare participating hospices. 2. Medicare Payment for Hospice Care Our regulations at 42 CFR part 418 establish eligibility requirements, payment standards and procedures, define covered services, and delineate the conditions a hospice must meet to be approved for participation in the Medicare program. Part 418 subpart G provides for payment in one of four prospectively-determined rate categories (routine home care, continuous home care, inpatient respite care, and general inpatient care) to hospices based on each day a qualified Medicare beneficiary is under a hospice election. B. Hospice Wage Index Our regulations at § 418.306(c) require each hospice’s labor market to be established using the most current hospital wage data available, including any changes by OMB to the Metropolitan Statistical Areas (MSAs) definitions. OMB revised the MSA definitions beginning in 2003 with new designations called the Core Based Statistical Areas (CBSAs). For the purposes of the hospice benefit, the term ‘‘MSA-based’’ refers to wage index values and designations based on the previous MSA designations before 2003. PO 00000 Frm 00020 Fmt 4702 Sfmt 4702 24001 Conversely, the term ‘‘CBSA-based’’ refers to wage index values and designations based on the OMB revised MSA designations in 2003, which now include CBSAs. In the August 11, 2004 IPPS final rule (69 FR 48916, 49026), revised labor market area definitions were adopted at § 412.64(b), which were effective October 1, 2004 for acute care hospitals. CMS also revised the labor market areas for hospices using the new OMB standards that included CBSAs. In the FY 2006 hospice wage index final rule (70 FR 45130), we implemented a 1-year transition policy using a 50/50 blend of the CBSA-based wage index values and the Metropolitan Statistical Area (MSA)-based wage index values for FY 2006. The one-year transition policy ended on September 30, 2006. For FY 2007 and FY 2008 we used wage index values based on CBSA designations. The hospice wage index is used to adjust payment rates for hospice agencies under the Medicare program to reflect local differences in area wage levels. The original hospice wage index was based on the 1981 Bureau of Labor Statistics hospital data and had not been updated since 1983. In 1994, because of disparity in wages from one geographical location to another, a committee was formulated to negotiate a wage index methodology that could be accepted by the industry and the government. This committee, functioning under a process established by the Negotiated Rulemaking Act of 1990, was comprised of national hospice associations; rural, urban, large and small hospices; multi-site hospices; consumer groups; and a government representative. On April 13, 1995, the Hospice Wage Index Negotiated Rulemaking Committee signed an agreement for the methodology to be used for updating the hospice wage index. In the August 8, 1997 Federal Register (62 FR 42860), we published a final rule implementing a new methodology for calculating the hospice wage index based on the recommendations of the negotiated rulemaking committee. The committee statement was included in the appendix of that final rule (62 FR 42883). The hospice wage index is updated annually. Our most recent annual update notice published in the Federal Register (72 FR 50214) on August 31, 2007 set forth updates to the hospice wage index for FY 2008. On October 1, 2007, we published a correction notice in the Federal Register (72 FR 55672) to correct technical errors that appeared in the August 31, 2007 final rule. E:\FR\FM\01MYP1.SGM 01MYP1 rfrederick on PROD1PC67 with PROPOSALS 24002 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 1. Raw Wage Index Values (Pre-Floor, Pre-Reclassified Hospital Wage Index) As described in the August 8, 1997 hospice wage index final rule (62 FR 42860), the pre-floor and prereclassified hospital wage index is used as the raw wage index for the hospice benefit. These raw wage index values are then subject to either a budget neutrality adjustment or application of the hospice floor to compute the hospice wage index used to determine payments to hospices. Pre-floor, pre-reclassified hospital wage index values of 0.8 or greater are adjusted by the BNAF. Pre-floor, prereclassified hospital wage index values below 0.8 are adjusted by the greater of: (1) The hospice BNAF; or (2) the hospice floor (which is a 15 percent increase) subject to a maximum wage index value of 0.8. For example, if County A has a pre-floor, prereclassified hospital wage index (raw wage index) value of 0.4000, we would perform the following calculations using the budget neutrality factor (which for this example is 1.060988) and the hospice floor to determine County A’s hospice wage index: Pre-floor, pre-reclassified hospital wage index value below 0.8 multiplied by the BNAF: (0.4000 × 1.060988 = 0.4244) Pre-floor, pre-reclassified hospital wage index value below 0.8 multiplied by the hospice floor: (0.4000 × 1.15 = 0.4600) Based on these calculations, County A’s hospice wage index would be 0.4600. As decided upon by the Hospice Wage Index Negotiated Rulemaking Committee, budget neutrality means that, in a given year, estimated aggregate payments for Medicare hospice services using the updated hospice values will equal estimated payments that would have been made for these services if the 1983 hospice wage index values had remained in effect, after adjusting the payment rates for inflation. The BNAF has been computed and applied annually to the labor portion of the hospice payment. Currently, the labor portion of the payment rates is as follows: for Routine Home Care, 68.71 percent; for Continuous Home Care, 68.71 percent; for General Inpatient Care, 64.01 percent; and for Respite Care, 54.13 percent. The non-labor portion is equal to 100 percent minus the labor portion for each level of care. Therefore the non-labor portion of the payment rates is as follows: for Routine Home Care, 31.29 percent; for Continuous Home Care, 31.29 percent; for General Inpatient Care, 35.99 VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 percent; and for Respite Care, 45.87 percent. 2. Changes to Core-Based Statistical Area (CBSA) Designations The annual update to the hospice wage index is published in the Federal Register and is based on the most current available hospital wage data, as well as any changes by the Office of Management and Budget (OMB) to the definitions of MSAs, which now include CBSA designations. The August 4, 2005 final rule (70 FR 45130) set forth the adoption of the changes discussed in the OMB Bulletin No. 03–04 (June 6, 2003), which announced revised definitions for Micropolitan Statistical Areas and the creation of MSAs and Combined Statistical Areas. In adopting the OMB CBSA geographic designations, we provided for a 1-year transition with a blended hospice wage index for all hospices for FY 2006. For FY 2006, the hospice wage index for each provider consisted of a blend of 50 percent of the FY 2006 MSA-based hospice wage index and 50 percent of the FY 2006 CBSA-based hospice wage index. Fiscal years 2007 and 2008 used the full CBSA-based hospice wage index values as discussed in their respective notices or rules (71 FR 52080 and 72 FR 50214). 3. Definition of Rural and Urban Areas Each hospice’s labor market is determined based on definitions of MSAs issued by OMB. In general, an urban area is defined as an MSA or New England County Metropolitan Area (NECMA) as defined by OMB. Under § 412.64(b)(1)(ii)(C), a rural area is defined as any area outside of the urban area. The urban and rural area geographic classifications are defined in § 412.64(b)(1)(ii)(A) through (C), and have been used for the Medicare hospice benefit since implementation. 4. Areas Without Hospital Wage Data When adopting OMB’s new labor market designations in FY 2006, 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 hospice wage index. Beginning in FY 2006, we adopted a policy to use the FY 2005 prefloor, pre-reclassified hospital wage index value for rural areas when no hospital wage data were available. We also adopted the policy that for urban labor markets without a hospital from which a hospital wage index data could be derived, all of the CBSAs within the State would be used to calculate a statewide urban average pre-floor, prereclassified hospital wage index value to PO 00000 Frm 00021 Fmt 4702 Sfmt 4702 use as a reasonable proxy for these areas. Consequently, in the FY 2006 final rule, the FY 2007 update notice, and the FY 2008 final rule, we applied the average pre-floor, pre-reclassified hospital wage index data from all urban areas in that state to urban areas without a hospital. The only affected CBSA is 25980, Hinesville-Fort Stewart, Georgia. Under the CBSA labor market areas, there are no hospitals in rural locations in Massachusetts and Puerto Rico. Since there was no rural proxy for more recent rural data within those areas, in the FY 2006 hospice wage index proposed rule (70 FR 22394, 22398), we proposed applying the FY 2005 pre-floor, prereclassified hospital wage index value to rural areas where no hospital wage data were available. In the FY 2006 final rule and in the FY 2007 update notice, we applied the FY 2005 pre-floor, prereclassified hospital wage index data for areas lacking hospital wage data in both FY 2006 and FY 2007 for rural Massachusetts and rural Puerto Rico. In the FY 2008 final rule (72 FR 50214, 50217) we considered alternatives to our methodology to update the pre-floor, pre-reclassified hospital wage index for rural areas without hospital wage data. We indicated that we believed that the best imputed proxy for rural areas, would: (1) Use pre-floor, pre-reclassified hospital data; (2) use the most local data available to impute a rural pre-floor, pre-reclassified hospital wage index; (3) be easy to evaluate; and, (4) be easy to update from year-to-year. Therefore, in FY 2008, in cases where there was a rural area without rural hospital wage data, we used the average pre-floor, pre-reclassified hospital wage index data from all contiguous CBSAs to represent a reasonable proxy for the rural area. This approach does not use rural data, however, the approach uses pre-floor, pre-reclassified hospital wage data, is easy to evaluate, is easy to update from year-to-year, and uses the most local data available. In the FY 2008 rule (72 FR at 50217), we noted that in determining an imputed rural pre-floor, pre-reclassified hospital wage index, we interpret the term ‘‘contiguous’’ to mean sharing a border. For example, in the case of Massachusetts, the entire rural area consists of Dukes and Nantucket counties. We determined that the borders of Dukes and Nantucket counties are contiguous with Barnstable and Bristol counties. Under the adopted methodology, the pre-floor, prereclassified hospital wage index values for the counties of Barnstable (CBSA 12700, Barnstable Town, MA) and Bristol (CBSA 39300, Providence-New Bedford-Fall River, RI–MA) would be E:\FR\FM\01MYP1.SGM 01MYP1 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules averaged resulting in an imputed prefloor, pre-reclassified rural hospital wage index for FY 2008. We noted in the FY 2008 final hospice wage index rule that while we believe that this policy could be readily applied to other rural areas that lack hospital wage data (possibly due to hospitals converting to a different provider type, such as a Critical Access Hospital, that does not submit the appropriate wage data), if a similar situation arose in the future, we would re-examine this policy. We also noted that we do not believe that this policy would be appropriate for Puerto Rico, as there are sufficient economic differences between hospitals in the United States and those in Puerto Rico, including the payment of hospitals in Puerto Rico using blended Federal/ Commonwealth-specific rates. Therefore we believe that a separate and distinct policy for Puerto Rico is necessary. Any alternative methodology for imputing a pre-floor, pre-reclassified hospital wage index for rural Puerto Rico would need to take into account the economic differences between hospitals in the United States and those in Puerto Rico. Our policy of imputing a rural pre-floor, pre-reclassified hospital wage index based on the pre-floor, pre-reclassified hospital wage index(es) of CBSAs contiguous to the rural area in question does not recognize the unique circumstances of Puerto Rico. While we have not yet identified an alternative methodology for imputing a pre-floor, pre-reclassified hospital wage index for rural Puerto Rico, we will continue to evaluate the feasibility of using existing hospital wage data and, possibly, wage data from other sources. For FY 2008, we used the most recent pre-floor, prereclassified hospital wage index available for Puerto Rico, which is 0.4047. rfrederick on PROD1PC67 with PROPOSALS 5. CBSA Nomenclature Changes The Office of Management and Budget (OMB) regularly publishes a bulletin that updates the titles of certain CBSAs. In the FY 2008 Final Rule (72 FR 50218) we noted that the FY 2008 rule and all subsequent hospice wage index rules and notices would incorporate CBSA changes from the most recent OMB bulletins. The OMB bulletins may be accessed at https://www.whitehouse.gov/ omb/bulletins/. 6. Hospice Payment Rates Section 4441(a) of the Balanced Budget Act of 1997 (BBA) amended section 1814(i)(1)(C)(ii) of the Act to establish updates to hospice rates for FYs 1998 through 2002. Hospice rates were to be updated by a factor equal to the market basket index, minus 1 VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 percentage point. However, neither the BBA nor subsequent legislation specified alteration to the market basket adjustment to be used to compute payment for fiscal years beyond 2002. Payment rates for FYs since 2002 have been updated according to section 1814(i)(1)(C)(ii)(VII) of the Act, which states that the update to the payment rates for subsequent fiscal years will be the market basket percentage for the fiscal year. It has been longstanding practice to use the inpatient hospital market basket as a proxy for a hospice market basket. Historically, the rate update has been published through a separate administrative instruction issued annually in July to provide adequate time to implement system change requirements. Providers determine their payments by applying the hospice wage index in this notice to the labor portion of the published hospice rates. II. Provisions of the Proposed Rule A. Clarification of New England Deemed Counties We are taking the opportunity to address the change in the designation of ‘‘New England deemed counties,’’ which are listed in § 412.64(b)(1)(ii)(B). These counties were deemed to be parts of urban areas under section 601(g) of the Social Security Amendments of 1983, yet the OMB designates these counties as rural. In the FY 2008 Inpatient Prospective Payment System (IPPS) final rule, IPPS adopted the OMB designation for the pre-floor, prereclassified hospital wage index. The counties include Litchfield County, Connecticut; York County, Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire; and Newport County, Rhode Island. Of these five ‘‘New England deemed counties,’’ three (York County, Sagadahoc County, and Newport County) are also included in metropolitan statistical areas defined by OMB and are considered urban under the current IPPS labor market area definitions in § 412.64(b)(1)(ii)(A). The remaining two, Litchfield County and Merrimack County, are geographically located in areas that are considered rural under the current IPPS labor market area definitions. However, they have been previously deemed urban under the IPPS in certain circumstances as discussed below. In the FY 2008 IPPS final rule with comment period (72 FR 47130, August 22, 2007), § 412.64(b)(1)(ii)(B) was revised such that the two ‘‘New England deemed counties’’ that are still considered rural by OMB (Litchfield County, CT and Merrimack County, NH) PO 00000 Frm 00022 Fmt 4702 Sfmt 4702 24003 are no longer considered urban effective for discharges occurring on or after October 1, 2007. Therefore, these two counties are considered rural in accordance with § 412.64(b)(1)(ii)(C). However, for purposes of payment under the IPPS, acute care hospitals located within those areas are treated as being reclassified to their deemed urban area effective for discharges occurring on or after October 1, 2007 (see 72 FR 47337 through 47338). We also noted in this discussion that this policy change was limited to the ‘‘New England deemed counties’’ IPPS hospitals only, and that any change to non-IPPS provider wage indexes would be addressed in the respective payment system rules. The hospice program does not provide for such geographic reclassification as the IPPS does, and we are taking this opportunity to clarify treatment of ‘‘New England deemed counties’’ under the hospice program in this proposed rule. As discussed, our regulations at § 418.306(c) require each hospice’s labor market to be established using the most current hospital wage data available. The original hospice wage index was based on the 1981 Bureau of Labor Statistics hospital data. In 1994, a committee functioning under a process established by the Negotiated Rulemaking Act of 1990, was formed to negotiate a hospice wage index methodology that could be accepted by the industry and the government. The revised hospice wage index was based on the recommendations of the Negotiated Rulemaking Advisory Committee. This committee was established to provide advice and make recommendations to the Secretary on the hospice wage index used to adjust payment rates for hospices under the Medicare program, to reflect local differences in area wage levels. The Committee recommended that the revised hospice wage index be based on the most current available data for each fiscal year, which would be used to construct a pre-floor, pre-reclassified hospital wage index under the prospective payment system before adjustments were made to take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and (d)(10) of the Act, as well as each hospice’s labor market area as established by OMB. The reason the unadjusted hospital wage data were recommended was to avoid further reductions in certain rural statewide wage index values that would result from reclassification. The recommendations are codified in E:\FR\FM\01MYP1.SGM 01MYP1 24004 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules rfrederick on PROD1PC67 with PROPOSALS § 418.306(c) of our regulations; however, there is no reference to § 412.64. In other words, while § 412.64 is not explicitly noted, the hospice program has used the urban definition in § 412.64(b)(1)(ii)(A) and (B), and the rural definition as any area outside of an urban area in § 412.64(b)(1)(ii)(C). Historical changes to the labor market area/geographic classifications and annual updates to the hospice wage index values have been made effective October 1 each year. When we established the hospice wage index values effective October 1, 2007 through September 30, 2008, we considered the ‘‘New England deemed counties’’ (including Litchfield County, CT and Merrimack County, NH) as urban for FY 2008 in accordance with the definitions of urban and rural areas in the FY 2008 hospice final rule (72 FR 50216). Therefore, Litchfield County was listed as one of the constituent counties of urban CBSA 25540 (Hartford-West Hartford-East Hartford, CT), and Merrimack County was listed as one of the constituent counties of urban CBSA 31700 (Manchester-Nashua, NH) (72 FR 50236 and 50239, respectively). As noted above, the terms ‘‘rural’’ and ‘‘urban’’ areas are defined in IPPS according to the definitions of those terms in § 412.64(b)(1)(ii)(A) through (C). Litchfield county, CT and Merrimack county, NH are considered rural areas for hospital IPPS purposes in accordance with § 412.64. Under this proposal, effective October 1, 2008, Litchfield county, CT would no longer be considered part of urban CBSA 25540 (Hartford-West Hartford-East Hartford, CT), and Merrimack County, NH would no longer be considered part of urban CBSA 31700 (Manchester-Nashua, NH). Rather, these counties would be considered to be rural areas within their respective states under the hospice payment system. This proposed policy is consistent with our policy of not taking into account IPPS geographic reclassifications in determining payments under the hospice wage index. We propose to amend § 418.306(c) to cross-reference to the definitions of urban and rural in the IPPS regulations in 42 CFR part 412 subpart D. B. Wage Data for Multi-Campus Hospitals In the 2007 IPPS final rule, we changed in the way that we treat multicampus hospital wage data in the creation of the pre-floor, pre-reclassified hospital wage index. The IPPS wage data used to determine the proposed FY 2009 hospice wage index values now apportion the wage data for multi- VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 campus hospitals located in different labor market areas (CBSAs) to the CBSAs where the campuses are located (see 72 FR 47317 through 47320). Historically, the hospice wage index is derived from the pre-floor, prereclassified hospital wage index. Consequently, for this proposed rule we propose to continue to use the most recent available pre-floor, prereclassified hospital wage index in computing the hospice wage index. The pre-floor, pre-reclassified hospital wage index values for the following CBSAs are affected by this change in how wage data from multi-campus hospitals are used in the computation of the pre-floor, pre-reclassified hospital wage index: Boston-Quincy, MA (CBSA 14484), Providence-New Bedford-Falls River, RI–MA (CBSA 39300), ChicagoNaperville-Joliet, IL (CBSA 16974) and Lake-County-Kenosha County, IL–WI (CBSA 29404). C. FY 2009 Hospice Wage Index With Phase-Out of the Budget Neutrality Adjustment Factor (BNAF) [If you choose to comment on issues in this section, please include the caption, ‘‘FY 2009 Hospice Wage Index with Phase-out of the Budget Neutrality Adjustment Factor (BNAF)’’ at the beginning of your comments.] 1. Background The hospice final rule published in the Federal Register on December 16, 1983 (48 FR 56008) provided for adjustment to hospice payment rates to reflect differences in area wage levels. We apply the appropriate hospice wage index value to the labor portion of the hospice payment rates based on the geographic area where hospice care was furnished. As noted earlier, each hospice’s labor market area is based on definitions of Metropolitan Statistical Areas (MSAs) issued by the OMB. For FY 2009, we propose to again use a prefloor, pre-reclassified hospital wage index based solely on the CBSA designations. As noted above, our hospice payment rules utilize the wage adjustment factors used by the Secretary for purposes of section 1886(d)(3)(E) of the Act for hospital wage adjustments. We are proposing again to use the pre-floor and pre-reclassified hospital wage index data to adjust the labor portion of the hospice payment rates based on the geographic area where the beneficiary receives hospice care. We believe the use of the pre-floor, pre-reclassified hospital wage index data results in the appropriate adjustment to the labor portion of the costs. For the FY 2009 update to hospice payment rates, we PO 00000 Frm 00023 Fmt 4702 Sfmt 4702 propose to continue to use the most recent pre-floor, pre-reclassified hospital wage index available at the time of publication. 2. Areas Without Hospital Wage Data In adopting the CBSA designations, we identified some geographic areas where there are no hospitals, and thus no hospital wage data on which to base the calculation of the hospice wage index. These areas were described in section I.B.4 of this proposed rule. Beginning in FY 2006, we adopted a policy that, for urban labor markets without an urban hospital from which a pre-floor, pre-reclassified hospital wage index can be derived, all of the urban CBSA pre-floor, pre-reclassified hospital wage index values within the State would be used to calculate a statewide urban average pre-floor, pre-reclassified hospital wage index to use as a reasonable proxy for these areas. Currently, the only CBSA that would be affected by this policy is CBSA 25980, Hinesville, Georgia. We propose to continue this policy for FY 2009. Currently, the only rural areas where there are no hospitals from which to calculate a pre-floor, pre-reclassified hospital wage index are Massachusetts and Puerto Rico. In August 2007 (72 FR 50217) we adopted the following methodology for imputing rural prefloor, pre-reclassified hospital wage index values for areas where no hospital wage data are available as an acceptable proxy. We imputed an average pre-floor, pre-reclassified hospital wage index value by averaging the pre-floor, prereclassified hospital wage index values from contiguous CBSAs as a reasonable proxy for rural areas with no hospital wage data from which to calculate a prefloor, pre-reclassified hospital wage index. In determining an imputed rural pre-floor, pre-reclassified hospital wage index, we define ‘‘contiguous’’ as sharing a border. For Massachusetts, rural Massachusetts currently consists of Dukes and Nantucket Counties. We determined that the borders of Dukes and Nantucket counties are ‘‘contiguous’’ with Barnstable and Bristol counties. We are again proposing to apply this methodology for imputing a rural pre-floor, pre-reclassified hospital wage index for those rural areas without rural hospital wage data in FY 2009. However, as we noted in our final rule at 72 FR 50218, we do not believe that this policy is appropriate for Puerto Rico. We noted that there are sufficient economic differences between the hospitals in the United States and those in Puerto Rico, including the fact that hospitals in Puerto Rico are paid on E:\FR\FM\01MYP1.SGM 01MYP1 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules rfrederick on PROD1PC67 with PROPOSALS blended Federal/Commonwealthspecific rates, to make a separate distinct policy for Puerto Rico necessary. For FY 2009, we again propose to continue to use the most recent pre-floor, pre-reclassified hospital wage index value available for Puerto Rico, which is 0.4047. This prefloor, pre-reclassified hospital wage index value is then adjusted upward by the hospice floor in the computing of the proposed FY 2009 hospice wage index. 3. Phase-Out of the Budget Neutrality Adjustment Factor (BNAF) As noted in section 1.B of this proposed rule, the current hospice wage index methodology was developed through a negotiated rule making process and implemented in 1997. The rule making committee sought to address the inaccuracies in the original Bureau of Labor Statistics (BLS)-based hospice wage index, account better for disparities from one geographic location to another, and develop a wage index that would be as accurate, reliable and equitable as possible. The resulting hospice wage index reflects a special adjustment (a BNAF) to ensure payments in the aggregate are budget neutral to payments using the original 1983 hospice wage index. The adjustment, still in place today, results in providers currently receiving about 4 percent more in payments than they would receive if the adjustment factor were not applied. The rationale for maintaining this adjustment is outdated given the time that has elapsed since it was put into place and the growth that is occurring in the hospice benefit. In this section, we propose to phase-out this adjustment over 3 years, reducing it by 25 percent in FY 2009, by an additional 50 percent for a total of 75 percent in FY 2010, and eliminating it completely in FY 2011. We also provide our rationale for the phase-out. As discussed in section I.B of this proposed rule, the original hospice wage index was based on the 1981 Bureau of Labor Statistics (BLS) hospital data and had not been updated since 1983. During earlier attempts to update the hospice wage index, the hospice industry raised concerns over the adverse financial impact of a new wage index on individual hospices and a possible overall reduction in Medicare payments. Thus, the result was that in the absence of agreement on a new wage index, we continued to use a wage index that was clearly obsolete for geographically adjusting Medicare hospice payments (see ‘‘Medicare Program; Notice Containing the Statement Drafted by the Committee VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 Established to Negotiate the Wage Index to be Used to Adjust Hospice Payment Rates Under Medicare,’’ November 29, 1995, 60 FR 61264). Changing to a new but more accurate wage index would result in some areas gaining as their wage index value would increase, but in other areas seeing declines in payments as their wage index value dropped. In 1994 we noted that a majority of hospices would have their wage index reduced with the new wage index based on using the pre-floor, pre-reclassified hospital wage index. These reductions would have occurred for two key reasons: (1) Hospices were located in areas where the original hospice wage index was artificially high due to flaws in the 1981 BLS data, and (2) hospices were located in areas where wages had gone down relative to other geographic areas (see ‘‘Hospice Services Under Medicare Program: Intent to Form Negotiated Rulemaking Committee,’’ October 14, 1994, 59 FR 52130). Because of the negative impact to certain areas that was expected with the change to a new wage index, a committee was formulated in 1994, under the process established by the Negotiated Rulemaking Act of 1990 (Pub. L. 101–648). The Committee was established to negotiate the hospice wage index methodology rather than to go through the usual rulemaking process. On September 4, 1996, we published a proposed rule (61 FR 46579) in which we proposed a methodology to update the hospice wage index used to adjust Medicare hospice payment rates. In formulating the provisions of that proposed rule, the Committee considered criteria in evaluating the available data sources. The need for fundamental equity of the wage index; data that reflected actual work performed by hospice personnel; compatibility with wage indexes used by CMS for other Medicare providers; and availability of the data for timely implementation were considered. The Committee agreed that the hospice wage index be derived from the 1993 hospital cost report data and that these data, prior to reclassification, would form the basis for the FY 1997 hospice wage index. That is the prefloor, pre-reclassified hospital wage index would not be adjusted to take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act. The methodology is codified in § 418.306(c). The hospice wage index for subsequent years would be based on pre-floor, pre-reclassified hospital wage index data for a subsequent year. PO 00000 Frm 00024 Fmt 4702 Sfmt 4702 24005 The Committee was also concerned that while some hospices would see increases, use of the pre-floor, prereclassified hospital wage index as the wage index for hospices would result in a net reduction in aggregate Medicare payments for hospices. As noted above, a majority of hospices would have had their wage index lowered by using the new wage index because the prior hospice wage indices were based on outdated data which were artificially high due to flaws in the 1981 BLS data, and because some hospices were located in areas where wages had gone down relative to other geographic areas. The reduction in overall Medicare payments if a new wage index were adopted was noted in the November 29, 1995 final rule (60 FR 61264). Therefore, the Committee also decided that, each year in updating the hospice wage index, aggregate Medicare payments to hospices would remain budget neutral to payments as if the 1983 wage index had been used. As decided upon by the Hospice Wage Index Negotiated Rulemaking Committee, budget neutrality means that, in a given year, estimated aggregate payments for Medicare hospice services using the updated hospice values will equal estimated payments that would have been made for these services if the 1983 hospice wage index values had remained in effect, after adjusting the payment rates for inflations. Being budget neutral does not take into account annual market basket updates to hospice payment rates. Therefore, although payments to individual hospice programs may change each year, the total payments each year to hospices would not be affected by using the updated hospice wage index because total payments would be budget neutral as if the 1983 wage index had been used. To implement this provision a BNAF would be computed and applied annually. The BNAF is calculated by computing estimated payments using the most recent completed year of hospice claims data. The units (days or hours) from those claims are multiplied by the updated hospice payment rates to calculate estimated payments. The updated hospice wage index values are then applied to the labor portion of the payments. For this proposed rule, that means estimating payments for FY 2009 using FY 2006 hospice claims data, and applying the estimated updated FY 2009 hospice payment rates (updating the FY 2008 rates by the estimated FY 2009 market basket update). The proposed FY 2009 hospice wage index values are then applied to the labor portion only. The procedure is repeated using the E:\FR\FM\01MYP1.SGM 01MYP1 rfrederick on PROD1PC67 with PROPOSALS 24006 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules same claims data and payment rates, but using the 1983 BLS-based wage index instead of the updated pre-floor, prereclassified hospital wage index. The total payments are then compared, and the adjustment required to make total payments equal is computed; that adjustment factor is the BNAF. In 1998, the BNAF increased all wage index values by just over 2 percent. All pre-floor, pre-reclassified hospital wage index values of 0.8 or greater would be adjusted by the BNAF. Also, all pre-floor, pre-reclassified hospital wage index values below 0.8 would receive the greater of the following: (1) A 15-percent increase subject to a maximum hospice wage index value of 0.8; or (2) an adjustment by the BNAF. All hospice wage index values of 0.8 or greater would be adjusted by the BNAF. The BNAF would be calculated and applied annually. While the Committee sought to adopt a wage index methodology that would be as accurate, reliable, and equitable as possible, the Committee also decided to incorporate a BNAF into the calculation of the hospice wage index that would otherwise apply in order to mitigate adverse financial impacts some hospices would experience through a decrease in their wage index value by transitioning to a pre-floor, pre-reclassified hospital wage index. In the August 8, 1997 final rule (62 FR 42860), we indicated that the annual updates of the hospice wage index values would be made in accordance with the methodology agreed to by the rulemaking committee. We also noted that in the event that if we decide to change this methodology by which the hospice wage index is computed, it would be reflected in a proposed rule published in the Federal Register. In this proposed rule, we now propose to change this methodology. In FY 1998, the BNAF was 1.020768; in FY 2008 it was 1.066671. In other words, any pre-floor, pre-reclassified hospital wage index value greater than 0.8 was increased by over 2 percent in FY 1998 and increased by almost 7 percent in FY 2008. In FY 2008, this adjustment resulted in hospice providers receiving about 4 percent more in payments than they would have received if the BNAF had not been applied. The negotiating committee also recommended that the transition to the new hospice wage index occur over 3 years, from FY 1998 to FY 2001. The intent of both the three year transition and the budget neutrality adjustment was to mitigate the negative financial impact to many hospices resulting from the wage index change. Additionally, VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 the committee sought to ensure that access to hospice care was not jeopardized as a result of the wage index change. We believe that the rationale for maintaining this adjustment is outdated for several reasons. First, the original purpose of the BNAF was to prevent reductions in payments to the majority of hospices whose wage index was based on the original hospice wage index which was artificially high due to flaws in the 1981 BLS data. While incorporating a BNAF into hospice wage indices could be rationalized in 1997 as a way to smooth the transition from an old wage index to a new one, since hospices have had plenty of time to adjust to the new wage index, it is difficult to justify maintaining in perpetuity a BNAF which was in part compensating for artificially high data to begin with. Second, the new wage index adopted in 1997 resulted in increases in wage index values for hospices in certain areas. The BNAF applies to hospices in all areas. Thus, hospices in areas that would have had increases without the BNAF received an artificial boost in the wage index for the past 11 years. We believe that continuation of this excess payment can no longer be justified. Third, an adjustment factor that is based on 24-year old wage index values is contrary to our goal of using a hospice wage index that is as accurate, reliable and equitable as possible in accounting for geographic variation in wages. We believe that those goals can be better achieved by using the pre-floor, prereclassified hospital wage index, without an outdated BNAF, consistent with other providers. For instance, Medicare payments to home health agencies, that utilize a similar labor mix, are adjusted by the pre-floor, prereclassified hospital wage index, without any budget neutrality adjustment. We believe that using the unadjusted pre-floor, pre-reclassified hospital wage index provides a good measure of area wage differences for both these home-based reimbursement systems. Fourth, in the 13 years since concerns about the impact of switching from an old to a new wage index were voiced, the hospice industry and hospice payments have grown substantially. Hospice expenditures in 2006 were $9.2 billion, compared to about $2.2 billion in 1998, a growth rate of almost 20 percent per year. Aggregate hospice expenditures are increasing at a rate of about $1 billion per year. MedPAC projects that expenditures will continue to grow at a rate of 9 percent per year through 2015, outpacing the growth rate PO 00000 Frm 00025 Fmt 4702 Sfmt 4702 of projected expenditures for hospitals, skilled nursing facilities, and physician and home health services. We believe that this growth in Medicare spending for hospice indicates that the original rationale of the BNAF, to cushion the impact of using the new wage index, is no longer justified. These spending growth figures also indicate that any negative financial impact to the hospice industry as a result of eliminating the BNAF is no longer present, and thus the need for a transitional adjustment has passed. Fifth, 13 years ago the industry also voiced concerns about the negative financial impact on individual hospices that could occur by adopting a new wage index. In August 1994 there were 1,602 hospices; currently there are 2,986 hospices. Clearly any negative financial impact from adopting a new wage index in 1997 is no longer present, or we would not have seen an 86 percent increase in the number of hospices since 1994. The number of Medicare-certified hospices has continued to increase, with a 26 percent increase in the number of hospice providers from 2001 to 2005. This ongoing growth in the industry also suggests that phasing out the BNAF would not have a negative impact on access to care. Therefore for these reasons, we believe that continuing to apply a BNAF for the purpose of mitigating any adverse financial impact on hospices or negative impact on access to care is no longer necessary. We are proposing to phase out the BNAF over a 3-year period, reducing the BNAF by 25 percent in FY 2009, by 75 percent in FY 2010, and eliminating it in FY 2011. We believe that the proposed 3-year phaseout period will reduce any adverse financial impact that the industry might experience if we eliminated the BNAF in a single year. However, depending on the comments received, updated data, and subsequent analysis, for the final rule we may determine that a different percentage reduction in the BNAF (for any of the years) or a different phase-out timeframe would be more appropriate. Specifically, it may be determined that a more aggressive phase-out alternative (e.g. a 50 percent reduction in the BNAF in FY 2009, a 75 percent reduction in the BNAF in FY 2010, and elimination of the BNAF in FY 2011) is more appropriate. Consequently, we will continue to look at reduction percentages and timeframe alternatives for the phase-out of the BNAF and, for the final rule, will implement what is determined to be the most appropriate option based on the above information. We propose to maintain the hospice floor, which offers protection to E:\FR\FM\01MYP1.SGM 01MYP1 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules rfrederick on PROD1PC67 with PROPOSALS hospices with pre-floor, pre-reclassified hospital wage index values less than 0.8. We believe that we should have addressed this issue in previous years. We believe that using the BNAF has resulted in Medicare spending for hospice services in excess of what spending should have been in the absence of such an adjustment. However, we are not proposing to reduce Medicare payments to hospices for prior years. We are only proposing to remove the application of the BNAF on a prospective basis, beginning on October 1, 2008. Section II.C.3.a below discusses the effects of phasing out the BNAF over three years using the data from the published FY 2008 hospice wage index; by basing the analysis on this data, our simulations hold claims data, the wage index values, and payment rates constant, with the only change being the reduction in the BNAF. Section II.C.3.b discusses the effects of reducing the BNAF for FY 2009 using the proposed FY 2009 hospice wage index. a. Effects of Phasing-Out the BNAF Using the Published FY 2008 Hospice Wage Index For this proposed rule, we will use the FY 2008 hospice wage index (72 FR 50214, published August 31, 2007) to illustrate the effects of phasing out the BNAF over 3 years. This analysis and discussion is for illustrative purposes only and does not affect any of the hospice wage index values for FY 2008. The BNAF that was calculated and applied to the 2007 pre-floor, prereclassified hospital wage index values was 6.6671 percent. We propose reducing the BNAF by 25 percent for FY 2009, by 75 percent for FY 2010, and eliminating it altogether for FY 2011 and beyond. A 25 percent reduction in the BNAF can be accomplished by blending 75 percent of the FY 2008 hospice wage index that applied the full 6.6671 percent BNAF with 25 percent of the FY 2008 hospice wage index that used no BNAF. This is mathematically equivalent to taking 75 percent of the full BNAF value, or multiplying 0.066671 by 0.75, which equals 0.050003, or 5.0003 percent. The BNAF of 5.0003 percent reflects a 25 percent reduction in the BNAF. The 25 percent reduction in the BNAF of 5.0003 percent would be applied to the prefloor, pre-reclassified hospital wage index values of 0.8 or greater used in the published FY 2008 hospice wage index. The hospice floor calculation would still apply to any pre-floor, prereclassified hospital wage index values less then 0.8. Currently, the floor VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 calculation has 4 steps. Pre-floor, prereclassified hospital wage index values that are less than 0.8 are first multiplied by 1.15; second, the minimum of 0.8 or the pre-floor, pre-reclassified hospital wage index value times 1.15 is chosen as the preliminary hospice wage index value. Third, the pre-floor, prereclassified hospital wage index value is multiplied by BNAF. Finally, the greater result of either step 2 or step 3 is chosen as the final hospice wage index value. We propose to leave the hospice floor unchanged, noting that steps 3 and 4 will become unnecessary once the BNAF is eliminated. For the simulations of the BNAF phase-out for FY 2010 and FY 2011, we used the same pre-floor, pre-reclassified hospital wage index values and claims data as the example above, and simply changed the value of the BNAF to reflect either a 75 percent reduction for FY 2010 or a 100 percent reduction for FY 2011. In both cases we started with the full BNAF of 6.6671 percent. We changed the calculation to take 25 percent of the full BNAF to reflect a 75 percent reduction for FY 2010, or eliminated the BNAF altogether to reflect a 100 percent reduction for FY 2011. For FY 2010, the reduced BNAF or the hospice floor was then applied to the 2008 pre-floor, pre-reclassified hospital wage index as described previously. For FY 2011 and subsequent years, the pre-floor, pre-reclassified hospital wage index values would be unadjusted unless they are less than 0.8, in which case the hospice floor calculation would be applied. For our simulations, the calculations of the BNAF are as follows: • A 75 percent reduction to the BNAF in FY 2010 would be 0.066671 × 0.25 = 0.016668 or 1.6668 percent • A 100 percent reduction or elimination of the BNAF in FY 2011 would be 0.066671 × 0.0 = 0.0 or 0 percent We examined the effects of phasing out the BNAF versus using the full BNAF of 6.6671 percent on the FY 2008 hospice wage index. The FY 2009 BNAF reduction of 25 percent resulted in approximately a 1.55 to 1.57 percent reduction in the hospice wage index value. The FY 2010 BNAF reduction of 75 percent would result in an estimated additional 3.12 to 3.13 percent reduction from the FY 2009 hospice wage index values. The elimination of the BNAF in FY 2011 would result in an estimated final reduction of the FY 2011 hospice wage index values of approximately 1.55 to 1.57 percent compared to FY 2010 hospice wage index values. PO 00000 Frm 00026 Fmt 4702 Sfmt 4702 24007 Those CBSAs whose pre-floor, prereclassified hospital wage index values had the hospice floor calculation applied prior to the BNAF reduction would not be affected by this proposed phase-out of the BNAF. These CBSAs, which typically include rural areas, are protected by the hospice floor calculation. Additionally, those CBSAs whose hospice wage index values were previously 0.8 or greater after the BNAF was applied, but which would have values less than 0.8 after the reduced BNAF was applied would see a smaller reduction in their hospice wage index values since the hospice floor calculation would apply. We have estimated the number of CBSAs that would have their pre-floor, prereclassified hospital wage index value eligible for the floor calculation after applying the 25, 75, and 100 percent reductions in the BNAF. Three CBSAs would be affected by the 25 percent reduction, 12 would be affected by the 75 percent reduction, and 22 would be affected by the 100 percent reduction. Because of the protection given by the hospice floor calculation, these CBSAs would see smaller percentage decreases in their hospice wage index values than those CBSAs that are not eligible for the floor calculation. This will benefit those hospices with lower hospice wage index values, which are typically in rural areas. Finally, the hospice wage index values only apply to the labor portion of the payment rates; the labor portion was described in Section I.B.1 of this proposed rule. Therefore the estimated reduction in payments due to this proposed phase-out of the BNAF would be less than the percentage reductions to the hospice wage index values that would result from reducing or eliminating the BNAF. In addition, the effects of the proposed phase-out of the BNAF could also be mitigated by a hospital market basket update in payments, which in FY 2008 was a 3.3 percent increase in payment rates. We will not have the final market basket update for FY 2009 until the summer, but the current estimate of the hospital market basket update is expected to be around 3.0 percent. This update will be communicated through an administrative instruction and not through rulemaking. The estimated effects on payment described in column 5 of Table 1 in section IV.B of this proposed rule include the projected effect of an estimated 3.0 percent hospital market basket update. CMS may implement updates to the payment rates in future rulemaking. E:\FR\FM\01MYP1.SGM 01MYP1 rfrederick on PROD1PC67 with PROPOSALS 24008 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules b. Effects of Phasing-Out the BNAF Using the Updated Pre-floor, Prereclassified Hospital Wage Index Data (FY 2009 Proposal) For FY 2009, we propose updating the hospice wage index using the 2008 prefloor, pre-reclassified hospital wage index and the most complete claims data available (FY 2006 claims). Using these data, we computed a full BNAF of 6.5357 percent. For the first year of the BNAF phase-out (FY 2009), the BNAF would be reduced by 25 percent, or 0.065357 × 0.75 = 0.049018, to 4.9018 percent. This would decrease hospice wage index values by approximately 1.53 to 1.54 percent from wage index values with the full BNAF applied. As noted in the previous discussion on the effects of the BNAF reduction in the published FY 2008 hospice wage index, those CBSAs which already have prefloor, pre-reclassified hospital wage index values that have the hospice floor applied prior to implementing a proposed BNAF reduction would be completely unaffected by this proposed BNAF reduction. Those CBSAs which previously had hospice wage index values above 0.8 after applying the full BNAF, but which now are below 0.8 with the 25 percent reduction in the BNAF would be less affected by the BNAF reduction than those CBSAs which are 0.8 or above after applying the BNAF, as they are protected by the hospice floor calculation. Additionally, as mentioned in section I.B.1 of this proposed rule, the final hospice wage index is only applied to the labor portion of the payment rates, so the actual effect on estimated payment would be less than the anticipated 1.53 to 1.54 percent reduction in the hospice wage index value. Furthermore, that effect may be mitigated by a market basket update. As noted earlier, the market basket update will not be available until the summer, but estimates of the update are at about 3.0 percent. Column 3 of Table 1 (section IV of this proposed rule) shows the impact of using the most recent wage index data (the 2008 pre-floor, pre-reclassified hospital wage index not including any reclassification under section 1886(d)(8)(B) of the Act) compared to the 2007 pre-floor, pre-reclassified hospital wage index data which was used to derive the FY 2008 hospice wage index. Column 4 of Table 1 in Section IV of this proposed rule shows the impact of incorporating the 25 percent reduction in the BNAF in the proposed FY 2009 hospice wage index along with using the most recent wage index data (2008 pre-floor, pre- VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 reclassified hospital wage index). Finally, column 5 of Table 1 shows the combined effects of using the updated pre-floor, pre-reclassified hospital wage index, the 25 percent reduced BNAF, and an estimated market basket update of 3.0 percent. The proposed FY 2009 rural and urban hospice wage indexes can be found in Addenda A and B of this proposed rule. The pre-floor, prereclassified hospital wage index values were adjusted by the 25 percent reduced BNAF or by the hospice floor. D. Summary of the Provisions of the Proposed Rule • We propose to clarify that the hospice benefit will follow the definition of ‘‘urban’’ specified in § 412.64(b)(1)(ii)(A) and (B), and the rural definition as any area outside of an urban area in § 412.64(b)(1)(ii)(C). The regulatory text of § 418.306(c) will be amended to reference § 412.64(b)(1)(ii)(A) through (C). This affects two New England ‘‘deemed’’ counties that meet the OMB definition of rural, but were previously counted as urban; these two counties would now be considered rural. See section II.A of this proposed rule for details. • As a basis for the hospice wage index, we propose to continue to use the pre-floor, pre-reclassified hospital wage index, which includes a change to how wage data from multi-campus hospitals are apportioned. See section II.B of this proposed rule for more details. • We propose to continue to use a pre-floor, pre-reclassified hospital wage index based solely on the CBSA designations, using the most recent prefloor and pre-reclassified hospital wage index available at the time of publication. See section II.C.1 of this proposed rule for details. • We propose to continue the policy that for urban labor markets without an urban hospital from which a pre-floor, pre-reclassified hospital wage index could be derived, all of the urban CBSA pre-floor, pre-reclassified hospital wage index values within the State would be used to calculate a statewide urban average pre-floor, pre-reclassified hospital wage index to use as a reasonable proxy for these areas. See section II.C.2 of this proposed rule for details. • We propose to continue the policy that we impute an average pre-floor, pre-reclassified rural hospital wage index value by averaging the pre-floor, pre-reclassified hospital wage index values from contiguous CBSAs as a reasonable proxy for rural areas with no hospital wage data from which to calculate a pre-floor, pre-reclassified PO 00000 Frm 00027 Fmt 4702 Sfmt 4702 hospital wage index. See section II.C.2 f of this proposed rule or details. • We propose to continue to utilize the most recent pre-floor, prereclassified hospital wage index value available for Puerto Rico. See section II.C.2 of this proposed rule for details. • We propose to phase-out the hospice BNAF over 3 years, reducing it by 25 percent for FY 2009, by 75 percent for FY 2010, and eliminating it completely for FY 2011. See sections II.C.3.a and II.C.3.b of this proposed rule for details. As stated in section II.C.3, based on comments received, updated data, and subsequent analysis, for the final rule we may determine that a different percentage reduction in the BNAF (for any of the years) or a different phase-out timeframe would be more appropriate. Specifically, it may be determined that a more aggressive alternative (e.g., a 50 percent reduction in the BNAF in FY 2009, a 75 percent reduction in the BNAF in FY 2010, and elimination of the BNAF in FY 2011) is more appropriate. Consequently, we will continue to look at reduction percentages and time period alternatives for the phase-out of the BNAF and, for the final rule, will implement what is determined to be the most appropriate option based on the above information. • We propose to continue to maintain the hospice floor calculation. See section II.C.3 of this proposed rule for details. Addendum A reflects the proposed FY 2009 hospice wage index values for urban areas designations. Addendum B reflects the proposed FY 2009 hospice wage index values for rural areas designations. III. Collection of Information Requirements This document does not impose any information collection and recordkeeping requirements. Consequently, it does not need to be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 35). IV. Regulatory Impact Analysis A. Overall Impact We have examined the impacts of this 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 (Pub. L. 104–4), Executive Order 13132 on Federalism, and the Congressional Review Act (5 U.S.C. 804(2)). We E:\FR\FM\01MYP1.SGM 01MYP1 rfrederick on PROD1PC67 with PROPOSALS Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules estimated the impact on hospices, as a result of the changes to the proposed FY 2009 hospice wage index and of reducing the BNAF by 25 percent. As discussed previously, the methodology for computing the hospice wage index was determined through a negotiated rulemaking committee and implemented in the August 8, 1997 final rule (62 FR 42860). This rule proposes updates to the hospice wage index in accordance with our regulation but proposes to revise the Negotiated Rulemaking Committee methodology of including a BNAF. Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibility of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits including potential economic, environmental, public health and safety effects, distributive impacts, and equity. A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). We have determined that this proposed rule is an economically significant rule under this Executive Order. Column 4 of Table 1 shows the combined effects of the proposed 25 percent reduction in the BNAF and of the updated wage data, comparing estimated payments for FY 2009 to estimated payments for FY 2008. We estimate that the total hospice payments for FY 2009 will decrease by $100 million as a result of the application of the 25 percent reduction in the BNAF and the updated wage data. This estimate does not take into account any market basket update, which is currently forecast to be about 3.0 percent. The final market basket update will not be available until some time later this year and will be communicated through an administrative instruction. The estimated effect of a 3.0 percent forecasted market basket update on payments to hospices is approximately $280 million. If we were to take into account an estimated 3.0 percent market basket update, in addition to the 25 percent reduction in the BNAF and the updated wage data, it is estimated that hospice payments would increase by approximately $180 million ($280 million ¥ $100 million = $180 million). The percent change in payments to hospices due to the combined effects of the 25 percent reduction in the BNAF, the updated wage data, and the estimated market basket update of 3.0 VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 percent is reflected in column 5 of the impact table (Table 1). The RFA requires agencies to analyze options for regulatory relief of small businesses, if a rule has a significant impact on a substantial number of small entities. The great majority of hospices and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of less than $6.5 million to $31.5 million in any one year (for details, see the Small Business Administration’s regulation at 65 FR 69432, that sets forth size standards for health care industries). As indicated in Table 1 below, there are 2,986 hospices as of February 2008. Approximately 52.7 percent of Medicare certified hospices are identified as voluntary, government, or other agencies and, therefore, are considered small entities. Most of these and most of the remainder are also small hospice entities because their revenues fall below the SBA size thresholds. We note that the hospice wage index methodology was previously guided by consensus, through a negotiated rulemaking committee that included representatives of national hospice associations, rural, urban, large and small hospices, multisite hospices, and consumer groups. Based on all of the options considered, the committee agreed on the methodology described in the committee statement, and after notice and comment, it was adopted into regulation in the August 8, 1997 final rule. In developing the process for updating the hospice wage index in the 1997 final rule, we considered the impact of this methodology on small hospice entities and attempted to mitigate any potential negative effects. Small hospice entities are more likely to be in rural areas, which are less affected by the BNAF reduction than entities in urban areas. Generally, hospices in rural areas are protected by the hospice floor, which mitigates the effect of the BNAF reduction. The effects of this rule on hospices, as illustrated in Table 1, are small. Overall, Medicare payments to all hospices will decrease by an estimated 1.1 percent, reflecting the combined effects of the 25 percent reduction in the BNAF and the updated wage data. Within the hospice subgroups, Medicare payments will decrease by no more than 1.6 percent. Furthermore, when including the estimated market basket update of 3.0 percent into these figures, the combined effects of Medicare payment changes to all hospices will result in an increase of approximately 1.9 percent. Overall average hospice revenue effects will be slightly less than these estimates since according the PO 00000 Frm 00028 Fmt 4702 Sfmt 4702 24009 National Hospice and Palliative Care Organization, about 16 percent of hospice caseload is non-Medicare. Longstanding HHS practice in interpreting the RFA is to consider effects economically ‘‘significant’’ only if they reach a threshold of 3 to 5 percent or more. Accordingly, we have determined that this proposed rule does not create a significant economic impact on a substantial number of small entities. In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside a CBSA and has fewer than 100 beds. We have determined that this proposed rule will not have a significant impact on the operations of a substantial number of small rural hospitals. Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of about $130 million or more (the threshold in the statute, updated for inflation through 2008). This proposed rule is not anticipated to have an effect on State, local, or tribal governments or on the private sector of $130 million or more. Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. We have reviewed this proposed rule under the threshold criteria of Executive Order 13132, Federalism, and have determined that it will not have an impact on the rights, roles, and responsibilities of State, local, or tribal governments. B. Anticipated Effects This section discusses the impact of the projected effects of the proposed provisions of this rule, including the estimated effects of a projected 3.0 percent market basket update that will be communicated separately through an administrative instruction. The proposed provisions include continuing to use the CBSA-based pre-floor, prereclassified hospital wage index (to include the clarification of New England ‘‘deemed’’ counties and a change in the way that multi-campus hospital wage E:\FR\FM\01MYP1.SGM 01MYP1 24010 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules data are treated in the creation of the pre-floor, pre-reclassified hospital wage index), continuing the use the same policies for treatment of areas (rural and urban) without hospital wage data, and reducing the BNAF by 25 percent for the first year of a 3-year BNAF phase-out. The proposed FY 2009 hospice wage index is based upon the 2008 pre-floor, pre-reclassified hospital wage index and the most complete claims data available (FY 2006) with a 25 percent reduction in the BNAF. For the purposes of our impacts, our baseline is estimated FY 2008 payments using the 2007 pre-floor, pre-reclassified hospital wage index. Our first comparison (column 3, Table 1) compares our baseline to estimated FY 2009 payments (holding payment rates constant) using the updated wage data (2008 pre-floor, pre-reclassified hospital wage index). Consequently, the estimated effects illustrated in column 3 of Table 1 are for the updated wage data only. The effects of using the updated pre-floor, pre-reclassified hospital wage index data combined with the 25 percent reduction in the BNAF are illustrated in column 4 of Table 1. Even though the market basket update is not part of this proposed rule, we have included a comparison of the combined effects of the 25 percent BNAF reduction, the updated pre-floor, pre-reclassified hospital wage index, and an estimated 3.0 percent market basket increase for FY 2009 (Table 1, column 5). Presenting this data gives the hospice industry a more complete picture of the effects of the proposed changes in this rule and the market basket update. Certain events may limit the scope or accuracy of our impact analysis, because such an analysis is susceptible to forecasting errors due to other changes in the forecasted impact time period. The nature of the Medicare program is such that the changes may interact, and the complexity of the interaction of these changes could make it difficult to predict accurately the full scope of the impact upon hospices. TABLE 1.—ANTICIPATED IMPACT ON MEDICARE HOSPICE PAYMENTS OF REDUCING THE BNAF, UPDATING THE PREFLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX DATA, AND APPLYING AN ESTIMATED 3.0 PERCENT MARKET BASKET UPDATE FOR THE PROPOSED FY 2009 HOSPICE WAGE INDEX, COMPARED TO THE PUBLISHED FINAL FY 2008 HOSPICE WAGE INDEX (1) rfrederick on PROD1PC67 with PROPOSALS Number of routine home care days in thousands (2) 15:14 Apr 30, 2008 Jkt 214001 Percent change in payments due to the combined effects of the 25% reduction in the BNAF, the updated wage data (FY 2009 Proposed Wage Index), and estimated market basket update (3.0%) (5) (3) ALL HOSPICES ................................................. URBAN HOSPICES .................................... RURAL HOSPICES .................................... BY REGION—URBAN: NEW ENGLAND ......................................... MIDDLE ATLANTIC .................................... SOUTH ATLANTIC ..................................... EAST NORTH CENTRAL ........................... EAST SOUTH CENTRAL ........................... WEST NORTH CENTRAL .......................... WEST SOUTH CENTRAL .......................... MOUNTAIN ................................................. PACIFIC ...................................................... PUERTO RICO ........................................... BY REGION—RURAL: NEW ENGLAND ......................................... MIDDLE ATLANTIC .................................... SOUTH ATLANTIC ..................................... EAST NORTH CENTRAL ........................... EAST SOUTH CENTRAL ........................... WEST NORTH CENTRAL .......................... WEST SOUTH CENTRAL .......................... MOUNTAIN ................................................. PACIFIC ...................................................... PUERTO RICO ........................................... ROUTINE HOME CARE DAYS: 0–3499 DAYS (small) ................................. 3500–19,999 DAYS (medium) .................... 20,000+ DAYS (large) ................................ TYPE OF OWNERSHIP: VOLUNTARY .............................................. PROPRIETARY .......................................... GOVERNMENT .......................................... OTHER ....................................................... HOSPICE BASE: FREESTANDING ........................................ HOME HEALTH AGENCY ......................... HOSPITAL .................................................. VerDate Aug<31>2005 Percent change in payments due to the combined effects of the 25% reduction in the BNAF and the updated wage data (FY 2009 Proposed Wage Index) (4) Number of hospices* Percent change in payments due to the effects of the updated wage data (FY 2009 Proposed Wage Index) PO 00000 2,986 1,996 990 61,351 52,642 8,709 ¥0.1 ¥0.1 ¥0.1 ¥1.1 ¥1.1 ¥0.9 1.9 1.8 2.1 113 201 288 296 160 152 339 183 230 34 1,787 5,250 11,388 7,638 4,365 3,413 7,131 4,543 6,330 797 0.3 ¥0.5 ¥0.1 ¥0.3 ¥0.4 0.0 ¥0.2 0.0 0.8 ¥1.1 ¥0.8 ¥1.6 ¥1.1 ¥1.4 ¥1.3 ¥1.0 ¥1.2 ¥1.1 ¥0.4 ¥1.1 2.2 1.4 1.8 1.6 1.7 1.9 1.7 1.9 2.6 1.9 26 43 125 140 145 189 165 104 52 1 147 408 1,759 1,148 2,017 945 1,325 580 372 7 ¥0.4 0.3 0.0 0.0 ¥0.4 ¥0.3 ¥0.6 0.4 1.5 0.0 ¥1.4 ¥0.7 ¥0.9 ¥1.0 ¥1.1 ¥1.3 ¥0.8 ¥0.6 0.4 0.0 1.5 2.3 2.0 1.9 1.8 1.7 2.2 2.4 3.4 3.0 631 1,445 910 1,060 14,385 45,906 0.0 ¥0.1 ¥0.1 ¥0.9 ¥1.1 ¥1.1 2.0 1.9 1.9 1,194 1,412 192 188 27,185 30,017 986 3,163 ¥0.2 0.0 0.1 0.0 ¥1.2 ¥1.0 ¥0.8 ¥1.0 1.8 1.9 2.2 2.0 1,807 597 567 45,473 8,908 6,756 ¥0.1 0.0 0.0 ¥1.1 ¥1.0 ¥1.1 1.8 2.0 1.9 Frm 00029 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 24011 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules TABLE 1.—ANTICIPATED IMPACT ON MEDICARE HOSPICE PAYMENTS OF REDUCING THE BNAF, UPDATING THE PREFLOOR, PRE-RECLASSIFIED HOSPITAL WAGE INDEX DATA, AND APPLYING AN ESTIMATED 3.0 PERCENT MARKET BASKET UPDATE FOR THE PROPOSED FY 2009 HOSPICE WAGE INDEX, COMPARED TO THE PUBLISHED FINAL FY 2008 HOSPICE WAGE INDEX—Continued Number of routine home care days in thousands (1) (2) Percent change in payments due to the combined effects of the 25% reduction in the BNAF and the updated wage data (FY 2009 Proposed Wage Index) Percent change in payments due to the combined effects of the 25% reduction in the BNAF, the updated wage data (FY 2009 Proposed Wage Index), and estimated market basket update (3.0%) (4) Number of hospices* Percent change in payments due to the effects of the updated wage data (FY 2009 Proposed Wage Index) (5) (3) SKILLED NURSING FACILITY .................. 15 213 ¥0.6 ¥1.7 1.2 rfrederick on PROD1PC67 with PROPOSALS BNAF = Budget Neutrality Adjustment Factor. * As of February 2008. Table 1 shows the results of our analysis. In column 1, we indicate the number of hospices included in our analysis as of February 2008. In column 2, we indicate the number of routine home care days that were included in our analysis, although the analysis was performed on all types of hospice care. Column 3 shows the percentage change in estimated Medicare payments from FY 2008 to FY 2009 due to the effects of the updated wage data only. Column 4 shows the percentage change in estimated hospice payments from FY 2008 to FY 2009 due to the combined effects of using the 2008 pre-floor, prereclassified hospital wage index and reducing the BNAF by 25 percent. Column 5 shows the percentage change in estimated hospice payments from FY 2008 to FY 2009 due to the combined effects of using updated wage data, a 25 percent BNAF reduction, and a 3.0 percent estimated market basket update. Table 1 also categorizes hospices by various geographic and provider characteristics. The first row of data displays the aggregate result of the impact for all Medicare-certified hospices. The second and third rows of the table categorize hospices according to their geographic location (urban and rural). Our analysis indicated that there are 1,996 hospices located in urban areas and 990 hospices located in rural areas. The next two row groupings in the table indicate the number of hospices by census region, also broken down by urban and rural hospices. The next grouping shows the impact on hospices based on the size of the hospice’s program. We determined that the majority of hospice payments are made at the routine home care rate. Therefore, we based the size of each individual hospice’s program on the number of routine home care days VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 provided in FY 2006. The next grouping shows the impact on hospices by type of ownership. The final grouping shows the impact on hospices defined by whether they are provider-based or freestanding. As indicated in Table 1 below, there are 2,986 hospices. Approximately 52.7 percent of Medicare-certified hospices are identified as voluntary, government, or other agencies and, therefore, are considered small entities. Because the National Hospice and Palliative Care Organization estimates that approximately 83.7 percent of hospice patients are Medicare beneficiaries, we have not considered other sources of revenue in this analysis. As noted earlier, those CBSAs which had the hospice floor applied prior to our proposal to reduce the BNAF are unaffected by this proposed change in methodology. Those CBSAs that were not previously less than 0.8 after applying the full BNAF but which now are less than 0.8 after applying the reduced BNAF will see less of a reduction in payments as the floor protects their hospice wage index value. As stated previously, the following discussions are limited to demonstrating trends rather than projected dollars. We used the pre-floor, pre-reclassified hospital wage indexes as well as the most complete claims data available (FY 2006) in developing the impact analysis. The FY 2009 payment rates will be adjusted to reflect the full hospital market basket, as required by section 1814(i)(1)(C)(ii)(VII) of the Act. As previously noted, we publish these rates through administrative instructions rather than in a proposed rule. The FY 2008 update was 3.3 percent, and the FY 2009 update will not be available until the summer. Currently the FY 2009 update is estimated to be 3.0 PO 00000 Frm 00030 Fmt 4702 Sfmt 4702 percent; however this figure is subject to change. Since the inclusion of the effect of a market basket increase provides a more complete picture of estimated hospice payments for FY 2009, the last column of Table 1 shows the combined impacts of the 25 percent BNAF reduction, the updated wage index, and a projected 3.0 percent market basket update factor. As discussed in the FY 2006 final rule (70 FR 45129), hospice agencies may use multiple hospice wage index values to compute their payments based on potentially different geographic locations. Before January 1, 2008, the location of the beneficiary was used to determine the CBSA for routine and continuous home care and the location of the hospice agency was used to determine the CBSA for respite and general inpatient care. Beginning January 1, 2008, the hospice wage index utilized is based on the location of the site of service. As the location of the beneficiary’s home and the location of the facility may vary, there will still be variability in geographic location for an individual hospice. We anticipate that the location of the various sites will usually correspond with the geographic location of the hospice, and thus we will continue to use the location of the hospice for our analyses of the impact of the proposed changes to the hospice wage index in this rule. For this analysis, we use payments to the hospice in the aggregate based on the location of the hospice. The impact of hospice wage index changes has been analyzed according to the type of hospice, geographic location, type of ownership, hospice base, and size. Our analysis shows that most hospices are in urban areas and provide the vast majority of routine home care days. Most hospices are medium-sized E:\FR\FM\01MYP1.SGM 01MYP1 24012 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules followed by large hospices. Hospices are almost equal in numbers by ownership with 1,574 designated as non-profit and 1,412 as proprietary. The vast majority of hospices are freestanding. rfrederick on PROD1PC67 with PROPOSALS 1. Hospice Size Under the Medicare hospice benefit, hospices can provide four different levels of care days. The majority of the days provided by a hospice are routine home care (RHC) days representing about 97 percent of the services provided by a hospice. Therefore, the number of RHC days can be used as a proxy for the size of the hospice, that is, the more days of care provided, the larger the hospice. As discussed in the August 4, 2005 final rule, we currently use three size designations to present the impact analyses. The three categories are: (1) Small agencies having 0 to 3,499 RHC days; (2) medium agencies having 3,500 to 19,999 RHC days; and (3) large agencies having 20,000 or more RHC days. The proposed FY 2009 wage index values without the BNAF reduction are anticipated to have virtually no impact on small hospice providers, with a slight decrease of 0.1 percent anticipated for medium and large hospices (column 3); the proposed FY 2009 wage index values with the 25 percent BNAF reduction and the updated wage data are anticipated to decrease estimated payments by 0.9 percent to small hospices and by 1.1 percent to medium and large hospices (column 4); and finally, the proposed FY 2009 wage index values with the 25 percent BNAF reduction, the updated wage data, and the estimated 3.0 percent market basket update are projected to increase estimated payments by 2.0 percent for small hospices and by 1.9 percent for medium and large hospices (column 5). 2. Geographic Location Column 3 of Table 1 shows that FY 2009 wage index values without the BNAF reduction will result in little change in estimated payments with rural and urban hospices anticipated to experience a slight decrease of 0.1 percent. For urban hospices, the greatest increase of 0.8 percent is anticipated to be experienced by the Pacific regions, followed by an increase for New England of 0.3 percent and no change for the West North Central and Mountain regions. The remaining urban regions are anticipated to experience a decrease ranging from 0.1 percent in the South Atlantic region 1.1 percent is for Puerto Rico. Column 3 shows that for rural hospices, Puerto Rico, the South Atlantic, and the East North Central VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 regions are anticipated to experience no change. Four regions are anticipated to experience a decrease ranging from 0.3 percent for the West North Central region to 0.6 percent for West South Central region. The remaining regions are anticipated to experience an increase ranging from 0.3 percent for the Middle Atlantic region to 1.5 percent for the Pacific region. Column 4 shows the combined effect of the 25 percent BNAF reduction and the updated pre-floor, pre-reclassified hospital wage index values on estimated payments, as compared to the published FY 2008 payments. Overall urban hospices are anticipated to experience a 1.1 percent decrease in payments, while rural hospices expect a 0.9 percent decrease. The estimated percent decrease in payment for urban hospices ranged from 0.4 percent for Pacific hospices to 1.6 percent for Middle Atlantic hospices. The estimated percent decrease in payment for rural hospices ranged from 0.6 percent for Mountain hospices to 1.4 percent for New England hospices. Rural Puerto Rico’s estimated payments were unaffected, and the Pacific region saw a 0.4 percent increase in estimated payments. Column 5 shows the combined effects of the proposed FY 2009 wage index values with the 25 percent BNAF reduction, the updated wage data, and the estimated 3.0 percent market basket update on estimated payments as compared to the published FY 2008 payments. Overall, urban hospices are anticipated to experience a 1.8 percent increase in payments while rural hospices should experience a 2.1 percent increase in payments. Urban hospices are anticipated to see an increase in estimated payments ranging from 1.4 percent for the Middle Atlantic region to 2.6 percent for the Pacific region. Rural hospices are estimated to see an increase in estimated payments ranging from 1.5 percent for the New England region to 3.4 percent for the Pacific region. 3. Type of Ownership Column 3 demonstrates the effect of the updated pre-floor, pre-reclassified hospital wage index on FY 2009 estimated payments versus FY 2008 estimated payments. We anticipate that using the updated pre-floor, prereclassified hospital wage index data will have no effect on proprietary hospices. While we estimate a slight decrease in estimated payments for voluntary (non-profit) hospices (0.2 percent), other hospices are expected to experience no effect and government hospices are expected to experience a PO 00000 Frm 00031 Fmt 4702 Sfmt 4702 slight increase in payments (0.1 percent). Column 4 demonstrates the combined effects of using updated pre-floor, prereclassified hospital wage index data and of incorporating a 25 percent BNAF reduction. Estimated payments to proprietary hospices are anticipated to decrease by 1.0 percent, while voluntary (non-profit), other, and government hospices are anticipated to experience decreases of 1.2 percent, 1.0 percent, and 0.8 percent, respectively. Column 5 shows the combined effects of the updated pre-floor, pre-reclassified hospital wage index values with the 25 percent BNAF reduction, the updated wage data, and the estimated 3.0 percent market basket update on estimated payments, comparing FY 2009 to FY 2008. Estimated FY 2009 payments are anticipated to increase for all hospices, regardless of ownership type. Estimated payments are forecast to increase from 1.8 percent for voluntary hospices to 2.2 percent for government hospices. 4. Hospice Base Column 3 demonstrates the effect of using the updated pre-floor, prereclassified hospital wage index values, comparing estimated payments for FY 2009 to FY 2008. Estimated payments are anticipated to decrease by 0.1 percent for freestanding facilities and by 0.6 percent for skilled nursing facilities. Home health and hospital based facilities are anticipated to experience no change in estimated payments. Column 4 shows the combined effects of reducing the BNAF by 25 percent and updating the pre-floor, pre-reclassified hospital wage index values, comparing FY 2009 to FY 2008 estimated payments. Skilled nursing facility based hospices are estimated to see a 1.7 percent decline, while hospital based hospices and freestanding hospices are each anticipated to experience a 1.1 percent decrease in payments. Home health agency based hospices are expected to experience a 1.0 percent decrease. Column 5 shows the combined effects of the 25 percent BNAF reduction, the updated pre-floor, pre-reclassified hospital wage index, and the estimated 3.0 percent market basket update on estimated payments, comparing FY 2009 to FY 2008. Estimated increases in payments range from 1.2 percent for skilled nursing facility based hospices to 2.0 percent for home health agency based hospices. We note that the President’s budget includes a proposal for a zero percent payment update for hospices in FY 2009. The impacts outlined in Column 5 of Table 1 in this proposed rule, E:\FR\FM\01MYP1.SGM 01MYP1 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules which include the effects of a 3.0 percent market basket update, would need to change in the final rule to reflect any legislation that the Congress might enact which would affect the market basket update. TABLE 2.—ACCOUNTING STATEMENT: § 418.306 Determination of payment rates. * * * * CLASSIFICATION OF ESTIMATED EX- * PENDITURES, FROM FY 2008 TO FY (c) Each hospice’s labor market is 2009 [IN MILLIONS]—Continued determined based on definitions of As required by OMB Circular A–4 (available at https:// www.whitehouse.gov/omb/circulars/ a004/a-4.pdf), in Table 2 below, we have prepared an accounting statement showing the classification of the expenditures associated with the proposed provisions of this rule. This table provides our best estimate of the decrease in Medicare payments under the hospice benefit as a result of the changes presented in this proposed rule on data for 2,086 hospices in our database. All expenditures are classified as transfers to Medicare providers (that is, hospices). Category Transfers From Whom to Whom C. Accounting Statement Federal Government to Hospices. *The $100 million reduction in transfers includes the 25 percent reduction in the BNAF and the updated wage data. It does not include the market basket update, which is currently forecast to be about 3.0%. In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the Office of Management and Budget. List of Subjects in 42 CFR Part 418 Health facilities, Health professions, Medicare, and Reporting and recordkeeping requirements. For the reasons set forth in the preamble, the Centers for Medicare and Medicare Services proposes to amend 42 CFR chapter IV as set forth below: TABLE 2.—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED EX- PART 418—HOSPICE CARE PENDITURES, FROM FY 2008 TO FY 1. The authority citation for part 418 2009 [IN MILLIONS] continues to read as follows: Category Transfers Annualized Monetized Transfers. $–100*. 24013 Authority: Secs 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). Subpart G—Payment for Hospice Care 2. Section § 418.306 is amended by revising paragraph (c) to read as follows: Metropolitan Statistical Areas (MSAs) issued by OMB. CMS will issue annually, in the Federal Register, a hospice wage index based on the most current available CMS hospital wage data, including changes to the definition of MSAs. The urban and rural area geographic classifications are defined in § 412.64(b)(1)(ii)(A) through (C) of this chapter. The payment rates established by CMS are adjusted by the intermediary to reflect local differences in wages according to the revised wage data. * * * * * (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare—Hospital Insurance; and Program No. 93.774, Medicare—Supplementary Medical Insurance Program) Note: The following addendums will not appear in the Code of Federal Regulations. Dated: March 14, 2008. Kerry Weems, Acting Administrator, Centers for Medicare & Medicaid Services. Approved: April 7, 2008. Michael O. Leavitt, Secretary. ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009 CBSA code Urban area (constituent counties) 2 Wage index 1 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 Sebastian 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. 0.8347 10380 ......................... 10420 ......................... rfrederick on PROD1PC67 with PROPOSALS 10500 ......................... 10580 ......................... VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00032 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.3965 0.9225 0.8931 0.9009 24014 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 10740 ......................... 10780 ......................... 10900 ......................... 11020 ......................... 11100 ......................... 11180 ......................... 11260 ......................... 11300 ......................... 11340 ......................... 11460 ......................... 11500 ......................... 11540 ......................... 11700 ......................... 12020 ......................... rfrederick on PROD1PC67 with PROPOSALS 12060 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code 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 ............................................................................................................................................................. 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. 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00033 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 1.0022 0.8370 1.0349 0.9040 0.9563 1.0538 1.2497 0.9260 0.9531 1.1056 0.8315 1.0068 0.9635 1.1033 1.0310 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24015 ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 12100 ......................... 12220 ......................... 12260 ......................... 12420 ......................... 12540 ......................... 12580 ......................... 12620 ......................... 12700 ......................... 12940 ......................... 12980 ......................... 13020 ......................... 13140 ......................... 13380 ......................... 13460 ......................... 13644 ......................... rfrederick on PROD1PC67 with PROPOSALS 13740 ......................... 13780 ......................... 13820 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code 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 ........................................................................................................................................... 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-Frederick-Gaithersburg, 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. 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00034 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 1.2796 0.8487 1.0118 1.0012 1.1593 1.0631 1.0467 1.3221 0.8428 1.0678 0.9333 0.8949 1.2036 1.1478 1.1026 0.9091 0.9388 0.9334 24016 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 13900 ......................... 13980 ......................... 14020 ......................... 14060 ......................... 14260 ......................... 14484 ......................... 14500 ......................... 14540 ......................... 14740 ......................... 14860 ......................... 15180 ......................... 15260 ......................... 15380 ......................... 15500 ......................... 15540 ......................... 15764 ......................... 15804 ......................... 15940 ......................... rfrederick on PROD1PC67 with PROPOSALS 15980 ......................... 16180 ......................... 16220 ......................... 16300 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code 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 ........................................................................................................................................... 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. 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00035 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.8000 0.8594 0.9352 0.9782 0.9929 1.2370 1.0937 0.8559 1.1438 1.3359 0.9351 0.9939 1.0037 0.9176 1.0134 1.1765 1.0921 0.9373 0.9857 1.0493 0.9845 0.9286 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24017 ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued CBSA code Urban area (constituent counties) 2 Wage index 1 16580 ......................... 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. 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. 0.9852 16620 ......................... 16700 ......................... 16740 ......................... 16820 ......................... 16860 ......................... 16940 ......................... 16974 ......................... 17020 ......................... rfrederick on PROD1PC67 with PROPOSALS 17140 ......................... 17300 ......................... 17420 ......................... VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00036 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.8695 0.9571 0.9987 0.9732 0.9435 0.9764 1.1240 1.1843 1.0264 0.8655 0.8447 24018 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued CBSA code Urban area (constituent counties) 2 Wage index 1 17460 ......................... 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. 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. 0.9797 17660 ......................... 17780 ......................... 17820 ......................... 17860 ......................... 17900 ......................... 17980 ......................... 18020 ......................... 18140 ......................... 18580 ......................... 18700 ......................... 19060 ......................... 19124 ......................... rfrederick on PROD1PC67 with PROPOSALS 19140 ......................... 19180 ......................... 19260 ......................... 19340 ......................... VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00037 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.9999 0.9817 1.0195 0.9082 0.9231 0.9157 1.0004 1.0579 0.9009 1.1496 0.8701 1.0401 0.9189 0.9396 0.8644 0.9263 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24019 ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 19380 ......................... 19460 ......................... 19500 ......................... 19660 ......................... 19740 ......................... 19780 ......................... 19804 ......................... 20020 ......................... 20100 ......................... 20220 ......................... 20260 ......................... 20500 ......................... 20740 ......................... 20764 ......................... 20940 ......................... rfrederick on PROD1PC67 with PROPOSALS 21060 ......................... 21140 ......................... 21300 ......................... 21340 ......................... 21500 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code 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. 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. 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00038 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.9640 0.8272 0.8470 0.9474 1.1243 0.9678 1.0489 0.8000 1.0594 0.9502 1.0464 1.0297 0.9939 1.1729 0.9351 0.9138 1.0082 0.8669 0.9430 0.8911 24020 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued CBSA code Urban area (constituent counties) 2 Wage index 1 21660 ......................... 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. 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 ................................................................................................................................................................... 1.1468 21780 ......................... 21820 ......................... 21940 ......................... 22020 ......................... 22140 ......................... 22180 ......................... 22220 ......................... 22380 ......................... 22420 ......................... 22500 ......................... 22520 ......................... 22540 ......................... 22660 ......................... 22744 ......................... 22900 ......................... 23020 ......................... 23060 ......................... 23104 ......................... rfrederick on PROD1PC67 with PROPOSALS 23420 ......................... 23460 ......................... 23540 ......................... 23580 ......................... 23844 ......................... VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00039 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.9087 1.1592 0.5031 0.8436 1.0057 0.9827 0.9171 1.2260 1.1770 0.8653 0.8056 1.0141 1.0382 1.0730 0.8322 0.9172 0.9739 1.0168 1.1532 0.8559 0.9647 0.9668 0.9676 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24021 ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 24020 ......................... 24140 ......................... 24220 ......................... 24300 ......................... 24340 ......................... 24500 ......................... 24540 ......................... 24580 ......................... 24660 ......................... 24780 ......................... 24860 ......................... 25020 ......................... 25060 ......................... 25180 ......................... 25260 ......................... 25420 ......................... 25500 ......................... rfrederick on PROD1PC67 with PROPOSALS 25540 ......................... 25620 ......................... 25860 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code 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 .................................................................................................................................... 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. 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. 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00040 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.8661 0.9743 0.8267 1.0348 0.9772 0.9100 1.0131 1.0204 0.9452 0.9863 1.0343 0.3524 0.9203 0.9455 1.1014 0.9735 0.9302 1.1496 0.8000 0.9471 24022 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 25980 ......................... 26100 ......................... 26180 ......................... 26300 ......................... 26380 ......................... 26420 ......................... 26580 ......................... 26620 ......................... 26820 ......................... 26900 ......................... 26980 ......................... 27060 ......................... 27100 ......................... 27140 ......................... rfrederick on PROD1PC67 with PROPOSALS 27180 ......................... 27260 ......................... 27340 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code Catawba County, NC. Hinesville-Fort Stewart, GA 3 ................................................................................................................................... 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 ......................................................................................................................... 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. 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00041 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.9637 0.9447 1.2122 0.9556 0.8279 1.0426 0.9484 0.9594 0.9718 1.0327 1.0037 1.0102 0.9786 0.8404 0.9101 0.9463 0.8475 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24023 ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued CBSA code Urban area (constituent counties) 2 Wage index 1 27500 ......................... 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 ......................................................................................................................................................... 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. 1.0178 27620 ......................... 27740 ......................... 27780 ......................... 27860 ......................... 27900 ......................... 28020 ......................... 28100 ......................... 28140 ......................... 28420 ......................... 28660 ......................... 28700 ......................... 28740 ......................... 28940 ......................... rfrederick on PROD1PC67 with PROPOSALS 29020 ......................... 29100 ......................... 29140 ......................... VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00042 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.8894 0.8053 0.8000 0.8172 0.9390 1.0944 1.0740 0.9970 1.0569 0.8653 0.8033 1.0024 0.8430 1.0061 1.0160 0.9304 24024 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued CBSA code Urban area (constituent counties) 2 Wage index 1 29180 ......................... 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. Lake Havasu City - Kingman, AZ ........................................................................................................................... Mohave County, AZ. Lakeland, FL ............................................................................................................................................................ Polk County, FL. Lancaster, PA .......................................................................................................................................................... Lancaster County, PA. Lansing-East Lansing, MI ........................................................................................................................................ 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, KY-IN ...................................................................................................................................................... Clark County, IN. Floyd County, IN. Harrison County, IN. Washington County, IN. 0.8651 29340 ......................... 29404 ......................... 29420 ......................... 29460 ......................... 29540 ......................... 29620 ......................... 29700 ......................... 29740 ......................... 29820 ......................... 29940 ......................... 30020 ......................... 30140 ......................... 30300 ......................... 30340 ......................... 30460 ......................... 30620 ......................... 30700 ......................... 30780 ......................... 30860 ......................... 30980 ......................... rfrederick on PROD1PC67 with PROPOSALS 31020 ......................... 31084 ......................... 31140 ......................... VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00043 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.8158 1.1123 0.9790 0.9086 0.9706 1.0615 0.8490 0.9101 1.2377 0.8630 0.8418 0.8594 0.9917 0.9644 0.9642 0.9886 1.0544 0.9297 0.9633 0.9144 1.1358 1.2348 0.9509 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24025 ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 31180 ......................... 31340 ......................... 31420 ......................... 31460 ......................... 31540 ......................... 31700 ......................... 31900 ......................... 32420 ......................... 32580 ......................... 32780 ......................... 32820 ......................... 32900 ......................... 33124 ......................... 33140 ......................... 33260 ......................... rfrederick on PROD1PC67 with PROPOSALS 33340 ......................... 33460 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code 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. 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. Mansfield, OH .......................................................................................................................................................... Richland County, OH. Mayaguez, PR ......................................................................................................................................................... Hormigueros Municipio, PR. Mayaguez Municipio, PR. McAllen-Edinburg-Pharr, 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. 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00044 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.9105 0.9160 1.0009 0.8465 1.1471 1.0777 0.9725 0.4268 0.9570 1.0824 0.9703 1.2714 1.0492 0.9351 1.0508 1.0715 1.1637 24026 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 33540 ......................... 33660 ......................... 33700 ......................... 33740 ......................... 33780 ......................... 33860 ......................... 34060 ......................... 34100 ......................... 34580 ......................... 34620 ......................... 34740 ......................... 34820 ......................... 34900 ......................... 34940 ......................... 34980 ......................... 35004 ......................... rfrederick on PROD1PC67 with PROPOSALS 35084 ......................... 35300 ......................... 35380 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code 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. 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. 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00045 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.9392 0.8427 1.2548 0.8216 0.9875 0.8484 0.8729 0.8000 1.1045 0.8617 1.0318 0.9057 1.5186 0.9952 1.0164 1.3260 1.2443 1.2453 0.9333 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24027 ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 35644 ......................... 35660 ......................... 35980 ......................... 36084 ......................... 36100 ......................... 36140 ......................... 36220 ......................... 36260 ......................... 36420 ......................... 36500 ......................... 36540 ......................... 36740 ......................... 36780 ......................... rfrederick on PROD1PC67 with PROPOSALS 36980 ......................... 37100 ......................... 37340 ......................... 37380 ......................... 37460 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code Plaquemines Parish, LA. St. Bernard Parish, LA. St. Charles Parish, LA. St. John the Baptist Parish, LA. St. Tammany Parish, LA. New York-Wayne-White Plains, 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. 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, 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. Palm Coast, FL ....................................................................................................................................................... Flagler County, FL. Panama City-Lynn Haven, FL ................................................................................................................................. 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00046 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 1.3758 0.9589 1.1992 1.6454 0.9050 1.1527 1.0534 0.9441 0.9247 1.2076 1.0030 0.9678 1.0019 0.9076 1.2433 0.9782 0.9383 0.8720 24028 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 37620 ......................... 37700 ......................... 37764 ......................... 37860 ......................... 37900 ......................... 37964 ......................... 38060 ......................... 38220 ......................... 38300 ......................... 38340 ......................... 38540 ......................... 38660 ......................... 38860 ......................... 38900 ......................... rfrederick on PROD1PC67 with PROPOSALS 38940 ......................... 39100 ......................... 39140 ......................... 39300 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code Bay County, FL. Parkersburg-Marietta, WV-OH ................................................................................................................................ Washington County, OH. Pleasants County, WV. Wirt County, WV. Wood County, WV. Pascagoula, MS ...................................................................................................................................................... George County, MS. Jackson County, MS. Peabody, MA ........................................................................................................................................................... Essex County, MA. 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. 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 ........................................................................................................... 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00047 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.8502 0.9071 1.1172 0.8687 0.9755 1.1461 1.0767 0.8223 0.8943 1.0586 0.9929 0.5118 1.0534 1.2062 1.0507 1.1520 1.0511 1.1092 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24029 ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 39340 ......................... 39380 ......................... 39460 ......................... 39540 ......................... 39580 ......................... 39660 ......................... 39740 ......................... 39820 ......................... 39900 ......................... 40060 ......................... 40140 ......................... 40220 ......................... rfrederick on PROD1PC67 with PROPOSALS 40340 ......................... 40380 ......................... 40420 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code 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. 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 ............................................................................................................................................................. 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00048 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 1.0025 0.9285 0.9708 0.9964 1.0321 0.9243 0.9815 1.4205 1.1240 0.9887 1.1644 0.9117 1.1282 0.9292 1.0295 24030 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 40484 ......................... 40580 ......................... 40660 ......................... 40900 ......................... 40980 ......................... 41060 ......................... 41100 ......................... 41140 ......................... 41180 ......................... 41420 ......................... 41500 ......................... 41540 ......................... 41620 ......................... 41660 ......................... rfrederick on PROD1PC67 with PROPOSALS 41700 ......................... 41740 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code 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. 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. 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00049 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 1.0607 0.9442 0.9485 1.4167 0.9244 1.1066 0.9817 0.9191 0.9466 1.1090 1.5499 0.9435 0.9860 0.9000 0.9267 1.2055 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24031 ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued CBSA code Urban area (constituent counties) 2 Wage index 1 41780 ......................... 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. 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-Goleta, 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. 0.9254 41884 ......................... 41900 ......................... 41940 ......................... 41980 ......................... 42020 ......................... 42044 ......................... 42060 ......................... rfrederick on PROD1PC67 with PROPOSALS 42100 ......................... 42140 ......................... 42220 ......................... 42260 ......................... VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00050 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 1.5940 0.5438 1.6506 0.5207 1.3100 1.2343 1.2288 1.6912 1.1260 1.5416 1.0420 24032 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued CBSA code Urban area (constituent counties) 2 Wage index 1 42340 ......................... 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 .................................................................................................................................. King County, WA. Snohomish County, 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. 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 .................................................................................................................... 0.9579 42540 ......................... 42644 ......................... 42680 ......................... 43100 ......................... 43300 ......................... 43340 ......................... 43580 ......................... 43620 ......................... 43780 ......................... 43900 ......................... 44060 ......................... 44100 ......................... 44140 ......................... 44180 ......................... 44220 ......................... 44300 ......................... 44700 ......................... 44940 ......................... rfrederick on PROD1PC67 with PROPOSALS 45060 ......................... 45104 ......................... 45220 ......................... 45300 ......................... VerDate Aug<31>2005 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00051 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.8872 1.2139 0.9873 0.9415 0.8728 0.8891 0.9704 1.0032 1.0088 0.9884 1.0967 0.9382 1.0874 0.9121 0.9120 0.9198 1.2436 0.9021 1.0396 1.1597 0.9467 0.9462 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24033 ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 45460 ......................... 45500 ......................... 45780 ......................... 45820 ......................... 45940 ......................... 46060 ......................... 46140 ......................... 46220 ......................... 46340 ......................... 46540 ......................... 46660 ......................... 46700 ......................... 47020 ......................... 47220 ......................... rfrederick on PROD1PC67 with PROPOSALS 47260 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code 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. 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. 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00052 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 0.9237 0.8151 0.9893 0.8957 1.1223 0.9698 0.8749 0.8710 0.9561 0.8902 0.8495 1.5385 0.8709 1.0630 0.9250 24034 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued 47300 ......................... 47380 ......................... 47580 ......................... 47644 ......................... 47894 ......................... 47940 ......................... 48140 ......................... 48260 ......................... 48300 ......................... 48424 ......................... 48540 ......................... 48620 ......................... rfrederick on PROD1PC67 with PROPOSALS 48660 ......................... 48700 ......................... 48864 ......................... 48900 ......................... VerDate Aug<31>2005 Wage index 1 Urban area (constituent counties) 2 CBSA code 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. 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 ....................................................................................................................................................... 15:14 Apr 30, 2008 Jkt 214001 PO 00000 Frm 00053 Fmt 4702 Sfmt 4702 E:\FR\FM\01MYP1.SGM 01MYP1 1.0586 0.8936 0.9575 1.0491 1.1387 0.8937 1.0153 0.8312 1.2031 1.0205 0.8000 0.9506 0.8308 0.8437 1.1355 0.9871 Federal Register / Vol. 73, No. 85 / Thursday, May 1, 2008 / Proposed Rules 24035 ADDENDUM A.—PROPOSED HOSPICE WAGE INDEX FOR URBAN AREAS BY CBSA—FY 2009—Continued Wage index 1 Urban area (constituent counties) 2 CBSA code 49020 ......................... 49180 ......................... 49340 ......................... 49420 ......................... 49500 ......................... 49620 ......................... 49660 ......................... 49700 ......................... 49740 ......................... 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 ............................................................................................................................................................... ´ Guanica Municipio, PR. Guayanilla Municipio, PR. ˜ Penuelas Municipio, PR. Yauco Municipio, PR. 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. 1.0399 0.9565 1.1840 1.0770 0.3777 0.9818 0.9443 1.1283 0.9953 1 Wage index values are based on FY 2004 hospital cost report data before reclassification. These data form the basis for the pre-floor, pre-reclassified hospital wage index. The budget neutrality adjustment or the hospice floor is then applied to the pre-floor, pre-reclassified hospital wage index to derive the hospice wage index. Wage index values greater than or equal to 0.8 are subject to a budget neutrality adjustment. The hospice floor calculation is as follows: Wage index values below 0.8 are adjusted to be the greater of either the a) the 25 percent reduced budget neutrality adjustment OR b) the minimum of the pre-floor, pre-reclassified hospital wage index value x 1.15, or 0.8000. For the proposed FY 2009 hospice wage index, the budget neutrality adjustment was reduced by 25 percent. 2 This column lists each CBSA area name and each county or county equivalent, in the CBSA area. Counties not listed in this Table are considered to be rural areas. Wage index values for these areas are found in Addendum B. 3 Because there are no hospitals in this CBSA, the wage index value is calculated by taking the average of all other urban CBSAs in Georgia. ADDENDUM B.—PROPOSED HOSPICE WAGE INDEX FOR RURAL AREAS BY CBSA—FY 2009 rfrederick on PROD1PC67 with PROPOSALS CBSA code Non-urban area 1 ................... 2 ................... 3 ................... 4 ................... 5 ................... 6 ................... 7 ................... 8 ................... 10 ................. 11 ................. 12 ................. 13 ................. 14 ................. 15 ................. 16 ................. 17 ................. 18 ................. 19 ................. 20 ................. 21 ................. 22 ................. Alabama ............. Alaska ................ Arizona ............... Arkansas ............ California ............ Colorado ............ Connecticut ........ Delaware ............ Florida ................ Georgia .............. Hawaii ................ Idaho .................. Illinois ................. Indiana ............... Iowa ................... Kansas ............... Kentucky ............ Louisiana ........... Maine ................. Maryland ............ Massachusetts 1 VerDate Aug<31>2005 15:14 Apr 30, 2008 Wage index 0.8000 1.2703 0.8895 0.8000 1.2612 1.0180 1.1664 1.0204 0.8880 0.8034 1.1132 0.8308 0.8744 0.8996 0.8986 0.8372 0.8175 0.8000 0.8891 0.9477 1.2157 Jkt 214001 ADDENDUM B.—PROPOSED HOSPICE WAGE INDEX FOR RURAL AREAS BY CBSA—FY 2009—Continued CBSA code 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 PO 00000 ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. Frm 00054 Non-urban area Wage index Michigan ............ Minnesota .......... Mississippi ......... Missouri ............. Montana ............. Nebraska ........... Nevada .............. New Hampshire New Jersey 2 ...... New Mexico ....... New York ........... North Carolina ... North Dakota ..... Ohio ................... Oklahoma .......... Oregon ............... Pennsylvania ..... Puerto Rico 3 ...... Rhode Island 2 ... South Carolina ... South Dakota ..... 0.9392 0.9524 0.8077 0.8319 0.8790 0.9283 0.9726 1.0983 ................ 0.9378 0.8673 0.9025 0.8000 0.9141 0.8000 1.0392 0.8796 0.4654 ................ 0.9080 0.8968 Fmt 4702 Sfmt 4702 ADDENDUM B.—PROPOSED HOSPICE WAGE INDEX FOR RURAL AREAS BY CBSA—FY 2009—Continued CBSA code 44 45 46 47 48 49 50 51 52 53 65 ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. ................. Non-urban area Tennessee ......... Texas ................. Utah ................... Vermont ............. Virgin Islands ..... Virginia ............... Washington ........ West Virginia ..... Wisconsin .......... Wyoming ............ Guam ................. Wage index 0.8102 0.8359 0.8514 1.0405 0.7855 0.8283 1.0762 0.8000 1.0141 0.9742 1.0082 1 There are no hospitals in the rural areas of Massachusetts, so the wage index value used is the average of the contiguous counties. 2 There are no rural areas in this state. 3 Wage index values are obtained using the methodology described in this proposed rule. [FR Doc. 08–1198 Filed 4–28–08; 4:00 pm] BILLING CODE 4120–01–P E:\FR\FM\01MYP1.SGM 01MYP1

Agencies

[Federal Register Volume 73, Number 85 (Thursday, May 1, 2008)]
[Proposed Rules]
[Pages 24000-24035]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 08-1198]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 418

[CMS-1548-P]
RIN 0938-AP14


Medicare Program; Proposed Hospice Wage Index for Fiscal Year 
2009

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

ACTION: Proposed rule.

-----------------------------------------------------------------------

SUMMARY: This proposed rule proposes the hospice wage index for fiscal 
year 2009. This proposed rule also proposes to phase-out the Medicare 
hospice budget neutrality adjustment factor and clarify two wage index 
issues, pertaining to the definition of rural and urban areas and to 
multi-campus hospital facilities.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on June 27, 2008.

ADDRESSES: In commenting, please refer to file code CMS-1548-P. Because 
of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to https://www.regulations.gov. Follow the instructions for 
``Comment or Submission'' and enter the filecode to find the document 
accepting comments.
    2. By regular mail. You may mail written comments (one original and 
two copies) to the following address only: Centers for Medicare & 
Medicaid Services, Department of Health and Human Services, Attention: 
CMS-1548-P, P.O. Box 8012, Baltimore, MD 21244-1850.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments (one 
original and two copies) to the following address ONLY: Centers for 
Medicare & Medicaid Services, Department of Health and Human Services, 
Attention: CMS-1548-P, Mail Stop C4-26-05, 7500 Security Boulevard, 
Baltimore, MD 21244-1850.
    4. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments (one original and two copies) before the 
close of the comment period to either of the following addresses:

a. Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, 
SW., Washington, DC 20201.

    (Because access to the interior of the HHH Building is not readily 
available to persons without Federal Government identification, 
commenters are encouraged to leave their comments in the CMS drop slots 
located in the main lobby of the building. A stamp-in clock is 
available for persons wishing to retain a proof of filing by stamping 
in and retaining an extra copy of the comments being filed.)

b. 7500 Security Boulevard, Baltimore, MD 21244-1850.

    If you intend to deliver your comments to the Baltimore address, 
please call telephone number (410) 786-9994 in advance to schedule your 
arrival with one of our staff members.
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Randy Throndset (410) 786-0131 or 
Katie Lucas (410) 786-7723.

SUPPLEMENTARY INFORMATION:
    Submitting Comments: We welcome comments from the public on all 
issues set forth in this rule to assist us in fully considering issues 
and developing policies. You can assist us by

[[Page 24001]]

referencing the file code CMS-1548-P and the specific ``issue 
identifier'' that precedes the section on which you choose to comment.
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. We post all comments 
received before the close of the comment period on the following Web 
site as soon as possible after they have been received: https://
www.regulations.gov. Follow the search instructions on that Web site to 
view public comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, at the headquarters of the 
Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 
a.m. to 4 p.m. To schedule an appointment to view public comments, 
phone 1-800-743-3951.

Table of Contents

I. Background
    A. General
    1. Hospice Care
    2. Medicare Payment for Hospice Care
    B. Hospice Wage Index
    1. Raw Wage Index Values (Pre-Floor, Pre-Reclassified Hospital 
Wage Index)
    2. Changes to Core-Based Statistical Area (CBSA) Designations
    3. Definition of Urban and Rural Areas
    4. Areas Without Hospital Wage Data
    5. CBSA Nomenclature Changes
    6. Hospice Payment Rates
II. Provisions of the Proposed Rule
    A. Clarification of New England Deemed Counties
    B. Wage Data for Multi-Campus Hospitals
    C. FY 2009 Proposed Hospice Wage Index With Phase-Out of the 
Budget Neutrality Adjustment Factor (BNAF)
    1. Background
    2. Areas Without Hospital Wage Data
    3. Phase-Out of the BNAF
    a. Effects of phasing-out the BNAF using the published FY 2008 
Hospice Wage Index Data
    b. Effects of phasing-out the BNAF using the Updated Pre-floor, 
Pre-reclassified Hospital Wage Index Data (FY 2009 proposal)
    D. Summary of the Provisions of the Proposed Rule
III. Collection of Information Requirements
IV. Regulatory Impact Analysis
    A. Overall Impact
    B. Anticipated Effects
    1. Hospice Size
    2. Geographic Location
    3. Type of Ownership
    4. Hospice Base
    C. Accounting Statement

Part 418--Hospice Care

I. Background

A. General

1. Hospice Care
    Hospice care is an approach to treatment that recognizes that the 
impending death of an individual warrants a change in the focus from 
curative care to palliative care for relief of pain and for symptom 
management. The goal of hospice care is to help terminally ill 
individuals continue life with minimal disruption to normal activities 
while remaining primarily in the home environment. A hospice uses an 
interdisciplinary approach to deliver medical, nursing, social, 
psychological, emotional, and spiritual services through use of a broad 
spectrum of professional and other caregivers, with the goal of making 
the individual as physically and emotionally comfortable as possible. 
Counseling services and inpatient respite services are available to the 
family of the hospice patient. Hospice programs consider both the 
patient and the family as a unit of care.
    Section 1861(dd) of the Social Security Act (the Act) provides for 
coverage of hospice care for terminally ill Medicare beneficiaries who 
elect to receive care from a participating hospice. Section 1814(i) of 
the Act provides payment for Medicare participating hospices.
2. Medicare Payment for Hospice Care
    Our regulations at 42 CFR part 418 establish eligibility 
requirements, payment standards and procedures, define covered 
services, and delineate the conditions a hospice must meet to be 
approved for participation in the Medicare program. Part 418 subpart G 
provides for payment in one of four prospectively-determined rate 
categories (routine home care, continuous home care, inpatient respite 
care, and general inpatient care) to hospices based on each day a 
qualified Medicare beneficiary is under a hospice election.

B. Hospice Wage Index

    Our regulations at Sec.  418.306(c) require each hospice's labor 
market to be established using the most current hospital wage data 
available, including any changes by OMB to the Metropolitan Statistical 
Areas (MSAs) definitions. OMB revised the MSA definitions beginning in 
2003 with new designations called the Core Based Statistical Areas 
(CBSAs). For the purposes of the hospice benefit, the term ``MSA-
based'' refers to wage index values and designations based on the 
previous MSA designations before 2003. Conversely, the term ``CBSA-
based'' refers to wage index values and designations based on the OMB 
revised MSA designations in 2003, which now include CBSAs. In the 
August 11, 2004 IPPS final rule (69 FR 48916, 49026), revised labor 
market area definitions were adopted at Sec.  412.64(b), which were 
effective October 1, 2004 for acute care hospitals. CMS also revised 
the labor market areas for hospices using the new OMB standards that 
included CBSAs. In the FY 2006 hospice wage index final rule (70 FR 
45130), we implemented a 1-year transition policy using a 50/50 blend 
of the CBSA-based wage index values and the Metropolitan Statistical 
Area (MSA)-based wage index values for FY 2006. The one-year transition 
policy ended on September 30, 2006. For FY 2007 and FY 2008 we used 
wage index values based on CBSA designations.
    The hospice wage index is used to adjust payment rates for hospice 
agencies under the Medicare program to reflect local differences in 
area wage levels. The original hospice wage index was based on the 1981 
Bureau of Labor Statistics hospital data and had not been updated since 
1983. In 1994, because of disparity in wages from one geographical 
location to another, a committee was formulated to negotiate a wage 
index methodology that could be accepted by the industry and the 
government. This committee, functioning under a process established by 
the Negotiated Rulemaking Act of 1990, was comprised of national 
hospice associations; rural, urban, large and small hospices; multi-
site hospices; consumer groups; and a government representative. On 
April 13, 1995, the Hospice Wage Index Negotiated Rulemaking Committee 
signed an agreement for the methodology to be used for updating the 
hospice wage index.
    In the August 8, 1997 Federal Register (62 FR 42860), we published 
a final rule implementing a new methodology for calculating the hospice 
wage index based on the recommendations of the negotiated rulemaking 
committee. The committee statement was included in the appendix of that 
final rule (62 FR 42883). The hospice wage index is updated annually. 
Our most recent annual update notice published in the Federal Register 
(72 FR 50214) on August 31, 2007 set forth updates to the hospice wage 
index for FY 2008. On October 1, 2007, we published a correction notice 
in the Federal Register (72 FR 55672) to correct technical errors that 
appeared in the August 31, 2007 final rule.

[[Page 24002]]

1. Raw Wage Index Values (Pre-Floor, Pre-Reclassified Hospital Wage 
Index)
    As described in the August 8, 1997 hospice wage index final rule 
(62 FR 42860), the pre-floor and pre-reclassified hospital wage index 
is used as the raw wage index for the hospice benefit. These raw wage 
index values are then subject to either a budget neutrality adjustment 
or application of the hospice floor to compute the hospice wage index 
used to determine payments to hospices.
    Pre-floor, pre-reclassified hospital wage index values of 0.8 or 
greater are adjusted by the BNAF. Pre-floor, pre-reclassified hospital 
wage index values below 0.8 are adjusted by the greater of: (1) The 
hospice BNAF; or (2) the hospice floor (which is a 15 percent increase) 
subject to a maximum wage index value of 0.8. For example, if County A 
has a pre-floor, pre-reclassified hospital wage index (raw wage index) 
value of 0.4000, we would perform the following calculations using the 
budget neutrality factor (which for this example is 1.060988) and the 
hospice floor to determine County A's hospice wage index:

Pre-floor, pre-reclassified hospital wage index value below 0.8 
multiplied by the BNAF: (0.4000 x 1.060988 = 0.4244)
Pre-floor, pre-reclassified hospital wage index value below 0.8 
multiplied by the hospice floor: (0.4000 x 1.15 = 0.4600)

    Based on these calculations, County A's hospice wage index would be 
0.4600.
    As decided upon by the Hospice Wage Index Negotiated Rulemaking 
Committee, budget neutrality means that, in a given year, estimated 
aggregate payments for Medicare hospice services using the updated 
hospice values will equal estimated payments that would have been made 
for these services if the 1983 hospice wage index values had remained 
in effect, after adjusting the payment rates for inflation.
    The BNAF has been computed and applied annually to the labor 
portion of the hospice payment. Currently, the labor portion of the 
payment rates is as follows: for Routine Home Care, 68.71 percent; for 
Continuous Home Care, 68.71 percent; for General Inpatient Care, 64.01 
percent; and for Respite Care, 54.13 percent. The non-labor portion is 
equal to 100 percent minus the labor portion for each level of care. 
Therefore the non-labor portion of the payment rates is as follows: for 
Routine Home Care, 31.29 percent; for Continuous Home Care, 31.29 
percent; for General Inpatient Care, 35.99 percent; and for Respite 
Care, 45.87 percent.
2. Changes to Core-Based Statistical Area (CBSA) Designations
    The annual update to the hospice wage index is published in the 
Federal Register and is based on the most current available hospital 
wage data, as well as any changes by the Office of Management and 
Budget (OMB) to the definitions of MSAs, which now include CBSA 
designations. The August 4, 2005 final rule (70 FR 45130) set forth the 
adoption of the changes discussed in the OMB Bulletin No. 03-04 (June 
6, 2003), which announced revised definitions for Micropolitan 
Statistical Areas and the creation of MSAs and Combined Statistical 
Areas. In adopting the OMB CBSA geographic designations, we provided 
for a 1-year transition with a blended hospice wage index for all 
hospices for FY 2006. For FY 2006, the hospice wage index for each 
provider consisted of a blend of 50 percent of the FY 2006 MSA-based 
hospice wage index and 50 percent of the FY 2006 CBSA-based hospice 
wage index. Fiscal years 2007 and 2008 used the full CBSA-based hospice 
wage index values as discussed in their respective notices or rules (71 
FR 52080 and 72 FR 50214).
3. Definition of Rural and Urban Areas
    Each hospice's labor market is determined based on definitions of 
MSAs issued by OMB. In general, an urban area is defined as an MSA or 
New England County Metropolitan Area (NECMA) as defined by OMB. Under 
Sec.  412.64(b)(1)(ii)(C), a rural area is defined as any area outside 
of the urban area. The urban and rural area geographic classifications 
are defined in Sec.  412.64(b)(1)(ii)(A) through (C), and have been 
used for the Medicare hospice benefit since implementation.
4. Areas Without Hospital Wage Data
    When adopting OMB's new labor market designations in FY 2006, 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 hospice wage index. Beginning in FY 2006, we adopted a policy to 
use the FY 2005 pre-floor, pre-reclassified hospital wage index value 
for rural areas when no hospital wage data were available. We also 
adopted the policy that for urban labor markets without a hospital from 
which a hospital wage index data could be derived, all of the CBSAs 
within the State would be used to calculate a statewide urban average 
pre-floor, pre-reclassified hospital wage index value to use as a 
reasonable proxy for these areas. Consequently, in the FY 2006 final 
rule, the FY 2007 update notice, and the FY 2008 final rule, we applied 
the average pre-floor, pre-reclassified hospital wage index data from 
all urban areas in that state to urban areas without a hospital. The 
only affected CBSA is 25980, Hinesville-Fort Stewart, Georgia.
    Under the CBSA labor market areas, there are no hospitals in rural 
locations in Massachusetts and Puerto Rico. Since there was no rural 
proxy for more recent rural data within those areas, in the FY 2006 
hospice wage index proposed rule (70 FR 22394, 22398), we proposed 
applying the FY 2005 pre-floor, pre-reclassified hospital wage index 
value to rural areas where no hospital wage data were available. In the 
FY 2006 final rule and in the FY 2007 update notice, we applied the FY 
2005 pre-floor, pre-reclassified hospital wage index data for areas 
lacking hospital wage data in both FY 2006 and FY 2007 for rural 
Massachusetts and rural Puerto Rico.
    In the FY 2008 final rule (72 FR 50214, 50217) we considered 
alternatives to our methodology to update the pre-floor, pre-
reclassified hospital wage index for rural areas without hospital wage 
data. We indicated that we believed that the best imputed proxy for 
rural areas, would: (1) Use pre-floor, pre-reclassified hospital data; 
(2) use the most local data available to impute a rural pre-floor, pre-
reclassified hospital wage index; (3) be easy to evaluate; and, (4) be 
easy to update from year-to-year.
    Therefore, in FY 2008, in cases where there was a rural area 
without rural hospital wage data, we used the average pre-floor, pre-
reclassified hospital wage index data from all contiguous CBSAs to 
represent a reasonable proxy for the rural area. This approach does not 
use rural data, however, the approach uses pre-floor, pre-reclassified 
hospital wage data, is easy to evaluate, is easy to update from year-
to-year, and uses the most local data available. In the FY 2008 rule 
(72 FR at 50217), we noted that in determining an imputed rural pre-
floor, pre-reclassified hospital wage index, we interpret the term 
``contiguous'' to mean sharing a border. For example, in the case of 
Massachusetts, the entire rural area consists of Dukes and Nantucket 
counties. We determined that the borders of Dukes and Nantucket 
counties are contiguous with Barnstable and Bristol counties. Under the 
adopted methodology, the pre-floor, pre-reclassified hospital wage 
index values for the counties of Barnstable (CBSA 12700, Barnstable 
Town, MA) and Bristol (CBSA 39300, Providence-New Bedford-Fall River, 
RI-MA) would be

[[Page 24003]]

averaged resulting in an imputed pre-floor, pre-reclassified rural 
hospital wage index for FY 2008. We noted in the FY 2008 final hospice 
wage index rule that while we believe that this policy could be readily 
applied to other rural areas that lack hospital wage data (possibly due 
to hospitals converting to a different provider type, such as a 
Critical Access Hospital, that does not submit the appropriate wage 
data), if a similar situation arose in the future, we would re-examine 
this policy.
    We also noted that we do not believe that this policy would be 
appropriate for Puerto Rico, as there are sufficient economic 
differences between hospitals in the United States and those in Puerto 
Rico, including the payment of hospitals in Puerto Rico using blended 
Federal/Commonwealth-specific rates. Therefore we believe that a 
separate and distinct policy for Puerto Rico is necessary. Any 
alternative methodology for imputing a pre-floor, pre-reclassified 
hospital wage index for rural Puerto Rico would need to take into 
account the economic differences between hospitals in the United States 
and those in Puerto Rico. Our policy of imputing a rural pre-floor, 
pre-reclassified hospital wage index based on the pre-floor, pre-
reclassified hospital wage index(es) of CBSAs contiguous to the rural 
area in question does not recognize the unique circumstances of Puerto 
Rico. While we have not yet identified an alternative methodology for 
imputing a pre-floor, pre-reclassified hospital wage index for rural 
Puerto Rico, we will continue to evaluate the feasibility of using 
existing hospital wage data and, possibly, wage data from other 
sources. For FY 2008, we used the most recent pre-floor, pre-
reclassified hospital wage index available for Puerto Rico, which is 
0.4047.
5. CBSA Nomenclature Changes
    The Office of Management and Budget (OMB) regularly publishes a 
bulletin that updates the titles of certain CBSAs. In the FY 2008 Final 
Rule (72 FR 50218) we noted that the FY 2008 rule and all subsequent 
hospice wage index rules and notices would incorporate CBSA changes 
from the most recent OMB bulletins. The OMB bulletins may be accessed 
at https://www.whitehouse.gov/omb/bulletins/.
6. Hospice Payment Rates
    Section 4441(a) of the Balanced Budget Act of 1997 (BBA) amended 
section 1814(i)(1)(C)(ii) of the Act to establish updates to hospice 
rates for FYs 1998 through 2002. Hospice rates were to be updated by a 
factor equal to the market basket index, minus 1 percentage point. 
However, neither the BBA nor subsequent legislation specified 
alteration to the market basket adjustment to be used to compute 
payment for fiscal years beyond 2002. Payment rates for FYs since 2002 
have been updated according to section 1814(i)(1)(C)(ii)(VII) of the 
Act, which states that the update to the payment rates for subsequent 
fiscal years will be the market basket percentage for the fiscal year. 
It has been longstanding practice to use the inpatient hospital market 
basket as a proxy for a hospice market basket.
    Historically, the rate update has been published through a separate 
administrative instruction issued annually in July to provide adequate 
time to implement system change requirements. Providers determine their 
payments by applying the hospice wage index in this notice to the labor 
portion of the published hospice rates.

II. Provisions of the Proposed Rule

A. Clarification of New England Deemed Counties

    We are taking the opportunity to address the change in the 
designation of ``New England deemed counties,'' which are listed in 
Sec.  412.64(b)(1)(ii)(B). These counties were deemed to be parts of 
urban areas under section 601(g) of the Social Security Amendments of 
1983, yet the OMB designates these counties as rural. In the FY 2008 
Inpatient Prospective Payment System (IPPS) final rule, IPPS adopted 
the OMB designation for the pre-floor, pre-reclassified hospital wage 
index. The counties include Litchfield County, Connecticut; York 
County, Maine; Sagadahoc County, Maine; Merrimack County, New 
Hampshire; and Newport County, Rhode Island. Of these five ``New 
England deemed counties,'' three (York County, Sagadahoc County, and 
Newport County) are also included in metropolitan statistical areas 
defined by OMB and are considered urban under the current IPPS labor 
market area definitions in Sec.  412.64(b)(1)(ii)(A).
    The remaining two, Litchfield County and Merrimack County, are 
geographically located in areas that are considered rural under the 
current IPPS labor market area definitions. However, they have been 
previously deemed urban under the IPPS in certain circumstances as 
discussed below. In the FY 2008 IPPS final rule with comment period (72 
FR 47130, August 22, 2007), Sec.  412.64(b)(1)(ii)(B) was revised such 
that the two ``New England deemed counties'' that are still considered 
rural by OMB (Litchfield County, CT and Merrimack County, NH) are no 
longer considered urban effective for discharges occurring on or after 
October 1, 2007. Therefore, these two counties are considered rural in 
accordance with Sec.  412.64(b)(1)(ii)(C). However, for purposes of 
payment under the IPPS, acute care hospitals located within those areas 
are treated as being reclassified to their deemed urban area effective 
for discharges occurring on or after October 1, 2007 (see 72 FR 47337 
through 47338). We also noted in this discussion that this policy 
change was limited to the ``New England deemed counties'' IPPS 
hospitals only, and that any change to non-IPPS provider wage indexes 
would be addressed in the respective payment system rules. The hospice 
program does not provide for such geographic reclassification as the 
IPPS does, and we are taking this opportunity to clarify treatment of 
``New England deemed counties'' under the hospice program in this 
proposed rule.
    As discussed, our regulations at Sec.  418.306(c) require each 
hospice's labor market to be established using the most current 
hospital wage data available. The original hospice wage index was based 
on the 1981 Bureau of Labor Statistics hospital data. In 1994, a 
committee functioning under a process established by the Negotiated 
Rulemaking Act of 1990, was formed to negotiate a hospice wage index 
methodology that could be accepted by the industry and the government. 
The revised hospice wage index was based on the recommendations of the 
Negotiated Rulemaking Advisory Committee. This committee was 
established to provide advice and make recommendations to the Secretary 
on the hospice wage index used to adjust payment rates for hospices 
under the Medicare program, to reflect local differences in area wage 
levels. The Committee recommended that the revised hospice wage index 
be based on the most current available data for each fiscal year, which 
would be used to construct a pre-floor, pre-reclassified hospital wage 
index under the prospective payment system before adjustments were made 
to take into account the geographic reclassification of hospitals in 
accordance with sections 1886(d)(8)(B) and (d)(10) of the Act, as well 
as each hospice's labor market area as established by OMB. The reason 
the unadjusted hospital wage data were recommended was to avoid further 
reductions in certain rural statewide wage index values that would 
result from reclassification. The recommendations are codified in

[[Page 24004]]

Sec.  418.306(c) of our regulations; however, there is no reference to 
Sec.  412.64.
    In other words, while Sec.  412.64 is not explicitly noted, the 
hospice program has used the urban definition in Sec.  
412.64(b)(1)(ii)(A) and (B), and the rural definition as any area 
outside of an urban area in Sec.  412.64(b)(1)(ii)(C). Historical 
changes to the labor market area/geographic classifications and annual 
updates to the hospice wage index values have been made effective 
October 1 each year. When we established the hospice wage index values 
effective October 1, 2007 through September 30, 2008, we considered the 
``New England deemed counties'' (including Litchfield County, CT and 
Merrimack County, NH) as urban for FY 2008 in accordance with the 
definitions of urban and rural areas in the FY 2008 hospice final rule 
(72 FR 50216). Therefore, Litchfield County was listed as one of the 
constituent counties of urban CBSA 25540 (Hartford-West Hartford-East 
Hartford, CT), and Merrimack County was listed as one of the 
constituent counties of urban CBSA 31700 (Manchester-Nashua, NH) (72 FR 
50236 and 50239, respectively). As noted above, the terms ``rural'' and 
``urban'' areas are defined in IPPS according to the definitions of 
those terms in Sec.  412.64(b)(1)(ii)(A) through (C). Litchfield 
county, CT and Merrimack county, NH are considered rural areas for 
hospital IPPS purposes in accordance with Sec.  412.64. Under this 
proposal, effective October 1, 2008, Litchfield county, CT would no 
longer be considered part of urban CBSA 25540 (Hartford-West Hartford-
East Hartford, CT), and Merrimack County, NH would no longer be 
considered part of urban CBSA 31700 (Manchester-Nashua, NH). Rather, 
these counties would be considered to be rural areas within their 
respective states under the hospice payment system. This proposed 
policy is consistent with our policy of not taking into account IPPS 
geographic reclassifications in determining payments under the hospice 
wage index. We propose to amend Sec.  418.306(c) to cross-reference to 
the definitions of urban and rural in the IPPS regulations in 42 CFR 
part 412 subpart D.

B. Wage Data for Multi-Campus Hospitals

    In the 2007 IPPS final rule, we changed in the way that we treat 
multi-campus hospital wage data in the creation of the pre-floor, pre-
reclassified hospital wage index. The IPPS wage data used to determine 
the proposed FY 2009 hospice wage index values now apportion the wage 
data for multi-campus hospitals located in different labor market areas 
(CBSAs) to the CBSAs where the campuses are located (see 72 FR 47317 
through 47320). Historically, the hospice wage index is derived from 
the pre-floor, pre-reclassified hospital wage index. Consequently, for 
this proposed rule we propose to continue to use the most recent 
available pre-floor, pre-reclassified hospital wage index in computing 
the hospice wage index. The pre-floor, pre-reclassified hospital wage 
index values for the following CBSAs are affected by this change in how 
wage data from multi-campus hospitals are used in the computation of 
the pre-floor, pre-reclassified hospital wage index: Boston-Quincy, MA 
(CBSA 14484), Providence-New Bedford-Falls River, RI-MA (CBSA 39300), 
Chicago-Naperville-Joliet, IL (CBSA 16974) and Lake-County-Kenosha 
County, IL-WI (CBSA 29404).

C. FY 2009 Hospice Wage Index With Phase-Out of the Budget Neutrality 
Adjustment Factor (BNAF)

    [If you choose to comment on issues in this section, please include 
the caption, ``FY 2009 Hospice Wage Index with Phase-out of the Budget 
Neutrality Adjustment Factor (BNAF)'' at the beginning of your 
comments.]
1. Background
    The hospice final rule published in the Federal Register on 
December 16, 1983 (48 FR 56008) provided for adjustment to hospice 
payment rates to reflect differences in area wage levels. We apply the 
appropriate hospice wage index value to the labor portion of the 
hospice payment rates based on the geographic area where hospice care 
was furnished. As noted earlier, each hospice's labor market area is 
based on definitions of Metropolitan Statistical Areas (MSAs) issued by 
the OMB. For FY 2009, we propose to again use a pre-floor, pre-
reclassified hospital wage index based solely on the CBSA designations.
    As noted above, our hospice payment rules utilize the wage 
adjustment factors used by the Secretary for purposes of section 
1886(d)(3)(E) of the Act for hospital wage adjustments. We are 
proposing again to use the pre-floor and pre-reclassified hospital wage 
index data to adjust the labor portion of the hospice payment rates 
based on the geographic area where the beneficiary receives hospice 
care. We believe the use of the pre-floor, pre-reclassified hospital 
wage index data results in the appropriate adjustment to the labor 
portion of the costs. For the FY 2009 update to hospice payment rates, 
we propose to continue to use the most recent pre-floor, pre-
reclassified hospital wage index available at the time of publication.
2. Areas Without Hospital Wage Data
    In adopting the CBSA designations, we identified some geographic 
areas where there are no hospitals, and thus no hospital wage data on 
which to base the calculation of the hospice wage index. These areas 
were described in section I.B.4 of this proposed rule. Beginning in FY 
2006, we adopted a policy that, for urban labor markets without an 
urban hospital from which a pre-floor, pre-reclassified hospital wage 
index can be derived, all of the urban CBSA pre-floor, pre-reclassified 
hospital wage index values within the State would be used to calculate 
a statewide urban average pre-floor, pre-reclassified hospital wage 
index to use as a reasonable proxy for these areas. Currently, the only 
CBSA that would be affected by this policy is CBSA 25980, Hinesville, 
Georgia. We propose to continue this policy for FY 2009.
    Currently, the only rural areas where there are no hospitals from 
which to calculate a pre-floor, pre-reclassified hospital wage index 
are Massachusetts and Puerto Rico. In August 2007 (72 FR 50217) we 
adopted the following methodology for imputing rural pre-floor, pre-
reclassified hospital wage index values for areas where no hospital 
wage data are available as an acceptable proxy. We imputed an average 
pre-floor, pre-reclassified hospital wage index value by averaging the 
pre-floor, pre-reclassified hospital wage index values from contiguous 
CBSAs as a reasonable proxy for rural areas with no hospital wage data 
from which to calculate a pre-floor, pre-reclassified hospital wage 
index. In determining an imputed rural pre-floor, pre-reclassified 
hospital wage index, we define ``contiguous'' as sharing a border. For 
Massachusetts, rural Massachusetts currently consists of Dukes and 
Nantucket Counties. We determined that the borders of Dukes and 
Nantucket counties are ``contiguous'' with Barnstable and Bristol 
counties. We are again proposing to apply this methodology for imputing 
a rural pre-floor, pre-reclassified hospital wage index for those rural 
areas without rural hospital wage data in FY 2009.
    However, as we noted in our final rule at 72 FR 50218, we do not 
believe that this policy is appropriate for Puerto Rico. We noted that 
there are sufficient economic differences between the hospitals in the 
United States and those in Puerto Rico, including the fact that 
hospitals in Puerto Rico are paid on

[[Page 24005]]

blended Federal/Commonwealth-specific rates, to make a separate 
distinct policy for Puerto Rico necessary. For FY 2009, we again 
propose to continue to use the most recent pre-floor, pre-reclassified 
hospital wage index value available for Puerto Rico, which is 0.4047. 
This pre-floor, pre-reclassified hospital wage index value is then 
adjusted upward by the hospice floor in the computing of the proposed 
FY 2009 hospice wage index.
3. Phase-Out of the Budget Neutrality Adjustment Factor (BNAF)
    As noted in section 1.B of this proposed rule, the current hospice 
wage index methodology was developed through a negotiated rule making 
process and implemented in 1997. The rule making committee sought to 
address the inaccuracies in the original Bureau of Labor Statistics 
(BLS)-based hospice wage index, account better for disparities from one 
geographic location to another, and develop a wage index that would be 
as accurate, reliable and equitable as possible. The resulting hospice 
wage index reflects a special adjustment (a BNAF) to ensure payments in 
the aggregate are budget neutral to payments using the original 1983 
hospice wage index. The adjustment, still in place today, results in 
providers currently receiving about 4 percent more in payments than 
they would receive if the adjustment factor were not applied. The 
rationale for maintaining this adjustment is outdated given the time 
that has elapsed since it was put into place and the growth that is 
occurring in the hospice benefit. In this section, we propose to phase-
out this adjustment over 3 years, reducing it by 25 percent in FY 2009, 
by an additional 50 percent for a total of 75 percent in FY 2010, and 
eliminating it completely in FY 2011. We also provide our rationale for 
the phase-out.
    As discussed in section I.B of this proposed rule, the original 
hospice wage index was based on the 1981 Bureau of Labor Statistics 
(BLS) hospital data and had not been updated since 1983. During earlier 
attempts to update the hospice wage index, the hospice industry raised 
concerns over the adverse financial impact of a new wage index on 
individual hospices and a possible overall reduction in Medicare 
payments. Thus, the result was that in the absence of agreement on a 
new wage index, we continued to use a wage index that was clearly 
obsolete for geographically adjusting Medicare hospice payments (see 
``Medicare Program; Notice Containing the Statement Drafted by the 
Committee Established to Negotiate the Wage Index to be Used to Adjust 
Hospice Payment Rates Under Medicare,'' November 29, 1995, 60 FR 
61264).
    Changing to a new but more accurate wage index would result in some 
areas gaining as their wage index value would increase, but in other 
areas seeing declines in payments as their wage index value dropped. In 
1994 we noted that a majority of hospices would have their wage index 
reduced with the new wage index based on using the pre-floor, pre-
reclassified hospital wage index. These reductions would have occurred 
for two key reasons: (1) Hospices were located in areas where the 
original hospice wage index was artificially high due to flaws in the 
1981 BLS data, and (2) hospices were located in areas where wages had 
gone down relative to other geographic areas (see ``Hospice Services 
Under Medicare Program: Intent to Form Negotiated Rulemaking 
Committee,'' October 14, 1994, 59 FR 52130).
    Because of the negative impact to certain areas that was expected 
with the change to a new wage index, a committee was formulated in 
1994, under the process established by the Negotiated Rulemaking Act of 
1990 (Pub. L. 101-648). The Committee was established to negotiate the 
hospice wage index methodology rather than to go through the usual 
rulemaking process. On September 4, 1996, we published a proposed rule 
(61 FR 46579) in which we proposed a methodology to update the hospice 
wage index used to adjust Medicare hospice payment rates.
    In formulating the provisions of that proposed rule, the Committee 
considered criteria in evaluating the available data sources. The need 
for fundamental equity of the wage index; data that reflected actual 
work performed by hospice personnel; compatibility with wage indexes 
used by CMS for other Medicare providers; and availability of the data 
for timely implementation were considered.
    The Committee agreed that the hospice wage index be derived from 
the 1993 hospital cost report data and that these data, prior to 
reclassification, would form the basis for the FY 1997 hospice wage 
index. That is the pre-floor, pre-reclassified hospital wage index 
would not be adjusted to take into account the geographic 
reclassification of hospitals in accordance with sections 1886(d)(8)(B) 
and 1886(d)(10) of the Act. The methodology is codified in Sec.  
418.306(c). The hospice wage index for subsequent years would be based 
on pre-floor, pre-reclassified hospital wage index data for a 
subsequent year.
    The Committee was also concerned that while some hospices would see 
increases, use of the pre-floor, pre-reclassified hospital wage index 
as the wage index for hospices would result in a net reduction in 
aggregate Medicare payments for hospices. As noted above, a majority of 
hospices would have had their wage index lowered by using the new wage 
index because the prior hospice wage indices were based on outdated 
data which were artificially high due to flaws in the 1981 BLS data, 
and because some hospices were located in areas where wages had gone 
down relative to other geographic areas. The reduction in overall 
Medicare payments if a new wage index were adopted was noted in the 
November 29, 1995 final rule (60 FR 61264). Therefore, the Committee 
also decided that, each year in updating the hospice wage index, 
aggregate Medicare payments to hospices would remain budget neutral to 
payments as if the 1983 wage index had been used.
    As decided upon by the Hospice Wage Index Negotiated Rulemaking 
Committee, budget neutrality means that, in a given year, estimated 
aggregate payments for Medicare hospice services using the updated 
hospice values will equal estimated payments that would have been made 
for these services if the 1983 hospice wage index values had remained 
in effect, after adjusting the payment rates for inflations. Being 
budget neutral does not take into account annual market basket updates 
to hospice payment rates. Therefore, although payments to individual 
hospice programs may change each year, the total payments each year to 
hospices would not be affected by using the updated hospice wage index 
because total payments would be budget neutral as if the 1983 wage 
index had been used. To implement this provision a BNAF would be 
computed and applied annually.
    The BNAF is calculated by computing estimated payments using the 
most recent completed year of hospice claims data. The units (days or 
hours) from those claims are multiplied by the updated hospice payment 
rates to calculate estimated payments. The updated hospice wage index 
values are then applied to the labor portion of the payments. For this 
proposed rule, that means estimating payments for FY 2009 using FY 2006 
hospice claims data, and applying the estimated updated FY 2009 hospice 
payment rates (updating the FY 2008 rates by the estimated FY 2009 
market basket update). The proposed FY 2009 hospice wage index values 
are then applied to the labor portion only. The procedure is repeated 
using the

[[Page 24006]]

same claims data and payment rates, but using the 1983 BLS-based wage 
index instead of the updated pre-floor, pre-reclassified hospital wage 
index. The total payments are then compared, and the adjustment 
required to make total payments equal is computed; that adjustment 
factor is the BNAF. In 1998, the BNAF increased all wage index values 
by just over 2 percent.
    All pre-floor, pre-reclassified hospital wage index values of 0.8 
or greater would be adjusted by the BNAF. Also, all pre-floor, pre-
reclassified hospital wage index values below 0.8 would receive the 
greater of the following: (1) A 15-percent increase subject to a 
maximum hospice wage index value of 0.8; or (2) an adjustment by the 
BNAF. All hospice wage index values of 0.8 or greater would be adjusted 
by the BNAF. The BNAF would be calculated and applied annually.
    While the Committee sought to adopt a wage index methodology that 
would be as accurate, reliable, and equitable as possible, the 
Committee also decided to incorporate a BNAF into the calculation of 
the hospice wage index that would otherwise apply in order to mitigate 
adverse financial impacts some hospices would experience through a 
decrease in their wage index value by transitioning to a pre-floor, 
pre-reclassified hospital wage index.
    In the August 8, 1997 final rule (62 FR 42860), we indicated that 
the annual updates of the hospice wage index values would be made in 
accordance with the methodology agreed to by the rulemaking committee. 
We also noted that in the event that if we decide to change this 
methodology by which the hospice wage index is computed, it would be 
reflected in a proposed rule published in the Federal Register. In this 
proposed rule, we now propose to change this methodology.
    In FY 1998, the BNAF was 1.020768; in FY 2008 it was 1.066671. In 
other words, any pre-floor, pre-reclassified hospital wage index value 
greater than 0.8 was increased by over 2 percent in FY 1998 and 
increased by almost 7 percent in FY 2008. In FY 2008, this adjustment 
resulted in hospice providers receiving about 4 percent more in 
payments than they would have received if the BNAF had not been 
applied.
    The negotiating committee also recommended that the transition to 
the new hospice wage index occur over 3 years, from FY 1998 to FY 2001. 
The intent of both the three year transition and the budget neutrality 
adjustment was to mitigate the negative financial impact to many 
hospices resulting from the wage index change. Additionally, the 
committee sought to ensure that access to hospice care was not 
jeopardized as a result of the wage index change.
    We believe that the rationale for maintaining this adjustment is 
outdated for several reasons.
    First, the original purpose of the BNAF was to prevent reductions 
in payments to the majority of hospices whose wage index was based on 
the original hospice wage index which was artificially high due to 
flaws in the 1981 BLS data. While incorporating a BNAF into hospice 
wage indices could be rationalized in 1997 as a way to smooth the 
transition from an old wage index to a new one, since hospices have had 
plenty of time to adjust to the new wage index, it is difficult to 
justify maintaining in perpetuity a BNAF which was in part compensating 
for artificially high data to begin with.
    Second, the new wage index adopted in 1997 resulted in increases in 
wage index values for hospices in certain areas. The BNAF applies to 
hospices in all areas. Thus, hospices in areas that would have had 
increases without the BNAF received an artificial boost in the wage 
index for the past 11 years. We believe that continuation of this 
excess payment can no longer be justified.
    Third, an adjustment factor that is based on 24-year old wage index 
values is contrary to our goal of using a hospice wage index that is as 
accurate, reliable and equitable as possible in accounting for 
geographic variation in wages. We believe that those goals can be 
better achieved by using the pre-floor, pre-reclassified hospital wage 
index, without an outdated BNAF, consistent with other providers. For 
instance, Medicare payments to home health agencies, that utilize a 
similar labor mix, are adjusted by the pre-floor, pre-reclassified 
hospital wage index, without any budget neutrality adjustment. We 
believe that using the unadjusted pre-floor, pre-reclassified hospital 
wage index provides a good measure of area wage differences for both 
these home-based reimbursement systems.
    Fourth, in the 13 years since concerns about the impact of 
switching from an old to a new wage index were voiced, the hospice 
industry and hospice payments have grown substantially. Hospice 
expenditures in 2006 were $9.2 billion, compared to about $2.2 billion 
in 1998, a growth rate of almost 20 percent per year. Aggregate hospice 
expenditures are increasing at a rate of about $1 billion per year. 
MedPAC projects that expenditures will continue to grow at a rate of 9 
percent per year through 2015, outpacing the growth rate of projected 
expenditures for hospitals, skilled nursing facilities, and physician 
and home health services. We believe that this growth in Medicare 
spending for hospice indicates that the original rationale of the BNAF, 
to cushion the impact of using the new wage index, is no longer 
justified. These spending growth figures also indicate that any 
negative financial impact to the hospice industry as a result of 
eliminating the BNAF is no longer present, and thus the need for a 
transitional adjustment has passed.
    Fifth, 13 years ago the industry also voiced concerns about the 
negative financial impact on individual hospices that could occur by 
adopting a new wage index. In August 1994 there were 1,602 hospices; 
currently there are 2,986 hospices. Clearly any negative financial 
impact from adopting a new wage index in 1997 is no longer present, or 
we would not have seen an 86 percent increase in the number of hospices 
since 1994. The number of Medicare-certified hospices has continued to 
increase, with a 26 percent increase in the number of hospice providers 
from 2001 to 2005. This ongoing growth in the industry also suggests 
that phasing out the BNAF would not have a negative impact on access to 
care.
    Therefore for these reasons, we believe that continuing to apply a 
BNAF for the purpose of mitigating any adverse financial impact on 
hospices or negative impact on access to care is no longer necessary. 
We are proposing to phase out the BNAF over a 3-year period, reducing 
the BNAF by 25 percent in FY 2009, by 75 percent in FY 2010, and 
eliminating it in FY 2011. We believe that the proposed 3-year phase-
out period will reduce any adverse financial impact that the industry 
might experience if we eliminated the BNAF in a single year. However, 
depending on the comments received, updated data, and subsequent 
analysis, for the final rule we may determine that a different 
percentage reduction in the BNAF (for any of the years) or a different 
phase-out timeframe would be more appropriate. Specifically, it may be 
determined that a more aggressive phase-out alternative (e.g. a 50 
percent reduction in the BNAF in FY 2009, a 75 percent reduction in the 
BNAF in FY 2010, and elimination of the BNAF in FY 2011) is more 
appropriate. Consequently, we will continue to look at reduction 
percentages and timeframe alternatives for the phase-out of the BNAF 
and, for the final rule, will implement what is determined to be the 
most appropriate option based on the above information. We propose to 
maintain the hospice floor, which offers protection to

[[Page 24007]]

hospices with pre-floor, pre-reclassified hospital wage index values 
less than 0.8.
    We believe that we should have addressed this issue in previous 
years. We believe that using the BNAF has resulted in Medicare spending 
for hospice services in excess of what spending should have been in the 
absence of such an adjustment. However, we are not proposing to reduce 
Medicare payments to hospices for prior years. We are only proposing to 
remove the application of the BNAF on a prospective basis, beginning on 
October 1, 2008.
    Section II.C.3.a below discusses the effects of phasing out the 
BNAF over three years using the data from the published FY 2008 hospice 
wage index; by basing the analysis on this data, our simulations hold 
claims data, the wage index values, and payment rates constant, with 
the only change being the reduction in the BNAF. Section II.C.3.b 
discusses the effects of reducing the BNAF for FY 2009 using the 
proposed FY 2009 hospice wage index.
a. Effects of Phasing-Out the BNAF Using the Published FY 2008 Hospice 
Wage Index
    For this proposed rule, we will use the FY 2008 hospice wage index 
(72 FR 50214, published August 31, 2007) to illustrate the effects of 
phasing out the BNAF over 3 years. This analysis and discussion is for 
illustrative purposes only and does not affect any of the hospice wage 
index values for FY 2008.
    The BNAF that was calculated and applied to the 2007 pre-floor, 
pre-reclassified hospital wage index values was 6.6671 percent. We 
propose reducing the BNAF by 25 percent for FY 2009, by 75 percent for 
FY 2010, and eliminating it altogether for FY 2011 and beyond. A 25 
percent reduction in the BNAF can be accomplished by blending 75 
percent of the FY 2008 hospice wage index that applied the full 6.6671 
percent BNAF with 25 percent of the FY 2008 hospice wage index that 
used no BNAF. This is mathematically equivalent to taking 75 percent of 
the full BNAF value, or multiplying 0.066671 by 0.75, which equals 
0.050003, or 5.0003 percent. The BNAF of 5.0003 percent reflects a 25 
percent reduction in the BNAF. The 25 percent reduction in the BNAF of 
5.0003 percent would be applied to the pre-floor, pre-reclassified 
hospital wage index values of 0.8 or greater used in the published FY 
2008 hospice wage index.
    The hospice floor calculation would still apply to any pre-floor, 
pre-reclassified hospital wage index values less then 0.8. Currently, 
the floor calculation has 4 steps. Pre-floor, pre-reclassified hospital 
wage index values that are less than 0.8 are first multiplied by 1.15; 
second, the minimum of 0.8 or the pre-floor, pre-reclassified hospital 
wage index value times 1.15 is chosen as the preliminary hospice wage 
index value. Third, the pre-floor, pre-reclassified hospital wage index 
value is multiplied by BNAF. Finally, the greater result of either step 
2 or step 3 is chosen as the final hospice wage index value. We propose 
to leave the hospice floor unchanged, noting that steps 3 and 4 will 
become unnecessary once the BNAF is eliminated.
    For the simulations of the BNAF phase-out for FY 2010 and FY 2011, 
we used the same pre-floor, pre-reclassified hospital wage index values 
and claims data as the example above, and simply changed the value of 
the BNAF to reflect either a 75 percent reduction for FY 2010 or a 100 
percent reduction for FY 2011. In both cases we started with the full 
BNAF of 6.6671 percent. We changed the calculation to take 25 percent 
of the full BNAF to reflect a 75 percent reduction for FY 2010, or 
eliminated the BNAF altogether to reflect a 100 percent reduction for 
FY 2011. For FY 2010, the reduced BNAF or the hospice floor was then 
applied to the 2008 pre-floor, pre-reclassified hospital wage index as 
described previously. For FY 2011 and subsequent years, the pre-floor, 
pre-reclassified hospital wage index values would be unadjusted unless 
they are less than 0.8, in which case the hospice floor calculation 
would be applied.
    For our simulations, the calculations of the BNAF are as follows:
 A 75 percent reduction to the BNAF in FY 2010 would be 
0.066671 x 0.25 = 0.016668 or 1.6668 percent
 A 100 percent reduction or elimination of the BNAF in FY 2011 
would be 0.066671 x 0.0 = 0.0 or 0 percent

    We examined the effects of phasing out the BNAF versus using the 
full BNAF of 6.6671 percent on the FY 2008 hospice wage index. The FY 
2009 BNAF reduction of 25 percent resulted in approximately a 1.55 to 
1.57 percent reduction in the hospice wage index value. The FY 2010 
BNAF reduction of 75 percent would result in an estimated additional 
3.12 to 3.13 percent reduction from the FY 2009 hospice wage index 
values. The elimination of the BNAF in FY 2011 would result in an 
estimated final reduction of the FY 2011 hospice wage index values of 
approximately 1.55 to 1.57 percent compared to FY 2010 hospice wage 
index values.
    Those CBSAs whose pre-floor, pre-reclassified hospital wage index 
values had the hospice floor calculation applied prior to the BNAF 
reduction would not be affected by this proposed phase-out of the BNAF. 
These CBSAs, which typically include rural areas, are protected by the 
hospice floor calculation. Additionally, those CBSAs whose hospice wage 
index values were previously 0.8 or greater after the BNAF was applied, 
but which would have values less than 0.8 after the reduced BNAF was 
applied would see a smaller reduction in their hospice wage index 
values since the hospice floor calculation would apply. We have 
estimated the number of CBSAs that would have their pre-floor, pre-
reclassified hospital wage index value eligible for the floor 
calculation after applying the 25, 75, and 100 percent reductions in 
the BNAF. Three CBSAs would be affected by the 25 percent reduction, 12 
would be affected by the 75 percent reduction, and 22 would be affected 
by the 100 percent reduction. Because of the protection given by the 
hospice floor calculation, these CBSAs would see smaller percentage 
decreases in their hospice wage index values than those CBSAs that are 
not eligible for the floor calculation. This will benefit those 
hospices with lower hospice wage index values, which are typically in 
rural areas.
    Finally, the hospice wage index values only apply to the labor 
portion of the payment rates; the labor portion was described in 
Section I.B.1 of this proposed rule. Therefore the estimated reduction 
in payments due to this proposed phase-out of the BNAF would be less 
than the percentage reductions to the hospice wage index values that 
would result from reducing or eliminating the BNAF. In addition, the 
effects of the proposed phase-out of the BNAF could also be mitigated 
by a hospital market basket update in payments, which in FY 2008 was a 
3.3 percent increase in payment rates. We will not have the final 
market basket update for FY 2009 until the summer, but the current 
estimate of the hospital market basket update is expected to be around 
3.0 percent. This update will be communicated through an administrative 
instruction and not through rulemaking. The estimated effects on 
payment described in column 5 of Table 1 in section IV.B of this 
proposed rule include the projected effect of an estimated 3.0 percent 
hospital market basket update. CMS may implement updates to the payment 
rates in future rulemaking.

[[Page 24008]]

b. Effects of Phasing-Out the BNAF Using the Updated Pre-floor, Pre-
reclassified Hospital Wage Index Data (FY 2009 Proposal)
    For FY 2009, we propose updating the hospice wage index using the 
2008 pre-floor, pre-reclassified hospital wage index and the most 
complete claims data available (FY 2006 claims). Using these data, we 
computed a full BNAF of 6.5357 percent. For the first year of the BNAF 
phase-out (FY 2009), the BNAF would be reduced by 25 percent, or 
0.065357 x 0.75 = 0.049018, to 4.9018 percent. This would decrease 
hospice wage index values by approximately 1.53 to 1.54 percent from 
wage index values with the full BNAF applied. As noted in the previous 
discussion on the effects of the BNAF reduction in the published FY 
2008 hospice wage index, those CBSAs which already have pre-floor, pre-
reclassified hospital wage index values that have the hospice floor 
applied prior to implementing a proposed BNAF reduction would be 
completely unaffected by this proposed BNAF reduction. Those CBSAs 
which previously had hospice wage index values above 0.8 after applying 
the full BNAF, but which now are below 0.8 with the 25 percent 
reduction in the BNAF would be less affected by the BNAF reduction than 
those CBSAs which are 0.8 or above after applying the BNAF, as they are 
protected by the hospice floor calculation. Additionally, as mentioned 
in section I.B.1 of this proposed rule, the final hospice wage index is 
only applied to the labor portion of the payment rates, so the actual 
effect on estimated payment would be less than the anticipated 1.53 to 
1.54 percent reduction in the hospice wage index value. Furthermore, 
that effect may be mitigated by a market basket update. As noted 
earlier, the market basket update will not be available until the 
summer, but estimates of the update are at about 3.0 percent.
    Column 3 of Table 1 (section IV of this proposed rule) shows the 
impact of using the most recent wage index data (the 2008 pre-floor, 
pre-reclassified hospital wage index not including any reclassification 
under section 1886(d)(8)(B) of the Act) compared to the 2007 pre-floor, 
pre-reclassified hospital wage index data which was used to derive the 
FY 2008 hospice wage index. Column 4 of Table 1 in Section IV of this 
proposed rule shows the impact of incorporating the 25 percent 
reduction in the BNAF in the proposed FY 2009 hospice wage index along 
with using the most recent wage index data (2008 pre-floor, pre-
reclassified hospital wage index). Finally, column 5 of Table 1 shows 
the combined effects of using the updated pre-floor, pre-reclassified 
hospital wage index, the 25 percent reduced BNAF, and an estimated 
market basket update of 3.0 percent. The proposed FY 2009 rural and 
urban hospice wage indexes can be found in Addenda A and B of this 
proposed rule. The pre-floor, pre-reclassified hospital wage index 
values were adjusted by the 25 percent reduced BNAF or by the hospice 
floor.

D. Summary of the Provisions of the Proposed Rule

     We propose to clarify that the hospice benefit will follow 
the definition of ``urban'' specified in Sec.  412.64(b)(1)(ii)(A) and 
(B), and the rural definition as any area outside of an urban area in 
Sec.  412.64(b)(1)(ii)(C). The regulatory text of Sec.  418.306(c) will 
be amended to reference Sec.  412.64(b)(1)(ii)(A) through (C). This 
affects two New England ``deemed'' counties that meet the OMB 
definition of rural, but were previously counted as urban; these two 
counties would now be considered rural. See section II.A of this 
proposed rule for details.
     As a basis for the hospice wage index, we propose to 
continue to use the pre-floor, pre-reclassified hospital wage index, 
which includes a change to how wage data from multi-campus hospitals 
are apportioned. See section II.B of this proposed rule for more 
details.
     We propose to continue to use a pre-floor, pre-
reclassified hospital wage index based solely on the CBSA designations, 
using the most recent pre-floor and pre-reclassified hospital wage 
index available at the time of publication. See section II.C.1 of this 
proposed rule for details.
     We propose to continue the policy that for urban labor 
markets without an urban hospital from which a pre-floor, pre-
reclassified hospital wage index could be derived, all of the urban 
CBSA pre-floor, pre-reclassified hospital wage index values within the 
State would be used to calculate a statewide urban average pre-floor, 
pre-reclassified hospital wage index to use as a reasonable proxy for 
these areas. See section II.C.2 of this proposed rule for details.
     We propose to continue the policy that we impute an 
average pre-floor, pre-reclassified rural hospital wage index value by 
averaging the pre-floor, pre-reclassified hospital wage index values 
from contiguous CBSAs as a reasonable proxy for rural areas with no 
hospital wage data from which to calculate a pre-floor, pre-
reclassified hospital wage index. See section II.C.2 f of this proposed 
rule or details.
     We propose to continue to utilize the most recent pre-
floor, pre-reclassified hospital wage index value available for Puerto 
Rico. See section II.C.2 of this proposed rule for details.
     We propose to phase-out the hospice BNAF over 3 years, 
reducing it by 25 percent for FY 2009, by 75 percent for FY 2010, and 
eliminating it completely for FY 2011. See sections II.C.3.a and 
II.C.3.b of this proposed rule for details. As stated in section 
II.C.3, based on comments received, updated data, and subsequent 
analysis, for the final rule we may determine that a different 
percentage reduction in the BNAF (for any of the years) or a different 
phase-out timeframe would be more appropriate. Specifically, it may be 
determined that a more aggressive alternative (e.g., a 50 percent 
reduction in the BNAF in FY 2009, a 75 percent reduction in the BNAF in 
FY 2010, and elimination of the BNAF in FY 2011) is more appropriate. 
Consequently, we will continue to look at reduction percentages and 
time period alternatives for the phase-out of the BNAF and, for the 
final rule, will implement what is determined to be the most 
appropriate option based on the above information.
     We propose to continue to maintain the hospice floor 
calculation. See section II.C.3 of this proposed rule for details.
    Addendum A reflects the proposed FY 2009 hospice wage index values 
for urban areas designations. Addendum B reflects the proposed FY 2009 
hospice wage index values for rural areas designations.

III. Collection of Information Requirements

    This document does not impose any information collection and 
recordkeeping requirements. Consequently, it does not need to be 
reviewed by the Office of Management and Budget under the authority of 
the Paperwork Reduction Act of 1995 (44 U.S.C. 35).

IV. Regulatory Impact Analysis

A. Overall Impact

    We have examined the impacts of this 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 (Pub. L. 104-4), Executive Order 13132 on 
Federalism, and the Congressional Review Act (5 U.S.C. 804(2)). We

[[Page 24009]]

estimated the impact on hospices, as a result of the changes to the 
proposed FY 2009 hospice wage index and of reducing the BNAF by 25 
percent. As discussed previously, the methodology for computing the 
hospice wage index was determined through a negotiated rulemaking 
committee and implemented in the August 8, 1997 final rule (62 FR 
42860). This rule proposes updates to the hospice wage index in 
accordance with our regulation but proposes to revise the Negotiated 
Rulemaking Committee methodology of including a BNAF.
    Executive Order 12866 (as amended by Executive Order 13258, which 
merely reassigns responsibility of duties) directs agencies to assess 
all costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits including potential economic, environmental, public health 
and safety effects, distributive impacts, and equity. A regulatory 
impact analysis (RIA) must be prepared for major rules with 
economically significant effects ($100 million or more in any 1 year). 
We have determined that this proposed rule is an economically 
significant rule under this Executive Order.
    Column 4 of Table 1 shows the combined effects of the proposed 25 
percent reduction in the BNAF and of the updated wage data, comparing 
estimated payments for FY 2009 to estimated payments for FY 2008. We 
estimate that the total hosp
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