Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2009, 65351-65384 [E8-26142]

Download as PDF Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices By order of the Board of Governor of the Federal Reserve System, October 28, 2008. Jennifer J. Johnson, Secretary of the Board. [FR Doc. E8–26101 Filed 10–31–08; 8:45 am] BILLING CODE 6210–01–P DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS–1555–N] RIN 0938–AP20 Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2009 Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. AGENCY: SUMMARY: This notice sets forth an update to the 60-day national episode rates and the national per-visit amounts under the Medicare prospective payment system for home health services, effective on January 1, 2009. DATES: Effective Date: This notice is effective on January 1, 2009. FOR FURTHER INFORMATION CONTACT: Randy Throndset, (410) 786–0131. I. Background sroberts on PROD1PC70 with NOTICES A. Requirements of the Balanced Budget Act of 1997 for Establishing the Prospective Payment System for Home Health Services The Balanced Budget Act of 1997 (BBA) (Pub. L. 105–33) enacted on August 5, 1997, significantly changed the way Medicare pays for Medicare home health services. Section 4603 of the BBA mandated the development of the home health prospective payment system (HH PPS). Until the implementation of a HH PPS on October 1, 2000, home health agencies (HHAs) received payment under a cost-based reimbursement system. Section 4603(a) of the BBA mandated the development of a HH PPS for all Medicare-covered home health services provided under a plan of care that were paid on a reasonable cost basis by adding section 1895 of the Social Security Act (the Act), entitled ‘‘Prospective Payment For Home Health Services’’. Section 1895(b)(1) of the Act requires the Secretary to establish a HH PPS for all costs of home health services paid under Medicare. Section 1895(b)(3)(A) of the Act requires that (1) the computation of a standard prospective payment amount VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 include all costs for home health services covered and paid for on a reasonable cost basis and be initially based on the most recent audited cost report data available to the Secretary, and (2) the prospective payment amounts be standardized to eliminate the effects of case-mix and wage levels among HHAs. Section 1895(b)(3)(B) of the Act addresses the annual update to the standard prospective payment amounts by the home health applicable increase percentage as specified in the statute. Section 1895(b)(4) of the Act governs the payment computation. Sections 1895(b)(4)(A)(i) and (b)(4)(A)(ii) of the Act require the standard prospective payment amount to be adjusted for casemix and geographic differences in wage levels. Section 1895(b)(4)(B) of the Act requires the establishment of an appropriate case-mix change adjustment factor that adjusts for significant variation in costs among different units of services. Similarly, section 1895(b)(4)(C) of the Act requires the establishment of wage adjustment factors that reflect the relative level of wages, and wage-related costs applicable to home health services furnished in a geographic area compared to the applicable national average level. These wage-adjustment factors may be used by the Secretary for the different geographic wage levels for purposes of section 1886(d)(3)(E) of the Act. Section 1895(b)(5) of the Act gives the Secretary the option to make additions or adjustments to the payment amount otherwise paid in the case of outliers because of unusual variations in the type or amount of medically necessary care. Total outlier payments in a given fiscal year (FY) may not exceed 5 percent of total payments projected or estimated. In accordance with the statute, we published a final rule (65 FR 41128) in the Federal Register on July 3, 2000 to implement the HH PPS legislation. The July 2000 final rule established requirements for the new HH PPS for home health services as required by section 4603 of the BBA, as subsequently amended by section 5101 of the Omnibus Consolidated and Emergency Supplemental Appropriations Act (OCESAA) for Fiscal Year 1999, (Pub. L. 105–277), enacted on October 21, 1998; and by sections 302, 305, and 306 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act (BBRA) of 1999, (Pub. L. 106–113), enacted on November 29, 1999. The requirements include the implementation of a HH PPS for home PO 00000 Frm 00068 Fmt 4703 Sfmt 4703 65351 health services, consolidated billing requirements, and a number of other related changes. The HH PPS described in that rule replaced the retrospective reasonable cost-based system that was used by Medicare for the payment of home health services under Part A and Part B. For a complete and full description of the HH PPS as required by the BBA, see the July 2000 HH PPS final rule (65 FR 41128 through 41214). B. Deficit Reduction Act of 2005 On February 8, 2006, the Deficit Reduction Act of 2005 (Pub. L. 109–171) (DRA) was enacted. This legislation affected updates to HH payment rates for calendar year (CY) 2006. The DRA also required HHAs to submit home health care quality data and created a linkage between those data and payment, beginning in CY 2007. Specifically, section 5201 of the DRA changed the CY 2006 update from the applicable home health market basket percentage increase minus 0.8 percentage points to a 0 percent update. In addition, section 5201 of the DRA amends section 421(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108–173, enacted on December 8, 2003). The amended section 421(a) of the MMA requires that for home health services furnished in a rural area (as defined in section 1886(d)(2)(D) of the Act) on or after January 1, 2006 and before January 1, 2007, that the Secretary increase the payment amount otherwise made under section 1895 of the Act for home health services by 5 percent. The statute waives budget neutrality for purposes of this increase since it specifically states that the Secretary must not reduce the standard prospective payment amount (or amounts) under section 1895 of the Act applicable to home health services furnished during a period to offset the increase in payments resulting in the application of this section of the statute. The 0 percent update to the payment rates and the rural add-on provisions of the DRA were implemented through a CMS transmittal (Pub. 100–20, One Time Notification, Transmittal 211) issued on February 10, 2006. In addition, section 5201 of the DRA requires HHAs to submit data for purposes of measuring health care quality, and links the quality data submission to payment. This requirement is applicable for CY 2007 and each subsequent year. If an HHA does not submit quality data, the home health market basket percentage increase will be reduced 2 percentage points. In accordance with the statute, E:\FR\FM\03NON1.SGM 03NON1 65352 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices we published a final rule (71 FR 65884, 65935) in the Federal Register on November 9, 2006 to implement the pay-for-reporting requirement of the DRA, codified at 42 CFR 484.225(h) and (i). In addition, the November 2006 final rule ended the 1-year transition period that consisted of a blend of 50 percent of the new area labor market designations’ wage index and 50 percent of the previous area labor market designations’ wage index. We also revised the fixed dollar loss ratio, which is used in the calculation of outlier payments. sroberts on PROD1PC70 with NOTICES C. System for Payment of Home Health Services Generally, Medicare makes payment under the HH PPS on the basis of a national standardized 60-day episode payment rate that is adjusted for the applicable case-mix and wage index. The national standardized 60-day episode payment rate includes the six home health disciplines (skilled nursing, home health aide, physical therapy, speech-language pathology, occupational therapy, and medical social services) and non-routine medical supplies. Durable medical equipment covered under home health is paid for outside the HH PPS payment. To adjust for case-mix, the HH PPS uses a 153category case-mix classification to assign patients to a home health resource group (HHRG). Clinical needs, functional status, and service utilization are computed from responses to selected data elements in the OASIS assessment instrument. For episodes with four or fewer visits, Medicare pays on the basis of a national per-visit amount by discipline; an episode consisting of four or fewer visits within a 60-day period is referred to as a LUPA. Medicare also adjusts the national standardized 60-day episode payment rate for certain intervening events that are subject to a partial episode payment adjustment (PEP adjustment). For certain cases that exceed a specific cost threshold, an outlier adjustment may also be available. D. Updates to the HH PPS As required by section 1895(b)(3)(B) of the Act, we have historically updated the HH PPS rates annually in a separate Federal Register document. We published a final rule with comment period in the Federal Register on August 29, 2007 (72 FR 49762) that set forth a refinement and rate update to the Medicare prospective payment system for home health services. As part of the CY 2008 HH PPS final rule with comment period, we rebased and VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 revised the home health market basket to reflect FY 2003 Medicare cost report data, the latest available and most complete data on the structure of HHA costs. In the rebased and revised home health market basket, the labor-related share was 77.082 (an increase from the previous labor-related share of 76.775). The non-labor-related share is 22.918 (a decrease from the previous nonlaborrelated share of 23.225). The increase in the labor-related share using the FY 2003 home health market basket was primarily due to the increase in the benefit cost weight. The CY 2008 HH PPS final rule with comment period also implemented refinements to the payment system. Extensive research was conducted to investigate ways to improve the performance of the case-mix model. This research was the basis for our decision to refine the case-mix model. We refined the case-mix model to reflect different resource costs for early home health episodes versus later home health episodes and to expand the casemix variables included in the payment model. For 2008, we used a 4-equation case-mix model that recognizes and differentiates payment for episodes of care based on whether a patient is in an early (1st or 2nd episode in a sequence of adjacent episodes) or later (the 3rd episode and beyond in a sequence of adjacent episodes) episode of care as well as recognizing whether a patient was a high therapy (14 or more therapy visits) or low therapy (13 or fewer therapy visits) case. We defined episodes as adjacent if they were separated by no more than a 60-day period between claims. Analysis of the performance of the case-mix model for later episodes revealed two important differences for episodes occurring later in the home health treatment compared to earlier episodes: Higher resource use per episode and a different relationship between clinical conditions and resource use. We use additional variables to include scores for certain wound and skin conditions; more diagnosis groups such as pulmonary, cardiac, and cancer diagnoses; and certain secondary diagnoses. The 4equation model results in 153 case-mix groups. In addition, we replaced the previous single therapy threshold of 10 visits with three therapy thresholds at 6, 14, and 20 visits. The payment for additional therapy visits between the three thresholds increases gradually, incorporating a declining, rather than a constant, amount per added therapy visit. This approach does not reduce total payments to home health providers because the payment model still PO 00000 Frm 00069 Fmt 4703 Sfmt 4703 predicts total resource cost. The combined effect of the new therapy thresholds and payment gradations reduces the undesirable emphasis in treatment planning on a single therapy visit threshold and restores the primacy of clinical considerations in treatment planning for rehabilitation patients. In the CY 2008 HH PPS final rule with comment period, we further adjusted for case-mix that was not due to a change in the underlying health status of the home health users. Section 1895(b)(3)(B) of the Act requires that in compensating for case-mix change, a payment reduction must be applied to the standardized payment amount. For the CY 2008 HH PPS final rule with comment period, we conducted several analyses to determine if any portion of the total change in case-mix could be considered to be real change. Real change is a change in the underlying health status of the home health user population. The results of the analysis indicated that while a small amount (8.03 percent) of measured case-mix change was real, most of the change was unrelated to the underlying health status of home health users. Using 100 percent of the home health interim payment system (HH IPS) file for our baseline (12 months ending September 30, 2000), the average casemix weight per episode was 1.0960. (The HH IPS was the previous costbased payment system under which HHAs were paid, prior to the HH PPS.) The 2005 20 percent sample file yielded an average CMI (case mix indicator) of 1.2361. Therefore, the change measurement was (1.2361 ¥ 1.0960)/ 1.0960 = 12.78 percent. We adjusted this result downward by 8.03 percent (the percentage of total change in case-mix considered to be real) to get a final casemix change measure of 11.75 percent (0.1278 * (1¥0.0803) = 0.1175). To account for the 11.75 percent increase in case-mix which was not due to a change in the underlying health status of Medicare home health patients, we implemented a 2.75 percent reduction of the national standardized 60-day episode payment rate for 3 years beginning in 2008 and solicited comments on extending that adjustment period to a fourth year based on a 2.71 percent reduction for 2011 (see 72 FR 49833). Additionally, we modified a number of existing HH PPS payment adjustments. Specifically, we increased the payment for low utilization payment adjustment (LUPA) episodes that occur as the only episode or the initial episode during a sequence of adjacent episodes, by $87.93. We also eliminated the significant change in condition (SCIC) E:\FR\FM\03NON1.SGM 03NON1 sroberts on PROD1PC70 with NOTICES Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices payment adjustment for various reasons. Specifically, we ended the policy because of the apparent difficulty HHAs had in interpreting the SCIC policy, the association between negative margins and SCIC episodes, the decline in the occurrence of SCICs, and the estimated minimal impact on outlays from eliminating the SCIC policy. In the development of the HH PPS, non-routine medical supplies (NRS) were accounted for by attributing $49.62 to the standardized episode payment. In the CY 2008 HH PPS final rule with comment period, we applied a severity adjustment to the NRS portion of the HH PPS standardized episode payment. Specifically, we adopted a six-severitygroup approach to account for NRS costs (see 72 FR 49851–49852) based on measurable conditions that are feasible to administer. This change offers HHAs some protection against episodes with extremely high NRS costs. Finally, we did not modify the existing Partial Episode Payment (PEP) Adjustment. Section 1895(b)(5) of the Act also allows for the provision of an addition or adjustment to account for outlier episodes, which are those episodes that incur unusually large costs due to heavy patient care needs. Under the HH PPS, outlier payments are made for episodes for which the estimated cost exceeds a threshold amount. The wage adjusted fixed dollar loss (FDL) amount represents the amount of loss that an agency must bear before an episode becomes eligible for outlier payments. Section 1895(b)(5) of the Act requires that the estimated total outlier payments may not exceed 5 percent of total estimated HH PPS payments. In the CY 2008 HH PPS final rule with comment period, we adjusted the FDL ratio to 0.89, based on the most recently available data, analysis, trends, and unknown effects of the refinements on outliers (see 72 FR 49857). Finally, we expanded the list of quality measures identified in the update notice for CY 2007. In CY 2007, we specified 10 OASIS quality measures from the OASIS data set as appropriate for public reporting of measurements of health care quality. For CY 2008, we added two more quality measures from the OASIS data set for public reporting. All twelve publicly reported measures are National Quality Forum (NQF)endorsed measures. The additional measures for 2008 were as follows: • Emergent Care for Wound Infection, Deteriorating Wound Status; and • Improvement in the Status of Surgical Wounds (see 72 FR 49861). Accordingly, for CY 2008, we considered the existing OASIS data set submitted by HHAs to CMS for episodes VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 beginning on or after July 1, 2006, and before July 1, 2007, as meeting the reporting requirement for quality measures for CY 2008. II. Comments Received From CY 2008 HH PPS Final Rule With Comment Period In the CY 2008 HH PPS final rule with comment period, we implemented a 2.75 percent payment reduction of the national standardized 60-day episode payment rate for three years beginning in CY 2008 and a fourth year reduction of 2.71 percent for CY 2011. We sought comments only on the 2.71 percent case-mix change adjustment for 2011. We received approximately 44 items of correspondence from the public, only a few of which were directly related to the 2.71 percent adjustment to the HH PPS 60-day episode payment rate in the fourth year. The provision for the 2.71 percent adjustment was added as the fourth year’s reduction to the rates to account for the additional change in case-mix, that was indicated in the analysis for the CY 2008 final rule with comment period, that is not considered real; i.e., that is not related to an underlying change in patient health status. Comments originated from trade associations, HHAs, hospitals, and health care professionals such as physicians, nurses, social workers, and physical and occupational therapists. Because this is an update notice, we are not changing policy. However, in order to provide more meaningful and substantive responses we will respond to the above mentioned comments in future rulemaking. This approach allows us to respond comprehensively as more current data become available, while also affording the public ample opportunity to comment on possible future policy changes. At this time, CMS is maintaining our existing policy as implemented in the CY 2008 final rule with comment period and will impose a 2.75 percent reduction to the national standardized 60-day episode rate for CY 2009. We will continue to monitor any changes in case-mix and may revise the percentage reductions to the HH PPS rates in future rulemaking. III. Provisions of This Notice A. National Standardized 60-Day Episode Rate The Medicare HH PPS has been in effect since October 1, 2000. As set forth in the final rule published July 3, 2000 in the Federal Register (65 FR 41128), the unit of payment under the Medicare HH PPS is a national standardized 60day episode rate. As set forth in PO 00000 Frm 00070 Fmt 4703 Sfmt 4703 65353 § 484.220, we adjust the national standardized 60-day episode rate by a case-mix relative weight and a wage index value based on the site of service for the beneficiary. In the CY 2008 HH PPS final rule with comment period, we refined the case-mix methodology and also rebased and revised the home health market basket. The labor-related share of the case-mix adjusted 60-day episode rate is 77.082 percent and the non-labor-related share is 22.918 percent. The CY 2009 HH PPS rates use the same case-mix methodology and application of the wage index adjustment to the labor portion of the HH PPS rates as set forth in the CY 2008 HH PPS final rule with comment period. We multiply the national 60-day episode rate by the patient’s applicable case-mix weight. We divide the casemix adjusted amount into a labor and non-labor portion. We multiply the labor portion by the applicable wage index based on the site of service of the beneficiary. We add the wage-adjusted portion to the non-labor portion yielding the case-mix and wage-adjusted 60-day episode rate subject to any additional applicable adjustments. In accordance with section 1895(b)(3)(B) of the Act, we have updated the HH PPS rates annually in a separate Federal Register document. The HH PPS regulations at § 484.225 sets forth the specific annual percentage update. To reflect section 1895(b)(3)(B)(v) of the Act, as added by section 5201 of the DRA, we added § 484.225, paragraphs (h) and (i), in the November 9, 2006 final rule to reflect the requirement for submission of quality data, as follows: (h) For 2007 and subsequent calendar years, in the case of a home health agency that submits home health quality data, as specified by the Secretary, the unadjusted national prospective 60-day episode rate is equal to the rate for the previous calendar year increased by the applicable home health market basket index amount. (i) For 2007 and subsequent calendar years, in the case of a home health agency that does not submit home health quality data, as specified by the Secretary, the unadjusted national prospective 60-day episode rate is equal to the rate for the previous calendar year increased by the applicable home health market basket index amount minus 2 percentage points. Any reduction of the percentage change will apply only to the calendar year involved and will not be taken into account in computing the prospective payment amount for a subsequent calendar year. For CY 2009, we will base the wage index adjustment to the labor portion of E:\FR\FM\03NON1.SGM 03NON1 65354 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices the HH PPS rates on the most recent pre-floor and pre-reclassified hospital wage index. As discussed in the July 3, 2000 HH PPS final rule, for episodes with four or fewer visits, Medicare pays the national per-visit amount by discipline, referred to as a ‘‘low utilization payment adjustment’’ (LUPA). We update the national pervisit amounts by discipline annually by the applicable home health market basket percentage. We adjust the national per-visit amount by the appropriate wage index based on the site of service for the beneficiary, as set forth in § 484.230. We will adjust the labor portion of the updated national per-visit amounts by discipline used to calculate the LUPA by the most recent pre-floor and pre-reclassified hospital wage index, as discussed in the CY 2008 HH PPS final rule with comment period. We are also updating the amounts of the LUPA add-on and the NRS conversion factor by the applicable home health market basket update of 2.9 percent for CY 2009. Medicare pays the 60-day case-mix and wage-adjusted episode payment on a split percentage payment approach. The split percentage payment approach includes an initial percentage payment and a final percentage payment as set forth in § 484.205(b)(1) and § 484.205(b)(2). We may base the initial percentage payment on the submission of a request for anticipated payment (RAP) and the final percentage payment on the submission of the claim for the episode, as discussed in § 409.43. The claim for the episode that the HHA submits for the final percentage payment determines the total payment amount for the episode and whether we make an applicable adjustment to the 60-day case-mix and wage-adjusted episode payment. The end date of the 60-day episode as reported on the claim determines which calendar year rates Medicare would use to pay the claim. We may also adjust the 60-day casemix and wage-adjusted episode payment based on the information submitted on the claim to reflect the following: • A low utilization payment provided on a per-visit basis as set forth in § 484.205(c) and § 484.230. • A partial episode payment adjustment as set forth in § 484.205(d) and § 484.235. • An outlier payment as set forth in § 484.205(e) and § 484.240. B. CY 2009 Update to the Home Health Market Basket Index Section 1895(b)(3)(B) of the Act, as amended by section 5201 of the DRA, requires for CY 2009 that the standard prospective payment amounts be increased by a factor equal to the applicable home health market basket update for those HHAs that submit quality data as required by the Secretary. The applicable home health market basket update will be reduced by 2 percentage points for those HHAs that fail to submit the required quality data. This requirement has been codified in regulations at 42 CFR 484.225. The HH PPS market basket update for CY 2009 is 2.9 percent. This is based on Global Insights Inc.’s, third quarter 2008 forecast, utilizing historical data through the second quarter of 2008. A detailed description of how we derived the HHA market basket is available in the CY 2008 Home Health PPS proposed rule (72 FR 25356, 25435). • CY 2009 Adjustments In order to calculate the CY 2009 national standardized 60-day episode rate, we first increase the CY 2008 national standardized 60-day episode payment rate of $2,270.32 by the home health market basket update of 2.9% for CY 2009. Given this updated rate, we then take a reduction of 2.75 percent to account for the change in case-mix that is not related to the real change in patient acuity levels, as discussed above. The resulting updated CY 2009 national standardized 60-day episode rate for an HHA that submits the required quality data is shown in Table 1. The updated CY 2009 national standardized 60-day episode rate for an HHA that does not submit the required quality data is shown in Table 2. TABLE 1—NATIONAL 60-DAY EPISODE AMOUNTS UPDATED BY THE HOME HEALTH MARKET BASKET UPDATE FOR CY 2009, BEFORE CASE-MIX ADJUSTMENT, WAGE INDEX ADJUSTMENT BASED ON THE SITE OF SERVICE FOR THE BENEFICIARY Total CY 2008 National Standardized 60-Day Episode Payment Rate Multiply by the Home Health Market Basket Update (2.9 Percent) 1 Updated National Standardized 60-Day Episode Payment Reduce by 2.75 Percent for Nominal Change in Case-Mix CY 2009 National Standardized 60Day Episode Payment $2,270.32 .............................................................. × 1.029 ......................... $2,336.16 ...................... × 0.9725 ....................... $2,271.92 1 The estimated home health market basket update of 2.9 percent for CY 2009 is based on Global Insight Inc., 3rd Qtr 2008 forecast with historical data through 2nd Qtr 2008. TABLE 2—FOR HHAS THAT DO NOT SUBMIT THE REQUIRED QUALITY DATA—NATIONAL 60-DAY EPISODE AMOUNTS UPDATED BY THE HOME HEALTH MARKET BASKET UPDATE FOR CY 2009, BEFORE CASE-MIX ADJUSTMENT, WAGE INDEX ADJUSTMENT BASED ON THE SITE OF SERVICE FOR THE BENEFICIARY sroberts on PROD1PC70 with NOTICES Total CY 2008 National Standardized 60-Day Episode Payment Rate Multiply by the Home Health Market Basket Update (2.9 Percent) 1 minus 2 percent Updated National Standardized 60-Day Episode Payment for HHAs that do not submit required quality data Reduce by 2.75 Percent for Nominal Change in Case-Mix CY 2009 National Standardized 60Day Episode Payment for HHAs that do not submit required quality data $2,270.32 .............................................................. × 1.009 ......................... $2,290.75 ...................... × 0.9725 ....................... $2,227.75 1 The estimated home health market basket update of 2.9 percent for CY 2009 is based on Global Insight Inc., 3rd Qtr 2008 forecast with historical data through 2nd Qtr 2008. VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00071 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices • National Per-Visit Amounts Used To Pay LUPAs and Compute Imputed Costs Used in Outlier Calculations As discussed previously in the CY 2008 HH PPS final rule with comment period, the policies governing LUPAs and the outlier calculations set forth in the July 3, 2000 HH PPS final rule will continue (65 FR 41128). Also, we implemented a LUPA add-on amount of $87.93 for initial and only episode LUPAs during CY 2008. In calculating the CY 2009 national per-visit amounts used to calculate payments for LUPA episodes and to compute the imputed costs in outlier calculations, we start with the CY 2008 per-visit amounts. We 65355 increase the CY 2008 per-visit amounts for each home health discipline for CY 2009 by the home health market basket update (2.9 percent). LUPA rates are not reduced due to the nominal increase in case-mix since they are per-visit rates and hence are not subject to changes in case-mix. TABLE 3—NATIONAL PER-VISIT AMOUNTS FOR LUPAS (NOT INCLUDING THE INCREASE IN PAYMENT FOR A BENEFICIARY’S ONLY EPISODE OR THE INITIAL EPISODE IN A SEQUENCE OF ADJACENT EPISODES) AND OUTLIER CALCULATIONS UPDATED BY THE HOME HEALTH MARKET BASKET UPDATE FOR CY 2009, BEFORE WAGE INDEX ADJUSTMENT BASED ON THE SITE OF SERVICE FOR THE BENEFICIARY For HHAs that DO submit the required quality data CY 2008 per-visit payment Home Health Discipline Home Health Aide .................................. Medical Social Services ......................... Occupational Therapy ............................ Physical Therapy .................................... Skilled Nursing ........................................ Speech-Language Pathology ................. $47.51 168.17 115.48 114.71 104.91 124.65 ................... ................... ................... ................... ................... ................... Multiply by the Home Health Market Basket Update (2.9 Percent) 1 × × × × × × 1.029 1.029 1.029 1.029 1.029 1.029 .................. .................. .................. .................. .................. .................. For HHAs that DO NOT submit the required quality data CY 2009 per-visit payment $48.89 173.05 118.83 118.04 107.95 128.26 ................... ................... ................... ................... ................... ................... Multiply by the Home Health Market Basket Update (2.9 percent) 1 minus 2 percent CY 2009 pervisit payment × × × × × × $47.94 169.68 116.52 115.74 105.85 125.77 1.009 1.009 1.009 1.009 1.009 1.009 .................. .................. .................. .................. .................. .................. 1 The estimated home health market basket update of 2.9 percent for CY 2009 is based on Global Insight Inc., 3rd Qtr 2008 forecast with historical data through 2nd Qtr 2008. Payment for LUPA episodes changed in CY 2008 in that for LUPAs that occur as initial episodes in a sequence of adjacent episodes or as the only episode, an additional payment amount is added to the LUPA payment. The Table 3 per-visit rates noted above are before that additional payment is added to the LUPA payment, and are the pervisit rates paid to all other LUPA episodes and used in computing outlier payments. LUPA episodes that occur as the only episode or initial episode in a sequence of adjacent episodes are adjusted by adding an additional amount to the LUPA payment before adjusting for wage index. For CY 2008, that amount was $87.93. This additional LUPA amount is updated in the same manner as the national standardized 60day episode payment amount and the per-visit rates (i.e. by the home health market basket percentage update). Consequently, for CY 2009, the additional amount paid to LUPAs that occur as initial episodes in a sequence of adjacent episodes or as the only episode is 90.48 ($87.93 × 1.029). Beginning in CY 2008, to ensure that the variation in non-routine medical supplies (NRS) is more appropriately reflected in the HH PPS, we replaced the original portion ($49.62) of the HH PPS base rate that accounted for NRS, with a system that pays for NRS based on 6 severity groups. For a complete description of the analysis and research behind the development of this system for the payment of NRS, we refer readers to the CY 2008 HH PPS proposed rule (72 FR 25426–25434). Following public comment on the initial proposal made in the proposed rule, we made several modifications using a file of more recent data. The revisions resulted in some scoring changes, and the addition of the sixth severity group to the original five severity groups, to provide more adequate reimbursement for episodes with a high utilization of NRS. As we did in the CY 2008 HH PPS final rule with comment, payments for NRS are updated by the home health market basket and reduced by the 2.75 percent reduction to the rates through the updating of the NRS conversion factor. NRS payments are computed by multiplying the relative weight for a particular severity level by the NRS conversion factor. For this notice, the NRS conversion factor is updated by the home health market basket update of 2.9 percent and reduced by the 2.75 percent reduction to the rates. The NRS conversion factor for CY 2008 was $52.35. Consequently, for CY 2009, the NRS conversion factor is $52.39 (52.35 × (1.029 × (1¥0.0275))). The payment amounts for the various severity levels based on the updated conversion factor are calculated in Table 4. TABLE 4—RELATIVE WEIGHTS FOR THE 6–SEVERITY NRS SYSTEM Points (scoring) sroberts on PROD1PC70 with NOTICES Severity level 1 2 3 4 5 6 .................................................................................... .................................................................................... .................................................................................... .................................................................................... .................................................................................... .................................................................................... VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Relative weight 0 .................................................................................... 1 to 14 .......................................................................... 15 to 27 ........................................................................ 28 to 48 ........................................................................ 49 to 98 ........................................................................ 99+ ................................................................................ Frm 00072 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 0.2698 0.9742 2.6712 3.9686 6.1198 10.5254 NRS payment amount $14.13 51.04 139.94 207.91 320.62 551.43 65356 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices sroberts on PROD1PC70 with NOTICES C. Home Health Care Quality Improvement Section 5201(c)(2) of the DRA added section 1895(b)(3)(B)(v)(II) to the Act, requiring that, starting with the initial reporting year from July 2005 through June 2006 and each year thereafter, ‘‘each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality.’’ In response to the DRA requirements, CMS published information about the quality measures in the Federal Register as a proposed rule on August 3, 2006 (71 FR 44082– 44090) and as a final rule on November 9, 2006 (71 FR 65903). We proposed, and made final, the decision to use the subset of OASIS data that is publicly reported on Home Health Compare, as the appropriate measures of home health quality. Therefore, OASIS assessments submitted by HHAs to CMS in compliance with HHA conditions of participation for dates of service beginning July 1, 2007 and ending June 30, 2008 will fulfill the HH PPS quality reporting requirement for CY 2009 payments. This reporting time period allows for 12 full months of data and provides us the time necessary to analyze and make any necessary payment adjustments to the CY 2009 payment rates. The required quality measures for meeting the submission requirements for CY 2009 are the same as those required for meeting the submission requirements for CY 2008. These measures are: • Improvement in Ambulation/ Locomotion, • Improvement in Bathing, • Improvement in Transferring, • Improvement in Management of Oral Medication, • Improvement in Pain Interfering with Activity, • Acute Care Hospitalization, • Emergent Care, • Discharge to Community, • Improvement in Dyspnea, • Improvement in Urinary incontinence, • Improvement in surgical wounds, and • Emergent Care for wound deterioration. HHAs that meet the reporting requirements are eligible for the full home health market basket percentage increase. Consistent with our previous policy, home health agencies that are certified on or after May 1, 2007 for payments to be made in CY 2009 will be excluded from the quality reporting requirement in CY 2009 because data VerDate Aug<31>2005 18:44 Oct 31, 2008 Jkt 217001 submission and analysis will not be possible for an agency certified this late in the reporting time period. At the earliest time possible after obtaining the CCN number, reporting is mandatory. These exclusions only affect quality reporting requirements and do not affect the agency’s OASIS reporting responsibilities under the CoP submission requirement. Additionally, section 1895(b)(3)(B)(v)(I) of the Act requires that all HHAs, unless covered by specific exclusions, meet the reporting requirement, or be subject to a 2 percent reduction in the home health market basket percentage increase. CMS will reconcile the OASIS submissions with claims data in order to verify full compliance with the quality reporting requirements on an annual cycle July 1 through June 30. The 2 percent reduction applies to all HHAs who have not submitted an OASIS assessment in the required time frame for payments beginning in January 2007 and each year thereafter. We will reconcile the OASIS submissions with claims data in order to verify full compliance with the quality reporting requirements. Section 1895(b)(3)(B)(v)(III) of the Act further requires that ‘‘[t]he Secretary shall establish procedures for making data submitted under subclause (II) available to the public. Such procedures shall ensure that a home health agency has the opportunity to review the data that is to be made public with respect to the agency prior to such data being made public.’’ To meet the requirement for making such data public, we will continue to use the Home Health Compare Web site, which lists HHAs geographically. Currently, the Home Health Compare Web site lists 12 quality measures from the OASIS set, and these 12 measures are all NQFendorsed measures for public reporting. Consumers can search for all Medicareapproved home health providers that serve their city or zip code (which would include the quality measures) and then find the agencies offering the types of services they need. See http:// www.medicare.gov/HHCompare/ Home.asp. HHAs currently have prepublication access every November to their own agency’s quality data (collected and periodically updated by a contractor), which enables each agency to know how it is performing before public posting of data on the Home Health Compare Web site. In addition, each agency formally receives quarterly updates via the CASPER system known as Outcome Based Quality Improvement (OBQI) and Outcome Based Quality Monitoring (OBQM) and a report PO 00000 Frm 00073 Fmt 4703 Sfmt 4703 describing the agency patient characteristics based on OASIS. Continuing to use the OASIS instrument ensures that providers will not have an additional burden of reporting through a separate mechanism and that the costs associated with the development and testing of a new reporting mechanism can be avoided. For CY 2009, we will continue to require that the HHA submit OASIS data appropriate for the measurement of health care quality. Over the past year, CMS has tested new patient level best practice and process measures for home health agencies, and has continued to refine the current OASIS instrument. CMS is testing the new measure the NQF has developed a Global Measure for Flu/ Pneumonia vaccination across care settings. We anticipate making further modifications to the current OASIS items, including refinements to response categories. Any new data elements go through OMB process and measures go through the NQF consensus development process, prior to proposing them through the rulemaking process. Additionally, section 1895(b)(3)(B)(v)(II) of the Act requires each HHA to submit appropriate health care quality data in a form, manner, and at a time specified by the Secretary. Such measures would be evidence-based, clearly linked to improved outcomes, and reliably captured with the least burden to the provider. Data element revisions and measures across settings of care will be integral to CMS’ vision of addressing national quality care priorities and use of a future single instrument for quality, payment, clinical relevance, and risk adjustment. D. Consumer Assessment of Healthcare Providers and Systems (CAHPS) Home Health Care As part of the U.S. Department of Health and Human Services (DHHS) Transparency Initiative, CMS plans to implement a process to measure and publicly report patient experiences with home health care using a survey developed by the Agency for Healthcare Research and Quality’s (AHRQ’s) Consumer Assessment of Healthcare Providers and Systems (CAHPS) program. The CAHPS Home Health Care survey is part of a family of CAHPS surveys that ask patients to report on and rate their experiences with health care. This notice provides an update on the development of the CAHPS Home Health Care survey, as initially discussed in the May 4, 2007 proposed rule (72 FR 25356, 25452). The CAHPS Home Health Care survey presents home health patients with a set of standardized questions about their E:\FR\FM\03NON1.SGM 03NON1 sroberts on PROD1PC70 with NOTICES Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices home health care providers and the quality of their home health care. Prior to this survey, there was no national standard for collecting information about patient experience that would allow comparisons across all home health agencies. The survey captures topics such as patients’ interactions with home health staff, provider care and communication, and patient characteristics. The survey allows the patient to give an overall rating of the agency, and asks if the patient would recommend the agency to family and friends. AHRQ conducted a field test to determine the length and content of the CAHPS Home Health Care Survey. CMS has submitted the survey to the National Quality Forum (NQF) for consideration and approval in their consensus process. NQF endorsement represents the consensus opinion of many healthcare providers, consumer groups, professional organizations, purchasers, federal agencies, and research and quality organizations. The final survey will be submitted to the Office of Management and Budget (OMB) for their approval under the Paperwork Reduction Act (PRA) process. CMS is working with a contractor to develop protocols and guidelines for implementation of CAHPS Home Health Care survey. Administration of the survey will be conducted by multiple, independent survey vendors working under contract with home health agencies to facilitate data collection and reporting. During 2008, vendor training materials are being developed, and implementation procedures for data submission and processing will be finalized. Recruitment and training of vendors who wish to be approved to collect survey data will begin in 2009. The CAHPS Home Health Care survey will be implemented similar to the CAHPS Hospital survey where vendors are approved to conduct the survey and trained prior to agency participation in the survey. Home health agencies interested in learning about the survey are encouraged to view the CAHPS Home Health Care Survey Web site: http://www.homehealthCAHPS.org. They can also call toll-free: 1–866–354– 0985 or send an email to the project team at HHCAHPS@rti.org for more information. More information about the national implementation will be available next year in the Home Health Rule: The Home Health Prospective Payment System Refinement and Rate Update for Calendar Year 2010. VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 E. Outliers and the Fixed Dollar Loss Ratio In addition to the regular 60-day casemix and wage-adjusted episode payments, the HH PPS allows for outlier payments for episodes that incur unusually high costs. As noted in section I.A., of this notice, outlier payments are made for episodes for which the estimated cost exceeds a threshold amount. Section 1895(b)(5) of the Act requires that the estimated total outlier payments be no more than 5 percent of total estimated HH PPS payments for a given year. For a full description of our outlier policy, we refer to the CY 2008 HH PPS final rule with comment period (72 FR 49855– 49857). The wage adjusted fixed dollar loss (FDL) amount represents the amount of loss that an agency must bear before an episode becomes eligible for outlier payments. Annually, we review the percentage of outlier payments and adjust the FDL ratio as appropriate. Past experience has shown that outlier payments have been increasing as a percent of total payments from 4.1 percent in CY 2005, to 5.0 percent in CY 2006, to 6.4 percent in CY 2007. More recent analysis estimates outlier payments to increase to approximately 8.1 percent in CY 2008 (an increase of slightly more than 27 percent). In the CY 2008 final rule with comment period, in the interest of using the latest data and best analysis available, we performed supplemental analysis on the most recent data available in order to best estimate the FDL ratio. That analysis derived a final FDL ratio of 0.89 for CY 2008. In order to determine the appropriate value for the FDL ratio for CY 2009 we performed an updated analysis using the most recent, complete available data (CY 2007), applying a methodology similar to that which we used to update the FDL ratio in the CY 2008 HH PPS final rule with comment. That updated analysis projects that in CY 2009 we will expend an estimated 10.26 percent of total estimated HH PPS payments in outlier payments, more than double our 5 percent statutory limit. However, our analysis also revealed that this growth in outlier payments is primarily the result of excessive growth in a few specific areas of the country. Specifically, we have noticed statistical anomalies in outlier payments, as a percentage of total HH PPS payments, in areas such as Miami-Dade, Florida, where outlier payments to providers far exceed the national average and the 5 percent target for outlier payments. Using similar analysis to what was PO 00000 Frm 00074 Fmt 4703 Sfmt 4703 65357 performed for the CY 2009 final rule with comment; we estimated that we would need to raise our FDL ratio from 0.89 to 2.71 for CY 2009. This is a dramatic change that appears to be driven by statistical anomalies in outlier payments in areas such as Miami-Dade, Florida. In addition, the size of these statistical anomalies raises concerns about the medical necessity of the outlier episodes in some areas. We will be examining outlier payments in these areas in more detail and will take action to remedy inappropriate outlier payments as necessary. Therefore, we believe that raising the FDL ratio to 2.71 is not justified at this time, given the statistical outlier data anomalies that we have identified in certain areas, and the actions that are underway to address excessive, suspect outlier payments that are occurring in these areas. We believe the most reasonable policy to achieve paying no more than 5 percent outlier payments as a percentage of total estimated HH PPS payments is through the combined effects of maintaining the current (CY 2008) FDL ratio of 0.89 in CY 2009 and the actions being taken to remedy any inappropriate outlier payments in these areas of the country where outlier data anomalies exist. Any further update to the FDL ratio, if any, will not occur until future rulemaking when we expect to have a better understanding of appropriate outlier payments, particularly in those areas of the country with extremely high outlier payments as a percentage of total HH PPS payments. F. Hospital Wage Index Sections 1895(b)(4)(A)(ii) and (b)(4)(C) of the Act require the Secretary to establish area wage adjustment factors that reflect the relative level of wages and wage-related costs applicable to the furnishing of home health services and to provide appropriate adjustments to the episode payment amounts under the HH PPS to account for area wage differences. As discussed previously, we apply the appropriate wage index value to the labor portion (77.082 percent) of the HH PPS rates based on the site of service for the beneficiary (defined by section 1861(m) of the Act as the beneficiary’s place of residence). Generally, we determine each HHA’s labor market area based on definitions of Metropolitan Statistical Areas (MSAs) issued by the Office of Management and Budget (OMB). We have consistently used the pre-floor, pre-reclassified hospital wage index data to adjust the labor portion of the HH PPS rates. We believe the use of the pre-floor, prereclassified hospital wage index data results in the appropriate adjustment to E:\FR\FM\03NON1.SGM 03NON1 65358 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices sroberts on PROD1PC70 with NOTICES the labor portion of the costs as required by statute. In the November 9, 2005 final rule for CY 2006 (70 FR 68132), we adopted revised labor market area definitions based on Core-Based Statistical Areas (CBSAs). At the time, we noted that these were the same labor market area definitions (based on OMB’s new CBSA designations) implemented under the Hospital Inpatient Prospective Payment System (IPPS). 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 home health wage index. We continue to use the methodology discussed in the November 9, 2006 final rule for CY 2007 (71 FR 65884) to address the geographic areas that lack hospital wage data on which to base the calculation of their home health wage index. For rural areas that do not have IPPS hospitals, we use the average wage index from all contiguous CBSAs as a reasonable proxy. This methodology is used to calculate the wage index for rural Massachusetts. However, we could not apply this methodology to rural Puerto Rico due to the distinct economic circumstances that exist there, but instead continue using the most recent wage index previously available for that area (from CY 2005). For urban areas without IPPS hospitals, we use the average wage index of all urban areas within the State as a reasonable proxy for the wage index for that CBSA. The only urban area without IPPS hospital wage data is Hinesville-Fort Stewart, Georgia (CBSA 25980). 1. Clarification of New England Deemed Counties We are taking this opportunity to address the change in the treatment of ‘‘New England deemed counties’’ (that is, those counties in New England listed at 42 CFR 412.64(b)(1)(ii)(B) that were deemed to be part of urban areas under section 601(g) of the Social Security Amendments of 1983) that was made in the FY 2008 IPPS final rule with comment period (72 FR 47337 through 47338, August 22, 2007). These counties include the following: 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, ME; Sagadahoc County, ME; and Newport County, RI) are also included in metropolitan statistical areas defined by OMB and are considered urban under both the current IPPS and HH PPS labor market area definitions in VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 § 412.64(b)(1)(ii)(A). The remaining two, Litchfield County, CT, and Merrimack County, NH, are geographically located in areas that are considered rural under the current IPPS (and HH PPS) labor market area definitions, but have been previously deemed urban under the IPPS in certain circumstances, as discussed below. In the FY 2008 IPPS final rule with comment period, § 412.64(b)(1)(ii)(B) was revised such that the two ‘‘New England deemed counties’’ that are still considered rural under the OMB definitions (Litchfield County, CT and Merrimack County, NH), are no longer considered urban effective for discharges occurring on or after October 1, 2007, and therefore, 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 note that the HH PPS does not provide for such geographic reclassification. Also, in the FY 2008 IPPS final rule with comment period (72 FR 47338), we explained that we have limited this policy change for the ‘‘New England deemed counties’’ only to IPPS hospitals, and any change to non-IPPS provider wage indexes would be addressed in the respective payment system rules. Accordingly, we are taking this opportunity to clarify the treatment of ‘‘New England deemed counties’’ under the HH PPS in this notice. As discussed above, the HH PPS has consistently used the IPPS definition of ‘‘urban’’ and ‘‘rural’’ with regard to the wage index used in the HH PPS. Historical changes to the labor market area/geographic classifications and annual updates to the wage index values under the HH PPS are made effective January 1 each year. When we established the most recent HH PPS payment rate update, effective for HH services provided on or after January 1, 2008 through December 31, 2008, we considered the ‘‘New England deemed counties’’ (including Litchfield County, CT and Merrimack County, NH) as urban for CY 2008, as evidenced by the inclusion of Litchfield County as one of the constituent counties of urban CBSA 25540 (Hartford-West Hartford-East Hartford, CT), and the inclusion of Merrimack County as one of the constituent counties of urban CBSA 31700 (Manchester-Nashua, NH). At 42 CFR 484.202, the terms ‘‘rural’’ and ‘‘urban’’ are defined according to the definitions of those terms as used in PO 00000 Frm 00075 Fmt 4703 Sfmt 4703 the IPPS. Applying the IPPS definitions, Litchfield County, CT and Merrimack County, NH are not considered ‘‘urban’’ under § 412.64(b)(1)(ii)(A) through (B) as revised under the FY 2008 IPPS final rule and, therefore, are considered ‘‘rural’’ under § 412.64(b)(1)(ii)(C). Accordingly, reflecting our policy to use the IPPS definitions of ‘‘urban’’ and ‘‘rural,’’ these two counties will be considered ‘‘rural’’ under the HH PPS effective with the next update of the HH PPS payment rates on January 1, 2009, and will no longer be included in urban CBSA 25540 (Hartford-West HartfordEast Hartford, CT) and urban CBSA 31700 (Manchester-Nashua, NH), respectively. We note that this policy is consistent with our policy of not taking into account IPPS geographic reclassifications in determining payments under the HH PPS. 2. Multi-Campus Hospital Wage Index Data In the CY 2008 HH PPS final rule with comment period, we established HH PPS wage index values for CY 2008 calculated from the same data (collected from cost reports submitted by hospitals for cost reporting periods beginning during FY 2004) used to compute the FY 2008 acute care hospital inpatient wage index, without taking into account geographic reclassification under sections 1886(d)(8) and (d)(10) of the Act. However, the IPPS policy that apportions the wage data for multicampus hospitals was not finalized before the HH PPS final rule with comment period. We are continuing to use IPPS wage data for this CY 2009 update notice because we believe that in the absence of home health-specific wage data, using the hospital inpatient wage data is appropriate and reasonable for the HH PPS. We note that the IPPS wage data used to determine the CY 2009 HH wage index values reflect our policy that was adopted under the IPPS beginning in FY 2008, which apportions the wage data for multi-campus hospitals located in different labor market areas, or CoreBased Statistical Areas (CBSAs), to each CBSA where the campuses are located (see the FY 2008 IPPS final rule with comment period (72 FR 47317 through 47320)). Specifically, for the CY 2009 HH PPS, the wage index was computed using IPPS wage data (published by hospitals for cost reporting periods beginning in 2005, as with the FY 2009 IPPS wage index), which allocated salaries and hours to the campuses of two multi-campus hospitals with campuses that are located in different labor areas; one is Massachusetts and the other is Illinois. The wage index E:\FR\FM\03NON1.SGM 03NON1 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices sroberts on PROD1PC70 with NOTICES values for the CY 2009 HH PPS in the following CBSAs are affected by this policy: 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) (please refer to Addendum B in this notice). As previously discussed in the July 3, 2000 final rule (65 FR 41128), the statute provides that the wage adjustment factors may be the factors used by the Secretary for purposes of section 1886(d)(3)(E) of the Act for hospital wage adjustment factors. Since publication of the July 3, 2000 final rule, we continue to believe that the use of the pre-floor and pre-reclassified hospital wage index data results in the appropriate and reasonable adjustment to the labor portion of the costs as required by statute. The HH PPS does not use the hospital area wage index’s occupational mix adjustment, as this adjustment serves specifically to define the occupational categories more clearly in a hospital setting. See Addenda A and B of this notice, respectively, for the rural and urban pre-floor, prereclassified hospital wage indexes for 2009. The 2009 wage index is based on data collected from hospital cost reports submitted for cost reporting periods beginning during FY 2005. These data reflect the multi-campus and New England deemed counties policies discussed above. Under the HH PPS, we use the wage index value associated with the labor market in which the beneficiary’s home is located. As has been our longstanding practice, any area not included in an MSA (urban area) is considered to be nonurban (§ 412.64(b)(1)(ii)(C)) and receives the statewide rural wage index value (see, for example, 65 FR 41173). IV. Waiver of Proposed Rulemaking We ordinarily publish a notice of proposed rulemaking in the Federal Register to provide a period for public comment before the provisions of a notice such as this take effect. We can waive this procedure, however, if we find good cause that a notice-andcomment procedure is impracticable, unnecessary, or contrary to the public interest and incorporate a statement of finding and its reasons in the notice issued. We find that it is unnecessary, impracticable and contrary to the public interest to undertake proposed notice and comment rulemaking in this Notice. We believe it is unnecessary because the statute requires annual updates to the HH PPS rates and the methodologies used to update the rates have been VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 previously subject to public comment; we are simply applying the methodology to the most recent data. With respect to the update of the outlier FDL ratio, we find that insofar as we have deviated from our usual methodology in this calendar year, such change is an analytical change. Moreover, we believe that the difficulty of deriving a new methodology to address the limited data discrepancies in localized areas of the country makes issuing a notice of proposed rulemaking in this instance impracticable. Moreover, it would be contrary to the public interest to undertake notice and comment rulemaking as it would impose a hardship on home health agencies and their patients by delaying publication of this update in order to solicit comments. Since it would pose additional harm to those home health agencies across the country that would be deemed ineligible for outlier payments because of these localized data discrepancies, applying the FDL analysis that we have used in past years is likewise contrary to the public interest for CY 2009. Therefore, we find good cause to waive notice and comment procedures for CY 2009. V. Collection of Information Requirements This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 501 et seq. ). VI. Regulatory Impact Analysis A. Overall Impact We have examined the impacts of this notice 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)). Executive Order 12866, as amended, 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 rules with PO 00000 Frm 00076 Fmt 4703 Sfmt 4703 65359 economically significant effects ($100 million or more in any 1 year). This notice, as defined by Executive Order 12866, is not an economically significant rule. This notice would not be considered major under the Congressional Review Act. The update set forth in this notice applies to Medicare payments under HH PPS in CY 2009. Accordingly, the following analysis describes the impact in CY 2009 only. We estimate that the net impact in this notice, including a 2.75 percent reduction to the payment rate to account for the case-mix change adjustment, is estimated to be approximately $30 million in CY 2009 expenditures. This total estimated $30 million impact reflects the distributional effects of an updated wage index (¥$20 million) as well as the 2.9 percent home health market basket increase (an estimated additional $490 million in CY 2009 expenditures attributable only to the CY 2009 home health market basket update), and the 2.75 percent decrease (¥$440 million for the second year of a 4-year phase-in) to the HH PPS national standardized 60-day episode rate to account for the case-mix change adjustment under the HH PPS. The $30 million is reflected in column 3 of Table 5 as a 0.15 percent increase in expenditures when comparing the current CY 2008 system to the CY 2009 system. The RFA requires agencies to analyze options for regulatory relief of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $7 million to $34.5 million in any 1 year. For purposes of the RFA, approximately 75 percent of HHAs are considered small businesses according to the Small Business Administration’s size standards with total revenues of $13.5 million or less in any 1 year. Individuals and States are not included in the definition of a small entity. As stated above, this notice will have an estimated positive effect upon small entities that are HHAs (see Section IV.B ‘‘Anticipated Effects’’, of this rule, for supporting analysis). In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital E:\FR\FM\03NON1.SGM 03NON1 65360 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices as a hospital that is located outside of a Metropolitan Statistical Area and has fewer than 100 beds. We have determined that this notice will not have a significant economic impact on the operations of a substantial number of small rural hospitals. Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies assess anticipated costs and benefits before issuing any rule that may result in expenditure in any 1 year by State, local, or tribal governments, in the aggregate, or by the private sector, of $100 million adjusted for inflation. Using the Gross Domestic Price Deflator, the inflation adjusted threshold for 2008 is approximately $130 million. We believe this notice will not mandate expenditures in that amount. Executive Order 13132 established 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 notice under the threshold criteria of Executive Order 13132, Federalism. We have determined that this notice would not have substantial direct effects on the rights, roles, and responsibilities of States. sroberts on PROD1PC70 with NOTICES B. Anticipated Effects This notice updates the HH PPS rates contained in the CY 2008 HH PPS final rule with comment period. We use the latest data and best analysis available, but we do not attempt to predict behavioral responses to these changes, and we do not make adjustments for future changes in such variables as days or case-mix. This analysis incorporates the latest estimates of growth in service use and payments under the Medicare home health benefit, based on the latest available Medicare claims from 2006. We note that certain events may combine to limit the scope or accuracy of our impact analysis, because such an analysis is future-oriented and, thus, susceptible to forecasting errors due to other changes in the forecasted impact time period. Some examples of such possible events are newly-legislated VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 general Medicare program funding changes made by the Congress, or changes specifically related to HHAs. In addition, changes to the Medicare program may continue to be made as a result of the BBA, the BBRA, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, the MMA, the DRA, or new statutory provisions. Although these changes may not be specific to the HH PPS, 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 HHAs. Table 5 represents how home health agencies are likely to be affected by the policy changes described in this notice. Column one of this table classifies HHAs according to a number of characteristics including provider type, geographic region, and urban versus rural location. For the purposes of analyzing impacts on payments, we performed four simulations and compared them to each other. Based on our estimate that outliers, as a percentage of total HH PPS payments, will be at least 5 percent in CY 2008, the 2008 baseline, for the purposes of these simulations, we assumed that the full 5 percent outlay for outliers will be paid. The first simulation estimates 2008 payments under the current system (to include the 2008 wage index and 2008 payment rates). The second simulation estimates CY 2008 payments under the current system, but with the CY 2009 wage index. The second simulation produces an estimate of the effect of the CY 2009 wage index only. The third simulation estimates the effect of the CY 2009 payments using the CY 2009 payment rates and the CY 2008 wage index. The fourth simulation estimates CY 2009 payments using the new CY 2009 payment rates and CY 2009 wage index. These four simulations allow us to demonstrate the effects of the new CY 2009 wage index and a new 2009 payment rates as a percentage change in estimated expenditures. Specifically, the second column of Table 5 shows the percent change due to the effects of the CY 2009 wage index. The third column PO 00000 Frm 00077 Fmt 4703 Sfmt 4703 of Table 5 shows the percent change due to the combined effects of the CY 2009 wage index and the CY 2009 home health market basket update and the case-mix reduction. Column three shows the percentage change in estimated total payments in moving from the current CY 2008 to the revised CY 2009 system outlined in this notice. Our estimate of the change in total payments between CY 2008 and CY 2009 is an increase of approximately 0.15 percent. In general, most HHAs are estimated to see increases in total payments from CY 2008 to CY 2009. The increases range from ¥0.01 percent for other voluntary/non-profit freestanding agencies to 0.25 percent for facilitybased governmental HHAs. The only rural HHA’s estimated to see a decrease are free-standing, other voluntary/non-profit HHAs. The decrease is estimated to be 0.07 percent. In total, payments are estimated to increase 0.17 percent to HHAs in rural areas and 0.19 percent to HHAs in urban areas. The only urban HHAs estimated to see a decrease are facility-based voluntary/non-profits with an estimated decrease of 0.05 percent. Overall, payments are estimated to increase 0.15 percent to HHAs in urban areas. HHAs in the South and the West are expected to experience increases of 0.08 percent and 1.56 percent respectively from CY 2008 to CY 2009. The North and the Midwest are estimated to experience decreases of 0.08 percent and 0.44 percent respectively. It is estimated that New England, East South Central, West South Central, West North Central and Pacific HHAs will experience percentage increases of 0.36 percent, 0.02 percent, 0.34 percent, 0.61 percent, and 2.21 percent respectively. Conversely, Mid Atlantic, South Atlantic, East North Central, and Mountain area HHAs are expected to experience decreases of 0.32 percent, 0.18 percent, 0.70 percent, and 0.09 percent respectively. In general, all HHAs of varying facility size are expected to experience increases (ranging from 0.04 percent to 0.53 percent) in total payments from CY 2008 to CY 2009. E:\FR\FM\03NON1.SGM 03NON1 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices 65361 TABLE 5—IMPACT BY AGENCY TYPE Percent change due to the effects of the updated wage index only Percent change due to the effects of the updated wage index, the 2.9% home health market basket update, and the 2.75% reduction to the rates Free-Standing/Other Vol/NP ............................................................................................................................ Free-Standing/Other Proprietary ..................................................................................................................... Free-Standing/Other Government ................................................................................................................... Facility-Based Vol/NP ...................................................................................................................................... Facility-Based Proprietary ................................................................................................................................ Facility-Based Government ............................................................................................................................. Subtotal: Freestanding ............................................................................................................................. Subtotal: Facility-based ............................................................................................................................ Subtotal: Vol/PNP ..................................................................................................................................... Subtotal: Proprietary ................................................................................................................................. Subtotal: Government ............................................................................................................................... ¥0.22 ¥0.09 ¥0.11 ¥0.16 ¥0.01 0.10 ¥0.12 ¥0.12 ¥0.19 ¥0.09 ¥0.01 ¥0.01 0.24 0.07 0.01 0.14 0.25 0.17 0.05 0.00 0.24 0.16 Total ................................................................................................................................................... ¥0.12 0.15 ¥0.22 0.07 ¥0.16 0.06 0.20 0.09 ¥0.07 0.23 0.01 0.21 0.33 0.23 ¥0.22 ¥0.12 ¥0.06 ¥0.22 ¥0.16 0.11 0.00 0.25 0.16 0.05 0.01 0.28 Rural* ............................................................................................................................................................... Urban* .............................................................................................................................................................. 0.01 ¥0.15 0.17 0.15 Total .......................................................................................................................................................... ¥0.12 0.15 North ................................................................................................................................................................ South ................................................................................................................................................................ Midwest ............................................................................................................................................................ West ................................................................................................................................................................. Other ................................................................................................................................................................ ¥0.30 ¥0.25 ¥0.58 1.20 ¥0.09 ¥0.08 0.08 ¥0.44 1.56 0.07 Total .......................................................................................................................................................... ¥0.12 0.15 New England ................................................................................................................................................... Mid Atlantic ...................................................................................................................................................... South Atlantic ................................................................................................................................................... East South Central .......................................................................................................................................... West South Central ......................................................................................................................................... East North Central ........................................................................................................................................... West North Central .......................................................................................................................................... Mountain .......................................................................................................................................................... Pacific .............................................................................................................................................................. Other ................................................................................................................................................................ 0.15 ¥0.55 ¥0.65 ¥0.11 0.06 ¥0.84 0.45 ¥0.31 1.80 ¥0.09 0.36 ¥0.32 ¥0.18 0.02 0.34 ¥0.70 0.61 ¥0.09 2.21 0.07 Total .......................................................................................................................................................... ¥0.12 0.15 Group Type of Facility Type of Facility (Rural * Only) Free-Standing/Other Vol/NP ............................................................................................................................ Free-Standing/Other Proprietary ..................................................................................................................... Free-Standing/Other Government ................................................................................................................... Facility-Based Vol/NP ...................................................................................................................................... Facility-Based Proprietary ................................................................................................................................ Facility-Based Government ............................................................................................................................. Type of Facility (Urban * Only) Free-Standing/Other Vol/NP ............................................................................................................................ Free-Standing/Other Proprietary ..................................................................................................................... Free-Standing/Other Government ................................................................................................................... Facility-Based Vol/NP ...................................................................................................................................... Facility-Based Proprietary ................................................................................................................................ Facility-Based Government ............................................................................................................................. Type of Facility (Urban * or Rural *) Facility Location: Region * sroberts on PROD1PC70 with NOTICES Facility Location: Area of the Country VerDate Aug<31>2005 18:45 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00078 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 65362 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices TABLE 5—IMPACT BY AGENCY TYPE—Continued Percent change due to the effects of the updated wage index only Percent change due to the effects of the updated wage index, the 2.9% home health market basket update, and the 2.75% reduction to the rates 1 to 5 ................................................................................................................................................................ 6 to 9 ................................................................................................................................................................ 10 to 14 ............................................................................................................................................................ 15 to 19 ............................................................................................................................................................ 20 to 29 ............................................................................................................................................................ 30 to 49 ............................................................................................................................................................ 50 to 99 ............................................................................................................................................................ 100 to 199 ........................................................................................................................................................ 200 or More ..................................................................................................................................................... ¥0.29 ¥0.41 ¥0.38 ¥0.39 ¥0.25 ¥0.10 0.06 0.07 ¥0.17 0.34 0.17 0.17 0.19 0.28 0.37 0.50 0.36 0.04 Total .......................................................................................................................................................... ¥0.12 0.15 Group Facility Size (Number of First Episodes) Note: Based on a 20 percent sample of CY 2006 claims linked to OASIS assessments. * Urban/rural status, for the purposes of these simulations, is based on the wage index on which episode payment is based. The wage index is based on the site of service of the beneficiary. In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the Office of Management and budget. (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare—Hospital Insurance; and Program No. 93.774, Medicare—Supplementary Medical Insurance Program) Dated: October 9, 2008. Kerry Weems, Acting Administrator, Centers for Medicare & Medicaid Services. Approved: October 24, 2008. Michael O. Leavitt, Secretary. Note: The following addenda will not be published in the Code of Federal Regulations. Addendum A—CY 2009 Wage Index for Rural Areas by CBSA; Applicable Prefloor and Pre-Reclassified Hospital Wage Index CBSA code Nonurban area Wage index 01 ...... 02 ...... 03 ...... Alabama ........................ Alaska ............................ Arizona .......................... 0.7587 1.1898 0.8453 CBSA code 04 05 06 07 08 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... Nonurban area Wage index Arkansas ........................ California ....................... Colorado ........................ Connecticut .................... Delaware ....................... Florida ............................ Georgia .......................... Hawaii ............................ Idaho .............................. Illinois ............................. Indiana ........................... Iowa ............................... Kansas ........................... Kentucky ........................ Louisiana ....................... Maine ............................. Maryland ........................ Massachusetts1 ............. Michigan ........................ Minnesota ...................... Mississippi ..................... Missouri ......................... Montana ......................... Nebraska ....................... Nevada .......................... New Hampshire ............. New Jersey 1 ................. New Mexico ................... New York ....................... North Carolina ............... North Dakota ................. 0.7473 1.2275 0.9570 1.1016 0.9962 0.8504 0.7612 1.0999 0.7651 0.8386 0.8473 0.8804 0.8052 0.7803 0.7447 0.8644 0.8883 1.1670 0.8887 0.9059 0.7584 0.7982 0.8658 0.8730 0.9382 1.0219 ................ 0.8812 0.8145 0.8576 0.7205 CBSA code 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 65 ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... Nonurban area Wage index Ohio ............................... Oklahoma ...................... Oregon ........................... Pennsylvania ................. Puerto Rico 1 ................. Rhode Island 1 ............... South Carolina ............... South Dakota ................. Tennessee ..................... Texas ............................. Utah ............................... Vermont ......................... Virgin Islands ................. Virginia ........................... Washington .................... West Virginia ................. Wisconsin ...................... Wyoming ........................ Guam ............................. 0.8588 0.7732 1.0218 0.8365 0.4047 ................ 0.8538 0.8603 0.7789 0.7894 0.8267 1.0079 0.6971 0.7861 1.0181 0.7503 0.9373 0.9315 0.9611 1 All counties within the State are classified as urban, with the exception of Massachusetts and Puerto Rico. Massachusetts and Puerto Rico have areas designated as rural, however, no short-term, acute care hospitals are located in the area(s) for CY 2009. Addendum B—CY 2009 Wage Index for Urban Areas by CBSA; Applicable PreFloor and Pre-Reclassified Hospital Wage Index Urban area (constituent counties) Wage index 10180 ....... sroberts on PROD1PC70 with NOTICES CBSA code Abilene, TX ................................................................................................................................................................................ Callahan County, TX. Jones County, TX. Taylor County, TX. ´ Aguadilla-Isabela-San Sebastian, PR ....................................................................................................................................... Aguada Municipio, PR. Aguadilla Municipio, PR. 0.8097 10380 ....... VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00079 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 0.3399 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 10420 ....... 10500 ....... 10580 ....... 10740 ....... 10780 ....... 10900 ....... 11020 ....... 11100 ....... 11180 ....... 11260 ....... 11300 ....... 11340 ....... 11460 ....... 11500 ....... 11540 ....... 11700 ....... sroberts on PROD1PC70 with NOTICES 12020 ....... 12060 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index ˜ 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. 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. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00080 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 65363 03NON1 0.8917 0.8703 0.8707 0.9210 0.8130 0.9499 0.8521 0.8927 0.9487 1.1931 0.8760 0.9570 1.0445 0.7927 0.9440 0.9142 0.9591 0.9754 65364 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 12100 ....... 12220 ....... 12260 ....... 12420 ....... 12540 ....... 12580 ....... 12620 ....... 12700 ....... 12940 ....... sroberts on PROD1PC70 with NOTICES 12980 ....... 13020 ....... 13140 ....... 13380 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index Clayton County, GA. Cobb County, GA. Coweta County, GA. Dawson County, GA. DeKalb County, GA. Douglas County, GA. Fayette County, GA. Forsyth County, GA. Fulton County, GA. Gwinnett County, GA. Haralson County, GA. Heard County, GA. Henry County, GA. Jasper County, GA. Lamar County, GA. Meriwether County, GA. Newton County, GA. Paulding County, GA. Pickens County, GA. Pike County, GA. Rockdale County, GA. Spalding County, GA. Walton County, GA. Atlantic City, NJ ......................................................................................................................................................................... Atlantic County, NJ. Auburn-Opelika, AL ................................................................................................................................................................... Lee County, AL. Augusta-Richmond County, GA–SC ......................................................................................................................................... Burke County, GA. Columbia County, GA. McDuffie County, GA. Richmond County, GA. Aiken County, SC. Edgefield County, SC. Austin-Round Rock, TX ............................................................................................................................................................. 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 ......................................................................................................................................................................... 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00081 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 1.1973 0.7544 0.9615 0.9536 1.1189 1.0055 1.0174 1.2643 0.8163 1.0120 0.9248 0.8479 1.1640 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 13460 ....... 13644 ....... 13740 ....... 13780 ....... 13820 ....... 13900 ....... 13980 ....... 14020 ....... 14060 ....... 14260 ....... 14484 ....... 14500 ....... 14540 ....... 14600 ....... 14740 ....... 14860 ....... 15180 ....... 15260 ....... 15380 ....... 15500 ....... sroberts on PROD1PC70 with NOTICES 15540 ....... 15764 ....... 15804 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index 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. 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. Bradenton-Sarasota-Venice, FL ................................................................................................................................................ 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. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00082 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 65365 03NON1 1.1375 1.0548 0.8805 0.8574 0.8792 0.7148 0.8155 0.8979 0.9323 0.9268 1.1897 1.0302 0.8388 0.9900 1.0770 1.2868 0.8916 0.9567 0.9537 0.8736 0.9254 1.1086 1.0346 65366 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 15940 ....... 15980 ....... 16180 ....... 16220 ....... 16300 ....... 16580 ....... 16620 ....... 16700 ....... 16740 ....... 16820 ....... 16860 ....... 16940 ....... 16974 ....... 17020 ....... sroberts on PROD1PC70 with NOTICES 17140 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index Camden County, NJ. Gloucester County, NJ. Canton-Massillon, OH ............................................................................................................................................................... Carroll County, OH. Stark County, OH. Cape Coral-Fort Myers, FL ....................................................................................................................................................... Lee County, FL. Carson City, NV ........................................................................................................................................................................ Carson City, NV. Casper, WY ............................................................................................................................................................................... Natrona County, WY. Cedar Rapids, IA ....................................................................................................................................................................... Benton County, IA. Jones County, IA. Linn County, IA. Champaign-Urbana, IL .............................................................................................................................................................. Champaign County, IL. Ford County, IL. Piatt County, IL. Charleston, WV ......................................................................................................................................................................... Boone County, WV. Clay County, WV. Kanawha County, WV. Lincoln County, WV. Putnam County, WV. Charleston-North Charleston, SC ............................................................................................................................................. Berkeley County, SC. Charleston County, SC. Dorchester County, SC. Charlotte-Gastonia-Concord, NC–SC ....................................................................................................................................... Anson County, NC. Cabarrus County, NC. 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. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00083 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 0.8841 0.9396 1.0128 0.9579 0.8919 0.9461 0.8275 0.9209 0.9595 0.9816 0.8878 0.9276 1.0399 1.0897 0.9687 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 17300 ....... 17420 ....... 17460 ....... 17660 ....... 17780 ....... 17820 ....... 17860 ....... 17900 ....... 17980 ....... 18020 ....... 18140 ....... 18580 ....... 18700 ....... 19060 ....... sroberts on PROD1PC70 with NOTICES 19124 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index Brown County, OH. Butler County, OH. Clermont County, OH. Hamilton County, OH. Warren County, OH. Clarksville, TN-KY ..................................................................................................................................................................... Christian County, KY. Trigg County, KY. Montgomery County, TN. Stewart County, TN. Cleveland, TN ............................................................................................................................................................................ Bradley County, TN. Polk County, TN. Cleveland-Elyria-Mentor, OH .................................................................................................................................................... Cuyahoga County, OH. Geauga County, OH. Lake County, OH. Lorain County, OH. Medina County, OH. Coeur d’Alene, ID ...................................................................................................................................................................... Kootenai County, ID. College Station-Bryan, TX ......................................................................................................................................................... Brazos County, TX. Burleson County, TX. Robertson County, TX. Colorado Springs, CO ............................................................................................................................................................... El Paso County, CO. Teller County, CO. Columbia, MO ........................................................................................................................................................................... Boone County, MO. 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. 18:45 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00084 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 65367 03NON1 0.8298 0.8010 0.9241 0.9322 0.9346 0.9977 0.8540 0.8933 0.8739 0.9739 0.9943 0.8598 1.1304 0.7816 0.9945 65368 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code Urban area (constituent counties) Wage index 19140 ....... Dalton, GA ................................................................................................................................................................................. Murray County, GA. Whitfield County, GA. Danville, IL ................................................................................................................................................................................. Vermilion County, IL. Danville, VA ............................................................................................................................................................................... Pittsylvania County, VA. Danville City, VA. Davenport-Moline-Rock Island, IA-IL ........................................................................................................................................ Henry County, IL. Mercer County, IL. Rock Island County, IL. Scott County, IA. Dayton, OH ................................................................................................................................................................................ Greene County, OH. Miami County, OH. Montgomery County, OH. Preble County, OH. Decatur, AL ............................................................................................................................................................................... Lawrence County, AL. Morgan County, AL. Decatur, IL ................................................................................................................................................................................. Macon County, IL. Deltona-Daytona Beach-Ormond Beach, FL ............................................................................................................................ Volusia County, FL. Denver-Aurora, CO ................................................................................................................................................................... Adams County, CO. Arapahoe County, CO. 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, 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. 0.8705 19180 ....... 19260 ....... 19340 ....... 19380 ....... 19460 ....... 19500 ....... 19660 ....... 19740 ....... 19780 ....... 19804 ....... 20020 ....... 20100 ....... 20220 ....... 20260 ....... 20500 ....... 20740 ....... sroberts on PROD1PC70 with NOTICES 20764 ....... 20940 ....... 21060 ....... VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00085 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 0.9374 0.8395 0.8435 0.9203 0.7803 0.8145 0.8890 1.0818 0.9535 0.9958 0.7613 1.0325 0.8380 1.0363 0.9732 0.9668 1.1283 0.8746 0.8525 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 21140 ....... 21300 ....... 21340 ....... 21500 ....... 21660 ....... 21780 ....... 21820 ....... 21940 ....... 22020 ....... 22140 ....... 22180 ....... 22220 ....... 22380 ....... 22420 ....... 22500 ....... 22520 ....... 22540 ....... 22660 ....... 22744 ....... 22900 ....... 23020 ....... 23060 ....... sroberts on PROD1PC70 with NOTICES 23104 ....... 23420 ....... 23460 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index 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. 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 ............................................................................................................................................................................. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00086 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 65369 03NON1 0.9568 0.8247 0.8694 0.8713 1.1061 0.8690 1.1297 0.4061 0.8166 0.8051 0.9340 0.8970 1.1743 1.1425 0.8130 0.7871 0.9293 0.9867 0.9946 0.7697 0.8769 0.9176 0.9709 1.1009 0.7983 65370 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 23540 ....... 23580 ....... 23844 ....... 24020 ....... 24140 ....... 24220 ....... 24300 ....... 24340 ....... 24500 ....... 24540 ....... 24580 ....... 24660 ....... 24780 ....... 24860 ....... 25020 ....... 25060 ....... 25180 ....... 25260 ....... 25420 ....... sroberts on PROD1PC70 with NOTICES 25500 ....... 25540 ....... 25620 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index Etowah County, AL. Gainesville, FL ........................................................................................................................................................................... Alachua County, FL. Gilchrist County, FL. Gainesville, GA .......................................................................................................................................................................... Hall County, GA. Gary, IN ..................................................................................................................................................................................... Jasper County, IN. Lake County, IN. Newton County, IN. Porter County, IN. Glens Falls, NY ......................................................................................................................................................................... Warren County, NY. Washington County, NY. Goldsboro, NC ........................................................................................................................................................................... Wayne County, NC. Grand Forks, ND–MN ............................................................................................................................................................... Polk County, MN. Grand Forks County, ND. Grand Junction, CO .................................................................................................................................................................. Mesa County, CO. Grand Rapids-Wyoming, MI ...................................................................................................................................................... Barry County, MI. Ionia County, MI. Kent County, MI. Newaygo County, MI. Great Falls, MT ......................................................................................................................................................................... Cascade County, MT. Greeley, CO .............................................................................................................................................................................. Weld County, CO. Green Bay, WI ........................................................................................................................................................................... Brown County, WI. Kewaunee County, WI. Oconto County, WI. Greensboro-High Point, NC ...................................................................................................................................................... Guilford County, NC. Randolph County, NC. Rockingham County, NC. Greenville, NC ........................................................................................................................................................................... Greene County, NC. Pitt County, NC. Greenville, SC ........................................................................................................................................................................... Greenville County, SC. Laurens County, SC. Pickens County, SC. Guayama, PR ............................................................................................................................................................................ Arroyo Municipio, PR. Guayama Municipio, PR. Patillas Municipio, PR. Gulfport-Biloxi, MS .................................................................................................................................................................... Hancock County, MS. Harrison County, MS. Stone County, MS. Hagerstown-Martinsburg, MD-WV ............................................................................................................................................ Washington County, MD. Berkeley County, WV. Morgan County, WV. Hanford-Corcoran, CA ............................................................................................................................................................... Kings County, CA. Harrisburg-Carlisle, PA .............................................................................................................................................................. Cumberland County, PA. Dauphin County, PA. Perry County, PA. Harrisonburg, VA ....................................................................................................................................................................... Rockingham County, VA. Harrisonburg City, VA. Hartford-West Hartford-East Hartford, CT ................................................................................................................................ Hartford County, CT. Litchfield County, CT. Middlesex County, CT. Tolland County, CT. Hattiesburg, MS ......................................................................................................................................................................... Forrest County, MS. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00087 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 0.9312 0.9109 0.9250 0.8473 0.9143 0.7565 0.9812 0.9184 0.8784 0.9684 0.9709 0.9011 0.9448 0.9961 0.3249 0.9029 0.8997 1.0870 0.9153 0.8894 1.1069 0.7337 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 25860 ....... 25980 1 ..... 26100 ....... 26180 ....... 26300 ....... 26380 ....... 26420 ....... 26580 ....... 26620 ....... 26820 ....... 26900 ....... 26980 ....... 27060 ....... 27100 ....... sroberts on PROD1PC70 with NOTICES 27140 ....... 27180 ....... 27260 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index Lamar County, MS. Perry County, MS. Hickory-Lenoir-Morganton, NC .................................................................................................................................................. Alexander County, NC. Burke County, NC. Caldwell County, NC. Catawba County, NC. Hinesville-Fort Stewart, GA ....................................................................................................................................................... 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-Baytown-Sugar Land, 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, 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. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00088 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 65371 03NON1 0.8976 0.9110 0.9008 1.1811 0.9113 0.7758 0.9838 0.9254 0.9082 0.9080 0.9908 0.9483 0.9614 0.9309 0.8067 0.8523 0.8999 65372 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 27340 ....... 27500 ....... 27620 ....... 27740 ....... 27780 ....... 27860 ....... 27900 ....... 28020 ....... 28100 ....... 28140 ....... 28420 ....... 28660 ....... 28700 ....... 28740 ....... 28940 ....... sroberts on PROD1PC70 with NOTICES 29020 ....... 29100 ....... 29140 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index Nassau County, FL. St. Johns County, FL. Jacksonville, NC ........................................................................................................................................................................ Onslow County, NC. Janesville, WI ............................................................................................................................................................................ Rock County, WI. Jefferson City, MO .................................................................................................................................................................... Callaway County, MO. Cole County, MO. Moniteau County, MO. Osage County, MO. Johnson City, TN ....................................................................................................................................................................... Carter County, TN. Unicoi County, TN. Washington County, TN. Johnstown, PA .......................................................................................................................................................................... Cambria County, PA. Jonesboro, AR ........................................................................................................................................................................... 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. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00089 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 0.8177 0.9662 0.8775 0.7971 0.7920 0.7916 0.9406 1.0801 1.0485 0.9610 0.9911 0.8765 0.7743 0.9375 0.7881 0.9349 0.9758 0.9221 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 29180 ....... 29340 ....... 29404 ....... 29420 ....... 29460 ....... 29540 ....... 29620 ....... 29700 ....... 29740 ....... 29820 ....... 29940 ....... 30020 ....... 30140 ....... 30300 ....... 30340 ....... 30460 ....... 30620 ....... 30700 ....... 30780 ....... 30860 ....... 30980 ....... 31020 ....... sroberts on PROD1PC70 with NOTICES 31084 ....... 31140 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index Carroll County, IN. Tippecanoe County, IN. Lafayette, LA ............................................................................................................................................................................. Lafayette Parish, LA. St. Martin Parish, LA. Lake Charles, LA ....................................................................................................................................................................... Calcasieu Parish, LA. Cameron Parish, LA. Lake County-Kenosha County, IL-WI ....................................................................................................................................... Lake County, IL. Kenosha County, WI. Lake Havasu City-Kingman, 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. Bullitt County, KY. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00090 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 65373 03NON1 0.8374 0.7556 1.0389 0.9797 0.8530 0.9363 0.9931 0.8366 0.8929 1.1971 0.8343 0.8211 0.8954 0.9465 0.9200 0.9110 0.9427 0.9759 0.8672 0.8765 0.8370 1.1207 1.2208 0.9249 65374 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 31180 ....... 31340 ....... 31420 ....... 31460 ....... 31540 ....... 31700 ....... 31900 ....... 32420 ....... 32580 ....... 32780 ....... 32820 ....... 32900 ....... 33124 ....... 33140 ....... 33260 ....... 33340 ....... sroberts on PROD1PC70 with NOTICES 33460 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index 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. Merrimack 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. Ramsey County, MN. Scott County, MN. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00091 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 0.8731 0.8774 0.9570 0.7939 1.0967 1.0359 0.9330 0.3940 0.9009 1.0244 0.9232 1.2243 0.9830 0.9159 0.9827 1.0080 1.1150 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 33540 ....... 33660 ....... 33700 ....... 33740 ....... 33780 ....... 33860 ....... 34060 ....... 34100 ....... 34580 ....... 34620 ....... 34740 ....... 34820 ....... 34900 ....... 34940 ....... 34980 ....... 35004 ....... 35084 ....... sroberts on PROD1PC70 with NOTICES 35300 ....... 35380 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index 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. Plaquemines Parish, LA. St. Bernard Parish, LA. St. Charles Parish, LA. St. John the Baptist Parish, LA. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00092 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 65375 03NON1 0.8973 0.7908 1.2194 0.7900 0.8941 0.8283 0.8528 0.7254 1.0292 0.8489 1.0055 0.8652 1.4520 0.9672 0.9504 1.2453 1.1731 1.1742 0.9103 65376 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 35644 ....... 35660 ....... 35980 ....... 36084 ....... 36100 ....... 36140 ....... 36220 ....... 36260 ....... 36420 ....... 36500 ....... 36540 ....... 36740 ....... 36780 ....... 36980 ....... 37100 ....... 37340 ....... sroberts on PROD1PC70 with NOTICES 37380 ....... 37460 ....... 37620 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index 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 ................................................................................................................................................... Bay County, FL. Parkersburg-Marietta, WV–OH ................................................................................................................................................. Washington County, OH. Pleasants County, WV. Wirt County, WV. Wood County, WV. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00093 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 1.2885 0.9066 1.1398 1.6092 0.8512 1.1496 0.9475 0.9153 0.8724 1.1537 0.9441 0.9111 0.9474 0.8685 1.1951 0.9332 0.8963 0.8360 0.7867 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices 65377 CBSA code Urban area (constituent counties) Wage index 37700 ....... 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 ............................................................................................................................. Bristol County, MA. Bristol County, RI. Kent County, RI. Newport County, RI. Providence County, RI. Washington County, RI. Provo-Orem, UT ........................................................................................................................................................................ Juab County, UT. 0.8102 37764 ....... 37860 ....... 37900 ....... 37964 ....... 38060 ....... 38220 ....... 38300 ....... 38340 ....... 38540 ....... 38660 ....... 38860 ....... 38900 ....... 38940 ....... 39100 ....... 39140 ....... sroberts on PROD1PC70 with NOTICES 39300 ....... 39340 ....... VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00094 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 1.0747 0.8242 0.9038 1.0979 1.0379 0.7926 0.8678 1.0445 0.9343 0.4289 0.9942 1.1456 0.9870 1.0920 1.0221 1.0696 0.9381 65378 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 39380 ....... 39460 ....... 39540 ....... 39580 ....... 39660 ....... 39740 ....... 39820 ....... 39900 ....... 40060 ....... 40140 ....... 40220 ....... 40340 ....... 40380 ....... 40420 ....... sroberts on PROD1PC70 with NOTICES 40484 ....... 40580 ....... 40660 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index 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 ............................................................................................................................................................................... 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. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00095 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 0.8713 0.8976 0.9054 0.9817 0.9598 0.9242 1.3731 1.0317 0.9363 1.1468 0.8660 1.1214 0.8811 0.9835 0.9926 0.9031 0.9134 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices 65379 CBSA code Urban area (constituent counties) Wage index 40900 ....... 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. 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 ...................................................................................................................................... 1.3572 40980 ....... 41060 ....... 41100 ....... 41140 ....... 41180 ....... 41420 ....... 41500 ....... 41540 ....... 41620 ....... 41660 ....... 41700 ....... 41740 ....... 41780 ....... sroberts on PROD1PC70 with NOTICES 41884 ....... 41900 ....... 41940 ....... VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00096 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 0.8702 1.0976 0.9021 1.0380 0.9006 1.0884 1.4987 0.9246 0.9158 0.8424 0.8856 1.1538 0.8870 1.5529 0.4756 1.6141 65380 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 41980 ....... 42020 ....... 42044 ....... 42060 ....... 42100 ....... 42140 ....... 42220 ....... 42340 ....... 42540 ....... sroberts on PROD1PC70 with NOTICES 42644 ....... 42680 ....... 43100 ....... 43300 ....... 43340 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index 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. 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 ........................................................................................................................................................ Sheboygan, WI .......................................................................................................................................................................... Sheboygan County, WI. Sherman-Denison, TX ............................................................................................................................................................... Grayson County, TX. Shreveport-Bossier City, LA ...................................................................................................................................................... 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00097 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 0.4393 1.2441 1.1993 1.1909 1.6429 1.0610 1.5528 0.9152 0.8333 1.1755 0.9217 0.8920 0.9024 0.8442 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 43580 ....... 43620 ....... 43780 ....... 43900 ....... 44060 ....... 44100 ....... 44140 ....... 44180 ....... 44220 ....... 44300 ....... 44700 ....... 44940 ....... 45060 ....... 45104 ....... 45220 ....... 45300 ....... 45460 ....... 45500 ....... sroberts on PROD1PC70 with NOTICES 45780 ....... 45820 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index 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 ...................................................................................................................................... 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. 18:45 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00098 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 65381 03NON1 0.8915 0.9354 0.9761 0.9025 1.0559 0.9102 1.0405 0.8424 0.8876 0.8937 1.2015 0.8257 0.9787 1.1241 0.8964 0.8852 0.9085 0.8144 0.9407 0.8756 65382 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 45940 ....... 46060 ....... 46140 ....... 46220 ....... 46340 ....... 46540 ....... 46660 ....... 46700 ....... 47020 ....... 47220 ....... 47260 ....... 47300 ....... 47380 ....... 47580 ....... sroberts on PROD1PC70 with NOTICES 47644 ....... 47894 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index 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. 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-Farmington Hills-Troy, 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. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00099 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 03NON1 1.0604 0.9229 0.8445 0.8496 0.8804 0.8404 0.8027 1.4359 0.8124 1.0366 0.8884 1.0144 0.8596 0.8989 0.9904 1.0827 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code 47940 ....... 48140 ....... 48260 ....... 48300 ....... 48424 ....... 48540 ....... 48620 ....... 48660 ....... 48700 ....... 48864 ....... 48900 ....... 49020 ....... 49180 ....... 49340 ....... 49420 ....... sroberts on PROD1PC70 with NOTICES 49500 ....... 49620 ....... 49660 ....... VerDate Aug<31>2005 Urban area (constituent counties) Wage index Fairfax County, VA. Fauquier County, VA. Loudoun County, VA. Prince William County, VA. Spotsylvania County, VA. Stafford County, VA. Warren County, VA. Alexandria City, VA. Fairfax City, VA. Falls Church City, VA. Fredericksburg City, VA. Manassas City, VA. Manassas Park City, VA. Jefferson County, WV. Waterloo-Cedar Falls, IA ........................................................................................................................................................... Black Hawk County, IA. Bremer County, IA. Grundy County, IA. Wausau, WI ............................................................................................................................................................................... Marathon County, WI. Weirton-Steubenville, WV–OH .................................................................................................................................................. Jefferson County, OH. Brooke County, WV. Hancock County, WV. Wenatchee, WA ........................................................................................................................................................................ Chelan County, WA. Douglas County, WA. West Palm Beach-Boca Raton-Boynton Beach, FL ................................................................................................................. Palm Beach County, FL. Wheeling, WV–OH .................................................................................................................................................................... Belmont County, OH. Marshall County, WV. Ohio County, WV. Wichita, KS ................................................................................................................................................................................ Butler County, KS. Harvey County, KS. Sedgwick County, KS. Sumner County, KS. Wichita Falls, TX ....................................................................................................................................................................... Archer County, TX. Clay County, TX. Wichita County, TX. Williamsport, PA ........................................................................................................................................................................ Lycoming County, PA. Wilmington, DE–MD–NJ ............................................................................................................................................................ New Castle County, DE. Cecil County, MD. Salem County, NJ. Wilmington, NC ......................................................................................................................................................................... Brunswick County, NC. New Hanover County, NC. Pender County, NC. Winchester, VA–WV .................................................................................................................................................................. Frederick County, VA. Winchester City, VA. Hampshire County, WV. Winston-Salem, NC ................................................................................................................................................................... Davie County, NC. Forsyth County, NC. Stokes County, NC. Yadkin County, NC. Worcester, MA ........................................................................................................................................................................... Worcester County, MA. Yakima, WA ............................................................................................................................................................................... Yakima County, WA. Yauco, PR ................................................................................................................................................................................. ´ Guanica Municipio, PR. Guayanilla Municipio, PR. ˜ Penuelas Municipio, PR. Yauco Municipio, PR. York-Hanover, PA ..................................................................................................................................................................... York County, PA. Youngstown-Warren-Boardman, OH–PA .................................................................................................................................. 16:58 Oct 31, 2008 Jkt 217001 PO 00000 Frm 00100 Fmt 4703 Sfmt 4703 E:\FR\FM\03NON1.SGM 65383 03NON1 0.8490 0.9615 0.8079 0.9544 0.9757 0.6955 0.9069 0.8832 0.8096 1.0696 0.9089 0.9801 0.9016 1.0836 0.9948 0.3432 0.9518 0.8915 65384 Federal Register / Vol. 73, No. 213 / Monday, November 3, 2008 / Notices CBSA code Urban area (constituent counties) Wage index 49700 ....... Mahoning County, OH. Trumbull County, OH. Mercer County, PA. Yuba City, CA ............................................................................................................................................................................ Sutter County, CA. Yuba County, CA. Yuma, AZ .................................................................................................................................................................................. Yuma County, AZ. 1.1137 49740 ....... 0.9281 1 At this time, there are no hospitals in these urban areas on which to base a wage index. Therefore, the urban wage index value is based on the average wage index of all urban areas within the State. [FR Doc. E8–26142 Filed 10–30–08; 4:15 pm] BILLING CODE 4120–01–P DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration [Docket No. FDA–2008–N–0572] Agency Emergency Processing Under Office of Management and Budget Review; Implementation of the Animal Generic Drug User Fee Act of 2008; User Fee Cover Sheet Form FDA 3728 AGENCY: Food and Drug Administration, HHS. ACTION: Notice. SUMMARY: The Food and Drug Administration (FDA) is announcing that a proposed collection of information has been submitted to the Office of Management and Budget (OMB) for emergency processing under the Paperwork Reduction Act of 1995 (the PRA). The proposed collection of information concerns the burden hours required for the Animal Generic Drug User Fee Cover Sheet, Form FDA 3728 and the timeframe requirement under the Animal Generic Drug User Fee Act of 2008 (AGDUFA) (21 U.S.C. 379j–21) for implementing the new user fee cover sheet Form FDA 3728. DATES: Fax written comments on the collection of information by November 10, 2008. ADDRESSES: To ensure that comments on the information collection are received, OMB recommends that written comments be faxed to the Office of Information and Regulatory Affairs, OMB, Attn: FDA Desk Officer, FAX: 202–395–6974, or e-mailed to oira_submission@omb.eop.gov. All comments should be identified with the OMB control number 0910–NEW and ‘‘Implementation of the Animal Generic Drug User Fee Act of 2008 (21 U.S.C. 379j–21(a)); User Fee Cover Sheet Form 3728; Emergency Request.’’ Also include the FDA docket number found in brackets in the heading of this document. FOR FURTHER INFORMATION CONTACT: Denver Presley, Jr., Office of Information Management (HFA–710), Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857, 301–796–3793. SUPPLEMENTARY INFORMATION: FDA is requesting emergency processing of this proposed collection of information under section 3507(j) of the PRA (44 U.S.C. 3507(j) and 5 CFR 1320.13). The Federal Food, Drug, and Cosmetic Act (the act), as amended by AGDUFA authorizes FDA to collect user fees: (1) For certain abbreviated applications for a generic new animal drug, (2) on certain generic new animal drug products, and (3) on certain sponsors of such abbreviated applications for generic new animal drugs and/or investigational submissions for generic new animal drugs. With respect to the following collection of information, FDA invites comments on these topics: (1) Whether the proposed collection of information is necessary for the proper performance of FDA’s functions, including whether the information will have practical utility; (2) the accuracy of FDA’s estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) ways to minimize the burden of the collection of information on respondents, including through the use of automated collection techniques, when appropriate, and other forms of information technology. Implementation of the Animal Generic Drug User Fee Act of 2008; User Fee Cover Sheet Form FDA 3728 (21 U.S.C. 379j–21); Emergency Request Section 741 of the act (21 U.S.C. 379j– 21), establishes three different kinds of user fees: (1) Fees for certain types of abbreviated applications for generic new animal drugs, (2) annual fees for certain generic new animal drug products, and (3) annual fees for certain sponsors of abbreviated applications for generic new animal drugs and/or investigational submissions for generic new animal drugs. Because the submission of user fees concurrently with applications is required, the review of an application cannot begin until the fee is submitted. Form FDA 3728, the Animal Generic Drug User Fee Cover Sheet, is designed to provide the minimum necessary information in order to: (1) Determine whether a fee is required for review of an application, (2) determine the amount of fee required, and (3) account for and track user fees. FDA estimates the burden of this collection of information as follows: TABLE 1—ESTIMATED ANNUAL REPORTING BURDEN1 No. of Respondents 21 U.S.C. 379j–21. sroberts on PROD1PC70 with NOTICES Form FDA 3728 1 There Annual Frequency per Response 20 Total Annual Responses 2 Hours per Response 40 Total Hours .08 are no capital costs or operating and maintenance costs associated with this collection of information. Respondents to this collection of information are generic new animal VerDate Aug<31>2005 16:58 Oct 31, 2008 Jkt 217001 drug applicants. Based on FDA’s data base system, there are an estimated 20 PO 00000 Frm 00101 Fmt 4703 Sfmt 4703 sponsors of new animal drugs potentially subject to AGDUFA. The E:\FR\FM\03NON1.SGM 03NON1 3.2

Agencies

[Federal Register Volume 73, Number 213 (Monday, November 3, 2008)]
[Notices]
[Pages 65351-65384]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E8-26142]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-1555-N]
RIN 0938-AP20


Medicare Program; Home Health Prospective Payment System Rate 
Update for Calendar Year 2009

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

ACTION: Notice.

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SUMMARY: This notice sets forth an update to the 60-day national 
episode rates and the national per-visit amounts under the Medicare 
prospective payment system for home health services, effective on 
January 1, 2009.

DATES: Effective Date: This notice is effective on January 1, 2009.

FOR FURTHER INFORMATION CONTACT: Randy Throndset, (410) 786-0131.

I. Background

A. Requirements of the Balanced Budget Act of 1997 for Establishing the 
Prospective Payment System for Home Health Services

    The Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33) enacted on 
August 5, 1997, significantly changed the way Medicare pays for 
Medicare home health services. Section 4603 of the BBA mandated the 
development of the home health prospective payment system (HH PPS). 
Until the implementation of a HH PPS on October 1, 2000, home health 
agencies (HHAs) received payment under a cost-based reimbursement 
system.
    Section 4603(a) of the BBA mandated the development of a HH PPS for 
all Medicare-covered home health services provided under a plan of care 
that were paid on a reasonable cost basis by adding section 1895 of the 
Social Security Act (the Act), entitled ``Prospective Payment For Home 
Health Services''. Section 1895(b)(1) of the Act requires the Secretary 
to establish a HH PPS for all costs of home health services paid under 
Medicare.
    Section 1895(b)(3)(A) of the Act requires that (1) the computation 
of a standard prospective payment amount include all costs for home 
health services covered and paid for on a reasonable cost basis and be 
initially based on the most recent audited cost report data available 
to the Secretary, and (2) the prospective payment amounts be 
standardized to eliminate the effects of case-mix and wage levels among 
HHAs.
    Section 1895(b)(3)(B) of the Act addresses the annual update to the 
standard prospective payment amounts by the home health applicable 
increase percentage as specified in the statute.
    Section 1895(b)(4) of the Act governs the payment computation. 
Sections 1895(b)(4)(A)(i) and (b)(4)(A)(ii) of the Act require the 
standard prospective payment amount to be adjusted for case-mix and 
geographic differences in wage levels.
    Section 1895(b)(4)(B) of the Act requires the establishment of an 
appropriate case-mix change adjustment factor that adjusts for 
significant variation in costs among different units of services.
    Similarly, section 1895(b)(4)(C) of the Act requires the 
establishment of wage adjustment factors that reflect the relative 
level of wages, and wage-related costs applicable to home health 
services furnished in a geographic area compared to the applicable 
national average level. These wage-adjustment factors may be used by 
the Secretary for the different geographic wage levels for purposes of 
section 1886(d)(3)(E) of the Act.
    Section 1895(b)(5) of the Act gives the Secretary the option to 
make additions or adjustments to the payment amount otherwise paid in 
the case of outliers because of unusual variations in the type or 
amount of medically necessary care. Total outlier payments in a given 
fiscal year (FY) may not exceed 5 percent of total payments projected 
or estimated.
    In accordance with the statute, we published a final rule (65 FR 
41128) in the Federal Register on July 3, 2000 to implement the HH PPS 
legislation. The July 2000 final rule established requirements for the 
new HH PPS for home health services as required by section 4603 of the 
BBA, as subsequently amended by section 5101 of the Omnibus 
Consolidated and Emergency Supplemental Appropriations Act (OCESAA) for 
Fiscal Year 1999, (Pub. L. 105-277), enacted on October 21, 1998; and 
by sections 302, 305, and 306 of the Medicare, Medicaid, and SCHIP 
Balanced Budget Refinement Act (BBRA) of 1999, (Pub. L. 106-113), 
enacted on November 29, 1999. The requirements include the 
implementation of a HH PPS for home health services, consolidated 
billing requirements, and a number of other related changes. The HH PPS 
described in that rule replaced the retrospective reasonable cost-based 
system that was used by Medicare for the payment of home health 
services under Part A and Part B.
    For a complete and full description of the HH PPS as required by 
the BBA, see the July 2000 HH PPS final rule (65 FR 41128 through 
41214).

B. Deficit Reduction Act of 2005

    On February 8, 2006, the Deficit Reduction Act of 2005 (Pub. L. 
109-171) (DRA) was enacted. This legislation affected updates to HH 
payment rates for calendar year (CY) 2006. The DRA also required HHAs 
to submit home health care quality data and created a linkage between 
those data and payment, beginning in CY 2007.
    Specifically, section 5201 of the DRA changed the CY 2006 update 
from the applicable home health market basket percentage increase minus 
0.8 percentage points to a 0 percent update. In addition, section 5201 
of the DRA amends section 421(a) of the Medicare Prescription Drug, 
Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173, 
enacted on December 8, 2003). The amended section 421(a) of the MMA 
requires that for home health services furnished in a rural area (as 
defined in section 1886(d)(2)(D) of the Act) on or after January 1, 
2006 and before January 1, 2007, that the Secretary increase the 
payment amount otherwise made under section 1895 of the Act for home 
health services by 5 percent. The statute waives budget neutrality for 
purposes of this increase since it specifically states that the 
Secretary must not reduce the standard prospective payment amount (or 
amounts) under section 1895 of the Act applicable to home health 
services furnished during a period to offset the increase in payments 
resulting in the application of this section of the statute.
    The 0 percent update to the payment rates and the rural add-on 
provisions of the DRA were implemented through a CMS transmittal (Pub. 
100-20, One Time Notification, Transmittal 211) issued on February 10, 
2006.
    In addition, section 5201 of the DRA requires HHAs to submit data 
for purposes of measuring health care quality, and links the quality 
data submission to payment. This requirement is applicable for CY 2007 
and each subsequent year. If an HHA does not submit quality data, the 
home health market basket percentage increase will be reduced 2 
percentage points. In accordance with the statute,

[[Page 65352]]

we published a final rule (71 FR 65884, 65935) in the Federal Register 
on November 9, 2006 to implement the pay-for-reporting requirement of 
the DRA, codified at 42 CFR 484.225(h) and (i). In addition, the 
November 2006 final rule ended the 1-year transition period that 
consisted of a blend of 50 percent of the new area labor market 
designations' wage index and 50 percent of the previous area labor 
market designations' wage index. We also revised the fixed dollar loss 
ratio, which is used in the calculation of outlier payments.

C. System for Payment of Home Health Services

    Generally, Medicare makes payment under the HH PPS on the basis of 
a national standardized 60-day episode payment rate that is adjusted 
for the applicable case-mix and wage index. The national standardized 
60-day episode payment rate includes the six home health disciplines 
(skilled nursing, home health aide, physical therapy, speech-language 
pathology, occupational therapy, and medical social services) and non-
routine medical supplies. Durable medical equipment covered under home 
health is paid for outside the HH PPS payment. To adjust for case-mix, 
the HH PPS uses a 153-category case-mix classification to assign 
patients to a home health resource group (HHRG). Clinical needs, 
functional status, and service utilization are computed from responses 
to selected data elements in the OASIS assessment instrument.
    For episodes with four or fewer visits, Medicare pays on the basis 
of a national per-visit amount by discipline; an episode consisting of 
four or fewer visits within a 60-day period is referred to as a LUPA. 
Medicare also adjusts the national standardized 60-day episode payment 
rate for certain intervening events that are subject to a partial 
episode payment adjustment (PEP adjustment). For certain cases that 
exceed a specific cost threshold, an outlier adjustment may also be 
available.

D. Updates to the HH PPS

    As required by section 1895(b)(3)(B) of the Act, we have 
historically updated the HH PPS rates annually in a separate Federal 
Register document. We published a final rule with comment period in the 
Federal Register on August 29, 2007 (72 FR 49762) that set forth a 
refinement and rate update to the Medicare prospective payment system 
for home health services. As part of the CY 2008 HH PPS final rule with 
comment period, we rebased and revised the home health market basket to 
reflect FY 2003 Medicare cost report data, the latest available and 
most complete data on the structure of HHA costs. In the rebased and 
revised home health market basket, the labor-related share was 77.082 
(an increase from the previous labor-related share of 76.775). The non-
labor-related share is 22.918 (a decrease from the previous nonlabor-
related share of 23.225). The increase in the labor-related share using 
the FY 2003 home health market basket was primarily due to the increase 
in the benefit cost weight.
    The CY 2008 HH PPS final rule with comment period also implemented 
refinements to the payment system. Extensive research was conducted to 
investigate ways to improve the performance of the case-mix model. This 
research was the basis for our decision to refine the case-mix model. 
We refined the case-mix model to reflect different resource costs for 
early home health episodes versus later home health episodes and to 
expand the case-mix variables included in the payment model. For 2008, 
we used a 4-equation case-mix model that recognizes and differentiates 
payment for episodes of care based on whether a patient is in an early 
(1st or 2nd episode in a sequence of adjacent episodes) or later (the 
3rd episode and beyond in a sequence of adjacent episodes) episode of 
care as well as recognizing whether a patient was a high therapy (14 or 
more therapy visits) or low therapy (13 or fewer therapy visits) case. 
We defined episodes as adjacent if they were separated by no more than 
a 60-day period between claims. Analysis of the performance of the 
case-mix model for later episodes revealed two important differences 
for episodes occurring later in the home health treatment compared to 
earlier episodes: Higher resource use per episode and a different 
relationship between clinical conditions and resource use. We use 
additional variables to include scores for certain wound and skin 
conditions; more diagnosis groups such as pulmonary, cardiac, and 
cancer diagnoses; and certain secondary diagnoses. The 4-equation model 
results in 153 case-mix groups.
    In addition, we replaced the previous single therapy threshold of 
10 visits with three therapy thresholds at 6, 14, and 20 visits. The 
payment for additional therapy visits between the three thresholds 
increases gradually, incorporating a declining, rather than a constant, 
amount per added therapy visit. This approach does not reduce total 
payments to home health providers because the payment model still 
predicts total resource cost. The combined effect of the new therapy 
thresholds and payment gradations reduces the undesirable emphasis in 
treatment planning on a single therapy visit threshold and restores the 
primacy of clinical considerations in treatment planning for 
rehabilitation patients.
    In the CY 2008 HH PPS final rule with comment period, we further 
adjusted for case-mix that was not due to a change in the underlying 
health status of the home health users. Section 1895(b)(3)(B) of the 
Act requires that in compensating for case-mix change, a payment 
reduction must be applied to the standardized payment amount. For the 
CY 2008 HH PPS final rule with comment period, we conducted several 
analyses to determine if any portion of the total change in case-mix 
could be considered to be real change. Real change is a change in the 
underlying health status of the home health user population. The 
results of the analysis indicated that while a small amount (8.03 
percent) of measured case-mix change was real, most of the change was 
unrelated to the underlying health status of home health users.
    Using 100 percent of the home health interim payment system (HH 
IPS) file for our baseline (12 months ending September 30, 2000), the 
average case-mix weight per episode was 1.0960. (The HH IPS was the 
previous cost-based payment system under which HHAs were paid, prior to 
the HH PPS.) The 2005 20 percent sample file yielded an average CMI 
(case mix indicator) of 1.2361. Therefore, the change measurement was 
(1.2361 - 1.0960)/ 1.0960 = 12.78 percent. We adjusted this result 
downward by 8.03 percent (the percentage of total change in case-mix 
considered to be real) to get a final case-mix change measure of 11.75 
percent (0.1278 * (1-0.0803) = 0.1175). To account for the 11.75 
percent increase in case-mix which was not due to a change in the 
underlying health status of Medicare home health patients, we 
implemented a 2.75 percent reduction of the national standardized 60-
day episode payment rate for 3 years beginning in 2008 and solicited 
comments on extending that adjustment period to a fourth year based on 
a 2.71 percent reduction for 2011 (see 72 FR 49833).
    Additionally, we modified a number of existing HH PPS payment 
adjustments. Specifically, we increased the payment for low utilization 
payment adjustment (LUPA) episodes that occur as the only episode or 
the initial episode during a sequence of adjacent episodes, by $87.93. 
We also eliminated the significant change in condition (SCIC)

[[Page 65353]]

payment adjustment for various reasons. Specifically, we ended the 
policy because of the apparent difficulty HHAs had in interpreting the 
SCIC policy, the association between negative margins and SCIC 
episodes, the decline in the occurrence of SCICs, and the estimated 
minimal impact on outlays from eliminating the SCIC policy.
    In the development of the HH PPS, non-routine medical supplies 
(NRS) were accounted for by attributing $49.62 to the standardized 
episode payment. In the CY 2008 HH PPS final rule with comment period, 
we applied a severity adjustment to the NRS portion of the HH PPS 
standardized episode payment. Specifically, we adopted a six-severity-
group approach to account for NRS costs (see 72 FR 49851-49852) based 
on measurable conditions that are feasible to administer. This change 
offers HHAs some protection against episodes with extremely high NRS 
costs. Finally, we did not modify the existing Partial Episode Payment 
(PEP) Adjustment.
    Section 1895(b)(5) of the Act also allows for the provision of an 
addition or adjustment to account for outlier episodes, which are those 
episodes that incur unusually large costs due to heavy patient care 
needs. Under the HH PPS, outlier payments are made for episodes for 
which the estimated cost exceeds a threshold amount. The wage adjusted 
fixed dollar loss (FDL) amount represents the amount of loss that an 
agency must bear before an episode becomes eligible for outlier 
payments. Section 1895(b)(5) of the Act requires that the estimated 
total outlier payments may not exceed 5 percent of total estimated HH 
PPS payments. In the CY 2008 HH PPS final rule with comment period, we 
adjusted the FDL ratio to 0.89, based on the most recently available 
data, analysis, trends, and unknown effects of the refinements on 
outliers (see 72 FR 49857).
    Finally, we expanded the list of quality measures identified in the 
update notice for CY 2007. In CY 2007, we specified 10 OASIS quality 
measures from the OASIS data set as appropriate for public reporting of 
measurements of health care quality. For CY 2008, we added two more 
quality measures from the OASIS data set for public reporting. All 
twelve publicly reported measures are National Quality Forum (NQF)-
endorsed measures. The additional measures for 2008 were as follows:
     Emergent Care for Wound Infection, Deteriorating Wound 
Status; and
     Improvement in the Status of Surgical Wounds (see 72 FR 
49861).
    Accordingly, for CY 2008, we considered the existing OASIS data set 
submitted by HHAs to CMS for episodes beginning on or after July 1, 
2006, and before July 1, 2007, as meeting the reporting requirement for 
quality measures for CY 2008.

II. Comments Received From CY 2008 HH PPS Final Rule With Comment 
Period

    In the CY 2008 HH PPS final rule with comment period, we 
implemented a 2.75 percent payment reduction of the national 
standardized 60-day episode payment rate for three years beginning in 
CY 2008 and a fourth year reduction of 2.71 percent for CY 2011. We 
sought comments only on the 2.71 percent case-mix change adjustment for 
2011. We received approximately 44 items of correspondence from the 
public, only a few of which were directly related to the 2.71 percent 
adjustment to the HH PPS 60-day episode payment rate in the fourth 
year. The provision for the 2.71 percent adjustment was added as the 
fourth year's reduction to the rates to account for the additional 
change in case-mix, that was indicated in the analysis for the CY 2008 
final rule with comment period, that is not considered real; i.e., that 
is not related to an underlying change in patient health status. 
Comments originated from trade associations, HHAs, hospitals, and 
health care professionals such as physicians, nurses, social workers, 
and physical and occupational therapists. Because this is an update 
notice, we are not changing policy. However, in order to provide more 
meaningful and substantive responses we will respond to the above 
mentioned comments in future rulemaking. This approach allows us to 
respond comprehensively as more current data become available, while 
also affording the public ample opportunity to comment on possible 
future policy changes.
    At this time, CMS is maintaining our existing policy as implemented 
in the CY 2008 final rule with comment period and will impose a 2.75 
percent reduction to the national standardized 60-day episode rate for 
CY 2009. We will continue to monitor any changes in case-mix and may 
revise the percentage reductions to the HH PPS rates in future 
rulemaking.

III. Provisions of This Notice

A. National Standardized 60-Day Episode Rate

    The Medicare HH PPS has been in effect since October 1, 2000. As 
set forth in the final rule published July 3, 2000 in the Federal 
Register (65 FR 41128), the unit of payment under the Medicare HH PPS 
is a national standardized 60-day episode rate. As set forth in Sec.  
484.220, we adjust the national standardized 60-day episode rate by a 
case-mix relative weight and a wage index value based on the site of 
service for the beneficiary. In the CY 2008 HH PPS final rule with 
comment period, we refined the case-mix methodology and also rebased 
and revised the home health market basket. The labor-related share of 
the case-mix adjusted 60-day episode rate is 77.082 percent and the 
non-labor-related share is 22.918 percent. The CY 2009 HH PPS rates use 
the same case-mix methodology and application of the wage index 
adjustment to the labor portion of the HH PPS rates as set forth in the 
CY 2008 HH PPS final rule with comment period. We multiply the national 
60-day episode rate by the patient's applicable case-mix weight. We 
divide the case-mix adjusted amount into a labor and non-labor portion. 
We multiply the labor portion by the applicable wage index based on the 
site of service of the beneficiary. We add the wage-adjusted portion to 
the non-labor portion yielding the case-mix and wage-adjusted 60-day 
episode rate subject to any additional applicable adjustments.
    In accordance with section 1895(b)(3)(B) of the Act, we have 
updated the HH PPS rates annually in a separate Federal Register 
document. The HH PPS regulations at Sec.  484.225 sets forth the 
specific annual percentage update. To reflect section 1895(b)(3)(B)(v) 
of the Act, as added by section 5201 of the DRA, we added Sec.  
484.225, paragraphs (h) and (i), in the November 9, 2006 final rule to 
reflect the requirement for submission of quality data, as follows:
    (h) For 2007 and subsequent calendar years, in the case of a home 
health agency that submits home health quality data, as specified by 
the Secretary, the unadjusted national prospective 60-day episode rate 
is equal to the rate for the previous calendar year increased by the 
applicable home health market basket index amount.
    (i) For 2007 and subsequent calendar years, in the case of a home 
health agency that does not submit home health quality data, as 
specified by the Secretary, the unadjusted national prospective 60-day 
episode rate is equal to the rate for the previous calendar year 
increased by the applicable home health market basket index amount 
minus 2 percentage points. Any reduction of the percentage change will 
apply only to the calendar year involved and will not be taken into 
account in computing the prospective payment amount for a subsequent 
calendar year.
    For CY 2009, we will base the wage index adjustment to the labor 
portion of

[[Page 65354]]

the HH PPS rates on the most recent pre-floor and pre-reclassified 
hospital wage index. As discussed in the July 3, 2000 HH PPS final 
rule, for episodes with four or fewer visits, Medicare pays the 
national per-visit amount by discipline, referred to as a ``low 
utilization payment adjustment'' (LUPA). We update the national per-
visit amounts by discipline annually by the applicable home health 
market basket percentage. We adjust the national per-visit amount by 
the appropriate wage index based on the site of service for the 
beneficiary, as set forth in Sec.  484.230. We will adjust the labor 
portion of the updated national per-visit amounts by discipline used to 
calculate the LUPA by the most recent pre-floor and pre-reclassified 
hospital wage index, as discussed in the CY 2008 HH PPS final rule with 
comment period. We are also updating the amounts of the LUPA add-on and 
the NRS conversion factor by the applicable home health market basket 
update of 2.9 percent for CY 2009.
    Medicare pays the 60-day case-mix and wage-adjusted episode payment 
on a split percentage payment approach. The split percentage payment 
approach includes an initial percentage payment and a final percentage 
payment as set forth in Sec.  484.205(b)(1) and Sec.  484.205(b)(2). We 
may base the initial percentage payment on the submission of a request 
for anticipated payment (RAP) and the final percentage payment on the 
submission of the claim for the episode, as discussed in Sec.  409.43. 
The claim for the episode that the HHA submits for the final percentage 
payment determines the total payment amount for the episode and whether 
we make an applicable adjustment to the 60-day case-mix and wage-
adjusted episode payment. The end date of the 60-day episode as 
reported on the claim determines which calendar year rates Medicare 
would use to pay the claim.
    We may also adjust the 60-day case-mix and wage-adjusted episode 
payment based on the information submitted on the claim to reflect the 
following:
     A low utilization payment provided on a per-visit basis as 
set forth in Sec.  484.205(c) and Sec.  484.230.
     A partial episode payment adjustment as set forth in Sec.  
484.205(d) and Sec.  484.235.
     An outlier payment as set forth in Sec.  484.205(e) and 
Sec.  484.240.

B. CY 2009 Update to the Home Health Market Basket Index

    Section 1895(b)(3)(B) of the Act, as amended by section 5201 of the 
DRA, requires for CY 2009 that the standard prospective payment amounts 
be increased by a factor equal to the applicable home health market 
basket update for those HHAs that submit quality data as required by 
the Secretary.
    The applicable home health market basket update will be reduced by 
2 percentage points for those HHAs that fail to submit the required 
quality data. This requirement has been codified in regulations at 42 
CFR 484.225. The HH PPS market basket update for CY 2009 is 2.9 
percent. This is based on Global Insights Inc.'s, third quarter 2008 
forecast, utilizing historical data through the second quarter of 2008. 
A detailed description of how we derived the HHA market basket is 
available in the CY 2008 Home Health PPS proposed rule (72 FR 25356, 
25435).
 CY 2009 Adjustments
    In order to calculate the CY 2009 national standardized 60-day 
episode rate, we first increase the CY 2008 national standardized 60-
day episode payment rate of $2,270.32 by the home health market basket 
update of 2.9% for CY 2009.
    Given this updated rate, we then take a reduction of 2.75 percent 
to account for the change in case-mix that is not related to the real 
change in patient acuity levels, as discussed above. The resulting 
updated CY 2009 national standardized 60-day episode rate for an HHA 
that submits the required quality data is shown in Table 1. The updated 
CY 2009 national standardized 60-day episode rate for an HHA that does 
not submit the required quality data is shown in Table 2.

  Table 1--National 60-Day Episode Amounts Updated by the Home Health Market Basket Update for CY 2009, Before
           Case-Mix Adjustment, Wage Index Adjustment Based on the Site of Service for the Beneficiary
----------------------------------------------------------------------------------------------------------------
                                   Multiply by the    Updated National     Reduce by 2.75
     Total CY 2008 National      Home Health Market   Standardized 60-       Percent for       CY 2009 National
  Standardized 60-Day Episode    Basket Update (2.9      Day Episode      Nominal Change in  Standardized 60-Day
          Payment Rate              Percent) \1\           Payment            Case-Mix         Episode Payment
----------------------------------------------------------------------------------------------------------------
$2,270.32......................  x 1.029...........  $2,336.16.........  x 0.9725..........  $2,271.92
----------------------------------------------------------------------------------------------------------------
\1\ The estimated home health market basket update of 2.9 percent for CY 2009 is based on Global Insight Inc.,
  3rd Qtr 2008 forecast with historical data through 2nd Qtr 2008.


 Table 2--For HHAs That Do Not Submit the Required Quality Data--National 60-Day Episode Amounts Updated by the
  Home Health Market Basket Update for CY 2009, Before Case-Mix Adjustment, Wage Index Adjustment Based on the
                                       Site of Service for the Beneficiary
----------------------------------------------------------------------------------------------------------------
                                                      Updated National
                                   Multiply by the    Standardized 60-                         CY 2009 National
     Total CY 2008 National      Home Health Market      Day Episode       Reduce by 2.75    Standardized 60-Day
  Standardized 60-Day Episode    Basket Update (2.9   Payment for HHAs       Percent for     Episode Payment for
          Payment Rate           Percent) \1\ minus  that do not submit   Nominal Change in    HHAs that do not
                                      2 percent       required quality        Case-Mix         submit required
                                                            data                                 quality data
----------------------------------------------------------------------------------------------------------------
$2,270.32......................  x 1.009...........  $2,290.75.........  x 0.9725..........  $2,227.75
----------------------------------------------------------------------------------------------------------------
\1\ The estimated home health market basket update of 2.9 percent for CY 2009 is based on Global Insight Inc.,
  3rd Qtr 2008 forecast with historical data through 2nd Qtr 2008.


[[Page 65355]]

 National Per-Visit Amounts Used To Pay LUPAs and Compute 
Imputed Costs Used in Outlier Calculations
    As discussed previously in the CY 2008 HH PPS final rule with 
comment period, the policies governing LUPAs and the outlier 
calculations set forth in the July 3, 2000 HH PPS final rule will 
continue (65 FR 41128). Also, we implemented a LUPA add-on amount of 
$87.93 for initial and only episode LUPAs during CY 2008. In 
calculating the CY 2009 national per-visit amounts used to calculate 
payments for LUPA episodes and to compute the imputed costs in outlier 
calculations, we start with the CY 2008 per-visit amounts. We increase 
the CY 2008 per-visit amounts for each home health discipline for CY 
2009 by the home health market basket update (2.9 percent). LUPA rates 
are not reduced due to the nominal increase in case-mix since they are 
per-visit rates and hence are not subject to changes in case-mix.

    Table 3--National Per-Visit Amounts for LUPAs (Not including the Increase in Payment for a Beneficiary's Only Episode or the Initial Episode in a
 Sequence of Adjacent Episodes) and Outlier Calculations Updated by the Home Health Market Basket Update for CY 2009, Before Wage Index Adjustment Based
                                                       on the Site of Service for the Beneficiary
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                             For HHAs that DO submit the required quality     For HHAs that DO NOT submit the required
------------------------------------------------------------                     data                                       quality data
                                                            --------------------------------------------------------------------------------------------
                                                              Multiply by the Home                          Multiply by the Home
       Home Health Discipline           CY 2008 per-visit     Health Market Basket    CY 2009 per-visit     Health Market Basket     CY 2009 per-visit
                                             payment          Update (2.9 Percent)         payment          Update (2.9 percent)          payment
                                                                      \1\                                   \1\ minus 2 percent
--------------------------------------------------------------------------------------------------------------------------------------------------------
Home Health Aide...................  $47.51................  x 1.029..............  $48.89...............  x 1.009..............  $47.94
Medical Social Services............  168.17................  x 1.029..............  173.05...............  x 1.009..............  169.68
Occupational Therapy...............  115.48................  x 1.029..............  118.83...............  x 1.009..............  116.52
Physical Therapy...................  114.71................  x 1.029..............  118.04...............  x 1.009..............  115.74
Skilled Nursing....................  104.91................  x 1.029..............  107.95...............  x 1.009..............  105.85
Speech-Language Pathology..........  124.65................  x 1.029..............  128.26...............  x 1.009..............  125.77
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ The estimated home health market basket update of 2.9 percent for CY 2009 is based on Global Insight Inc., 3rd Qtr 2008 forecast with historical
  data through 2nd Qtr 2008.

    Payment for LUPA episodes changed in CY 2008 in that for LUPAs that 
occur as initial episodes in a sequence of adjacent episodes or as the 
only episode, an additional payment amount is added to the LUPA 
payment. The Table 3 per-visit rates noted above are before that 
additional payment is added to the LUPA payment, and are the per-visit 
rates paid to all other LUPA episodes and used in computing outlier 
payments. LUPA episodes that occur as the only episode or initial 
episode in a sequence of adjacent episodes are adjusted by adding an 
additional amount to the LUPA payment before adjusting for wage index. 
For CY 2008, that amount was $87.93. This additional LUPA amount is 
updated in the same manner as the national standardized 60-day episode 
payment amount and the per-visit rates (i.e. by the home health market 
basket percentage update). Consequently, for CY 2009, the additional 
amount paid to LUPAs that occur as initial episodes in a sequence of 
adjacent episodes or as the only episode is 90.48 ($87.93 x 1.029).
    Beginning in CY 2008, to ensure that the variation in non-routine 
medical supplies (NRS) is more appropriately reflected in the HH PPS, 
we replaced the original portion ($49.62) of the HH PPS base rate that 
accounted for NRS, with a system that pays for NRS based on 6 severity 
groups. For a complete description of the analysis and research behind 
the development of this system for the payment of NRS, we refer readers 
to the CY 2008 HH PPS proposed rule (72 FR 25426-25434). Following 
public comment on the initial proposal made in the proposed rule, we 
made several modifications using a file of more recent data. The 
revisions resulted in some scoring changes, and the addition of the 
sixth severity group to the original five severity groups, to provide 
more adequate reimbursement for episodes with a high utilization of 
NRS. As we did in the CY 2008 HH PPS final rule with comment, payments 
for NRS are updated by the home health market basket and reduced by the 
2.75 percent reduction to the rates through the updating of the NRS 
conversion factor. NRS payments are computed by multiplying the 
relative weight for a particular severity level by the NRS conversion 
factor. For this notice, the NRS conversion factor is updated by the 
home health market basket update of 2.9 percent and reduced by the 2.75 
percent reduction to the rates. The NRS conversion factor for CY 2008 
was $52.35. Consequently, for CY 2009, the NRS conversion factor is 
$52.39 (52.35 x (1.029 x (1-0.0275))). The payment amounts for the 
various severity levels based on the updated conversion factor are 
calculated in Table 4.

                             Table 4--Relative Weights for the 6-Severity NRS System
----------------------------------------------------------------------------------------------------------------
                                                                                     Relative       NRS payment
                Severity level                          Points  (scoring)             weight          amount
----------------------------------------------------------------------------------------------------------------
1.............................................  0...............................          0.2698          $14.13
2.............................................  1 to 14.........................          0.9742           51.04
3.............................................  15 to 27........................          2.6712          139.94
4.............................................  28 to 48........................          3.9686          207.91
5.............................................  49 to 98........................          6.1198          320.62
6.............................................  99+.............................         10.5254          551.43
----------------------------------------------------------------------------------------------------------------


[[Page 65356]]

C. Home Health Care Quality Improvement

    Section 5201(c)(2) of the DRA added section 1895(b)(3)(B)(v)(II) to 
the Act, requiring that, starting with the initial reporting year from 
July 2005 through June 2006 and each year thereafter, ``each home 
health agency shall submit to the Secretary such data that the 
Secretary determines are appropriate for the measurement of health care 
quality.'' In response to the DRA requirements, CMS published 
information about the quality measures in the Federal Register as a 
proposed rule on August 3, 2006 (71 FR 44082-44090) and as a final rule 
on November 9, 2006 (71 FR 65903). We proposed, and made final, the 
decision to use the subset of OASIS data that is publicly reported on 
Home Health Compare, as the appropriate measures of home health 
quality.
    Therefore, OASIS assessments submitted by HHAs to CMS in compliance 
with HHA conditions of participation for dates of service beginning 
July 1, 2007 and ending June 30, 2008 will fulfill the HH PPS quality 
reporting requirement for CY 2009 payments. This reporting time period 
allows for 12 full months of data and provides us the time necessary to 
analyze and make any necessary payment adjustments to the CY 2009 
payment rates. The required quality measures for meeting the submission 
requirements for CY 2009 are the same as those required for meeting the 
submission requirements for CY 2008. These measures are:
     Improvement in Ambulation/Locomotion,
     Improvement in Bathing,
     Improvement in Transferring,
     Improvement in Management of Oral Medication,
     Improvement in Pain Interfering with Activity,
     Acute Care Hospitalization,
     Emergent Care,
     Discharge to Community,
     Improvement in Dyspnea,
     Improvement in Urinary incontinence,
     Improvement in surgical wounds, and
     Emergent Care for wound deterioration.
    HHAs that meet the reporting requirements are eligible for the full 
home health market basket percentage increase. Consistent with our 
previous policy, home health agencies that are certified on or after 
May 1, 2007 for payments to be made in CY 2009 will be excluded from 
the quality reporting requirement in CY 2009 because data submission 
and analysis will not be possible for an agency certified this late in 
the reporting time period. At the earliest time possible after 
obtaining the CCN number, reporting is mandatory. These exclusions only 
affect quality reporting requirements and do not affect the agency's 
OASIS reporting responsibilities under the CoP submission requirement.
    Additionally, section 1895(b)(3)(B)(v)(I) of the Act requires that 
all HHAs, unless covered by specific exclusions, meet the reporting 
requirement, or be subject to a 2 percent reduction in the home health 
market basket percentage increase. CMS will reconcile the OASIS 
submissions with claims data in order to verify full compliance with 
the quality reporting requirements on an annual cycle July 1 through 
June 30. The 2 percent reduction applies to all HHAs who have not 
submitted an OASIS assessment in the required time frame for payments 
beginning in January 2007 and each year thereafter. We will reconcile 
the OASIS submissions with claims data in order to verify full 
compliance with the quality reporting requirements. Section 
1895(b)(3)(B)(v)(III) of the Act further requires that ``[t]he 
Secretary shall establish procedures for making data submitted under 
subclause (II) available to the public. Such procedures shall ensure 
that a home health agency has the opportunity to review the data that 
is to be made public with respect to the agency prior to such data 
being made public.'' To meet the requirement for making such data 
public, we will continue to use the Home Health Compare Web site, which 
lists HHAs geographically. Currently, the Home Health Compare Web site 
lists 12 quality measures from the OASIS set, and these 12 measures are 
all NQF-endorsed measures for public reporting. Consumers can search 
for all Medicare-approved home health providers that serve their city 
or zip code (which would include the quality measures) and then find 
the agencies offering the types of services they need. See http://
www.medicare.gov/HHCompare/Home.asp. HHAs currently have pre-
publication access every November to their own agency's quality data 
(collected and periodically updated by a contractor), which enables 
each agency to know how it is performing before public posting of data 
on the Home Health Compare Web site. In addition, each agency formally 
receives quarterly updates via the CASPER system known as Outcome Based 
Quality Improvement (OBQI) and Outcome Based Quality Monitoring (OBQM) 
and a report describing the agency patient characteristics based on 
OASIS. Continuing to use the OASIS instrument ensures that providers 
will not have an additional burden of reporting through a separate 
mechanism and that the costs associated with the development and 
testing of a new reporting mechanism can be avoided. For CY 2009, we 
will continue to require that the HHA submit OASIS data appropriate for 
the measurement of health care quality.
    Over the past year, CMS has tested new patient level best practice 
and process measures for home health agencies, and has continued to 
refine the current OASIS instrument. CMS is testing the new measure the 
NQF has developed a Global Measure for Flu/Pneumonia vaccination across 
care settings. We anticipate making further modifications to the 
current OASIS items, including refinements to response categories. Any 
new data elements go through OMB process and measures go through the 
NQF consensus development process, prior to proposing them through the 
rulemaking process. Additionally, section 1895(b)(3)(B)(v)(II) of the 
Act requires each HHA to submit appropriate health care quality data in 
a form, manner, and at a time specified by the Secretary. Such measures 
would be evidence-based, clearly linked to improved outcomes, and 
reliably captured with the least burden to the provider. Data element 
revisions and measures across settings of care will be integral to CMS' 
vision of addressing national quality care priorities and use of a 
future single instrument for quality, payment, clinical relevance, and 
risk adjustment.

D. Consumer Assessment of Healthcare Providers and Systems 
(CAHPS[supreg]) Home Health Care

    As part of the U.S. Department of Health and Human Services (DHHS) 
Transparency Initiative, CMS plans to implement a process to measure 
and publicly report patient experiences with home health care using a 
survey developed by the Agency for Healthcare Research and Quality's 
(AHRQ's) Consumer Assessment of Healthcare Providers and Systems 
(CAHPS[supreg]) program. The CAHPS Home Health Care survey is part of a 
family of CAHPS[supreg] surveys that ask patients to report on and rate 
their experiences with health care. This notice provides an update on 
the development of the CAHPS Home Health Care survey, as initially 
discussed in the May 4, 2007 proposed rule (72 FR 25356, 25452). The 
CAHPS[supreg] Home Health Care survey presents home health patients 
with a set of standardized questions about their

[[Page 65357]]

home health care providers and the quality of their home health care. 
Prior to this survey, there was no national standard for collecting 
information about patient experience that would allow comparisons 
across all home health agencies.
    The survey captures topics such as patients' interactions with home 
health staff, provider care and communication, and patient 
characteristics. The survey allows the patient to give an overall 
rating of the agency, and asks if the patient would recommend the 
agency to family and friends.
    AHRQ conducted a field test to determine the length and content of 
the CAHPS Home Health Care Survey. CMS has submitted the survey to the 
National Quality Forum (NQF) for consideration and approval in their 
consensus process. NQF endorsement represents the consensus opinion of 
many healthcare providers, consumer groups, professional organizations, 
purchasers, federal agencies, and research and quality organizations. 
The final survey will be submitted to the Office of Management and 
Budget (OMB) for their approval under the Paperwork Reduction Act (PRA) 
process.
    CMS is working with a contractor to develop protocols and 
guidelines for implementation of CAHPS Home Health Care survey. 
Administration of the survey will be conducted by multiple, independent 
survey vendors working under contract with home health agencies to 
facilitate data collection and reporting. During 2008, vendor training 
materials are being developed, and implementation procedures for data 
submission and processing will be finalized. Recruitment and training 
of vendors who wish to be approved to collect survey data will begin in 
2009. The CAHPS Home Health Care survey will be implemented similar to 
the CAHPS Hospital survey where vendors are approved to conduct the 
survey and trained prior to agency participation in the survey. Home 
health agencies interested in learning about the survey are encouraged 
to view the CAHPS Home Health Care Survey Web site: http://
www.homehealthCAHPS.org. They can also call toll-free: 1-866-354-0985 
or send an email to the project team at HHCAHPS@rti.org for more 
information.
    More information about the national implementation will be 
available next year in the Home Health Rule: The Home Health 
Prospective Payment System Refinement and Rate Update for Calendar Year 
2010.

E. Outliers and the Fixed Dollar Loss Ratio

    In addition to the regular 60-day case-mix and wage-adjusted 
episode payments, the HH PPS allows for outlier payments for episodes 
that incur unusually high costs. As noted in section I.A., of this 
notice, outlier payments are made for episodes for which the estimated 
cost exceeds a threshold amount. Section 1895(b)(5) of the Act requires 
that the estimated total outlier payments be no more than 5 percent of 
total estimated HH PPS payments for a given year. For a full 
description of our outlier policy, we refer to the CY 2008 HH PPS final 
rule with comment period (72 FR 49855-49857).
    The wage adjusted fixed dollar loss (FDL) amount represents the 
amount of loss that an agency must bear before an episode becomes 
eligible for outlier payments. Annually, we review the percentage of 
outlier payments and adjust the FDL ratio as appropriate.
    Past experience has shown that outlier payments have been 
increasing as a percent of total payments from 4.1 percent in CY 2005, 
to 5.0 percent in CY 2006, to 6.4 percent in CY 2007. More recent 
analysis estimates outlier payments to increase to approximately 8.1 
percent in CY 2008 (an increase of slightly more than 27 percent).
    In the CY 2008 final rule with comment period, in the interest of 
using the latest data and best analysis available, we performed 
supplemental analysis on the most recent data available in order to 
best estimate the FDL ratio. That analysis derived a final FDL ratio of 
0.89 for CY 2008.
    In order to determine the appropriate value for the FDL ratio for 
CY 2009 we performed an updated analysis using the most recent, 
complete available data (CY 2007), applying a methodology similar to 
that which we used to update the FDL ratio in the CY 2008 HH PPS final 
rule with comment. That updated analysis projects that in CY 2009 we 
will expend an estimated 10.26 percent of total estimated HH PPS 
payments in outlier payments, more than double our 5 percent statutory 
limit. However, our analysis also revealed that this growth in outlier 
payments is primarily the result of excessive growth in a few specific 
areas of the country. Specifically, we have noticed statistical 
anomalies in outlier payments, as a percentage of total HH PPS 
payments, in areas such as Miami-Dade, Florida, where outlier payments 
to providers far exceed the national average and the 5 percent target 
for outlier payments. Using similar analysis to what was performed for 
the CY 2009 final rule with comment; we estimated that we would need to 
raise our FDL ratio from 0.89 to 2.71 for CY 2009. This is a dramatic 
change that appears to be driven by statistical anomalies in outlier 
payments in areas such as Miami-Dade, Florida. In addition, the size of 
these statistical anomalies raises concerns about the medical necessity 
of the outlier episodes in some areas. We will be examining outlier 
payments in these areas in more detail and will take action to remedy 
inappropriate outlier payments as necessary.
    Therefore, we believe that raising the FDL ratio to 2.71 is not 
justified at this time, given the statistical outlier data anomalies 
that we have identified in certain areas, and the actions that are 
underway to address excessive, suspect outlier payments that are 
occurring in these areas. We believe the most reasonable policy to 
achieve paying no more than 5 percent outlier payments as a percentage 
of total estimated HH PPS payments is through the combined effects of 
maintaining the current (CY 2008) FDL ratio of 0.89 in CY 2009 and the 
actions being taken to remedy any inappropriate outlier payments in 
these areas of the country where outlier data anomalies exist. Any 
further update to the FDL ratio, if any, will not occur until future 
rulemaking when we expect to have a better understanding of appropriate 
outlier payments, particularly in those areas of the country with 
extremely high outlier payments as a percentage of total HH PPS 
payments.

F. Hospital Wage Index

    Sections 1895(b)(4)(A)(ii) and (b)(4)(C) of the Act require the 
Secretary to establish area wage adjustment factors that reflect the 
relative level of wages and wage-related costs applicable to the 
furnishing of home health services and to provide appropriate 
adjustments to the episode payment amounts under the HH PPS to account 
for area wage differences. As discussed previously, we apply the 
appropriate wage index value to the labor portion (77.082 percent) of 
the HH PPS rates based on the site of service for the beneficiary 
(defined by section 1861(m) of the Act as the beneficiary's place of 
residence). Generally, we determine each HHA's labor market area based 
on definitions of Metropolitan Statistical Areas (MSAs) issued by the 
Office of Management and Budget (OMB). We have consistently used the 
pre-floor, pre-reclassified hospital wage index data to adjust the 
labor portion of the HH PPS rates. We believe the use of the pre-floor, 
pre-reclassified hospital wage index data results in the appropriate 
adjustment to

[[Page 65358]]

the labor portion of the costs as required by statute.
    In the November 9, 2005 final rule for CY 2006 (70 FR 68132), we 
adopted revised labor market area definitions based on Core-Based 
Statistical Areas (CBSAs). At the time, we noted that these were the 
same labor market area definitions (based on OMB's new CBSA 
designations) implemented under the Hospital Inpatient Prospective 
Payment System (IPPS). 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 home health 
wage index. We continue to use the methodology discussed in the 
November 9, 2006 final rule for CY 2007 (71 FR 65884) to address the 
geographic areas that lack hospital wage data on which to base the 
calculation of their home health wage index. For rural areas that do 
not have IPPS hospitals, we use the average wage index from all 
contiguous CBSAs as a reasonable proxy. This methodology is used to 
calculate the wage index for rural Massachusetts. However, we could not 
apply this methodology to rural Puerto Rico due to the distinct 
economic circumstances that exist there, but instead continue using the 
most recent wage index previously available for that area (from CY 
2005). For urban areas without IPPS hospitals, we use the average wage 
index of all urban areas within the State as a reasonable proxy for the 
wage index for that CBSA. The only urban area without IPPS hospital 
wage data is Hinesville-Fort Stewart, Georgia (CBSA 25980).
1. Clarification of New England Deemed Counties
    We are taking this opportunity to address the change in the 
treatment of ``New England deemed counties'' (that is, those counties 
in New England listed at 42 CFR 412.64(b)(1)(ii)(B) that were deemed to 
be part of urban areas under section 601(g) of the Social Security 
Amendments of 1983) that was made in the FY 2008 IPPS final rule with 
comment period (72 FR 47337 through 47338, August 22, 2007). These 
counties include the following: 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, ME; Sagadahoc County, 
ME; and Newport County, RI) are also included in metropolitan 
statistical areas defined by OMB and are considered urban under both 
the current IPPS and HH PPS labor market area definitions in Sec.  
412.64(b)(1)(ii)(A). The remaining two, Litchfield County, CT, and 
Merrimack County, NH, are geographically located in areas that are 
considered rural under the current IPPS (and HH PPS) labor market area 
definitions, but have been previously deemed urban under the IPPS in 
certain circumstances, as discussed below.
    In the FY 2008 IPPS final rule with comment period, Sec.  
412.64(b)(1)(ii)(B) was revised such that the two ``New England deemed 
counties'' that are still considered rural under the OMB definitions 
(Litchfield County, CT and Merrimack County, NH), are no longer 
considered urban effective for discharges occurring on or after October 
1, 2007, and therefore, 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 note that the HH PPS does not provide for such geographic 
reclassification. Also, in the FY 2008 IPPS final rule with comment 
period (72 FR 47338), we explained that we have limited this policy 
change for the ``New England deemed counties'' only to IPPS hospitals, 
and any change to non-IPPS provider wage indexes would be addressed in 
the respective payment system rules. Accordingly, we are taking this 
opportunity to clarify the treatment of ``New England deemed counties'' 
under the HH PPS in this notice.
    As discussed above, the HH PPS has consistently used the IPPS 
definition of ``urban'' and ``rural'' with regard to the wage index 
used in the HH PPS. Historical changes to the labor market area/
geographic classifications and annual updates to the wage index values 
under the HH PPS are made effective January 1 each year. When we 
established the most recent HH PPS payment rate update, effective for 
HH services provided on or after January 1, 2008 through December 31, 
2008, we considered the ``New England deemed counties'' (including 
Litchfield County, CT and Merrimack County, NH) as urban for CY 2008, 
as evidenced by the inclusion of Litchfield County as one of the 
constituent counties of urban CBSA 25540 (Hartford-West Hartford-East 
Hartford, CT), and the inclusion of Merrimack County as one of the 
constituent counties of urban CBSA 31700 (Manchester-Nashua, NH).
    At 42 CFR 484.202, the terms ``rural'' and ``urban'' are defined 
according to the definitions of those terms as used in the IPPS. 
Applying the IPPS definitions, Litchfield County, CT and Merrimack 
County, NH are not considered ``urban'' under Sec.  412.64(b)(1)(ii)(A) 
through (B) as revised under the FY 2008 IPPS final rule and, 
therefore, are considered ``rural'' under Sec.  412.64(b)(1)(ii)(C). 
Accordingly, reflecting our policy to use the IPPS definitions of 
``urban'' and ``rural,'' these two counties will be considered 
``rural'' under the HH PPS effective with the next update of the HH PPS 
payment rates on January 1, 2009, and will no longer be included in 
urban CBSA 25540 (Hartford-West Hartford-East Hartford, CT) and urban 
CBSA 31700 (Manchester-Nashua, NH), respectively. We note that this 
policy is consistent with our policy of not taking into account IPPS 
geographic reclassifications in determining payments under the HH PPS.
2. Multi-Campus Hospital Wage Index Data
    In the CY 2008 HH PPS final rule with comment period, we 
established HH PPS wage index values for CY 2008 calculated from the 
same data (collected from cost reports submitted by hospitals for cost 
reporting periods beginning during FY 2004) used to compute the FY 2008 
acute care hospital inpatient wage index, without taking into account 
geographic reclassification under sections 1886(d)(8) and (d)(10) of 
the Act. However, the IPPS policy that apportions the wage data for 
multi-campus hospitals was not finalized before the HH PPS final rule 
with comment period.
    We are continuing to use IPPS wage data for this CY 2009 update 
notice because we believe that in the absence of home health-specific 
wage data, using the hospital inpatient wage data is appropriate and 
reasonable for the HH PPS. We note that the IPPS wage data used to 
determine the CY 2009 HH wage index values reflect our policy that was 
adopted under the IPPS beginning in FY 2008, which apportions the wage 
data for multi-campus hospitals located in different labor market 
areas, or Core-Based Statistical Areas (CBSAs), to each CBSA where the 
campuses are located (see the FY 2008 IPPS final rule with comment 
period (72 FR 47317 through 47320)). Specifically, for the CY 2009 HH 
PPS, the wage index was computed using IPPS wage data (published by 
hospitals for cost reporting periods beginning in 2005, as with the FY 
2009 IPPS wage index), which allocated salaries and hours to the 
campuses of two multi-campus hospitals with campuses that are located 
in different labor areas; one is Massachusetts and the other is 
Illinois. The wage index

[[Page 65359]]

values for the CY 2009 HH PPS in the following CBSAs are affected by 
this policy: 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) (please refer 
to Addendum B in this notice).
    As previously discussed in the July 3, 2000 final rule (65 FR 
41128), the statute provides that the wage adjustment factors may be 
the factors used by the Secretary for purposes of section 1886(d)(3)(E) 
of the Act for hospital wage adjustment factors. Since publication of 
the July 3, 2000 final rule, we continue to believe that the use of the 
pre-floor and pre-reclassified hospital wage index data results in the 
appropriate and reasonable adjustment to the labor portion of the costs 
as required by statute. The HH PPS does not use the hospital area wage 
index's occupational mix adjustment, as this adjustment serves 
specifically to define the occupational categories more clearly in a 
hospital setting. See Addenda A and B of this notice, respectively, for 
the rural and urban pre-floor, pre-reclassified hospital wage indexes 
for 2009. The 2009 wage index is based on data collected from hospital 
cost reports submitted for cost reporting periods beginning during FY 
2005. These data reflect the multi-campus and New England deemed 
counties policies discussed above.
    Under the HH PPS, we use the wage index value associated with the 
labor market in which the beneficiary's home is located. As has been 
our longstanding practice, any area not included in an MSA (urban area) 
is considered to be nonurban (Sec.  412.64(b)(1)(ii)(C)) and receives 
the statewide rural wage index value (see, for example, 65 FR 41173).

IV. Waiver of Proposed Rulemaking

    We ordinarily publish a notice of proposed rulemaking in the 
Federal Register to provide a period for public comment before the 
provisions of a notice such as this take effect. We can waive this 
procedure, however, if we find good cause that a notice-and-comment 
procedure is impracticable, unnecessary, or contrary to the public 
interest and incorporate a statement of finding and its reasons in the 
notice issued.
    We find that it is unnecessary, impracticable and contrary to the 
public interest to undertake proposed notice and comment rulemaking in 
this Notice. We believe it is unnecessary because the statute requires 
annual updates to the HH PPS rates and the methodologies used to update 
the rates have been previously subject to public comment; we are simply 
applying the methodology to the most recent data. With respect to the 
update of the outlier FDL ratio, we find that insofar as we have 
deviated from our usual methodology in this calendar year, such change 
is an analytical change. Moreover, we believe that the difficulty of 
deriving a new methodology to address the limited data discrepancies in 
localized areas of the country makes issuing a notice of proposed 
rulemaking in this instance impracticable. Moreover, it would be 
contrary to the public interest to undertake notice and comment 
rulemaking as it would impose a hardship on home health agencies and 
their patients by delaying publication of this update in order to 
solicit comments. Since it would pose additional harm to those home 
health agencies across the country that would be deemed ineligible for 
outlier payments because of these localized data discrepancies, 
applying the FDL analysis that we have used in past years is likewise 
contrary to the public interest for CY 2009. Therefore, we find good 
cause to waive notice and comment procedures for CY 2009.

V. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 501 et seq. ).

VI. Regulatory Impact Analysis

A. Overall Impact

    We have examined the impacts of this notice 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)).
    Executive Order 12866, as amended, 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 rules with economically significant 
effects ($100 million or more in any 1 year). This notice, as defined 
by Executive Order 12866, is not an economically significant rule. This 
notice would not be considered major under the Congressional Review 
Act. The update set forth in this notice applies to Medicare payments 
under HH PPS in CY 2009. Accordingly, the following analysis describes 
the impact in CY 2009 only.
    We estimate that the net impact in this notice, including a 2.75 
percent reduction to the payment rate to account for the case-mix 
change adjustment, is estimated to be approximately $30 million in CY 
2009 expenditures. This total estimated $30 million impact reflects the 
distributional effects of an updated wage index (-$20 million) as well 
as the 2.9 percent home health market basket increase (an estimated 
additional $4