Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Fiscal Year Beginning October 1, 2012 (FY 2013)

As Enacted ( Federal Register)

Cited authorities 7

Cited in

Federal Register, Volume 77 Issue 152 (Tuesday, August 7, 2012)

Federal Register Volume 77, Number 152 (Tuesday, August 7, 2012)

Notices

Pages 47223-47266

From the Federal Register Online via the Government Printing Office www.gpo.gov

FR Doc No: 2012-19118

Page 47223

Vol. 77

Tuesday,

No. 152

August 7, 2012

Part III

Department of Health and Human Services

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

Centers for Medicare & Medicaid Services

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

Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System--Update for Fiscal Year Beginning October 1, 2012 (FY 2013); Notice

Page 47224

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

CMS-1440-N

RIN 0938-AR22

Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System--Update for Fiscal Year Beginning October 1, 2012 (FY 2013)

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

ACTION: Notice.

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

SUMMARY: This notice updates the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilities (IPFs). These changes are applicable to IPF discharges occurring during the fiscal year (FY) beginning October 1, 2012 through September 30, 2013.

DATES: Effective Date: The updated IPF prospective payment rates are effective for discharges occurring on or after October 1, 2012 through September 30, 2013.

FOR FURTHER INFORMATION CONTACT: Dorothy Myrick or Jana Lindquist, (410) 786-4533 (for general information). Mary Carol Barron, (410) 786-

7943, or Bridget Dickensheets, (410) 786-8670, (for information regarding the market basket and labor-related share).

Theresa Bean, (410) 786-2287 (for information regarding the regulatory impact analysis).

SUPPLEMENTARY INFORMATION:

Executive Summary
1. Purpose
  
  This notice updates the prospective payment rates for Medicare inpatient hospital services provided by inpatient psychiatric facilitates for discharges occurring during the fiscal year (FY) beginning October 1, 2012 through September 30, 2013.
  
  Section 124 of the Medicare, Medicaid and SCHIP (State Children's Health Insurance Program) Balanced Budget Refinement Act of the 1999 (BBRA) (Pub. L. 106-113) required implementation of the inpatient psychiatric facilities (IPF) prospective payment system (PPS). Specifically, section 124 of the BBRA mandated that the Secretary develop a per diem PPS for inpatient hospital services furnished in psychiatric hospitals and psychiatric units that includes an adequate patient classification system that reflects the differences in patient resource use and costs among psychiatric hospitals and psychiatric units.
  
  Section 405(g)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173) extended the IPF PPS to distinct part psychiatric units of critical access hospitals (CAHs).
  
  To implement these provisions, we published various notices, and proposed and final rules in the Federal Register.
2. Summary of the Major Provisions
  
  In this notice, we update the IPF PPS, as specified in 42 CFR 412.428. The updates include the following:
  
  The FY 2008-based Rehabilitation, Psychiatric, and Long Term Care (RPL) market basket update of 2.7 percent adjusted by a 0.1 percentage point reduction as required by section 1886(s)(2)(A)(ii) of the Social Security Act (the Act) and a 0.7 percentage point reduction as required by 1886(s)(2)(A)(i) of the Act.
  
  The fixed dollar loss threshold amount in order to maintain the appropriate outlier percentage.
  
  The electroconvulsive therapy payment by a factor specified by CMS.
  
  The national urban and rural cost-to-charge ratio medians and ceilings.
  
  The cost of living adjustment factors for IPFs located in Alaska and Hawaii, if appropriate.
  
  Description of the ICD-9-CM and MS-DRG classification changes discussed in the annual update to the hospital inpatient PPS regulations.
  
  Use of the best available hospital wage index and information regarding whether an adjustment to the Federal per diem base rate is needed to maintain budget neutrality.
  
  The MS-DRG listing and comorbidity categories to reflect the ICD-9-CM revisions effective October 1, 2012.
  
  Retaining the 17 percent adjustment for IPFs located in rural areas, the 1.31 adjustment for IPFs with a qualifying emergency department, the 0.5150 teaching adjustment to the Federal per diem rate, the MS-DRG adjustment factors and comorbidity adjustment factors currently being paid to IPFs for RY 2012
3. Summary of Costs and Benefits
  
  ------------------------------------------------------------------------
  
  Provision description Total costs Total benefits
  
  ------------------------------------------------------------------------
  
  FY 2013 IPF PPS payment rate The overall economic ....................
  
  update. impact of this
  
  notice is an
  
  estimated $36
  
  million in
  
  increased payments
  
  to IPFs during FY
  
  2013.
  
  ------------------------------------------------------------------------
  
  Table of Contents
  
  To assist readers in referencing sections contained in this document, we are providing the following table of contents.
Executive Summary
1. Purpose
2. Summary of Major Provisions
3. Summary of Costs and Benefits
Background
1. Annual Requirements for Updating the IPF PPS
2. Overview of the Legislative Requirements of the IPF PPS
3. General Overview of the IPF PPS
Transition Period for Implementation of the IPF PPS
Changing the IPF PPS Payment Rate Update Period From a Rate Year to a Fiscal Year
Market Basket for the IPF PPS
1. Background
2. FY 2013 Market Basket Update
3. Labor-Related Share
Updates to the IPF PPS for FY Beginning October 1, 2012
1. Determining the Standardized Budget-Neutral Federal Per Diem Base Rate
  
  1. Standardization of the Federal Per Diem Base Rate and Electroconvulsive Therapy (ECT) Rate
  
  2. Calculation of the Budget Neutrality Adjustment
  
  a. Outlier Adjustment
  
  b. Stop-Loss Provision Adjustment
  
  c. Behavioral Offset
2. Update of the Federal Per Diem Base Rate and Electroconvulsive Therapy Rate
Update of the IPF PPS Adjustment Factors
1. Overview of the IPF PPS Adjustment Factors
2. Patient-Level Adjustments
  
  1. Adjustment for MS-DRG Assignment
  
  2. Payment for Comorbid Conditions
  
  3. Patient Age Adjustments
  
  4. Variable Per Diem Adjustments
3. Facility-Level Adjustments
  
  1. Wage Index Adjustment
  
  a. Background
  
  b. Wage Index for FY 2013
  
  c. OMB Bulletins
  
  2. Adjustment for Rural Location
  
  3. Teaching Adjustment
  
  a. FTE Intern and Resident Cap Adjustment
  
  b. Temporary Adjustment to FTE Cap To Reflect Residents Added Due to Hospital Closure
  
  c. Temporary Adjustment to FTE Cap To Reflect Residents Affected by Residency Program Closure
  
  Page 47225
  
  i. Receiving IPF
  
  ii. IPF That Closed Its Program
  
  4. Cost of Living Adjustment for IPFs Located in Alaska and Hawaii
  
  5. Adjustment for IPFs With a Qualifying Emergency Department (ED)
4. Other Payment Adjustments and Policies
  
  1. Outlier Payments
  
  a. Update to the Outlier Fixed Dollar Loss Threshold Amount
  
  b. Update to IPF Cost-to-Charge Ratio Ceilings
  
  2. Expiration of the Stop-Loss Provision
  
  3. Future Refinements
Secretary's Recommendations
Waiver of Proposed Rulemaking
Collection of Information Requirements
Regulatory Impact Analysis

Addenda

Acronyms

Because of the many terms to which we refer by acronym in this notice, we are listing the acronyms used and their corresponding meanings in alphabetical order below:

BBRA Medicare, Medicaid and SCHIP State Children's Health Insurance Program Balanced Budget Refinement Act of 1999, (Pub. L. 106-113)

CBSA Core-Based Statistical Area

CCR Cost-to-charge ratio

CAH Critical access hospital

DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders Fourth Edition--Text Revision

DRGs Diagnosis-related groups

FY Federal fiscal year (October 1 through September 30)

ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification

IPFs Inpatient psychiatric facilities

IRFs Inpatient rehabilitation facilities

LTCHs Long-term care hospitals

MedPAR Medicare provider analysis and review file

RPL Rehabilitation, Psychiatric, and Long-Term Care

RY Rate Year (July 1 through June 30)

TEFRA Tax Equity and Fiscal Responsibility Act of 1982, (Pub. L. 97-

248)
Background
1. Annual Requirements for Updating the IPF PPS
  
  In November 2004, we implemented the inpatient psychiatric facilities (IPF) prospective payment system (PPS) in a final rule that appeared in the November 15, 2004 Federal Register (69 FR 66922). In developing the IPF PPS, in order to ensure that the IPF PPS is able to account adequately for each IPF's case-mix, we performed an extensive regression analysis of the relationship between the per diem costs and certain patient and facility characteristics to determine those characteristics associated with statistically significant cost differences on a per diem basis. For characteristics with statistically significant cost differences, we used the regression coefficients of those variables to determine the size of the corresponding payment adjustments.
  
  In that final rule, we explained that we believe it is important to delay updating the adjustment factors derived from the regression analysis until we have IPF PPS data that includes as much information as possible regarding the patient-level characteristics of the population that each IPF serves. Therefore, we indicated that we did not intend to update the regression analysis and recalculate the Federal per diem base rate and the patient-and facility-level adjustments until we complete that analysis. Until that analysis is complete, we stated our intention to publish a notice in the Federal Register each spring to update the IPF PPS (71 FR 27041). In the May 6, 2011 IPF PPS final rule (76 FR 26432), we changed the payment rate update period to a rate year (RY) that coincides with a fiscal year (FY) update. Therefore, future update notices will be published in the Federal Register in the summer to be effective on October 1. For further discussion on changing the IPF PPS payment rate update period from a RY to a FY, see the IPF PPS final rule published in the Federal Register on May 6, 2011 (76 FR 26434 through 26435).
  
  Updates to the IPF PPS, as specified in 42 CFR Sec. 412.428, include the following:
  
  A description of the methodology and data used to calculate the updated Federal per diem base payment amount.
  
  The rate of increase factor as described in Sec. 412.424(a)(2)(iii), which is based on the Excluded Hospital with Capital market basket under the update methodology of section 1886(b)(3)(B)(ii) of the Act for each year (effective from the implementation period until June 30, 2006).
  
  For discharges occurring on or after July 1, 2006, the rate of increase factor for the Federal portion of the IPF's payment, which is based on the Rehabilitation, Psychiatric, and Long-Term Care (RPL) market basket.
  
  The best available hospital wage index and information regarding whether an adjustment to the Federal per diem base rate is needed to maintain budget neutrality.
  
  Updates to the fixed dollar loss threshold amount in order to maintain the appropriate outlier percentage.
  
  Description of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding and diagnosis-related groups (DRGs) classification changes discussed in the annual update to the hospital inpatient prospective payment system (IPPS) regulations.
  
  Update to the electroconvulsive therapy (ECT) payment by a factor specified by CMS.
  
  Update to the national urban and rural cost-to-charge ratio medians and ceilings.
  
  Update to the cost of living adjustment factors for IPFs located in Alaska and Hawaii, if appropriate.
  
  Our most recent IPF PPS annual update occurred in the May 6, 2011 Federal Register final rule (76 FR 26432) (hereinafter referred to as the May 2011 IPF PPS final rule) that set forth updates to the IPF PPS payment rates for RY 2012. That final rule updated the IPF PPS per diem payment rates that were published in the April 2010 IPF PPS notice in accordance with our established policies.
  
  Since implementation of the IPF PPS, we have explained that we believe it is important to delay updating the adjustment factors derived from the regression analysis until we have IPF PPS data that include as much information as possible regarding the patient-level characteristics of the population that each IPF serves. Because we are now approximately 7 years into the system, we believe that we have enough data to begin that process. Therefore, we have begun the necessary analysis to make future refinements. While we do not propose to make refinements in this notice, as explained in section V.D.3 below, we expect that in the future rulemaking, for FY 2014, we will be ready to propose potential refinements.
2. Overview of the Legislative Requirements of the IPF PPS
  
  Section 124 of the Medicare, Medicaid, and SCHIP (State Children's Health Insurance Program) Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L. 106-113) required implementation of the IPF PPS. Specifically, section 124 of the BBRA mandated that the Secretary develop a per diem PPS for inpatient hospital services furnished in psychiatric hospitals and psychiatric units that includes an adequate patient classification system that reflects the differences in patient resource use and costs among psychiatric hospitals and psychiatric units.
  
  Section 405(g)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173) extended the IPF PPS to distinct part psychiatric units of critical access hospitals (CAHs).
  
  Page 47226
  
  To implement these provisions, we published various proposed and final rules in the Federal Register. For more information regarding these rules, see the CMS Web site http://www.cms.hhs.gov/InpatientPsychFacilPPS/.
  
  Section 3401(f) of the Patient Protection and Affordable Care Act (Pub. L. 111-148) as amended by section 10319(e) of that Act and by section 1105(d) of the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152) (hereafter referred to as ``the Affordable Care Act'') added subsection (s) to section 1886 of the Act.
  
  Section 1886(s)(1) is titled ``Reference to Establishment and Implementation of System'' and it refers to section 124 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, which relates to the establishment of the IPF PPS.
  
  Section 1886(s)(2)(A)(i) of the Act requires the application of the productivity adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act to the IPF PPS for the RY beginning in 2012 (that is, a RY that coincides with a FY) and each subsequent RY. For the RY beginning in 2012 (that is, FY 2013), the reduction is equal to 0.7 percentage point, which we are implementing in this notice. Section 1886(s)(2)(A)(ii) of the Act requires the application of an ``other adjustment'' that reduces any update to an IPF PPS base rate by percentages specified in section 1886(s)(3) of the Act for RY beginning in 2010 through the RY beginning in 2019. For the RY beginning in 2012 (that is, FY 2013), section 1886(s)(3)(B) of the Act requires the reduction to be 0.1 percentage point. We are implementing that provision in this FY 2013 IPF PPS notice.
  
  Section 1886(s)(4) of the Act requires the establishment of a quality data reporting program for the IPF PPS beginning in RY 2014. We proposed new requirements for quality reporting for IPFs in the ``Hospital Inpatient Prospective Payment System for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates'' proposed rule (May 11, 2012) (77 FR 27870, 28105 through 28116).
3. General Overview of the IPF PPS
  
  The November 2004 IPF PPS final rule (69 FR 66922) established the IPF PPS, as authorized under section 124 of the BBRA and codified at subpart N of part 412 of the Medicare regulations. The November 2004 IPF PPS final rule set forth the per diem Federal rates for the implementation year (the 18-month period from January 1, 2005 through June 30, 2006), and it provided payment for the inpatient operating and capital costs to IPFs for covered psychiatric services they furnish (that is, routine, ancillary, and capital costs, but not costs of approved educational activities, bad debts, and other services or items that are outside the scope of the IPF PPS). Covered psychiatric services include services for which benefits are provided under the fee-for-service Part A (Hospital Insurance Program) Medicare program.
  
  The IPF PPS established the Federal per diem base rate for each patient day in an IPF derived from the national average daily routine operating, ancillary, and capital costs in IPFs in FY 2002. The average per diem cost was updated to the midpoint of the first year under the IPF PPS, standardized to account for the overall positive effects of the IPF PPS payment adjustments, and adjusted for budget neutrality.
  
  The Federal per diem payment under the IPF PPS is comprised of the Federal per diem base rate described above and certain patient- and facility-level payment adjustments that were found in the regression analysis to be associated with statistically significant per diem cost differences.
  
  The patient-level adjustments include age, DRG assignment, comorbidities, and variable per diem adjustments to reflect higher per diem costs in the early days of an IPF stay. Facility-level adjustments include adjustments for the IPF's wage index, rural location, teaching status, a cost of living adjustment for IPFs located in Alaska and Hawaii, and presence of a qualifying emergency department (ED).
  
  The IPF PPS provides additional payment policies for: outlier cases; stop-loss protection (which was applicable only during the IPF PPS transition period); interrupted stays; and a per treatment adjustment for patients who undergo ECT.
  
  A complete discussion of the regression analysis appears in the November 2004 IPF PPS final rule (69 FR 66933 through 66936).
  
  Section 124 of BBRA does not specify an annual update rate strategy for the IPF PPS and is broadly written to give the Secretary discretion in establishing an update methodology. Therefore, in the November 2004 IPF PPS final rule, we implemented the IPF PPS using the following update strategy:
  
  Calculate the final Federal per diem base rate to be budget neutral for the 18-month period of January 1, 2005 through June 30, 2006.
  
  Use a July 1 through June 30 annual update cycle.
  
  Allow the IPF PPS first update to be effective for discharges on or after July 1, 2006 through June 30, 2007.
Transition Period for Implementation of the IPF PPS

In the November 2004 IPF PPS final rule, we provided for a 3-year transition period. During this 3-year transition period, an IPF's total payment under the PPS was based on an increasing percentage of the Federal rate with a corresponding decreasing percentage of the IPF PPS payment that is based on reasonable cost concepts. However, effective for cost reporting periods beginning on or after January 1, 2008, IPF PPS payments are based on 100 percent of the Federal rate.
Changing the IPF PPS Payment Rate Update Period From a Rate Year to a Fiscal Year

In the RY 2012 IPF PPS proposed rule (76 FR 4998) and final rule (76 FR 26432), we revised the IPF PPS payment rate update period by switching from a RY (that is July 1 through June 30) to a period that coincides with a FY (that is, October 1 through September 30). Beginning with the update period that begins in 2012, that is, FY 2013, we now refer to update periods as FY. We specified that this change in the annual update period would allow us to consolidate Medicare publications by aligning the IPF PPS update with the annual update of the ICD-9-CM codes, which are effective on October 1 of each year. In addition to our annual proposed and final rulemaking documents, we publish a change request transmittal every August updating the ICD-9-CM codes related to the DRG and comorbidity adjustments. By aligning the IPF PPS with the same update period as the ICD-9-CM codes, we eliminated the need to publish a transmittal off-cycle.

We maintain the same diagnostic coding and DRG classification for IPFs that are used under the IPPS for providing the psychiatric care. When the IPF PPS was implemented, we adopted the same diagnostic code set and DRG patient classification systems (that is, the CMS DRGs) that was used at the time under the hospital prospective payment system (IPPS). Every year, changes to the ICD-9-CM coding system are addressed in the IPPS proposed and final rules. These changes are effective October 1 of each year and must be used by acute care hospitals as well as other providers to report diagnostic and procedure information. The IPF PPS has always incorporated ICD-9-CM coding changes made in the annual IPPS update. This change to the

Page 47227

annual payment rate update period allows the annual update to the rates and the ICD-9-CM coding update to occur on the same schedule and appear in the same Federal Register document.

Our intent in making the change in the payment rate update schedule was to place the IPF PPS on the same update cycle as other PPSs, making it administratively efficient. To smoothly transition into a payment update period that runs from October 1 through September 30, we proposed and finalized that the RY 2012 period run from July 1, 2011 through September 30, 2012, so that the RY 2012 would be 15 months. As proposed and finalized, after RY 2012, the rate update period for the IPF PPS payment rates and other policy changes begin on October 1 through September 30. Therefore, the update cycle for FY 2013 will be October 1, 2012 through September 30, 2013. In the May 2011 final rule, we changed the regulations at Sec. 412.402 to add the term ``Inpatient Psychiatric Facilities prospective payment system rate year'' which means October 1 through September 30. We proposed and finalized that the RY would be referred to as a FY. For further discussion of the 15-

month market basket update for RY 2012 and changing the payment rate update period from a RY to a FY, we refer readers to the RY 2012 IPF PPS proposed rule (76 FR 4998) and the RY 2012 IPF PPS final rule (76 FR 26432).
Market Basket for the IPF PPS
1. Background
  
  The input price index (that is, the market basket) that was used to develop the IPF PPS was the Excluded Hospital with Capital market basket. This market basket was based on 1997 Medicare cost report data and included data for Medicare participating IPFs, inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), cancer hospitals, and children's hospitals. Although ``market basket'' technically describes the mix of goods and services used in providing hospital care, this term is also commonly used to denote the input price index (that is, cost category weights and price proxies combined) derived from that market basket. Accordingly, the term ``market basket'' as used in this document refers to a hospital input price index.
  
  Beginning with the May 2006 IPF PPS final rule (71 FR 27046 through 27054), IPF PPS payments were updated using a FY 2002-based market basket reflecting the operating and capital cost structures for IRFs, IPFs, and LTCHs (hereafter referred to as the Rehabilitation, Psychiatric, and Long-Term Care (RPL) market basket).
  
  We excluded cancer and children's hospitals from the RPL market basket because these hospitals are not reimbursed through a PPS; rather, their payments are based entirely on reasonable costs subject to rate-of-increase limits established under the authority of section 1886(b) of the Act, which are implemented in regulations at Sec. 413.40. Moreover, the FY 2002 cost structures for cancer and children's hospitals are noticeably different than the cost structures of the IRFs, IPFs, and LTCHs. A complete discussion of the FY 2002-based RPL market basket appears in the May 2006 IPF PPS final rule (71 FR 27046 through 27054).
  
  In the May 1, 2009 IPF PPS notice (74 FR 20362), we expressed our interest in exploring the possibility of creating a stand-alone IPF market basket that reflects the cost structures of only IPF providers. We noted that, of the available options, one would be to join the Medicare cost report data from freestanding IPF providers (presently incorporated into the FY 2002-based RPL market basket) with data from hospital-based IPF providers (not currently incorporated in any market basket cost weights). We indicated that an examination of the Medicare cost report data comparing freestanding and hospital-based IPFs revealed considerable differences between the two with respect to cost levels and cost structures. At that time, we were unable to fully understand the differences between these two types of IPF providers. As a result, we felt that further research was required, therefore we solicited public comment for additional information that might help us to better understand the reasons for the variations in costs and cost structures, as indicated by the cost report data, between freestanding and hospital-based IPFs (74 FR 20376).
  
  We summarized the public comments received and our responses in the April 2010 IPF PPS notice (75 FR 23111 through 23113). Despite receiving comments from the public on this issue, we remain unable to understand the observed differences in costs and cost structures between hospital-based and freestanding IPFs. Therefore, we do not believe it is appropriate, at this time, to incorporate data from hospital-based IPFs with those of freestanding IPFs to create a stand-
  
  alone IPF market basket.
  
  We continue to explore the viability of creating two separate market baskets from the current RPL, one which may include freestanding IPFs and freestanding IRFs and be used to update payments under both the IPF and IRF payment systems. We also are still considering the possibility of creating a stand-alone IPF market basket. We recently proposed a stand-alone LTCH market basket, in the May 11, 2012 FY 2013 IPPS/LTCH proposed rule (77 FR 27870 at 28019). In the RY 2012 IPF PPS proposed rule (76 FR 5001), we welcomed public comment on the possibility of using a rehabilitation and psychiatric (RP) market basket to update IPF payments in the future. Comments received and our responses are summarized in the RY 2012 final rule (76 FR 26436). We note that comments received were in support of our efforts, and we are continuing to investigate the viability of alternative market baskets. Any possible changes to the market basket used to update IPF payments would appear in a future rulemaking and be subject to public comment.
  
  In the RY 2012 IPF PPS proposed rule (76 FR 4998) and final rule (76 FR 26432), we rebased and revised the RPL market basket to reflect a 2008 base year. We also proposed and finalized the use of the 2008-
  
  based RPL market basket to update IPF payments. Therefore, for the FY 2013 IPF PPS update, we are using the percentage increase in the 2008-
  
  based RPL market basket to determine the IPF PPS market basket update.
2. FY 2013 Market Basket Update
  
  The FY 2013 update for the IPF PPS using the FY 2008-based RPL market basket and Information Handling Services (IHS) Global Insight's second quarter 2012 forecast for the market basket components is 2.7 percent (prior to the application of any statutory adjustments). This includes increases in both the operating and the capital components for FY 2013 (that is, October 1, 2012 through September 30, 2013). IHS Global Insight, Inc. is a nationally recognized economic and financial forecasting firm that contracts with CMS to forecast the components of the market baskets.
  
  As previously described in section I.B, section 1886(s)(2)(A)(i) of the Affordable Care Act requires the application of the productivity adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act to the IPF PPS for the RY beginning in 2012 and each subsequent RY. The statute defines the productivity adjustment to be equal to the 10-year moving average of changes in annual economy-wide private nonfarm business multifactor productivity (MFP) (as projected by the Secretary for the 10-year period ending with the applicable FY, year, cost reporting period, or other annual period) (the ``MFP adjustment'').
  
  Page 47228
  
  The Bureau of Labor Statistics (BLS) is the agency that publishes the official measure of private non-farm business MFP. We refer readers to the BLS Web site at http://www.bls.gov/mfp to obtain the BLS historical published MFP data. The MFP adjustment for FY 2013 applicable to the IPF PPS is derived using a projection of MFP that is currently produced by IHS Global Insight, Inc. For a detailed description of the model currently used by IHS Global Insight, Inc. to project MFP, as well as a description of how the MFP adjustment is calculated, we refer readers to the FY 2012 IPPS/LTCH final rule (76 FR 51690 through 51692). Based on IHS Global Insight, Inc 2012 second quarter forecast, the productivity adjustment for the RY beginning in 2012 (that is FY 2013) is 0.7 percentage point. Section 1886(s)(2)(A)(ii) of the Act requires the application of an ``other adjustment'' that reduces any update to an IPF PPS base rate by percentages specified in section 1886(s)(3) of the Act for rate years beginning in 2010 through the RY beginning in 2019. For the RY beginning in 2012 (that is, FY 2013), the reduction is 0.1 percentage point. We are implementing the productivity adjustment and ``other adjustment'' for FY 2013 in this FY 2013 IPF PPS notice.
3. Labor-Related Share
  
  Due to the variations in costs and geographic wage levels, we believe that payment rates under the IPF PPS should continue to be adjusted by a geographic wage index. This wage index would apply to the labor-related portion of the Federal per diem base rate, hereafter referred to as the labor-related share.
  
  The labor-related share is determined by identifying the national average proportion of total costs that are related to, influenced by, or vary with the local labor market. We classify a cost category as labor-related if the costs are labor-intensive and vary with the local labor market. Based on our definition of the labor-related share, we include in the labor-related share the sum of the relative importance of Wages and Salaries, Employee Benefits, Professional Fees: Labor-
  
  related, Administrative and Business Support Services, All Other: Labor-related Services, and a portion of the Capital-Related cost weight.
  
  Therefore, to determine the labor-related share for the IPF PPS for FY 2013, we used the FY 2008-based RPL market basket cost weights relative importance to determine the labor-related share for the IPF PPS. This estimate of the FY 2013 labor-related share is based on IHS Global Insight Inc.'s second quarter 2012 forecast, which is the same forecast used to derive the FY 2013 market basket update.
  
  Table 1 below shows the FY 2013 relative importance labor-related share using the FY 2008-based RPL market basket along with the FY 2012 relative importance labor-related share.
  
  Table 1--FY 2013 Relative Importance Labor-Related Share and the RY 2012
  
  (15-Month) Relative Importance Labor-Related Share Based on the FY 2008-
  
  Based RPL Market Basket
  
  ------------------------------------------------------------------------
  
  RY 2012 FY 2013
  
  Relative Relative
  
  importance importance
  
  labor-related labor-related
  
  share \1\ share \2\
  
  ------------------------------------------------------------------------
  
  Wages and Salaries...................... 49.049 48.796
  
  Employee Benefits....................... 13.036 13.021
  
  Professional Fees: Labor-Related........ 2.073 2.070
  
  Administrative and Business............. 0.416 0.417
  
  Support Services........................
  
  All Other: Labor-Related Services....... 2.094 2.077
  
  Subtotal................................ 66.668 66.381
  
  Labor-Related Portion of Capital Costs 3.649 3.600
  
  (46%)..................................
  
  -------------------------------
  
  Total Labor-Related Share........... 70.317 69.981
  
  ------------------------------------------------------------------------
  
  \1\ Published in the RY 2012 IPF PPS final rule (76 FR 26447) and based
  
  on the IHS Global Insight, Inc. first quarter 2011 forecast of the
  
  2008-based RPL market basket. RY 2012 represents a 15-month update,
  
  which includes the period July 1, 2011 through September 30, 2012.
  
  \2\ Based on IHS Global Insight, Inc. second quarter 2012 forecast of
  
  the 2008-based RPL market basket.
  
  The labor-related share for FY 2013 is the sum of the FY 2013 relative importance of each labor-related cost category, and would reflect the different rates of price change for these cost categories between the base year (FY 2008) and FY 2013. The sum of the relative importance for FY 2013 for operating costs (Wages and Salaries, Employee Benefits, Professional Fees: Labor-Related, Administrative and Business Support Services, and All Other: Labor-related Services) is 66.381 percent, as shown in Table 1 above. The portion of Capital-
  
  related cost that is influenced by the local labor market is estimated to be 46 percent, which is the same percentage that was applied to the FY 2002-based RPL market basket. Since the relative importance for Capital-Related Costs is 7.825 percent of the FY 2008-based RPL market basket in FY 2013, we take 46 percent of 7.825 percent to determine the labor-related share of Capital-related cost for FY 2013. The result is 3.600 percent, which we add to 66.381 percent for the operating cost amount to determine the total labor-related share for FY 2013. Therefore, the labor-related share for the IPF PPS in FY 2013 is 69.981 percent. This labor-related share is determined using the same methodology as employed in calculating all previous IPF labor-related shares (69 FR 66952). The wage index and the labor-related share are reflected in budget neutrality adjustments.
Updates to the IPF PPS for FY Beginning October 1, 2012

The IPF PPS is based on a standardized Federal per diem base rate calculated from the IPF average per diem costs and adjusted for budget-

neutrality in the implementation year. The Federal per diem base rate is used as the standard payment per day under the IPF PPS and is adjusted by the patient- and facility-level adjustments that are applicable to the IPF stay. A detailed explanation of how we calculated the average per diem cost appears in the November 2004 IPF PPS final rule (69 FR 66926).

Page 47229
1. Determining the Standardized Budget-Neutral Federal Per Diem Base Rate
  
  Section 124(a)(1) of the BBRA required that we implement the IPF PPS in a budget neutral manner. In other words, the amount of total payments under the IPF PPS, including any payment adjustments, must be projected to be equal to the amount of total payments that would have been made if the IPF PPS were not implemented. Therefore, we calculated the budget-neutrality factor by setting the total estimated IPF PPS payments to be equal to the total estimated payments that would have been made under the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) (Pub. L. 97-248) methodology had the IPF PPS not been implemented.
  
  Under the IPF PPS methodology, we calculated the final Federal per diem base rate to be budget neutral during the IPF PPS implementation period (that is, the 18-month period from January 1, 2005 through June 30, 2006) using a July 1 update cycle. We updated the average cost per day to the midpoint of the IPF PPS implementation period (that is, October 1, 2005), and this amount was used in the payment model to establish the budget-neutrality adjustment.
  
  A step-by-step description of the methodology used to estimate payments under the TEFRA payment system appears in the November 2004 IPF PPS final rule (69 FR 66926).
  
  1. Standardization of the Federal Per Diem Base Rate and Electroconvulsive Therapy (ECT) Rate
  
  In the November 2004 IPF PPS final rule, we describe how we standardized the IPF PPS Federal per diem base rate to account for the overall positive effects of the IPF PPS payment adjustment factors. To standardize the IPF PPS payments, we compared the IPF PPS payment amounts calculated from the FY 2002 Medicare Provider Analysis and Review (MedPAR) file to the projected TEFRA payments from the FY 2002 cost report file updated to the midpoint of the IPF PPS implementation period (that is, October 2005). The standardization factor was calculated by dividing total estimated payments under the TEFRA payment system by estimated payments under the IPF PPS. The standardization factor was calculated to be 0.8367.
  
  As described in detail in the May 2006 IPF PPS final rule (71 FR 27045), in reviewing the methodology used to simulate the IPF PPS payments used for the November 2004 IPF PPS final rule, we discovered that due to a computer code error, total IPF PPS payments were underestimated by about 1.36 percent. Since the IPF PPS payment total should have been larger than the estimated figure, the standardization factor should have been smaller (0.8254 vs. 0.8367). In turn, the Federal per diem base rate and the ECT rate should have been reduced by 0.8254 instead of 0.8367.
  
  To resolve this issue, in RY 2007, we amended the Federal per diem base rate and the ECT payment rate prospectively. Using the standardization factor of 0.8254, the average cost per day was effectively reduced by 17.46 percent (100 percent minus 82.54 percent = 17.46 percent).
  
  2. Calculation of the Budget Neutrality Adjustment
  
  To compute the budget neutrality adjustment for the IPF PPS, we separately identified each component of the adjustment, that is, the outlier adjustment, stop-loss adjustment, and behavioral offset.
  
  A complete discussion of how we calculate each component of the budget neutrality adjustment appears in the November 2004 IPF PPS final rule (69 FR 66932 through 66933) and in the May 2006 IPF PPS final rule (71 FR 27044 through 27046).
  
  a. Outlier Adjustment
  
  Since the IPF PPS payment amount for each IPF includes applicable outlier amounts, we reduced the standardized Federal per diem base rate to account for aggregate IPF PPS payments estimated to be made as outlier payments. The outlier adjustment was calculated to be 2 percent. As a result, the standardized Federal per diem base rate was reduced by 2 percent to account for projected outlier payments.
  
  b. Stop-Loss Provision Adjustment
  
  As explained in the November 2004 IPF PPS final rule, we provided a stop-loss payment during the transition from cost-based reimbursement to the per diem payment system to ensure that an IPF's total PPS payments were no less than a minimum percentage of their TEFRA payment, had the IPF PPS not been implemented. We reduced the standardized Federal per diem base rate by the percentage of aggregate IPF PPS payments estimated to be made for stop-loss payments. As a result, the standardized Federal per diem base rate was reduced by 0.39 percent to account for stop-loss payments. Since the transition was completed in RY 2009, the stop-loss provision is no longer applicable, and for cost reporting periods beginning on or after January 1, 2008, IPFs were paid 100 percent PPS.
  
  c. Behavioral Offset
  
  As explained in the November 2004 IPF PPS final rule, implementation of the IPF PPS may result in certain changes in IPF practices, especially with respect to coding for comorbid medical conditions. As a result, Medicare may make higher payments than assumed in our calculations. Accounting for these effects through an adjustment is commonly known as a behavioral offset.
  
  Based on accepted actuarial practices and consistent with the assumptions made in other PPSs, we assumed in determining the behavioral offset that IPFs would regain 15 percent of potential ``losses'' and augment payment increases by 5 percent. We applied this actuarial assumption, which is based on our historical experience with new payment systems, to the estimated ``losses'' and ``gains'' among the IPFs. The behavioral offset for the IPF PPS was calculated to be 2.66 percent. As a result, we reduced the standardized Federal per diem base rate by 2.66 percent to account for behavioral changes. As indicated in the November 2004 IPF PPS final rule, we do not plan to change adjustment factors or projections until we analyze IPF PPS data.
  
  If we find that an adjustment is warranted, the percent difference may be applied prospectively to the established PPS rates to ensure the rates accurately reflect the payment level intended by the statute. In conducting this analysis, we will be interested in the extent to which improved coding of patients' principal and other diagnoses, which may not reflect real increases in underlying resource demands, has occurred under the PPS.
2. Update of the Federal Per Diem Base Rate and Electroconvulsive Therapy Rate
  
  As described in the November 2004 IPF PPS final rule (69 FR 66931), the average per diem cost was updated to the midpoint of the implementation year. This updated average per diem cost of $724.43 was reduced by--(1) 17.46 percent to account for standardization to projected TEFRA payments for the implementation period; (2) 2 percent to account for outlier payments; (3) 0.39 percent to account for stop-
  
  loss payments; and (4) 2.66 percent to account for the behavioral offset. The Federal per diem base rate in the implementation year was $575.95. The increase in the per diem base rate for RY 2009 included the 0.39 percent increase due to the removal of the stop-loss provision. We indicated in the November 2004 IPF PPS final rule
  
  Page 47230
  
  (69 FR 66932) that we would remove this 0.39 percent reduction to the Federal per diem base rate after the transition. As discussed in section IV.D.2. of the May 2008 IPF PPS notice, we increased the Federal per diem base rate and the ECT base rate by 0.39 percent in RY 2009. Therefore for RY 2009 and beyond, the stop-loss provision has ended and is no longer a part of budget neutrality.
  
  In accordance with section 1886(s)(2)(A)(ii) of the Act, which requires the application of an ``other adjustment,'' described in section 1886(s)(3) of the Act (specifically, section 1886(s)(3)(B)) for RYs 2013 and 2014 that reduces the update to the IPF PPS base rate for the FY beginning in Calendar Year (CY) 2012, we are adjusting the IPF PPS update by a 0.1 percentage point reduction for FY 2013. In addition, in accordance with section 1886(s)(2)(A)(i) of the Act, which requires the application of the productivity adjustment that reduces the update to the IPF PPS base rate for the FY beginning in CY 2012, we are adjusting the IPF PPS update by a 0.7 percentage point reduction for FY 2013.
  
  For this notice, we are applying the 2008-based RPL market basket increase for FY 2013 of 2.7 percent, as adjusted by the ``other adjustment'' of minus 0.1 percentage point, the productivity adjustment of minus 0.7 percentage point, and the wage index budget neutrality factor of 1.0007 to the RY 2012 Federal per diem base rate of $685.01, yielding a Federal per diem base rate of $698.51 for FY 2013. Similarly, we are applying the market basket increase, as adjusted by the ``other adjustment,'' the productivity adjustment, and the wage index budget neutrality factor to the RY 2012 ECT base rate, yielding an ECT base rate of $300.72 for FY 2013.
Update of the IPF PPS Adjustment Factors
1. Overview of the IPF PPS Adjustment Factors
  
  The IPF PPS payment adjustments were derived from a regression analysis of 100 percent of the FY 2002 MedPAR data file, which contained 483,038 cases. For this notice, we used the same results of the regression analysis used to implement the November 2004 IPF PPS final rule. For a more detailed description of the data file used for the regression analysis, see the November 2004 IPF PPS final rule (69 FR 66935 through 66936). While we have since used more recent claims data to set the fixed dollar loss threshold amount, we used the same results of this regression analysis to update the IPF PPS for RY 2012 and for FY 2013. Now that we are approximately 7 years into the IPF PPS, we believe that we have enough data to begin looking at the process of refining the IPF PPS as appropriate. We expect that in future rulemaking, we may propose potential refinements to the system.
  
  As we stated previously, we do not plan to update the regression analysis until we are able to analyze IPF PPS claims and cost report data. However, we continue to monitor claims and payment data independently from cost report data to assess issues, to determine whether changes in case-mix or payment shifts have occurred among freestanding governmental, non-profit and private psychiatric hospitals, and psychiatric units of general hospitals, and CAHs and other issues of importance to IPFs.
2. Patient-Level Adjustments
  
  In the May 2011 IPF PPS final rule (76 FR 26440 through 26453), we announced payment adjustments for the following patient-level characteristics: Medicare Severity diagnosis related groups (MS-DRGs) assignment of the patient's principal diagnosis, selected comorbidities, patient age, and the variable per diem adjustments.
  
  1. Adjustment for MS-DRG Assignment
  
  The IPF PPS includes payment adjustments for the psychiatric DRG assigned to the claim based on each patient's principal diagnosis. The IPF PPS recognizes the MS-DRGs. The DRG adjustment factors were expressed relative to the most frequently reported psychiatric DRG in FY 2002, that is, DRG 430 (psychoses). The coefficient values and adjustment factors were derived from the regression analysis.
  
  In accordance with Sec. 412.27(a), payment under the IPF PPS is conditioned on IPFs admitting ``only patients whose admission to the unit is required for active treatment, of an intensity that can be provided appropriately only in an inpatient hospital setting, of a psychiatric principal diagnosis that is listed in Chapter Five (``Mental Disorders'') of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)'' or in the Fourth Edition, Text Revision of the American Psychiatric Association's Diagnostic and Statistical Manual, (DSM-IV-TR). IPF claims with a principal diagnosis included in Chapter Five of the ICD-9-CM or the DSM-IV-TR are paid the Federal per diem base rate under the IPF PPS and all other applicable adjustments, including any applicable DRG adjustment. Psychiatric principal diagnoses that do not group to one of the designated DRGs will still receive the Federal per diem base rate and all other applicable adjustments, but the payment will not include a DRG adjustment.
  
  The Standards for Electronic Transaction final rule published in the Federal Register on August 17, 2000 (65 FR 50312), adopted the ICD-
  
  9-CM as the designated code set for reporting diseases, injuries, impairments, other health related problems, their manifestations, and causes of injury, disease, impairment, or other health related problems. Therefore, we use the ICD-9-CM as the designated code set for the IPF PPS.
  
  We believe that it is important to maintain the same diagnostic coding and DRG classification for IPFs that are used under the IPPS for providing psychiatric care. Therefore, when the IPF PPS was implemented for cost reporting periods beginning on or after January 1, 2005, we adopted the same diagnostic code set and DRG patient classification system (that is, the CMS DRGs) that were utilized at the time under the hospital inpatient IPPS. Since the inception of the IPF PPS, the DRGs used as the patient classification system under the IPF PPS have corresponded exactly with the CMS DRGs applicable under the IPPS for acute care hospitals.
  
  Every year, changes to the ICD-9-CM coding system are addressed in the IPPS proposed and final rules. The changes to the codes are effective October 1 of each year and must be used by acute care hospitals as well as other providers to report diagnostic and procedure information. The IPF PPS has always incorporated ICD-9-CM coding changes made in the annual IPPS update. We publish coding changes in a Transmittal/Change Request, similar to how coding changes are announced by the IPPS and LTCH PPS. Those ICD-9-CM coding changes are also published in the following IPF PPS FY update, in either the IPF PPS proposed and final rules, or in an IPF PPS update notice.
  
  In the May 2008 IPF PPS notice (73 FR 25709), we discussed CMS' effort to better recognize resource use and the severity of illness among patients. CMS adopted the new MS-DRGs for the IPPS in the FY 2008 IPPS final rule with comment period (72 FR 47130). A crosswalk, to reflect changes that were made to the DRGs under the IPF PPS to the new MS-DRGs was provided (73 FR 25716). We believe by better accounting for patients' severity of illness in Medicare payment rates, the MS-DRGs encourage hospitals to improve their coding and documentation of patient
  
  Page 47231
  
  diagnoses. The MS-DRGs, which are based on the IPPS MS-DRGs, represent a significant increase in the number of DRGs (from 538 to 745, an increase of 207). For a full description of the development and implementation of the MS-DRGs, see the FY 2008 IPPS final rule with comment period (72 FR 47141 through 47175).
  
  All of the ICD-9-CM coding changes are reflected in the FY 2013 GROUPER, Version 30.0, effective for IPPS discharges occurring on or after October 1, 2012 through September 30, 2013. The GROUPER Version 30.0 software package assigns each case to an MS-DRG on the basis of the diagnosis and procedure codes and demographic information (that is, age, sex, and discharge status). The Medicare Code Editor (MCE) 30.0 uses the new ICD-9-CM codes to validate coding for IPPS discharges on or after October 1, 2012. For additional information on the GROUPER Version 30.0 and MCE 30.0, see Transmittal 2289 (Change Request 7506), dated August 26, 2011. The IPF PPS has always used the same GROUPER and Code Editor as the IPPS. Therefore, the ICD-9-CM changes, which were reflected in the GROUPER Version 30.0 and MCE 30.0 on October 1, 2012, also became effective for the IPF PPS for discharges occurring on or after October 1, 2012.
  
  The impact of the new MS-DRGs on the IPF PPS was negligible. Mapping to the MS-DRGs resulted in the current 17 MS-DRGs, instead of the original 15, for which the IPF PPS provides an adjustment. Although the code set is updated, the same associated adjustment factors apply now that have been in place since implementation of the IPF PPS, with one exception that is unrelated to the update to the codes. When DRGs 521 and 522 were consolidated into MS-DRG 895, we carried over the adjustment factor of 1.02 from DRG 521 to the newly consolidated MS-
  
  DRG. This was done to reflect the higher claims volume under DRG 521, with more than eight times the number of claims than billed under DRG 522. For a detailed description of the mapping changes from the original DRG adjustment categories to the current MS-DRG adjustment categories, we refer readers to the May 2008 IPF PPS notice (73 FR 25714).
  
  The official version of the ICD-9-CM is available on CD-ROM from the U.S. Government Printing Office. The FY 2012 version can be ordered by contacting the Superintendent of Documents, U.S. Government Printing Office, Department 50, Washington, DC 20402-9329, telephone number (202) 512-1800. Questions concerning the ICD-9-CM should be directed to Patricia E. Brooks, Co-Chairperson, ICD-9-CM Coordination and Maintenance Committee, CMS, Center for Medicare Management, Hospital and Ambulatory Policy Group, Division of Acute Care, Mailstop C4-08-06, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. The Web site for the CD-ROM which contains the complete official version of the International Classification of Diseases, Ninth Revision, Clinical Modification is located at: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/CDROM.html.
  
  Further information concerning the official version of the ICD-9-CM can be found on the IPPS Web site at: http://cms.hhs.gov/medicare/coding/icd9providerdiagnosticcodes/addendum.html.
  
  The MS-IPF-DRG adjustment factors (as shown in Table 2) will continue to be paid for discharges occurring in FY 2013.
  
  TABLE 2--FY 2013 Current MS-IPF-DRGS Applicable for the Principal Diagnosis Adjustment
  
  ----------------------------------------------------------------------------------------------------------------
  
  Adjustment
  
  MS-DRG MS-DRG descriptions factor
  
  ----------------------------------------------------------------------------------------------------------------
  
  056........................................... Degenerative nervous system disorders w MCC..... 1.05
  
  057........................................... Degenerative nervous system disorders w/o MCC... 1.05
  
  080........................................... Nontraumatic stupor & coma w MCC................ 1.07
  
  081........................................... Nontraumatic stupor & coma w/o MCC.............. 1.07
  
  876........................................... O.R. procedure w principal diagnoses of mental 1.22
  
  illness.
  
  880........................................... Acute adjustment reaction & psychosocial 1.05
  
  dysfunction.
  
  881........................................... Depressive neuroses............................. 0.99
  
  882........................................... Neuroses except depressive...................... 1.02
  
  883........................................... Disorders of personality & impulse control...... 1.02
  
  884........................................... Organic disturbances & mental retardation....... 1.03
  
  885........................................... Psychoses....................................... 1.00
  
  886........................................... Behavioral & developmental disorders............ 0.99
  
  887........................................... Other mental disorder diagnoses................. 0.92
  
  894........................................... Alcohol/drug abuse or dependence, left AMA...... 0.97
  
  895........................................... Alcohol/drug abuse or dependence w 1.02
  
  rehabilitation therapy.
  
  896........................................... Alcohol/drug abuse or dependence w/o 0.88
  
  rehabilitation therapy w MCC.
  
  897........................................... Alcohol/drug abuse or dependence w/o 0.88
  
  rehabilitation therapy w/o MCC.
  
  ----------------------------------------------------------------------------------------------------------------
  
  2. Payment for Comorbid Conditions
  
  The intent of the comorbidity adjustments is to recognize the increased costs associated with comorbid conditions by providing additional payments for certain concurrent medical or psychiatric conditions that are expensive to treat. In the May 2011 IPF PPS final rule (76 FR 26451 through 26452), we explained that the IPF PPS includes 17 comorbidity categories and identified the new, revised, and deleted ICD-9-CM diagnosis codes that generate a comorbid condition payment adjustment under the IPF PPS for RY 2012 (76 FR 26451).
  
  Comorbidities are specific patient conditions that are secondary to the patient's principal diagnosis and that require treatment during the stay. Diagnoses that relate to an earlier episode of care and have no bearing on the current hospital stay are excluded and must not be reported on IPF claims. Comorbid conditions must exist at the time of admission or develop subsequently, and affect the treatment received, length of stay (LOS), or both treatment and LOS.
  
  For each claim, an IPF may receive only one comorbidity adjustment within a comorbidity category, but it may receive an adjustment for more than one comorbidity category. Billing instructions require that IPFs must enter
  
  Page 47232
  
  the full ICD-9-CM codes for up to 8 additional diagnoses if they co-
  
  exist at the time of admission or develop subsequently and impact the treatment provided.
  
  The comorbidity adjustments were determined based on the regression analysis using the diagnoses reported by IPFs in FY 2002. The principal diagnoses were used to establish the DRG adjustments and were not accounted for in establishing the comorbidity category adjustments, except where ICD-9-CM ``code first'' instructions apply. As we explained in the May 2011 IPF PPS final rule (76 FR 265451), the code first rule applies when a condition has both an underlying etiology and a manifestation due to the underlying etiology. For these conditions, the ICD-9-CM has a coding convention that requires the underlying conditions to be sequenced first followed by the manifestation. Whenever a combination exists, there is a ``use additional code'' note at the etiology code and a code first note at the manifestation code.
  
  As discussed in the MS-DRG section, it is our policy to maintain the same diagnostic coding set for IPFs that is used under the IPPS for providing the same psychiatric care.
  
  For FY 2013, we are applying the seventeen comorbidity categories for which we are providing an adjustment, their respective codes, and their respective adjustment factors in Table 3 below.
  
  Table 3--FY 2013 Diagnosis Codes and Adjustment Factors for Comorbidity Categories
  
  ----------------------------------------------------------------------------------------------------------------
  
  Adjustment
  
  Description of comorbidity Diagnoses codes factor
  
  ----------------------------------------------------------------------------------------------------------------
  
  Developmental Disabilities.................... 317, 3180, 3181, 3182, and 319.................. 1.04
  
  Coagulation Factor Deficits................... 2860 through 2864............................... 1.13
  
  Tracheostomy.................................. 51900 through 51909 and V440.................... 1.06
  
  Renal Failure, Acute.......................... 5845 through 5849, 63630, 63631, 63632, 63730, 1.11
  
  63731, 63732, 6383, 6393, 66932, 66934, 9585.
  
  Renal Failure, Chronic........................ 40301, 40311, 40391, 40402, 40412, 40413, 40492, 1.11
  
  40493, 5853, 5854, 5855, 5856, 5859,586, V4511,
  
  V4512, V560, V561, and V562.
  
  Oncology Treatment............................ 1400 through 2399 with a radiation therapy code 1.07
  
  92.21-92.29 or chemotherapy code 99.25.
  
  Uncontrolled Diabetes-Mellitus with or without 25002, 25003, 25012, 25013, 25022, 25023, 25032, 1.05
  
  complications. 25033, 25042, 25043, 25052, 25053, 25062,
  
  25063, 25072, 25073, 25082, 25083, 25092, and
  
  25093.
  
  Severe Protein Calorie Malnutrition........... 260 through 262................................. 1.13
  
  Eating and Conduct Disorders.................. 3071, 30750, 31203, 31233, and 31234............ 1.12
  
  Infectious Disease............................ 01000 through 04110, 042, 04500 through 05319, 1.07
  
  05440 through 05449, 0550 through 0770, 0782
  
  through 07889, and 07950 through 07959.
  
  Drug and/or Alcohol Induced Mental Disorders.. 2910, 2920, 29212, 2922, 30300, and 30400....... 1.03
  
  Cardiac Conditions............................ 3910, 3911, 3912, 40201, 40403, 4160, 4210, 1.11
  
  4211, and 4219.
  
  Gangrene...................................... 44024 and 7854.................................. 1.10
  
  Chronic Obstructive Pulmonary Disease......... 49121, 4941, 5100, 51883, 51884, V4611, V4612, 1.12
  
  V4613 and V4614.
  
  Artificial Openings--Digestive and Urinary.... 56960 through 56969, 9975, and V441 through V446 1.08
  
  Severe Musculoskeletal and Connective Tissue 6960, 7100, 73000 through 73009, 73010 through 1.09
  
  Diseases. 73019, and 73020 through 73029.
  
  Poisoning..................................... 96500 through 96509, 9654, 9670 through 9699, 1.11
  
  9770, 9800 through 9809, 9830 through 9839,
  
  986, 9890 through 9897.
  
  ----------------------------------------------------------------------------------------------------------------
  
  3. Patient Age Adjustments
  
  As explained in the November 2004 IPF PPS final rule (69 FR 66922), we analyzed the impact of age on per diem cost by examining the age variable (that is, the range of ages) for payment adjustments.
  
  In general, we found that the cost per day increases with age. The older age groups are more costly than the under 45 age group, the differences in per diem cost increase for each successive age group, and the differences are statistically significant.
  
  We do not plan to update the regression analysis until we are able to analyze IPF PPS data. Therefore, for FY 2013, we are continuing to use the patient age adjustments currently in effect as shown in Table 4 below.
  
  TABLE 4--Age Groupings and Adjustment Factors
  
  ------------------------------------------------------------------------
  
  Adjustment
  
  Age factor
  
  ------------------------------------------------------------------------
  
  Under 45................................................ 1.00
  
  45 and under 50......................................... 1.01
  
  50 and under 55......................................... 1.02
  
  55 and under 60......................................... 1.04
  
  60 and under 65......................................... 1.07
  
  65 and under 70......................................... 1.10
  
  70 and under 75......................................... 1.13
  
  75 and under 80......................................... 1.15
  
  80 and over............................................. 1.17
  
  ------------------------------------------------------------------------
  
  4. Variable per Diem Adjustments
  
  We explained in the November 2004 IPF PPS final rule (69 FR 66946) that the regression analysis indicated that per diem cost declines as the LOS increases. The variable per diem adjustments to the Federal per diem base rate account for ancillary and administrative costs that occur disproportionately in the first days after admission to an IPF.
  
  We used a regression analysis to estimate the average differences in per diem cost among stays of different lengths. As a result of this analysis, we established variable per diem adjustments that begin on day 1 and decline gradually until day 21 of a patient's stay. For day 22 and thereafter, the variable per diem adjustment remains the same each day for the remainder of the stay. However, the adjustment applied to day 1 depends upon whether the IPF has a qualifying ED. If an IPF has a qualifying ED, it receives a 1.31 adjustment factor for day 1 of each stay. If an IPF does not have a qualifying ED, it receives a 1.19 adjustment factor for day 1 of the stay. The ED adjustment is explained in more detail in section VII.C.5 of this notice.
  
  Page 47233
  
  For FY 2013, we are continuing to use the variable per diem adjustment factors currently in effect as shown in Table 5 below. A complete discussion of the variable per diem adjustments appears in the November 2004 IPF PPS final rule (69 FR 66946).
  
  Table 5--Variable per Diem Adjustments
  
  ------------------------------------------------------------------------
  
  Adjustment
  
  Day-of-stay factor
  
  ------------------------------------------------------------------------
  
  Day 1--IPF Without a Qualifying ED...................... 1.19
  
  Day 1--IPF With a Qualifying ED......................... 1.31
  
  Day 2................................................... 1.12
  
  Day 3................................................... 1.08
  
  Day 4................................................... 1.05
  
  Day 5................................................... 1.04
  
  Day 6................................................... 1.02
  
  Day 7................................................... 1.01
  
  Day 8................................................... 1.01
  
  Day 9................................................... 1.00
  
  Day 10.................................................. 1.00
  
  Day 11.................................................. 0.99
  
  Day 12.................................................. 0.99
  
  Day 13.................................................. 0.99
  
  Day 14.................................................. 0.99
  
  Day 15.................................................. 0.98
  
  Day 16.................................................. 0.97
  
  Day 17.................................................. 0.97
  
  Day 18.................................................. 0.96
  
  Day 19.................................................. 0.95
  
  Day 20.................................................. 0.95
  
  Day 21.................................................. 0.95
  
  After Day 21............................................ 0.92
  
  ------------------------------------------------------------------------
3. Facility-Level Adjustments
  
  The IPF PPS includes facility-level adjustments for the wage index, IPFs located in rural areas, teaching IPFs, cost of living adjustments for IPFs located in Alaska and Hawaii, and IPFs with a qualifying ED.
  
  1. Wage Index Adjustment
  
  a. Background
  
  As discussed in the May 2006 IPF PPS final rule and in the May 2008 and May 2009 IPF PPS notices, in providing an adjustment for geographic wage levels, the labor-related portion of an IPF's payment is adjusted using an appropriate wage index. Currently, an IPF's geographic wage index value is determined based on the actual location of the IPF in an urban or rural area as defined in Sec. 412.64(b)(1)(ii)(A) through (C).
  
  b. Wage Index for FY 2013
  
  Since the inception of the IPF PPS, we have used hospital wage data in developing a wage index to be applied to IPFs. We are continuing that practice for FY 2013. We apply the wage index adjustment to the labor-related portion of the Federal rate, which is 69.981 percent. This percentage reflects the labor-related relative importance of the FY 2008-based RPL market basket for FY 2013 (see section V.C. of this notice). The IPF PPS uses the pre-floor, pre-reclassified hospital wage index. Changes to the wage index are made in a budget neutral manner so that updates do not increase expenditures.
  
  For FY 2013, we are applying the most recent hospital wage index (that is, the FY 2012 pre-floor, pre-reclassified hospital wage index because this is the most appropriate index as it best reflects the variation in local labor costs of IPFs in the various geographic areas) using the most recent hospital wage data (that is, data from hospital cost reports for the cost reporting period beginning during FY 2008), and applying an adjustment in accordance with our budget neutrality policy. This policy requires us to estimate the total amount of IPF PPS payments in RY 2012 using the applicable wage index value divided by the total estimated IPF PPS payments in FY 2013 using the most recent wage index. The estimated payments are based on FY 2011 IPF claims, inflated to the appropriate FY. This quotient is the wage index budget neutrality factor, and it is applied in the update of the Federal per diem base rate for FY 2013 in addition to the market basket described in section VI.B. of this notice. The wage index budget neutrality factor for FY 2013 is 1.0007.
  
  The wage index applicable for FY 2013 appears in Table 1 and Table 2 in Addendum B of this notice. As explained in the May 2006 IPF PPS final rule for RY 2007 (71 FR 27061), the IPF PPS applies the hospital wage index without a hold-harmless policy, and without an out-commuting adjustment or out-migration adjustment because the statutory authority for these policies applies only to the IPPS.
  
  Also in the May 2006 IPF PPS final rule for RY 2007 (71 FR 27061), we adopted the changes discussed in the Office of Management and Budget (OMB) Bulletin No. 03-04 (June 6, 2003), which announced revised definitions for Metropolitan Statistical Areas (MSAs), and the creation of Micropolitan Statistical Areas and Combined Statistical Areas. In adopting the OMB Core-Based Statistical Area (CBSA) geographic designations, since the IPF PPS was already in a transition period from TEFRA payments to PPS payments, we did not provide a separate transition for the CBSA-based wage index.
  
  As was the case in RY 2012, for FY 2013, we will continue to use the CBSA-based wage index values as presented in Tables 1 and 2 in Addendum B of this notice. A complete discussion of the CBSA labor market definitions appears in the May 2006 IPF PPS final rule (71 FR 27061 through 27067).
  
  In summary, for FY 2013, we will use the FY 2012 wage index data (collected from cost reports submitted by hospitals for cost reporting periods beginning during FY 2008) to adjust IPF PPS payments beginning October 1, 2012.
  
  c. OMB Bulletins
  
  OMB publishes bulletins regarding CBSA changes, including changes to CBSA numbers and titles. In the May 2008 IPF PPS notice, we incorporated the CBSA nomenclature changes published in the most recent OMB bulletin that applies to the hospital wage data used to determine the current IPF PPS wage index (73 FR 25721). We will continue to do the same for all the OMB CBSA nomenclature changes in future IPF PPS rules and notices, as necessary. The OMB bulletins may be accessed online at http://www.whitehouse.gov/omb/bulletins/index.html.
  
  2. Adjustment for Rural Location
  
  In the November 2004 IPF PPS final rule, we provided a 17 percent payment adjustment for IPFs located in a rural area. This adjustment was based on the regression analysis, which indicated that the per diem cost of rural facilities was 17 percent higher than that of urban facilities after accounting for the influence of the other variables included in the regression. For FY 2013, we are applying a 17 percent payment adjustment for IPFs located in a rural area as defined at Sec. 412.64(b)(1)(ii)(C). As stated in the November 2004 IPF PPS final rule, we do not intend to update the adjustment factors derived from the regression analysis until we are able to analyze IPF PPS data. A complete discussion of the adjustment for rural locations appears in the November 2004 IPF PPS final rule (69 FR 66954).
  
  3. Teaching Adjustment
  
  In the November 2004 IPF PPS final rule, we implemented regulations at Sec. 412.424(d)(1)(iii) to establish a facility-level adjustment for IPFs that are, or are part of, teaching hospitals. The teaching adjustment accounts for the higher indirect operating costs experienced by hospitals that participate in graduate medical education (GME) programs. The payment adjustments are made based on the number of full-
  
  time equivalent (FTE) interns and residents training in the IPF and the IPF's average daily census.
  
  Medicare makes direct GME payments (for direct costs such as resident and teaching physician salaries, and other
  
  Page 47234
  
  direct teaching costs) to all teaching hospitals including those paid under a PPS, and those paid under the TEFRA rate-of-increase limits. These direct GME payments are made separately from payments for hospital operating costs and are not part of the PPSs. The direct GME payments do not address the estimated higher indirect operating costs teaching hospitals may face.
  
  For teaching hospitals paid under the TEFRA rate-of-increase limits, Medicare does not make separate payments for indirect medical education costs because payments to these hospitals are based on the hospitals' reasonable costs which already include these higher indirect costs that may be associated with teaching programs.
  
  The results of the regression analysis of FY 2002 IPF data established the basis for the payment adjustments included in the November 2004 IPF PPS final rule. The results showed that the indirect teaching cost variable is significant in explaining the higher costs of IPFs that have teaching programs. We calculated the teaching adjustment based on the IPF's ``teaching variable,'' which is one plus the ratio of the number of FTE residents training in the IPF (subject to limitations described below) to the IPF's average daily census (ADC).
  
  We established the teaching adjustment in a manner that limited the incentives for IPFs to add FTE residents for the purpose of increasing their teaching adjustment. We imposed a cap on the number of FTE residents that may be counted for purposes of calculating the teaching adjustment. The cap limits the number of FTE residents that teaching IPFs may count for the purpose of calculating the IPF PPS teaching adjustment, not the number of residents teaching institutions can hire or train. We calculated the number of FTE residents that trained in the IPF during a ``base year'' and used that FTE resident number as the cap. An IPF's FTE resident cap is ultimately determined based on the final settlement of the IPF's most recent cost report filed before November 15, 2004 (that is, the publication date of the IPF PPS final rule).
  
  In the regression analysis, the logarithm of the teaching variable had a coefficient value of 0.5150. We converted this cost effect to a teaching payment adjustment by treating the regression coefficient as an exponent and raising the teaching variable to a power equal to the coefficient value. We note that the coefficient value of 0.5150 was based on the regression analysis holding all other components of the payment system constant.
  
  As with other adjustment factors derived through the regression analysis, we do not plan to rerun the regression analysis until we analyze IPF PPS data. Therefore, in this notice, for FY 2013, we are retaining the coefficient value of 0.5150 for the teaching adjustment to the Federal per diem base rate.
  
  A complete discussion of how the teaching adjustment was calculated appears in the November 2004 IPF PPS final rule (69 FR 66954 through 66957) and the May 2008 IPF PPS notice (73 FR 25721).
  
  a. FTE Intern and Resident Cap Adjustment
  
  CMS had been asked to reconsider the original IPF teaching policy and permit a temporary increase in the FTE resident cap when an IPF increases the number of FTE residents it trains due to the acceptance of displaced residents (residents that are training in an IPF or a program before the IPF or program closed) when another IPF closes or closes its medical residency training program.
  
  To help us assess how many IPFs had been, or were expected to be adversely affected by their inability to adjust their caps under Sec. 412.424(d)(1) and under these situations, we specifically requested public comment from IPFs in the May 1, 2009 IPF PPS notice (74 FR 20376 through 20377). A summary of the comments and our response can be reviewed in the April 30, 2010 IPF PPS notice (75 FR 23106, 23117). All of the commenters recommended that CMS modify the IPF PPS teaching adjustment policy, supporting a policy change that would permit the IPF PPS residency cap to be temporarily adjusted when that IPF trains displaced residents due to closure of an IPF or closure of an IPF's medical residency training program(s). The commenters recommended a temporary resident cap adjustment policy similar to the policies applied in similar contexts for acute care hospitals.
  
  We agreed with the commenters that, when a hospital temporarily takes on residents because another hospital closes or discontinues its program, a temporary adjustment to the cap would be appropriate for rotation that occurs in an IPF setting (freestanding or units). In these situations, residents may have partially completed a medical residency training program at the hospital that has closed its training program and may be unable to complete their training at another hospital that is already training residents up to or in excess of its cap. We believe that it is appropriate to allow temporary adjustments to the FTE caps for an IPF that provides residency training to medical residents who have partially completed a residency training program at an IPF that closes or at an IPF that discontinues training residents in a residency training program(s) (also referred to as a ``closed'' program throughout this preamble). For this reason, we adopted the following temporary resident cap adjustment policies, similar to the temporary adjustments to the FTE cap used for acute care hospitals. We proposed and finalized that the cap adjustment would be temporary because it is resident specific and would only apply to the displaced resident(s) until the resident(s) completes training in that specialty. As under the IPPS policy for displaced residents, the IPF PPS temporary cap adjustment would apply only to residents that were still training at the IPF at the time the IPF closed or at the time the IPF ceased training residents in the residency training program(s). Residents who leave the IPF, for whatever reason, before the closure of the IPF hospital or medical residency training program would not be considered displaced residents for purposes of the IPF temporary cap adjustment policy. Similarly, as under the IPPS policy, medical students who match to a program at an IPF but the IPF or medical residency training program closes before the individual begins training at that IPF are also not considered displaced residents for purposes of the IPF temporary cap adjustments. For detailed information on these acute care hospital GME/IME payment policies, we refer the reader to the (66 FR 39899) August 1, 2001 final rule, (64 FR 41522) July 30, 1999 final rule, and (64 FR 24736) May 7, 1999 proposed rule. We note that although we adopted a policy under the IPF PPS that is consistent with the policy applicable under the IPPS, the actual caps under the two payment systems may not be commingled.
  
  b. Temporary Adjustment to the FTE Cap To Reflect Residents Added Due to Hospital Closure
  
  In the May 6, 2011 IPF PPS final rule, we indicated that we would allow an IPF to receive a temporary adjustment to the FTE cap to reflect residents added because of another IPF's closure. This adjustment is intended to account for medical residents who would have partially completed a medical residency training program at the hospital that has closed and may be unable to complete their training at another hospital because that hospital is already training residents up to or in excess of its cap. We made this change because IPFs have indicated a reluctance to accept additional residents from a closed IPF
  
  Page 47235
  
  without a temporary adjustment to their caps. For purposes of this policy on IPF closure, we adopted the IPPS definition of ``closure of a hospital'' in 42 CFR 413.79(h) to mean the IPF terminates its Medicare provider agreement as specified in 42 CFR 489.52. Therefore, we added a new Sec. 412.424(d)(1)(iii)(F)(1) to allow a temporary adjustment to an IPF's FTE cap to reflect residents added because of an IPF's closure on or after July 1, 2011, to be effective for cost reporting periods beginning on or after July 1, 2011. Under this policy, we allow an adjustment to an IPF's FTE cap if the IPF meets the following criteria: (1) The IPF is training displaced residents from an IPF that closed on or after July 1, 2011; and (2) the IPF that is training the displaced residents from the closed IPF submits a request for a temporary adjustment to its FTE cap to its Medicare contractor no later than 60 days after the hospital first begins training the displaced residents, and documents that the IPF is eligible for this temporary adjustment to its FTE cap by identifying the residents who have come from the closed IPF and have caused the IPF to exceed its cap, (or the IPF may already be over its cap), and specifies the length of time that the adjustment is needed. After the displaced residents leave the IPF's training program or complete their residency program, the IPF's cap would revert to its original level. This means that the temporary adjustment to the FTE cap would be available to the IPF only for the period of time necessary for the displaced residents to complete their training. Further, as under the IPPS policy, we also indicated that the total amount of temporary cap adjustment that can be distributed to all receiving hospitals cannot exceed the cap amount of the IPF that closed.
  
  c. Temporary Adjustment to FTE Cap to Reflect Residents Affected by Residency Program Closure
  
  In the May 6, 2011 final rule (76 FR 26455), we indicated that if an IPF that ceases training residents in a residency training program(s) agrees to temporarily reduce its FTE cap, we would allow another IPF to receive a temporary adjustment to its FTE cap to reflect residents added because of the closure of another IPF's residency training program. For purposes of this policy on closed residency programs, we adopted the IPPS definition of ``closure of a hospital residency training program'' to mean that the hospital ceases to offer training for residents in a particular approved medical residency training program as specified in Sec. 413.79(h). The methodology for adjusting the caps for the ``receiving IPF'' and the ``IPF that closed its program'' is described below.
  
  i. Receiving IPF
  
  We proposed and finalized that an IPF(s) may receive a temporary adjustment to its FTE cap to reflect residents added because of the closure of another IPF's residency training program for cost reporting periods beginning on or after July 1, 2011 if --
  
  The IPF is training additional residents from the residency training program of an IPF that closed its program on or after July 1, 2011.
  
  No later than 60 days after the IPF begins to train the residents, the IPF submits to its Medicare Contractor a request for a temporary adjustment to its FTE cap, documents that the IPF is eligible for this temporary adjustment by identifying the residents who have come from another IPF's closed program and have caused the IPF to exceed its cap, (or the IPF may already be in excess of its cap), specifies the length of time the adjustment is needed, and, submits to its Medicare contractor a copy of the FTE cap reduction statement by the IPF closing the residency training program.
  
  In general, the temporary adjustment criteria established for closed medical residency training programs at IPFs is similar to the criteria established for closed IPFs. More than one IPF may be eligible to apply for the temporary adjustment because residents from one closed program may complete their training at one IPF, or at several IPFs. Also, an IPF would be eligible for the temporary adjustment only to the extent that the displaced residents would cause the IPF to exceed its FTE cap.
  
  Finally, we proposed and finalized that IPFs meeting the proposed criteria would be eligible to receive temporary adjustments to their FTE caps for cost reporting periods beginning on or after July 1, 2011.
  
  ii. IPF That Closed Its Program
  
  We indicated that an IPF that agrees to train residents who have been displaced by the closure of another IPF's resident teaching program, may receive a temporary FTE cap adjustment only if the IPF that closed a program:
  
  Temporarily reduces its FTE cap by the number of FTE residents in each program year, training in the program at the time of the program's closure. The yearly reduction would be determined by deducting the number of those residents who would have been training in the program during the year of the closure, had the program not closed.
  
  No later than 60 days after the residents who were in the closed program begin training at another IPF, submits to its Medicare contractor a statement signed and dated by its representative that specifies that it agrees to the temporary reduction in its FTE cap to allow the IPF training the displaced residents to obtain a temporary adjustment to its cap; identifies the residents who were training at the time of the program's closure; identifies the IPFs to which the residents are transferring once the program closes; and specifies the reduction for the applicable program years.
  
  We proposed and finalized that the cap reduction for the IPF with the closed program would be based on the number of FTE residents in each program year who were in the program at the IPF at the time of the program's closure, and who begin training at another IPF.
  
  In summary, we added Sec. 412.424(d)(1)(iii)(F)(1) and Sec. 412.424(d)(1)(iii)(F)(2) to implement policies related to temporary adjustments to FTE caps to reflect residents added due to closure of an IPF or an IPFs medical residency training program respectfully.
  
  A complete discussion on the Temporary adjustment to the FTE cap to reflect residents added due to hospital closure and by residency program appears in the January 27, 2011 IPF PPS proposed rule (76 FR 5018 through 5020) and the May 6, 2011 IPF PPS final rule (76 FR 26453 through 26456).
  
  4. Cost of Living Adjustment for IPFs Located in Alaska and Hawaii
  
  The IPF PPS includes a payment adjustment for IPFs located in Alaska and Hawaii based upon the county in which the IPF is located. As we explained in the November 2004 IPF PPS final rule, the FY 2002 data demonstrated that IPFs in Alaska and Hawaii had per diem costs that were disproportionately higher than other IPFs. Other Medicare PPSs (for example, the IPPS and LTCH PPS) have adopted a cost of living adjustment (COLA) to account for the cost differential of care furnished in Alaska and Hawaii.
  
  We analyzed the effect of applying a COLA to payments for IPFs located in Alaska and Hawaii. The results of our analysis demonstrated that a COLA for IPFs located in Alaska and Hawaii would improve payment equity for these facilities. As a result of this analysis, we provided a COLA in the November 2004 IPF PPS final rule.
  
  A COLA adjustment for IPFs located in Alaska and Hawaii is made by
  
  Page 47236
  
  multiplying the nonlabor-related portion of the Federal per diem base rate by the applicable COLA factor based on the COLA area in which the IPF is located.
  
  The COLA factors are published on the Office of Personnel Management (OPM) Web site at (http://www.opm.gov/oca/cola/rates.asp).
  
  We note that the COLA areas for Alaska are not defined by county as are the COLA areas for Hawaii. In 5 CFR 591.207, the OPM established the following COLA areas:
  
  City of Anchorage, and 80-kilometer (50-mile) radius by road, as measured from the Federal courthouse;
  
  City of Fairbanks, and 80-kilometer (50-mile) radius by road, as measured from the Federal courthouse;
  
  City of Juneau, and 80-kilometer (50-mile) radius by road, as measured from the Federal courthouse;
  
  Rest of the State of Alaska.
  
  As previously stated in the November 2004 IPF PPS final rule, we update the COLA factors according to updates established by the OPM. Sections 1911 through 1919 of the Nonforeign Area Retirement Equity Assurance Act, as contained in subtitle B of title XIX of the National Defense Authorization Act (NDAA) for Fiscal Year 2010 (Pub. L. 111-84, October 28, 2009), transitions the Alaska and Hawaii COLAs to locality pay. Under section 1914 of Pubic Law 111-84, locality pay is being phased in over a 3-year period beginning in January 2010, with COLA rates frozen as of the date of enactment, October 28, 2009, and then proportionately reduced to reflect the phase-in of locality pay.
  
  When we published the proposed COLA adjustment factors in the January 2011 IPF proposed rule (76 FR 4998), we inadvertently selected the FY 2010 COLA rates. The FY 2010 COLA rates were reduced rates to account for the phase-in of locality pay. We did not intend to propose reduced COLA rates, and we do not believe it is appropriate to finalize the reduced COLAs that we showed in our January 2011 proposed rule. The 2009 COLA rates do not reflect the phase-in of locality pay. Therefore, we finalized the FY 2009 COLA rates, which are the same rates that were in effect for both RY 2010, through RY 2012. We plan to address COLA in the future refinement process in FY 2014. For FY 2013, IPFs located in Alaska and Hawaii will continue to receive the updated COLA factors based on the COLA area in which the IPF is located as shown in Table 6 below.
  
  Table 6--COLA Factors for Alaska and Hawaii IPFs
  
  ------------------------------------------------------------------------
  
  Cost of living
  
  Area adjustment
  
  factor
  
  ------------------------------------------------------------------------
  
  Alaska:
  
  City of Anchorage and 80-kilometer (50-mile) 1.23
  
  radius by road...................................
  
  City of Fairbanks and 80-kilometer (50-mile) 1.23
  
  radius by road...................................
  
  City of Juneau and 80-kilometer (50-mile) radius 1.23
  
  by road..........................................
  
  Rest of Alaska.................................... 1.25
  
  Hawaii:
  
  City and County of Honolulu....................... 1.25
  
  County of Hawaii.................................. 1.18
  
  County of Kauai................................... 1.25
  
  County of Maui and County of Kalawao.............. 1.25
  
  ------------------------------------------------------------------------
  
  (The above factors are based on data obtained from the U.S. Office of
  
  Personnel Management Web site at: http://www.opm.gov/oca/cola/rates.asp.).
  
  5. Adjustment for IPFs With a Qualifying Emergency Department (ED)
  
  Currently, the IPF PPS includes a facility-level adjustment for IPFs with qualifying EDs. We provide an adjustment to the Federal per diem base rate to account for the costs associated with maintaining a full-service ED. The adjustment is intended to account for ED costs incurred by a freestanding psychiatric hospital with a qualifying ED or a distinct part psychiatric unit of an acute hospital or a CAH for preadmission services otherwise payable under the Medicare Outpatient Prospective Payment System (OPPS) furnished to a beneficiary during the day immediately preceding the date of admission to the IPF (see Sec. 413.40(c)(2)) and the overhead cost of maintaining the ED. This payment is a facility-level adjustment that applies to all IPF admissions (with one exception described below), regardless of whether a particular patient receives preadmission services in the hospital's ED.
  
  The ED adjustment is incorporated into the variable per diem adjustment for the first day of each stay for IPFs with a qualifying ED. That is, IPFs with a qualifying ED receive an adjustment factor of 1.31 as the variable per diem adjustment for day 1 of each stay. If an IPF does not have a qualifying ED, it receives an adjustment factor of 1.19 as the variable per diem adjustment for day 1 of each patient stay.
  
  The ED adjustment is made on every qualifying claim except as described below. As specified in Sec. 412.424(d)(1)(v)(B), the ED adjustment is not made where a patient is discharged from an acute care hospital or CAH and admitted to the same hospital's or CAH's psychiatric unit. An ED adjustment is not made in this case because the costs associated with ED services are reflected in the DRG payment to the acute care hospital or through the reasonable cost payment made to the CAH. If we provided the ED adjustment in these cases, the hospital would be paid twice for the overhead costs of the ED, as stated in the November 2004 IPF PPS final rule (69 FR 66960).
  
  Therefore, when patients are discharged from an acute care hospital or CAH and admitted to the same hospital's or CAH's psychiatric unit, the IPF receives the 1.19 adjustment factor as the variable per diem adjustment for the first day of the patient's stay in the IPF.
  
  For FY 2013, we are retaining the 1.31 adjustment factor for IPFs with qualifying EDs. A complete discussion of the steps involved in the calculation of the ED adjustment factor appears in the November 2004 IPF PPS final rule (69 FR 66959 through 66960) and the May 2006 IPF PPS final rule (71 FR 27070 through 27072).
4. Other Payment Adjustments and Policies
  
  For FY 2013, the IPF PPS includes an outlier adjustment to promote access to IPF care for those patients who require expensive care and to limit the financial
  
  Page 47237
  
  risk of IPFs treating unusually costly patients. In this section, we also explain the reason for ending the stop-loss provision that was applicable during the transition period.
  
  1. Outlier Payments
  
  In the November 2004 IPF PPS final rule, we implemented regulations at Sec. 412.424(d)(3)(i) to provide a per-case payment for IPF stays that are extraordinarily costly. Providing additional payments to IPFs for extremely costly cases strongly improves the accuracy of the IPF PPS in determining resource costs at the patient and facility level. These additional payments reduce the financial losses that would otherwise be incurred in treating patients who require more costly care and, therefore, reduce the incentives for IPFs to under-serve these patients.
  
  We make outlier payments for discharges in which an IPF's estimated total cost for a case exceeds a fixed dollar loss threshold amount (multiplied by the IPF's facility-level adjustments) plus the Federal per diem payment amount for the case.
  
  In instances when the case qualifies for an outlier payment, we pay 80 percent of the difference between the estimated cost for the case and the adjusted threshold amount for days 1 through 9 of the stay (consistent with the median LOS for IPFs in FY 2002), and 60 percent of the difference for day 10 and thereafter. We established the 80 percent and 60 percent loss sharing ratios because we were concerned that a single ratio established at 80 percent (like other Medicare PPSs) might provide an incentive under the IPF per diem payment system to increase LOS in order to receive additional payments. After establishing the loss sharing ratios, we determined the current fixed dollar loss threshold amount of $7,340 through payment simulations designed to compute a dollar loss beyond which payments are estimated to meet the 2 percent outlier spending target.
  
  a. Update to the Outlier Fixed Dollar Loss Threshold Amount
  
  In accordance with the update methodology described in Sec. 412.428(d), we are updating the fixed dollar loss threshold amount used under the IPF PPS outlier policy. Based on the regression analysis and payment simulations used to develop the IPF PPS, we established a 2 percent outlier policy which strikes an appropriate balance between protecting IPFs from extraordinarily costly cases while ensuring the adequacy of the Federal per diem base rate for all other cases that are not outlier cases.
  
  We believe it is necessary to update the fixed dollar loss threshold amount because an analysis of the latest available data (that is, FY 2011 IPF claims) and rate increases indicate that adjusting the fixed dollar loss amount is necessary in order to maintain an outlier percentage that equals 2 percent of total estimated IPF PPS payments.
  
  In the May 2006 IPF PPS final rule (71 FR 27072), we describe the process by which we calculate the outlier fixed dollar loss threshold amount. We will continue to use this process for FY 2013. We begin by simulating aggregate payments with and without an outlier policy, and applying an iterative process to determine an outlier fixed dollar loss threshold amount that will result in estimated outlier payments being equal to 2 percent of total estimated payments under the simulation. Based on this process, using the FY 2011 claims data, we estimate that IPF outlier payments as a percentage of total estimated payments are approximately 3.1 percent in RY 2012. Thus, for this notice, we are updating the FY 2013 IPF outlier threshold amount to ensure that estimated FY 2013 outlier payments are approximately 2 percent of total estimated IPF payments. The outlier fixed dollar loss threshold amount of $7,340 for RY 2012 will be changed to $11,600 for FY 2013 to reduce estimated outlier payments and thereby maintain estimated outlier payments at 2 percent of total estimated aggregate IPF payments for FY 2013.
  
  b. Update to IPF Cost-to-Charge Ratio Ceilings
  
  As previously stated, under the IPF PPS, an outlier payment is made if an IPF's cost for a stay exceeds a fixed dollar loss threshold amount. In order to establish an IPF's cost for a particular case, we multiply the IPF's reported charges on the discharge bill by its overall cost-to-charge ratio (CCR). This approach to determining an IPF's cost is consistent with the approach used under the IPPS and other PPSs. In the June 2003 IPPS final rule (68 FR 34494), we implemented changes to the IPPS policy used to determine CCRs for acute care hospitals because we became aware that payment vulnerabilities resulted in inappropriate outlier payments. Under the IPPS, we established a statistical measure of accuracy for CCRs in order to ensure that aberrant CCR data did not result in inappropriate outlier payments.
  
  As we indicated in the November 2004 IPF PPS final rule, because we believe that the IPF outlier policy is susceptible to the same payment vulnerabilities as the IPPS, we adopted an approach to ensure the statistical accuracy of CCRs under the IPF PPS (69 FR 66961). Therefore, we adopted the following procedure in the November 2004 IPF PPS final rule:
  
  We calculated two national ceilings, one for IPFs located in rural areas and one for IPFs located in urban areas. We computed the ceilings by first calculating the national average and the standard deviation of the CCR for both urban and rural IPFs using the most recent CCRs entered in the CY 2012 Provider Specific File.
  
  To determine the rural and urban ceilings, we multiplied each of the standard deviations by 3 and added the result to the appropriate national CCR average (either rural or urban). The upper threshold CCR for IPFs in FY 2013 is 1.9155 for rural IPFs, and 1.7072 for urban IPFs, based on CBSA-based geographic designations. If an IPF's CCR is above the applicable ceiling, the ratio is considered statistically inaccurate and we assign the appropriate national (either rural or urban) median CCR to the IPF.
  
  We apply the national CCRs to the following situations:
  
  ++ New IPFs that have not yet submitted their first Medicare cost report.
  
  ++ IPFs whose overall CCR is in excess of 3 standard deviations above the corresponding national geometric mean (that is, above the ceiling).
  
  ++ Other IPFs for which the Medicare contractor obtains inaccurate or incomplete data with which to calculate a CCR.
  
  For new IPFs, we are using these national CCRs until the facility's actual CCR can be computed using the first tentatively or final settled cost report.
  
  We are not making any changes to the procedures for updating the CCR ceilings in FY 2013. However, we are updating the FY 2013 national median and ceiling CCRs for urban and rural IPFs based on the CCRs entered in the latest available IPF PPS Provider Specific File. Specifically, for FY 2013, and to be used in each of the three situations listed above, using the most recent CCRs entered in the CY 2012 Provider Specific File we estimate the national median CCR of 0.622 for rural IPFs and the national median CCR of 0.496 for urban IPFs. These calculations are based on the IPF's location (either urban or rural) using the CBSA-based geographic designations.
  
  A complete discussion regarding the national median CCRs appears in the November 2004 IPF PPS final rule (69 FR 66961 through 66964).
  
  Page 47238
  
  2. Expiration of the Stop-Loss Provision
  
  In the November 2004 IPF PPS final rule, we implemented a stop-loss policy that reduced financial risk to IPFs projected to experience substantial reductions in Medicare payments during the period of transition to the IPF PPS. This stop-loss policy guaranteed that each facility received total IPF PPS payments that were no less than 70 percent of its TEFRA payments had the IPF PPS not been implemented. This policy was applied to the IPF PPS portion of Medicare payments during the 3-year transition.
  
  In the implementation year, the 70 percent of TEFRA payment stop-
  
  loss policy required a reduction in the standardized Federal per diem and ECT base rates of 0.39 percent in order to make the stop-loss payments budget neutral. As described in the May 2008 IPF PPS notice for RY 2009, we increased the Federal per diem base rate and ECT rate by 0.39 percent because these rates were reduced by 0.39 percent in the implementation year to ensure stop-loss payments were budget neutral.
  
  The stop-loss provision ended during RY 2009 (that is for discharges occurring on or after July 1, 2008 through June 30, 2009). The stop-loss policy is no longer applicable under the IPF PPS.
  
  3. Future Refinements
  
  As we have indicated throughout this notice, we have delayed making refinements to the IPF PPS until we have adequate IPF PPS data to base those decisions. Specifically, we explained that we will delay updating the adjustment factors derived from regression analysis until we have IPF PPS data that includes as much information as possible regarding the patient-level characteristics of the population that each IPF serves. Now that we are approximately 7 years into the system, we believe that we have enough data to begin that process. We have begun the necessary analysis to better understand IPF industry practices so that we may refine the IPF PPS as appropriate. Using more recent data, we plan to re-run the regression analyses and recalculate the Federal per diem base rate and the patient- and facility-level adjustments. While we are not making these refinements in this notice, we expect that in the rulemaking for FY 2014 we will be ready to present the results of our analysis.
  
  For RY 2012, we published several areas of concern for future refinement and we invited comments on these issues in our RY 2012 proposed and final rules. For further discussion of these issues and to review public comments, we refer readers to the RY 2012 IPF PPS proposed rule (76 FR 4998) and final rule (76 FR 26432).
Secretary's Recommendations

Section 1886(e)(4)(A) of the Act requires the Secretary, taking into consideration the recommendations of MedPAC, to recommend update factors for inpatient hospital services (including IPFs) for each FY that take into account the amounts necessary for the efficient and effective delivery of medically appropriate and necessary care of high quality. Section 1886(e)(5) of the Act requires the Secretary to publish the recommended and final update factors in the Federal Register.

In the past, the Secretary's recommendations and a discussion about the MedPAC recommendations for the IPF PPS were included in the IPPS proposed and final rules. The market basket update for the IPF PPS was also included in the IPPS proposed and final rules, as well as in the IPF PPS annual update.

Beginning FY 2013, however, we will only publish the market basket update for the IPF PPS in the annual IPF PPS FY update and not in the IPPS proposed and final rules. Furthermore, for any years which MedPAC makes recommendations for the IPF PPS, those recommendations will be noted and considered in the IPF PPS update.

MedPAC did not make any recommendations for the IPF PPS for FY 2013. For the update to the IPF PPS standard Federal rate for FY 2013, see section IV B. of this notice.
Waiver of Notice and Comment

We ordinarily publish a notice of proposed rulemaking in the Federal Register to provide a period for public comment before the provisions of a rule take effect. We can waive this procedure, however, if we find good cause that notice and comment procedures are impracticable, unnecessary, or contrary to the public interest and we incorporate a statement of finding and its reasons in the notice.

We find it is unnecessary to undertake notice and comment rulemaking for this action because the updates in this notice do not reflect any substantive changes in policy, but merely reflect the application of previously established methodologies. Therefore, under 5 U.S.C. 553(b)(3)(B), for good cause, we waive notice and comment procedures.
Collection of Information Requirements

This notice does not impose any new or revised information collection or recordkeeping requirements. Consequently, it does not need Office of Management and Budget review under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 35).
Regulatory Impact Analysis
1. Statement of Need
  
  This notice will update the prospective payment rates for Medicare inpatient hospital services provided by IPF for discharges occurring during the FY beginning October 1, 2012 through September 30, 2013. We are applying the FY 2008-based RPL market basket increase of 2.7 percent, less the 0.1 percentage point required by sections 1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the Act and less the productivity adjustment of 0.7 percentage point as required by 1886(s)(2)(A)(i) of the Act.
2. Overall Impact
  
  We have examined the impact of this notice as required by Executive Order 12866 on Regulatory Planning and Review (September 30, 1993), Executive Order 13563 on Improving Regulation and Regulatory Review (January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, section 202 of the Unfunded Mandates Reform Act of 1995 (March 22, 1995; Pub. L. 104-4), Executive Order 13132 on Federalism (August 4, 1999) and the Congressional Review Act (5 U.S.C. 804(2)).
  
  Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). This notice is not designated as economically ``significant'' under section 3(f)(1) of Executive Order 12866.
  
  We estimate that the total impact of these changes for FY 2013 payments compared to RY 2012 payments would be a net increase of approximately $36 million (this reflects a $86 million increase from the update to the payment rates and a $50 million decrease due to the update to the outlier threshold amount to decrease outlier payments from approximately 3.1 percent in RY 2012 to 2.0 percent in FY 2013).
  
  The RFA requires agencies to analyze options for regulatory relief of small entities, if a rule has a significant impact on a substantial number of small
  
  Page 47239
  
  entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Most IPFs 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 details, refer to the SBA Small Business Size Standards found at http://www.sba.gov/sites/default/files/files/Size_Standards_Table.pdf), or being nonprofit organizations that are not dominant in their markets.
  
  Because we lack data on individual hospital receipts, we cannot determine the number of small proprietary IPFs or the proportion of IPFs' revenue that is derived from Medicare payments. Therefore, we assume that all IPFs are considered small entities. The Department of Health and Human Services generally uses a revenue impact of 3 to 5 percent as a significance threshold under the RFA.
  
  As shown in Table 7, we estimate the revenue impact of this notice on all IPFs is to increase Medicare payments by approximately 0.8 percent, with rural IPFs receiving an increase of 1.2 percent in Medicare payments. As a result, the Secretary has determined that this notice will not have a significant impact on a substantial number of small entities. Medicare fiscal intermediaries, Medicare Administrative Contractors, and Carriers are not considered to be small entities. Individuals and States are not included in the definition of a small entity.
  
  In addition, section 1102(b) of the Social Security Act requires us to prepare a regulatory impact analysis, if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a metropolitan statistical area and has fewer than 100 beds. As discussed in detail below, the rates and policies set forth in this notice will not have an adverse impact on the rural hospitals based on the data of the 311 rural units and 71 rural hospitals in our database of 1,627 IPFs for which data were available. Therefore, the Secretary has determined that this notice will not have a significant impact on the operations of a substantial number of small rural hospitals.
  
  Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. In 2013, that threshold is approximately $139 million. This notice will not impose spending costs on State, local, or tribal governments in the aggregate, or by the private sector, of $139 million.
  
  Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. As stated above, this notice would not have a substantial effect on State and local governments.
3. Anticipated Effects
  
  As discussed earlier in the preamble, in the RY 2012 IPF PPS proposed rule (76 FR 4998) and final rule (76 FR 26432), we revised the IPF PPS payment rate update period by switching from a RY (that is July 1 through June 30) to a period that coincides with a FY (that is, October 1 through September 30). Beginning with the update period that starts in 2012, that is, FY 2013, we now refer to update periods as FY. This change, in the annual update period, is reflected in the quantitative analysis presented in this Regulatory Impact Analysis section. Furthermore, this change allows us to consolidate Medicare publications by aligning the IPF PPS update with the annual update of the ICD-9-CM codes, which are effective on October 1 of each year. Below, we discuss the historical background of the IPF PPS and the impact of this notice on the Federal Medicare budget and on IPFs.
  
  1. Budgetary Impact
  
  As discussed in the November 2004 and May 2006 IPF PPS final rules, we applied a budget neutrality factor to the Federal per diem and ECT base rates to ensure that total estimated payments under the IPF PPS in the implementation period would equal the amount that would have been paid if the IPF PPS had not been implemented. The budget neutrality factor includes the following components: Outlier adjustment, stop-loss adjustment, and the behavioral offset. As discussed in the May 2008 IPF PPS notice (73 FR 25711), the stop-loss adjustment is no longer applicable under the IPF PPS.
  
  In accordance with Sec. 412.424(c)(3)(ii), we indicated that we will evaluate the accuracy of the budget neutrality adjustment within the first 5 years after implementation of the payment system. We may make a one-time prospective adjustment to the Federal per diem and ECT base rates to account for differences between the historical data on cost-based TEFRA payments (the basis of the budget neutrality adjustment) and estimates of TEFRA payments based on actual data from the first year of the IPF PPS. As part of that process, we will reassess the accuracy of all of the factors impacting budget neutrality. In addition, as discussed in section VII.C.1 of this notice, we are using the wage index and labor-related share in a budget neutral manner by applying a wage index budget neutrality factor to the Federal per diem and ECT base rates. Therefore, the budgetary impact to the Medicare program of this notice will be due to the market basket update for FY 2013 of 2.7 percent (see section V.B. of this notice) less the ``other adjustment'' of 0.1 percentage point according to sections 1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the Act, less the productivity adjustment of 0.7 percentage point required by section 1886(s)(2)(A)(i) of the Act, and the update to the outlier fixed dollar loss threshold amount.
  
  We estimate that the FY 2013 impact will be a net increase of $36 million in payments to IPF providers. This reflects an estimated $86 million increase from the update to the payment rates and a $50 million decrease due to the update to the outlier threshold amount to decrease outlier payments from approximately 3.1 percent in RY 2012 to 2.0 percent in FY 2013.
  
  2. Impact on Providers
  
  To understand the impact of the changes to the IPF PPS on providers, discussed in this notice, it is necessary to compare estimated payments under the IPF PPS rates and factors for FY 2013 versus those under RY 2012. The estimated payments for RY 2012 and FY 2013 will be 100 percent of the IPF PPS payment, since the transition period has ended and stop-loss payments are no longer paid. We determined the percent change of estimated FY 2013 IPF PPS payments to RY 2012 IPF PPS payments for each category of IPFs. In addition, for each category of IPFs, we have included the estimated percent change in payments resulting from the update to the outlier fixed dollar loss threshold amount, the labor-related share and wage index changes for the FY 2013 IPF PPS, and the market basket update for FY 2013, as adjusted by the ``other adjustment'' according to sections 1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the Act and the productivity adjustment according to section 1886(s)(2)(A)(i).
  
  To illustrate the impacts of the FY 2013 changes in this notice, our analysis begins with a RY 2012 baseline
  
  Page 47240
  
  simulation model based on FY 2011 IPF payments inflated to the midpoint of RY 2012 using IHS Global Insight's most recent forecast of the market basket update (see section V.B. of this notice); the estimated outlier payments in RY 2012; the CBSA designations for IPFs based on OMB's MSA definitions after June 2003; the FY 2011 pre-floor, pre-
  
  reclassified hospital wage index; the RY 2012 labor-related share; and the RY 2012 percentage amount of the rural adjustment. During the simulation, the total estimated outlier payments are maintained at 2 percent of total IPF PPS payments.
  
  Each of the following changes is added incrementally to this baseline model in order for us to isolate the effects of each change:
  
  The update to the outlier fixed dollar loss threshold amount.
  
  The FY 2012 pre-floor, pre-reclassified hospital wage index and FY 2013 labor-related share.
  
  The market basket update for FY 2013 of 2.7 percent less the ``other adjustment'' of 0.1 percentage point in accordance with sections 1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the Act and less the productivity adjustment of 0.7 percentage point reduction in accordance with section 1886(s)(2)(A)(i) of the Act.
  
  Our final comparison illustrates the percent change in payments from RY 2012 (that is, July 1, 2011 to September 30, 2012) to FY 2013 (that is, October 1, 2012 to September 30, 2013) including all the changes in this notice.
  
  Table 7--IPF Impact Table for FY 2013
  
  ----------------------------------------------------------------------------------------------------------------
  
  Projected impacts (% change in columns 3-6)
  
  -----------------------------------------------------------------------------------------------------------------
  
  CBSA wage Adjusted
  
  Facility by type Number of Outlier index & labor market basket Total percent
  
  facilities share update \1\ change \2\
  
  (1) (2) (3) (4) (5) (6)
  
  ----------------------------------------------------------------------------------------------------------------
  
  All Facilities.................. 1,627 -1.1 0.0 1.9 0.8
  
  Total Urban................. 1,245 -1.2 0.0 1.9 0.7
  
  Total Rural................. 382 -0.7 0.0 1.9 1.2
  
  Urban unit.................. 844 -1.6 0.0 1.9 0.2
  
  Urban hospital.............. 401 -0.4 -0.1 1.9 1.5
  
  Rural unit.................. 311 -0.9 -0.1 1.9 1.0
  
  Rural hospital.............. 71 -0.3 0.2 1.9 1.8
  
  By Type of Ownership:
  
  Freestanding IPFs:
  
  Urban Psychiatric Hospitals:
  
  Government.............. 152 -0.7 0.0 1.9 1.1
  
  Non-Profit.............. 109 -0.2 -0.2 1.9 1.5
  
  For-Profit.............. 136 -0.2 0.0 1.9 1.7
  
  Rural Psychiatric Hospitals:
  
  Government.............. 40 -0.7 0.3 1.9 1.5
  
  Non-Profit.............. 9 -0.1 0.5 1.9 2.3
  
  For-Profit.............. 21 0.0 0.2 1.9 2.0
  
  IPF Units:
  
  Urban:
  
  Government.............. 147 -2.6 0.0 1.9 -0.7
  
  Non-Profit.............. 561 -1.5 0.0 1.9 0.3
  
  For-Profit.............. 133 -1.1 0.1 1.9 0.9
  
  Rural:
  
  Government.............. 74 -0.8 0.1 1.9 1.2
  
  Non-Profit.............. 177 -0.8 -0.1 1.9 1.0
  
  For-Profit.............. 60 -1.2 -0.1 1.9 0.6
  
  Unknown Ownership Type.......... 8 -2.2 -0.1 1.9 -0.5
  
  By Teaching Status:
  
  Non-teaching................ 1,419 -0.9 0.0 1.9 0.9
  
  Less than 10% interns and 114 -1.3 0.1 1.9 0.6
  
  residents to beds..........
  
  10% to 30% interns and 69 -2.7 0.2 1.9 -0.7
  
  residents to beds..........
  
  More than 30% interns and 25 -2.5 0.1 1.9 -0.6
  
  residents to beds..........
  
  By Region:
  
  New England................. 112 -1.5 0.1 1.9 0.5
  
  Mid-Atlantic................ 263 -1.1 0.2 1.9 0.9
  
  South Atlantic.............. 230 -0.7 -0.2 1.9 1.0
  
  East North Central.......... 265 -1.1 -0.4 1.9 0.4
  
  East South Central.......... 168 -1.0 -0.3 1.9 0.5
  
  West North Central.......... 141 -1.2 0.3 1.9 1.0
  
  West South Central.......... 228 -0.7 0.3 1.9 1.5
  
  Mountain.................... 95 -0.9 0.1 1.9 1.0
  
  Pacific..................... 125 -2.1 0.1 1.9 -0.2
  
  By Bed Size:
  
  Psychiatric Hospitals:
  
  Beds: 0-24.............. 75 -0.7 0.0 1.9 1.2
  
  Beds: 25-49............. 69 -0.5 -0.1 1.9 1.3
  
  Beds: 50-75............. 75 -0.7 -0.4 1.9 0.8
  
  Beds: 76+............... 253 -0.2 0.1 1.9 1.7
  
  Psychiatric Units:
  
  Beds: 0-24.............. 690 -1.7 0.0 1.9 0.2
  
  Beds: 25-49............. 310 -1.2 0.0 1.9 0.6
  
  Page 47241
  
  Beds: 50-75............. 95 -1.3 0.0 1.9 0.6
  
  Beds: 76+............... 60 -1.8 0.1 1.9 0.1
  
  ----------------------------------------------------------------------------------------------------------------
  
  \1\ This column reflects the impact of the market basket update factor for FY 2013 of 1.9 percent, which
  
  includes a market basket update of 2.7 percent, a 0.1 percentage point reduction in accordance with sections
  
  1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the Act, and a 0.7 percentage point reduction for the productivity
  
  adjustment as required by section 1886(s)(2)(A)(i) of the Act.
  
  \2\ Percent changes in estimated payments from RY 2012 to FY 2013 include all of the changes of this rule. Note,
  
  the products of these impacts may be different from the percentage changes shown here due to rounding effects.
  
  3. Results
  
  Table 7 above displays the results of our analysis. The table groups IPFs into the categories listed below based on characteristics provided in the Provider of Services (POS) file, the IPF provider specific file, and cost report data from HCRIS:
  
  Facility Type
  
  Location
  
  Teaching Status Adjustment
  
  Census Region
  
  Size
  
  The top row of the table shows the overall impact on the 1,627 IPFs included in this analysis.
  
  In column 3, we present the effects of the update to the outlier fixed dollar loss threshold amount. We estimate that IPF outlier payments as a percentage of total IPF payments are 3.1 percent in RY 2012. Thus, we are adjusting the outlier threshold amount in this notice to set total estimated outlier payments equal to 2 percent of total payments in FY 2013. The estimated change in total IPF payments for FY 2013, therefore, includes an approximate 1.1 percent decrease in payments because the outlier portion of total payments is expected to decrease from approximately 3.1 percent to 2 percent.
  
  The overall impact of this outlier adjustment update (as shown in column 3 of table 7), across all hospital groups, is to decrease total estimated payments to IPFs by 1.1 percent. We do not estimate that any group of IPFs will experience an increase in payments from this update. The largest decrease in payments is estimated to reflect a 2.7 percent decrease in payments for IPFs located in teaching hospitals with an intern and resident ADC ratio greater than or equal to 10 percent and less than or equal to 30 percent. This is due to the high volume of outlier payments made to the IPFs in this category.
  
  In column 4, we present the effects of the budget-neutral update to the labor-related share and the wage index adjustment under the CBSA geographic area definitions announced by OMB in June 2003. This is a comparison of the simulated FY 2013 payments under the FY 2012 hospital wage index under CBSA classification and associated labor-related share to the simulated RY 2012 payments under the FY 2011 hospital wage index under CBSA classifications and associated labor-related share. We note that there is no projected change in aggregate payments to IPFs, as indicated in the first row of column 4. However, there will be small distributional effects among different categories of IPFs. For example, we estimate the largest increase in payments to be a 0.5 percent increase for rural, non-profit freestanding psychiatric hospitals and the largest decrease in payments to be a 0.4 percent decrease for IPFs in the East North Central region and freestanding IPFs in the 50 to 75 bed size category.
  
  Column 5 shows the estimated effect of the update to the IPF PPS payment rates, which includes a 2.7 percent market basket update less the 0.1 percentage point in accordance with section 1886(s)(2)(A)(ii) and 1886(s)(3)(B) and less the 0.7 percentage point in accordance with section 1886(s)(2)(A)(i).
  
  Column 6 compares our estimates of the changes reflected in this notice for FY 2013, to our payments for RY 2012 (without these changes). This column reflects all FY 2013 changes relative to RY 2012. The average estimated increase for all IPFs is approximately 0.8 percent. This estimated net increase includes the effects of the 2.7 percent market basket update adjusted by the ``other adjustment'' of minus 0.1 percentage point, as required by sections 1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the Act and the productivity adjustment of minus 0.7 percentage point, as required by section 1886(s)(2)(A)(i) of the Act. It also includes the overall estimated 1.1 percent decrease in estimated IPF outlier payments from the update to the outlier fixed dollar loss threshold amount. Since we are making the updates to the IPF labor-related share and wage index in a budget-neutral manner, they will not affect total estimated IPF payments in the aggregate. However, they will affect the estimated distribution of payments among providers.
  
  Overall, the estimated payments to IPFs in FY 2013 are projected to increase by 0.8 percent, compared with the payments in RY 2012. IPF payments are estimated to increase 0.7 percent in urban areas and 1.2 percent in rural areas, compared with RY 2012 payments. The largest payment increase is estimated at 2.3 percent for rural, non-profit freestanding psychiatric hospitals and the largest payment decrease is estimated at 0.7 percent for urban government IPF units and IPFs located in teaching hospitals with an intern and resident ADC ratio greater than or equal to 10 percent and less than or equal to 30 percent.
  
  4. Effect on the Medicare Program
  
  Based on actuarial projections resulting from our experience with other PPSs, we estimate that Medicare spending (total Medicare program payments) for IPF services over the next 5 years would be as shown in Table 8 below.
  
  TABLE 8--Estimated Payments
  
  ------------------------------------------------------------------------
  
  Dollars in
  
  Fiscal year millions
  
  ------------------------------------------------------------------------
  
  2013.................................................... 4,960
  
  2014.................................................... 5,380
  
  2015.................................................... 5,860
  
  2016.................................................... 6,390
  
  2017.................................................... 6,900
  
  ------------------------------------------------------------------------
  
  These estimates are based on the current forecast of the increases in the RPL market basket, including an
  
  Page 47242
  
  adjustment for productivity, for the RY beginning in 2012 and each subsequent RY, as required by section 1886(s)(2)(A)(i) of the Act, as follows:
  
  2.0 percent for FY 2013.
  
  2.3 percent for FY 2014.
  
  2.7 percent for FY 2015.
  
  2.8 percent for FY 2016.
  
  2.6 percent for FY 2017.
  
  The estimates in Table 8 also include the application of the ``other adjustment,'' as required by sections 1886(s)(2)(A)(ii) and 1886(s)(3)(B) of the Act, as follows:
  
  -0.1 percentage point for rate years beginning in 2012.
  
  -0.1 percentage point for rate years beginning in 2013.
  
  -0.3 percentage point for rate years beginning in 2014.
  
  -0.2 percentage point for rate years beginning in 2015.
  
  -0.2 percentage point for rate years beginning in 2016.
  
  We estimate that there would be a change in fee-for-service Medicare beneficiary enrollment as follows:
  
  3.8 percent in FY 2013.
  
  5.7 percent in FY 2014.
  
  6.8 percent in FY 2015.
  
  7.0 percent in FY 2016.
  
  5.1 percent in FY 2017.
  
  5. Effect on Beneficiaries
  
  Under the IPF PPS, IPFs will receive payment based on the average resources consumed by patients for each day. We do not expect changes in the quality of care or access to services for Medicare beneficiaries under the FY 2013 IPF PPS. In fact, we believe that access to IPF services will be enhanced due to the patient- and facility-level adjustment factors, all which are intended to adequately reimburse IPFs for expensive cases. Finally, the outlier policy is intended to assist IPFs that experience high-cost cases.
4. Alternatives Considered
  
  The statute does not specify an update strategy for the IPF PPS and is broadly written to give the Secretary discretion in establishing an update methodology. Therefore, we are updating the IPF PPS using the methodology published in the November 2004 IPF PPS final rule. Lastly, no alternative policy options were considered in this notice, since this notice does not initiate policy changes with regard to the IPF PPS. This notice simply provides an update to the rates for FY 2013.
  
  (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
  
  Supplementary Medical Insurance Program)
  
  Dated: June 28, 2012.
  
  Marilyn Tavenner,
  
  Acting Administrator, Centers for Medicare & Medicaid Services.
  
  Approved: August 1, 2012.
  
  Kathleen Sebelius,
  
  Secretary.
  
  Addendum A--Rate and Adjustment Factors
  
  Per Diem Rate
  
  ------------------------------------------------------------------------
  
  ------------------------------------------------------------------------
  
  Federal Per Diem Base Rate.................................. $698.51
  
  Labor Share (0.69981)....................................... 488.82
  
  Non-Labor Share (0.30019)................................... 209.69
  
  ------------------------------------------------------------------------
  
  Fixed Dollar Loss Threshold Amount: $11,600.
  
  Wage Index Budget Neutrality Factor: 1.0007.
  
  Facility Adjustments
  
  ------------------------------------------------------------------------
  
  ------------------------------------------------------------------------
  
  Rural Adjustment Factor................... 1.17.
  
  Teaching Adjustment Factor................ 0.5150.
  
  Wage Index................................ Pre-reclass Hospital Wage
  
  Index (FY 2012).
  
  ------------------------------------------------------------------------
  
  Cost of Living Adjustments (COLAs)
  
  ------------------------------------------------------------------------
  
  Cost of living
  
  Area adjustment
  
  factor
  
  ------------------------------------------------------------------------
  
  Alaska:
  
  City of Anchorage and 80-kilometer (50-mile) 1.23
  
  radius by road...................................
  
  City of Fairbanks and 80-kilometer (50-mile) 1.23
  
  radius by road...................................
  
  City of Juneau and 80-kilometer (50-mile) radius 1.23
  
  by road..........................................
  
  Rest of Alaska.................................... 1.25
  
  Hawaii:
  
  City and County of Honolulu....................... 1.25
  
  County of Hawaii.................................. 1.18
  
  County of Kauai................................... 1.25
  
  County of Maui and County of Kalawao.............. 1.25
  
  ------------------------------------------------------------------------
  
  Patient Adjustments
  
  ------------------------------------------------------------------------
  
  ------------------------------------------------------------------------
  
  ECT--Per Treatment......................................... $300.72
  
  ------------------------------------------------------------------------
  
  Variable per Diem Adjustments
  
  ------------------------------------------------------------------------
  
  Adjustment
  
  factor
  
  ------------------------------------------------------------------------
  
  Day 1--Facility Without a Qualifying Emergency 1.19
  
  Department...........................................
  
  Day 1--Facility With a Qualifying Emergency Department 1.31
  
  Day 2................................................. 1.12
  
  Day 3................................................. 1.08
  
  Day 4................................................. 1.05
  
  Day 5................................................. 1.04
  
  Day 6................................................. 1.02
  
  Day 7................................................. 1.01
  
  Day 8................................................. 1.01
  
  Day 9................................................. 1.00
  
  Day 10................................................ 1.00
  
  Day 11................................................ 0.99
  
  Day 12................................................ 0.99
  
  Page 47243
  
  Day 13................................................ 0.99
  
  Day 14................................................ 0.99
  
  Day 15................................................ 0.98
  
  Day 16................................................ 0.97
  
  Day 17................................................ 0.97
  
  Day 18................................................ 0.96
  
  Day 19................................................ 0.95
  
  Day 20................................................ 0.95
  
  Day 21................................................ 0.95
  
  After Day 21.......................................... 0.92
  
  ------------------------------------------------------------------------
  
  Age Adjustments
  
  ------------------------------------------------------------------------
  
  Adjustment
  
  Age (in years) factor
  
  ------------------------------------------------------------------------
  
  Under 45.............................................. 1.00
  
  45 and under 50....................................... 1.01
  
  50 and under 55....................................... 1.02
  
  55 and under 60....................................... 1.04
  
  60 and under 65....................................... 1.07
  
  65 and under 70....................................... 1.10
  
  70 and under 75....................................... 1.13
  
  75 and under 80....................................... 1.15
  
  80 and over........................................... 1.17
  
  ------------------------------------------------------------------------
  
  DRG Adjustments
  
  ------------------------------------------------------------------------
  
  Adjustment
  
  MS-DRG MS-DRG Descriptions factor
  
  ------------------------------------------------------------------------
  
  056................ Degenerative nervous system 1.05
  
  disorders w MCC.
  
  057................ Degenerative nervous system ................
  
  disorders w/o MCC.
  
  080................ Nontraumatic stupor & coma w MCC. 1.07
  
  081................ Nontraumatic stupor & coma w/o ................
  
  MCC.
  
  876................ O.R. procedure w principal 1.22
  
  diagnoses of mental illness.
  
  880................ Acute adjustment reaction & 1.05
  
  psychosocial dysfunction.
  
  881................ Depressive neuroses.............. 0.99
  
  882................ Neuroses except depressive....... 1.02
  
  883................ Disorders of personality & 1.02
  
  impulse control.
  
  884................ Organic disturbances & mental 1.03
  
  retardation.
  
  885................ Psychoses........................ 1.00
  
  886................ Behavioral & developmental 0.99
  
  disorders.
  
  887................ Other mental disorder diagnoses.. 0.92
  
  894................ Alcohol/drug abuse or dependence, 0.97
  
  left AMA.
  
  895................ Alcohol/drug abuse or dependence 1.02
  
  w rehabilitation therapy.
  
  896................ Alcohol/drug abuse or dependence 0.88
  
  w/o rehabilitation therapy w MCC.
  
  897................ Alcohol/drug abuse or dependence ................
  
  w/o rehabilitation therapy w/o
  
  MCC.
  
  ------------------------------------------------------------------------
  
  Comorbidity Adjustments
  
  ------------------------------------------------------------------------
  
  Adjustment
  
  Comorbidity factor
  
  ------------------------------------------------------------------------
  
  Developmental Disabilities............................ 1.04
  
  Coagulation Factor Deficit............................ 1.13
  
  Tracheostomy.......................................... 1.06
  
  Eating and Conduct Disorders.......................... 1.12
  
  Infectious Diseases................................... 1.07
  
  Renal Failure, Acute.................................. 1.11
  
  Renal Failure, Chronic................................ 1.11
  
  Oncology Treatment.................................... 1.07
  
  Uncontrolled Diabetes Mellitus........................ 1.05
  
  Severe Protein Malnutrition........................... 1.13
  
  Drug/Alcohol Induced Mental Disorders................. 1.03
  
  Cardiac Conditions.................................... 1.11
  
  Gangrene.............................................. 1.10
  
  Chronic Obstructive Pulmonary Disease................. 1.12
  
  Artificial Openings--Digestive & Urinary.............. 1.08
  
  Severe Musculoskeletal & Connective Tissue Diseases... 1.09
  
  Poisoning............................................. 1.11
  
  ------------------------------------------------------------------------
  
  Page 47244
  
  Addendum B--FY 2013 CBSA Wage Index Tables
  
  In this addendum, we provide the wage index tables referred to in the preamble to this notice. The tables presented below are as follows:
  
  Table 1--FY 2013 Wage Index For Urban Areas Based On CBSA Labor Market Areas.
  
  Table 2--FY 2013 Wage Index Based On CBSA Labor Market Areas For Rural Areas.
  
  Table 1--FY 2013 Wage Index for Urban Areas Based on CBSA Labor Market
  
  Areas
  
  ------------------------------------------------------------------------
  
  Urban area (constituent
  
  CBSA Code counties) Wage index
  
  ------------------------------------------------------------------------
  
  10180........................ Abilene, TX............ 0.8444
  
  Callahan County, TX....
  
  Jones County, TX.......
  
  Taylor County, TX......
  
  10380........................ Aguadilla-Isabela-San 0.3611
  
  Sebastiaacuten, PR.
  
  Aguada Municipio, PR...
  
  Aguadilla Municipio, PR
  
  Antildeasco
  
  Municipio, PR.
  
  Isabela Municipio, PR..
  
  Lares Municipio, PR....
  
  Moca Municipio, PR.....
  
  Rincoacuten
  
  Municipio, PR.
  
  San Sebastiaacuten
  
  Municipio, PR.
  
  10420........................ Akron, OH.............. 0.8814
  
  Portage County, OH.....
  
  Summit County, OH......
  
  10500........................ Albany, GA............. 0.8687
  
  Baker County, GA.......
  
  Dougherty County, GA...
  
  Lee County, GA.........
  
  Terrell County, GA.....
  
  Worth County, GA.......
  
  10580........................ Albany-Schenectady- 0.8680
  
  Troy, NY.
  
  Albany County, NY......
  
  Rensselaer County, NY..
  
  Saratoga County, NY....
  
  Schenectady County, NY.
  
  Schoharie County, NY...
  
  10740........................ Albuquerque, NM........ 0.9550
  
  Bernalillo County, NM..
  
  Sandoval County, NM....
  
  Torrance County, NM....
  
  Valencia County, NM....
  
  10780........................ Alexandria, LA......... 0.8026
  
  Grant Parish, LA.......
  
  Rapides Parish, LA.....
  
  10900........................ Allentown-Bethlehem- 0.9260
  
  Easton, PA-NJ.
  
  Warren County, NJ......
  
  Carbon County, PA......
  
  Lehigh County, PA......
  
  Northampton County, PA.
  
  11020........................ Altoona, PA............ 0.8917
  
  Blair County, PA.......
  
  11100........................ Amarillo, TX........... 0.8714
  
  Armstrong County, TX...
  
  Carson County, TX......
  
  Potter County, TX......
  
  Randall County, TX.....
  
  11180........................ Ames, IA............... 1.0009
  
  Story County, IA.......
  
  11260........................ Anchorage, AK.......... 1.2133
  
  Anchorage Municipality,
  
  AK.
  
  Matanuska-Susitna
  
  Borough, AK.
  
  11300........................ Anderson, IN........... 0.9266
  
  Madison County, IN.....
  
  11340........................ Anderson, SC........... 0.8524
  
  Anderson County, SC....
  
  11460........................ Ann Arbor, MI.......... 1.0128
  
  Washtenaw County, MI...
  
  11500........................ Anniston-Oxford, AL.... 0.7979
  
  Calhoun County, AL.....
  
  11540........................ Appleton, WI........... 0.9226
  
  Calumet County, WI.....
  
  Outagamie County, WI...
  
  11700........................ Asheville, NC.......... 0.8918
  
  Buncombe County, NC....
  
  Page 47245
  
  Haywood County, NC.....
  
  Henderson County, NC...
  
  Madison County, NC.....
  
  12020........................ Athens-Clarke County, 0.9642
  
  GA.
  
  Clarke County, GA......
  
  Madison County, GA.....
  
  Oconee County, GA......
  
  Oglethorpe County, GA..
  
  12060........................ Atlanta-Sandy Springs- 0.9575
  
  Marietta, GA.
  
  Barrow County, GA......
  
  Bartow County, GA......
  
  Butts County, GA.......
  
  Carroll County, GA.....
  
  Cherokee County, GA....
  
  Clayton County, GA.....
  
  Cobb County, GA........
  
  Coweta County, GA......
  
  Dawson County, GA......
  
  DeKalb County, GA......
  
  Douglas County, GA.....
  
  Fayette County, GA.....
  
  Forsyth County, GA.....
  
  Fulton County, GA......
  
  Gwinnett County, GA....
  
  Haralson County, GA....
  
  Heard County, GA.......
  
  Henry County, GA.......
  
  Jasper County, GA......
  
  Lamar County, GA.......
  
  Meriwether County, GA..
  
  Newton County, GA......
  
  Paulding County, GA....
  
  Pickens County, GA.....
  
  Pike County, GA........
  
  Rockdale County, GA....
  
  Spalding County, GA....
  
  Walton County, GA......
  
  12100........................ Atlantic City- 1.1033
  
  Hammonton, NJ.
  
  Atlantic County, NJ....
  
  12220........................ Auburn-Opelika, AL..... 0.7877
  
  Lee County, AL.........
  
  12260........................ Augusta-Richmond 0.9529
  
  County, GA-SC.
  
  Burke County, GA.......
  
  Columbia County, GA....
  
  McDuffie County, GA....
  
  Richmond County, GA....
  
  Aiken County, SC.......
  
  Edgefield County, SC...
  
  12420........................ Austin-Round Rock-San 0.9535
  
  Marcos, TX.
  
  Bastrop County, TX.....
  
  Caldwell County, TX....
  
  Hays County, TX........
  
  Travis County, TX......
  
  Williamson County, TX..
  
  12540........................ Bakersfield-Delano, CA. 1.1817
  
  Kern County, CA........
  
  12580........................ Baltimore-Towson, MD... 1.0151
  
  Anne Arundel County, MD
  
  Baltimore County, MD...
  
  Carroll County, MD.....
  
  Harford County, MD.....
  
  Howard County, MD......
  
  Queen Anne's County, MD
  
  Baltimore City, MD.....
  
  12620........................ Bangor, ME............. 0.9979
  
  Penobscot County, ME...
  
  12700........................ Barnstable Town, MA.... 1.2838
  
  Barnstable County, MA..
  
  12940........................ Baton Rouge, LA........ 0.8523
  
  Ascension Parish, LA...
  
  East Baton Rouge
  
  Parish, LA.
  
  Page 47246
  
  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.
  
  12980........................ Battle Creek, MI....... 0.9935
  
  Calhoun County, MI.....
  
  13020........................ Bay City, MI........... 0.8927
  
  Bay County, MI.........
  
  13140........................ Beaumont-Port Arthur, 0.8723
  
  TX.
  
  Hardin County, TX......
  
  Jefferson County, TX...
  
  Orange County, TX......
  
  13380........................ Bellingham, WA......... 1.1748
  
  Whatcom County, WA.....
  
  13460........................ Bend, OR............... 1.1395
  
  Deschutes County, OR...
  
  13644........................ Bethesda-Rockville- 1.0305
  
  Frederick, MD.
  
  Frederick County, MD...
  
  Montgomery County, MD..
  
  13740........................ Billings, MT........... 0.8576
  
  Carbon County, MT......
  
  Yellowstone County, MT.
  
  13780........................ Binghamton, NY......... 0.8731
  
  Broome County, NY......
  
  Tioga County, NY.......
  
  13820........................ Birmingham-Hoover, AL.. 0.8436
  
  Bibb County, AL........
  
  Blount County, AL......
  
  Chilton County, AL.....
  
  Jefferson County, AL...
  
  St. Clair County, AL...
  
  Shelby County, AL......
  
  Walker County, AL......
  
  13900........................ Bismarck, ND........... 0.7232
  
  Burleigh County, ND....
  
  Morton County, ND......
  
  13980........................ Blacksburg- 0.8281
  
  Christiansburg-
  
  Radford, VA.
  
  Giles County, VA.......
  
  Montgomery County, VA..
  
  Pulaski County, VA.....
  
  Radford City, VA.......
  
  14020........................ Bloomington, IN........ 0.8725
  
  Greene County, IN......
  
  Monroe County, IN......
  
  Owen County, IN........
  
  14060........................ Bloomington-Normal, IL. 0.9477
  
  McLean County, IL......
  
  14260........................ Boise City-Nampa, ID... 0.9279
  
  Ada County, ID.........
  
  Boise County, ID.......
  
  Canyon County, ID......
  
  Gem County, ID.........
  
  Owyhee County, ID......
  
  14484........................ Boston-Quincy, MA...... 1.2283
  
  Norfolk County, MA.....
  
  Plymouth County, MA....
  
  Suffolk County, MA.....
  
  14500........................ Boulder, CO............ 1.0086
  
  Boulder County, CO.....
  
  14540........................ Bowling Green, KY...... 0.8599
  
  Edmonson County, KY....
  
  Warren County, KY......
  
  14740........................ Bremerton-Silverdale, 1.1288
  
  WA.
  
  Kitsap County, WA......
  
  14860........................ Bridgeport-Stamford- 1.2914
  
  Norwalk, CT.
  
  Fairfield County, CT...
  
  15180........................ Brownsville-Harlingen, 0.9183
  
  TX.
  
  Cameron County, TX.....
  
  Page 47247
  
  15260........................ Brunswick, GA.......... 0.9068
  
  Brantley County, GA....
  
  Glynn County, GA.......
  
  McIntosh County, GA....
  
  15380........................ Buffalo-Niagara Falls, 0.9750
  
  NY.
  
  Erie County, NY........
  
  Niagara County, NY.....
  
  15500........................ Burlington, NC......... 0.8665
  
  Alamance County, NC....
  
  15540........................ Burlington-South 1.0021
  
  Burlington, VT.
  
  Chittenden County, VT..
  
  Franklin County, VT....
  
  Grand Isle County, VT..
  
  15764........................ Cambridge-Newton- 1.1210
  
  Framingham, MA.
  
  Middlesex County, MA...
  
  15804........................ Camden, NJ............. 1.0202
  
  Burlington County, NJ..
  
  Camden County, NJ......
  
  Gloucester County, NJ..
  
  15940........................ Canton-Massillon, OH... 0.8939
  
  Carroll County, OH.....
  
  Stark County, OH.......
  
  15980........................ Cape Coral-Fort Myers, 0.9341
  
  FL.
  
  Lee County, FL.........
  
  16020........................ Cape Girardeau-Jackson, 0.8672
  
  MO-IL.
  
  Alexander County, IL...
  
  Bollinger County, MO...
  
  Cape Girardeau County,
  
  MO.
  
  16180........................ Carson City, NV........ 1.0597
  
  Carson City, NV........
  
  16220........................ Casper, WY............. 1.0117
  
  Natrona County, WY.....
  
  16300........................ Cedar Rapids, IA....... 0.8831
  
  Benton County, IA......
  
  Jones County, IA.......
  
  Linn County, IA........
  
  16580........................ Champaign-Urbana, IL... 0.9890
  
  Champaign County, IL...
  
  Ford County, IL........
  
  Piatt County, IL.......
  
  16620........................ Charleston, WV......... 0.8144
  
  Boone County, WV.......
  
  Clay County, WV........
  
  Kanawha County, WV.....
  
  Lincoln County, WV.....
  
  Putnam County, WV......
  
  16700........................ Charleston-North 0.9063
  
  Charleston-
  
  Summerville, SC.
  
  Berkeley County, SC....
  
  Charleston County, SC..
  
  Dorchester County, SC..
  
  16740........................ Charlotte-Gastonia-Rock 0.9321
  
  Hill, NCdashSC.
  
  Anson County, NC.......
  
  Cabarrus County, NC....
  
  Gaston County, NC......
  
  Mecklenburg County, NC.
  
  Union County, NC.......
  
  York County, SC........
  
  16820........................ Charlottesville, VA.... 0.9188
  
  Albemarle County, VA...
  
  Fluvanna County, VA....
  
  Greene County, VA......
  
  Nelson County, VA......
  
  Charlottesville City,
  
  VA.
  
  16860........................ Chattanooga, TN-GA..... 0.8740
  
  Catoosa County, GA.....
  
  Dade County, GA........
  
  Walker County, GA......
  
  Hamilton County, TN....
  
  Marion County, TN......
  
  Sequatchie County, TN..
  
  16940........................ Cheyenne, WY........... 0.9844
  
  Page 47248
  
  Laramie County, WY.....
  
  16974........................ Chicago-Joilet- 1.0600
  
  Naperville, 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........
  
  17020........................ Chico, CA.............. 1.1094
  
  Butte County, CA.......
  
  17140........................ Cincinnati-Middletown, 0.9430
  
  OH-KY-IN.
  
  Dearborn County, IN....
  
  Franklin County, IN....
  
  Ohio County, IN........
  
  Boone County, KY.......
  
  Bracken County, KY.....
  
  Campbell County, KY....
  
  Gallatin County, KY....
  
  Grant County, KY.......
  
  Kenton County, KY......
  
  Pendleton County, KY...
  
  Brown County, OH.......
  
  Butler County, OH......
  
  Clermont County, OH....
  
  Hamilton County, OH....
  
  Warren County, OH......
  
  17300........................ Clarksville, TN-KY..... 0.8193
  
  Christian County, KY...
  
  Trigg County, KY.......
  
  Montgomery County, TN..
  
  Stewart County, TN.....
  
  17420........................ Cleveland, TN.......... 0.7674
  
  Bradley County, TN.....
  
  Polk County, TN........
  
  17460........................ Cleveland-Elyria- 0.8941
  
  Mentor, OH.
  
  Cuyahoga County, OH....
  
  Geauga County, OH......
  
  Lake County, OH........
  
  Lorain County, OH......
  
  Medina County, OH......
  
  17660........................ Coeur d'Alene, ID...... 0.9367
  
  Kootenai County, ID....
  
  17780........................ College Station-Bryan, 0.9690
  
  TX.
  
  Brazos County, TX......
  
  Burleson County, TX....
  
  Robertson County, TX...
  
  17820........................ Colorado Springs, CO... 0.9846
  
  El Paso County, CO.....
  
  Teller County, CO......
  
  17860........................ Columbia, MO........... 0.8105
  
  Boone County, MO.......
  
  Howard County, MO......
  
  17900........................ Columbia, SC........... 0.8758
  
  Calhoun County, SC.....
  
  Fairfield County, SC...
  
  Kershaw County, SC.....
  
  Lexington County, SC...
  
  Richland County, SC....
  
  Saluda County, SC......
  
  17980........................ Columbus, GA-AL........ 0.9040
  
  Russell County, AL.....
  
  Chattahoochee County,
  
  GA.
  
  Harris County, GA......
  
  Marion County, GA......
  
  Muscogee County, GA....
  
  18020........................ Columbus, IN........... 0.9723
  
  Bartholomew County, IN.
  
  18140........................ Columbus, OH........... 0.9994
  
  Delaware County, OH....
  
  Page 47249
  
  Fairfield County, OH...
  
  Franklin County, OH....
  
  Licking County, OH.....
  
  Madison County, OH.....
  
  Morrow County, OH......
  
  Pickaway County, OH....
  
  Union County, OH.......
  
  18580........................ Corpus Christi, TX..... 0.8677
  
  Aransas County, TX.....
  
  Nueces County, TX......
  
  San Patricio County, TX
  
  18700........................ Corvallis, OR.......... 1.0898
  
  Benton County, OR......
  
  18880........................ Crestview-Fort Walton 0.8961
  
  Beach-Destin, FL.
  
  Okaloosa County, FL....
  
  19060........................ Cumberland, MD-WV...... 0.7825
  
  Allegany County, MD....
  
  Mineral County, WV.....
  
  19124........................ Dallas-Plano-Irving, TX 0.9844
  
  Collin County, TX......
  
  Dallas County, TX......
  
  Delta County, TX.......
  
  Denton County, TX......
  
  Ellis County, TX.......
  
  Hunt County, TX........
  
  Kaufman County, TX.....
  
  Rockwall County, TX....
  
  19140........................ Dalton, GA............. 0.8374
  
  Murray County, GA......
  
  Whitfield County, GA...
  
  19180........................ Danville, IL........... 0.9832
  
  Vermilion County, IL...
  
  19260........................ Danville, VA........... 0.7896
  
  Pittsylvania County, VA
  
  Danville City, VA......
  
  19340........................ Davenport-Moline-Rock 0.9056
  
  Island, IA-IL.
  
  Henry County, IL.......
  
  Mercer County, IL......
  
  Rock Island County, IL.
  
  Scott County, IA.......
  
  19380........................ Dayton, OH............. 0.9281
  
  Greene County, OH......
  
  Miami County, OH.......
  
  Montgomery County, OH..
  
  Preble County, OH......
  
  19460........................ Decatur, AL............ 0.7334
  
  Lawrence County, AL....
  
  Morgan County, AL......
  
  19500........................ Decatur, IL............ 0.8008
  
  Macon County, IL.......
  
  19660........................ Deltona-Daytona Beach- 0.8865
  
  Ormond Beach, FL.
  
  Volusia County, FL.....
  
  19740........................ Denver-Aurora- 1.0647
  
  Broomfield, 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........
  
  19780........................ Des Moines-West Des 0.9801
  
  Moines, IA.
  
  Dallas County, IA......
  
  Guthrie County, IA.....
  
  Madison County, IA.....
  
  Polk County, IA........
  
  Warren County, IA......
  
  19804........................ Detroit-Livonia- 0.9511
  
  Dearborn, MI.
  
  Wayne County, MI.......
  
  Page 47250
  
  20020........................ Dothan, AL............. 0.7390
  
  Geneva County, AL......
  
  Henry County, AL.......
  
  Houston County, AL.....
  
  20100........................ Dover, DE.............. 0.9909
  
  Kent County, DE........
  
  20220........................ Dubuque, IA............ 0.8698
  
  Dubuque County, IA.....
  
  20260........................ Duluth, MN-WI.......... 1.0335
  
  Carlton County, MN.....
  
  St. Louis County, MN...
  
  Douglas County, WI.....
  
  20500........................ Durham-Chapel Hill, NC. 0.9699
  
  Chatham County, NC.....
  
  Durham County, NC......
  
  Orange County, NC......
  
  Person County, NC......
  
  20740........................ Eau Claire, WI......... 0.9597
  
  Chippewa County, WI....
  
  Eau Claire County, WI..
  
  20764........................ Edison-New Brunswick, 1.0868
  
  NJ.
  
  Middlesex County, NJ...
  
  Monmouth County, NJ....
  
  Ocean County, NJ.......
  
  Somerset County, NJ....
  
  20940........................ El Centro, CA.......... 0.9601
  
  Imperial County, CA....
  
  21060........................ Elizabethtown, KY...... 0.8719
  
  Hardin County, KY......
  
  Larue County, KY.......
  
  21140........................ Elkhart-Goshen, IN..... 0.9405
  
  Elkhart County, IN.....
  
  21300........................ Elmira, NY............. 0.8522
  
  Chemung County, NY.....
  
  21340........................ El Paso, TX............ 0.8515
  
  El Paso County, TX.....
  
  21500........................ Erie, PA............... 0.8147
  
  Erie County, PA........
  
  21660........................ Eugene-Springfield, OR. 1.1587
  
  Lane County, OR........
  
  21780........................ Evansville, IN-KY...... 0.8679
  
  Gibson County, IN......
  
  Posey County, IN.......
  
  Vanderburgh County, IN.
  
  Warrick County, IN.....
  
  Henderson County, KY...
  
  Webster County, KY.....
  
  21820........................ Fairbanks, AK.......... 1.1322
  
  Fairbanks North Star
  
  Borough, AK.
  
  21940........................ Fajardo, PR............ 0.3823
  
  Ceiba Municipio, PR....
  
  Fajardo Municipio, PR..
  
  Luquillo Municipio, PR.
  
  22020........................ Fargo, ND-MN........... 0.8136
  
  Cass County, ND........
  
  Clay County, MN........
  
  22140........................ Farmington, NM......... 0.9795
  
  San Juan County, NM....
  
  22180........................ Fayetteville, NC....... 0.9213
  
  Cumberland County, NC..
  
  Hoke County, NC........
  
  22220........................ Fayetteville-Springdale- 0.9263
  
  Rogers, AR-MO.
  
  Benton County, AR......
  
  Madison County, AR.....
  
  Washington County, AR..
  
  McDonald County, MO....
  
  22380........................ Flagstaff, AZ.......... 1.2427
  
  Coconino County, AZ....
  
  22420........................ Flint, MI.............. 1.1137
  
  Genesee County, MI.....
  
  22500........................ Florence, SC........... 0.8217
  
  Page 47251
  
  Darlington County, SC..
  
  Florence County, SC....
  
  22520........................ Florence-Muscle Shoals, 0.7738
  
  AL County, AL.
  
  Colbert County, AL.....
  
  Lauderdale.............
  
  22540........................ Fond du Lac, WI........ 0.9291
  
  Fond du Lac County, WI.
  
  22660........................ Fort Collins-Loveland, 0.9876
  
  CO.
  
  Larimer County, CO.....
  
  22744........................ Fort Lauderdale-Pompano 1.0160
  
  Beach-Deerfield, FL.
  
  Broward County, FL.....
  
  22900........................ Fort Smith, AR-OK...... 0.7620
  
  Crawford County, AR....
  
  Franklin County, AR....
  
  Sebastian County, AR...
  
  Le Flore County, OK....
  
  Sequoyah County, OK....
  
  23060........................ Fort Wayne, IN......... 0.9368
  
  Allen County, IN.......
  
  Wells County, IN.......
  
  Whitley County, IN.....
  
  23104........................ Fort Worth-Arlington, 0.9525
  
  TX.
  
  Johnson County, TX.....
  
  Parker County, TX......
  
  Tarrant County, TX.....
  
  Wise County, TX........
  
  23420........................ Fresno, CA............. 1.1281
  
  Fresno County, CA......
  
  23460........................ Gadsden, AL............ 0.7934
  
  Etowah County, AL......
  
  23540........................ Gainesville, FL........ 0.9375
  
  Alachua County, FL.....
  
  Gilchrist County, FL...
  
  23580........................ Gainesville, GA........ 0.9010
  
  Hall County, GA........
  
  23844........................ Gary, IN............... 0.9193
  
  Jasper County, IN......
  
  Lake County, IN........
  
  Newton County, IN......
  
  Porter County, IN......
  
  24020........................ Glens Falls, NY........ 0.8504
  
  Warren County, NY......
  
  Washington County, NY..
  
  24140........................ Goldsboro, NC.......... 0.8690
  
  Wayne County, NC.......
  
  24220........................ Grand Forks, ND-MN..... 0.7573
  
  Polk County, MN........
  
  Grand Forks County, ND.
  
  24300........................ Grand Junction, CO..... 0.9394
  
  Mesa County, CO........
  
  24340........................ Grand Rapids-Wyoming, 0.9145
  
  MI.
  
  Barry County, MI.......
  
  Ionia County, MI.......
  
  Kent County, MI........
  
  Newaygo County, MI.....
  
  24500........................ Great Falls, MT........ 0.8462
  
  Cascade County, MT.....
  
  24540........................ Greeley, CO............ 0.9553
  
  Weld County, CO........
  
  24580........................ Green Bay, WI.......... 0.9824
  
  Brown County, WI.......
  
  Kewaunee County, WI....
  
  Oconto County, WI......
  
  24660........................ Greensboro-High Point, 0.8798
  
  NC.
  
  Guilford County, NC....
  
  Randolph County, NC....
  
  Rockingham County, NC..
  
  24780........................ Greenville, NC......... 0.9637
  
  Greene County, NC......
  
  Pitt County, NC........
  
  24860........................ Greenville-Mauldin- 0.9620
  
  Easley, SC.
  
  Page 47252
  
  Greenville County, SC..
  
  Laurens County, SC.....
  
  Pickens County, SC.....
  
  25020........................ Guayama, PR............ 0.3730
  
  Arroyo Municipio, PR...
  
  Guayama Municipio, PR..
  
  Patillas Municipio, PR.
  
  25060........................ Gulfport-Biloxi, MS.... 0.8505
  
  Hancock County, MS.....
  
  Harrison County, MS....
  
  Stone County, MS.......
  
  25180........................ Hagerstown-Martinsburg, 0.9168
  
  MD-WV.
  
  Washington County, MD..
  
  Berkeley County, WV....
  
  Morgan County, WV......
  
  25260........................ Hanford-Corcoran, CA... 1.0700
  
  Kings County, CA.......
  
  25420........................ Harrisburg-Carlisle, PA 0.9400
  
  Cumberland County, PA..
  
  Dauphin County, PA.....
  
  Perry County, PA.......
  
  25500........................ Harrisonburg, VA....... 0.8773
  
  Rockingham County, VA..
  
  Harrisonburg City, VA..
  
  25540........................ Hartford-West Hartford- 1.0700
  
  East Hartford, CT.
  
  Hartford County, CT....
  
  Middlesex County, CT...
  
  Tolland County, CT.....
  
  25620........................ Hattiesburg, MS........ 0.7940
  
  Forrest County, MS.....
  
  Lamar County, MS.......
  
  Perry County, MS.......
  
  25860........................ Hickory-Lenoir- 0.8859
  
  Morganton, NC.
  
  Alexander County, NC...
  
  Burke County, NC.......
  
  Caldwell County, NC....
  
  Catawba County, NC.....
  
  25980........................ Hinesville-Fort 0.8926
  
  Stewart, GASec. \1\.
  
  Liberty County, GA.....
  
  Long County, GA........
  
  26100........................ Holland-Grand Haven, MI 0.8523
  
  Ottawa County, MI......
  
  26180........................ Honolulu, HI........... 1.1698
  
  Honolulu County, HI....
  
  26300........................ Hot Springs, AR........ 0.9076
  
  Garland County, AR.....
  
  26380........................ Houma-Bayou Cane- 0.7841
  
  Thibodaux, LA.
  
  Lafourche Parish, LA...
  
  Terrebonne Parish, LA..
  
  26420........................ Houston-Sugar Land- 0.9945
  
  Baytown, TX.
  
  Austin County, TX......
  
  Brazoria County, TX....
  
  Chambers County, TX....
  
  Fort Bend County, TX...
  
  Galveston County, TX...
  
  Harris County, TX......
  
  Liberty County, TX.....
  
  Montgomery County, TX..
  
  San Jacinto County, TX.
  
  Waller County, TX......
  
  26580........................ Huntington-Ashland, WV- 0.8893
  
  KY-OH.
  
  Boyd County, KY........
  
  Greenup County, KY.....
  
  Lawrence County, OH....
  
  Cabell County, WV......
  
  Wayne County, WV.......
  
  26620........................ Huntsville, AL......... 0.8996
  
  Limestone County, AL...
  
  Madison County, AL.....
  
  26820........................ Idaho Falls, ID........ 0.9336
  
  Bonneville County, ID..
  
  Page 47253
  
  Jefferson County, ID...
  
  26900........................ Indianapolis-Carmel, IN 0.9662
  
  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......
  
  26980........................ Iowa City, IA.......... 1.0070
  
  Johnson County, IA.....
  
  Washington County, IA..
  
  27060........................ Ithaca, NY............. 0.8819
  
  Tompkins County, NY....
  
  27100........................ Jackson, MI............ 0.8938
  
  Jackson County, MI.....
  
  27140........................ Jackson, MS............ 0.8172
  
  Copiah County, MS......
  
  Hinds County, MS.......
  
  Madison County, MS.....
  
  Rankin County, MS......
  
  Simpson County, MS.....
  
  27180........................ Jackson, TN............ 0.8149
  
  Chester County, TN.....
  
  Madison County, TN.....
  
  27260........................ Jacksonville, FL....... 0.8882
  
  Baker County, FL.......
  
  Clay County, FL........
  
  Duval County, FL.......
  
  Nassau County, FL......
  
  St. Johns County, FL...
  
  27340........................ Jacksonville, NC....... 0.8074
  
  Onslow County, NC......
  
  27500........................ Janesville, WI......... 0.9234
  
  Rock County, WI........
  
  27620........................ Jefferson City, MO..... 0.8222
  
  Callaway County, MO....
  
  Cole County, MO........
  
  Moniteau County, MO....
  
  Osage County, MO.......
  
  27740........................ Johnson City, TN....... 0.7796
  
  Carter County, TN......
  
  Unicoi County, TN......
  
  Washington County, TN..
  
  27780........................ Johnstown, PA.......... 0.8715
  
  Cambria County, PA.....
  
  27860........................ Jonesboro, AR.......... 0.7718
  
  Craighead County, AR...
  
  Poinsett County, AR....
  
  27900........................ Joplin, MO............. 0.8227
  
  Jasper County, MO......
  
  Newton County, MO......
  
  28020........................ Kalamazoo-Portage, MI.. 0.9939
  
  Kalamazoo County, MI...
  
  Van Buren County, MI...
  
  28100........................ Kankakee-Bradley, IL... 0.9807
  
  Kankakee County, IL....
  
  28140........................ Kansas City, MO-KS..... 0.9637
  
  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........
  
  Page 47254
  
  Clinton County, MO.....
  
  Jackson County, MO.....
  
  Lafayette County, MO...
  
  Platte County, MO......
  
  Ray County, MO.........
  
  28420........................ Kennewick-Pasco- 0.9582
  
  Richland, WA.
  
  Benton County, WA......
  
  Franklin County, WA....
  
  28660........................ Killeen-Temple-Fort 0.9501
  
  Hood, TX.
  
  Bell County, TX........
  
  Coryell County, TX.....
  
  Lampasas County, TX....
  
  28700........................ Kingsport-Bristol- 0.7399
  
  Bristol, TN-VA.
  
  Hawkins County, TN.....
  
  Sullivan County, TN....
  
  Bristol City, VA.......
  
  Scott County, VA.......
  
  Washington County, VA..
  
  28740........................ Kingston, NY........... 0.9170
  
  Ulster County, NY......
  
  28940........................ Knoxville, TN.......... 0.7838
  
  Anderson County, TN....
  
  Blount County, TN......
  
  Knox County, TN........
  
  Loudon County, TN......
  
  Union County, TN.......
  
  29020........................ Kokomo, IN............. 0.9186
  
  Howard County, IN......
  
  Tipton County, IN......
  
  29100........................ La Crosse, WI-MN....... 0.9685
  
  Houston County, MN.....
  
  La Crosse County, WI...
  
  29140........................ Lafayette, IN.......... 0.9507
  
  Benton County, IN......
  
  Carroll County, IN.....
  
  Tippecanoe County, IN..
  
  29180........................ Lafayette, LA.......... 0.8319
  
  Lafayette Parish, LA...
  
  St. Martin Parish, LA..
  
  29340........................ Lake Charles, LA....... 0.7998
  
  Calcasieu Parish, LA...
  
  Cameron Parish, LA.....
  
  29404........................ Lake County-Kenosha 1.0311
  
  County, IL-WI.
  
  Lake County, IL........
  
  Kenosha County, WI.....
  
  29420........................ Lake Havasu City- 0.9967
  
  Kingman, AZ.
  
  Mohave County, AZ......
  
  29460........................ Lakeland-Winter Haven, 0.8432
  
  FL.
  
  Polk County, FL........
  
  29540........................ Lancaster, PA.......... 0.9439
  
  Lancaster County, PA...
  
  29620........................ Lansing-East Lansing, 1.0477
  
  MI.
  
  Clinton County, MI.....
  
  Eaton County, MI.......
  
  Ingham County, MI......
  
  29700........................ Laredo, TX............. 0.7730
  
  Webb County, TX........
  
  29740........................ Las Cruces, NM......... 0.9106
  
  Dona Ana County, NM....
  
  29820........................ Las Vegas-Paradise, NV. 1.2050
  
  Clark County, NV.......
  
  29940........................ Lawrence, KS........... 0.8853
  
  Douglas County, KS.....
  
  30020........................ Lawton, OK............. 0.8545
  
  Comanche County, OK....
  
  30140........................ Lebanon, PA............ 0.8042
  
  Lebanon County, PA.....
  
  30300........................ Lewiston, ID-WA........ 0.9067
  
  Nez Perce County, ID...
  
  Asotin County, WA......
  
  30340........................ Lewiston-Auburn, ME.... 0.9038
  
  Page 47255
  
  Androscoggin County, ME
  
  30460........................ Lexington-Fayette, KY.. 0.8833
  
  Bourbon County, KY.....
  
  Clark County, KY.......
  
  Fayette County, KY.....
  
  Jessamine County, KY...
  
  Scott County, KY.......
  
  Woodford County, KY....
  
  30620........................ Lima, OH............... 0.9371
  
  Allen County, OH.......
  
  30700........................ Lincoln, NE............ 0.9612
  
  Lancaster County, NE...
  
  Seward County, NE......
  
  30780........................ Little Rock-North 0.8558
  
  Little Rock-Conway, AR.
  
  Faulkner County, AR....
  
  Grant County, AR.......
  
  Lonoke County, AR......
  
  Perry County, AR.......
  
  Pulaski County, AR.....
  
  Saline County, AR......
  
  30860........................ Logan, UT-ID........... 0.8592
  
  Franklin County, ID....
  
  Cache County, UT.......
  
  30980........................ Longview, TX........... 0.8530
  
  Gregg County, TX.......
  
  Rusk County, TX........
  
  Upshur County, TX......
  
  31020........................ Longview, WA........... 0.9989
  
  Cowlitz County, WA.....
  
  31084........................ Los Angeles-Long Beach- 1.2287
  
  Santa Ana, CA.
  
  Los Angeles County, CA.
  
  31140........................ Louisville-Jefferson 0.8900
  
  County, KY-IN.
  
  Clark County, IN.......
  
  Floyd County, IN.......
  
  Harrison County, IN....
  
  Washington County, IN..
  
  Bullitt County, KY.....
  
  Henry County, KY.......
  
  Meade County, KY.......
  
  Nelson County, KY......
  
  Oldham County, KY......
  
  Shelby County, KY......
  
  Spencer County, KY.....
  
  Trimble County, KY.....
  
  31180........................ Lubbock, TX............ 0.8794
  
  Crosby County, TX......
  
  Lubbock County, TX.....
  
  31340........................ Lynchburg, VA.......... 0.8768
  
  Amherst County, VA.....
  
  Appomattox County, VA..
  
  Bedford County, VA.....
  
  Campbell County, VA....
  
  Bedford City, VA.......
  
  Lynchburg City, VA.....
  
  31420........................ Macon, GA.............. 0.9122
  
  Bibb County, GA........
  
  Crawford County, GA....
  
  Jones County, GA.......
  
  Monroe County, GA......
  
  Twiggs County, GA......
  
  31460........................ Madera-Chowchilla, CA.. 0.8114
  
  Madera County, CA......
  
  31540........................ Madison, WI............ 1.1234
  
  Columbia County, WI....
  
  Dane County, WI........
  
  Iowa County, WI........
  
  31700........................ Manchester-Nashua, NH.. 1.0083
  
  Hillsborough County, NH
  
  31740........................ Manhattan, KS.......... 0.7912
  
  Geary County, KS.......
  
  Pottawatomie County, KS
  
  Page 47256
  
  Riley County, KS.......
  
  31860........................ Mankato-North Mankato, 0.9346
  
  MN.
  
  Blue Earth County, MN..
  
  Nicollet County, MN....
  
  31900........................ Mansfield, OH.......... 0.9215
  
  Richland County, OH....
  
  32420........................ Mayaguumlez, PR...... 0.3676
  
  Hormigueros Municipio,
  
  PR.
  
  Mayaguumlez
  
  Municipio, PR.
  
  32580........................ McAllen-Edinburg- 0.8878
  
  Mission, TX.
  
  Hidalgo County, TX.....
  
  32780........................ Medford, OR............ 1.0318
  
  Jackson County, OR.....
  
  32820........................ Memphis, TN-MS-AR...... 0.9275
  
  Crittenden County, AR..
  
  DeSoto County, MS......
  
  Marshall County, MS....
  
  Tate County, MS........
  
  Tunica County, MS......
  
  Fayette County, TN.....
  
  Shelby County, TN......
  
  Tipton County, TN......
  
  32900........................ Merced, CA............. 1.2424
  
  Merced County, CA......
  
  33124........................ Miami-Miami Beach- 1.0085
  
  Kendall, FL.
  
  Miami-Dade County, FL..
  
  33140........................ Michigan City-La Porte, 0.9358
  
  IN.
  
  LaPorte County, IN.....
  
  33260........................ Midland, TX............ 1.0514
  
  Midland County, TX.....
  
  33340........................ Milwaukee-Waukesha-West 0.9961
  
  Allis, WI.
  
  Milwaukee County, WI...
  
  Ozaukee County, WI.....
  
  Washington County, WI..
  
  Waukesha County, WI....
  
  33460........................ Minneapolis-St. Paul- 1.1105
  
  Bloomington, MN-WI.
  
  Anoka County, MN.......
  
  Carver County, MN......
  
  Chisago County, MN.....
  
  Dakota County, MN......
  
  Hennepin County, MN....
  
  Isanti County, MN......
  
  Ramsey County, MN......
  
  Scott County, MN.......
  
  Sherburne County, MN...
  
  Washington County, MN..
  
  Wright County, MN......
  
  Pierce County, WI......
  
  St. Croix County, WI...
  
  33540........................ Missoula, MT........... 0.9154
  
  Missoula County, MT....
  
  33660........................ Mobile, AL............. 0.8002
  
  Mobile County, AL......
  
  33700........................ Modesto, CA............ 1.2670
  
  Stanislaus County, CA..
  
  33740........................ Monroe, LA............. 0.7964
  
  Ouachita Parish, LA....
  
  Union Parish, LA.......
  
  33780........................ Monroe, MI............. 0.8727
  
  Monroe County, MI......
  
  33860........................ Montgomery, AL......... 0.8103
  
  Autauga County, AL.....
  
  Elmore County, AL......
  
  Lowndes County, AL.....
  
  Montgomery County, AL..
  
  34060........................ Morgantown, WV......... 0.8197
  
  Monongalia County, WV..
  
  Preston County, WV.....
  
  34100........................ Morristown, TN......... 0.7031
  
  Grainger County, TN....
  
  Hamblen County, TN.....
  
  Page 47257
  
  Jefferson County, TN...
  
  34580........................ Mount Vernon-Anacortes, 1.0235
  
  WA.
  
  Skagit County, WA......
  
  34620........................ Muncie, IN............. 0.7817
  
  Delaware County, IN....
  
  34740........................ Muskegon-Norton Shores, 0.9967
  
  MI.
  
  Muskegon County, MI....
  
  34820........................ Myrtle Beach-North 0.8653
  
  Myrtle Beach-Conway,
  
  SC.
  
  Horry County, SC.......
  
  34900........................ Napa, CA...............
  
  Napa County, CA........ 1.4511
  
  Horry County, SC.......
  
  34940........................ Naples-Marco Island, FL 0.9740
  
  Collier County, FL.....
  
  34980........................ Nashville-Davidson- 0.9340
  
  Murfreesboro-Franklin,
  
  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......
  
  35004........................ Nassau-Suffolk, NY..... 1.2416
  
  Nassau County, NY......
  
  Suffolk County, NY.....
  
  35084........................ Newark-Union, NJ-PA.... 1.1322
  
  Essex County, NJ.......
  
  Hunterdon County, NJ...
  
  Morris County, NJ......
  
  Sussex County, NJ......
  
  Union County, NJ.......
  
  Pike County, PA........
  
  35300........................ New Haven-Milford, CT.. 1.1556
  
  New Haven County, CT...
  
  35380........................ New Orleans-Metairie- 0.9026
  
  Kenner, LA.
  
  Jefferson Parish, LA...
  
  Orleans Parish, LA.....
  
  Plaquemines Parish, LA.
  
  St. Bernard Parish, LA.
  
  St. Charles Parish, LA.
  
  St. John the Baptist
  
  Parish, LA.
  
  St. Tammany Parish, LA.
  
  35644........................ New York-White Plains- 1.3052
  
  Wayne, NY-NJ.
  
  Bergen County, NJ......
  
  Hudson County, NJ......
  
  Passaic County, NJ.....
  
  Bronx County, NY.......
  
  Kings County, NY.......
  
  New York County, NY....
  
  Putnam County, NY......
  
  Queens County, NY......
  
  Richmond County, NY....
  
  Rockland County, NY....
  
  Westchester County, NY.
  
  35660........................ Niles-Benton Harbor, MI 0.8653
  
  Berrien County, MI.....
  
  35840........................ North Port-Bradenton- 0.9435
  
  Sarasota, FL.
  
  Manatee County, FL.....
  
  Sarasota County, FL....
  
  35980........................ Norwich-New London, CT. 1.1227
  
  New London County, CT..
  
  36084........................ Oakland-Fremont- 1.6080
  
  Hayward, CA.
  
  Alameda County, CA.....
  
  Contra Costa County, CA
  
  36100........................ Ocala, FL.............. 0.8449
  
  Page 47258
  
  Marion County, FL......
  
  36140........................ Ocean City, NJ......... 1.0641
  
  Cape May County, NJ....
  
  36220........................ Odessa, TX............. 0.9809
  
  Ector County, TX.......
  
  36260........................ Ogden-Clearfield, UT... 0.9220
  
  Davis County, UT.......
  
  Morgan County, UT......
  
  Weber County, UT.......
  
  36420........................ Oklahoma City, OK...... 0.8934
  
  Canadian County, OK....
  
  Cleveland County, OK...
  
  Grady County, OK.......
  
  Lincoln County, OK.....
  
  Logan County, OK.......
  
  McClain County, OK.....
  
  Oklahoma County, OK....
  
  36500........................ Olympia, WA............ 1.1339
  
  Thurston County, WA....
  
  36540........................ Omaha-Council Bluffs, 0.9864
  
  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..
  
  36740........................ Orlando-Kissimmee- 0.9128
  
  Sanford, FL.
  
  Lake County, FL........
  
  Orange County, FL......
  
  Osceola County, FL.....
  
  Seminole County, FL....
  
  36780........................ Oshkosh-Neenah, WI..... 0.9319
  
  Winnebago County, WI...
  
  36980........................ Owensboro, KY.......... 0.8202
  
  Daviess County, KY.....
  
  Hancock County, KY.....
  
  McLean County, KY......
  
  37100........................ Oxnard-Thousand Oaks- 1.2830
  
  Ventura, CA.
  
  Ventura County, CA.....
  
  37340........................ Palm Bay-Melbourne- 0.9042
  
  Titusville, FL.
  
  Brevard County, FL.....
  
  37380........................ Palm Coast, FL......... 0.9373
  
  Flagler County, FL.....
  
  37460........................ Panama City-Lynn Haven- 0.8388
  
  Panama City Beach, FL.
  
  Bay County, FL.........
  
  37620........................ Parkersburg-Marietta- 0.7647
  
  Vienna, WV-OH.
  
  Washington County, OH..
  
  Pleasants County, WV...
  
  Wirt County, WV........
  
  Wood County, WV........
  
  37700........................ Pascagoula, MS......... 0.7885
  
  George County, MS......
  
  Jackson County, MS.....
  
  37764........................ Peabody, MA............ 1.0698
  
  Essex County, MA.......
  
  37860........................ Pensacola-Ferry Pass- 0.8013
  
  Brent, FL.
  
  Escambia County, FL....
  
  Santa Rosa County, FL..
  
  37900........................ Peoria, IL............. 0.8830
  
  Marshall County, IL....
  
  Peoria County, IL......
  
  Stark County, IL.......
  
  Tazewell County, IL....
  
  Woodford County, IL....
  
  37964........................ Philadelphia, PA....... 1.0760
  
  Bucks County, PA.......
  
  Chester County, PA.....
  
  Delaware County, PA....
  
  Montgomery County, PA..
  
  Page 47259
  
  Philadelphia County, PA
  
  38060........................ Phoenix-Mesa-Glendale, 1.0566
  
  AZ.
  
  Maricopa County, AZ....
  
  Pinal County, AZ.......
  
  38220........................ Pine Bluff, AR......... 0.7700
  
  Cleveland County, AR...
  
  Jefferson County, AR...
  
  Lincoln County, AR.....
  
  38300........................ Pittsburgh, PA......... 0.8669
  
  Allegheny County, PA...
  
  Armstrong County, PA...
  
  Beaver County, PA......
  
  Butler County, PA......
  
  Fayette County, PA.....
  
  Washington County, PA..
  
  Westmoreland County, PA
  
  38340........................ Pittsfield, MA......... 1.0616
  
  Berkshire County, MA...
  
  38540........................ Pocatello, ID.......... 0.9426
  
  Bannock County, ID.....
  
  Power County, ID.......
  
  38660........................ Ponce, PR.............. 0.4185
  
  Juana Diacuteaz
  
  Municipio, PR.
  
  Ponce Municipio, PR....
  
  Villalba Municipio, PR.
  
  38860........................ Portland-South Portland- 0.9661
  
  Biddeford, ME.
  
  Cumberland County, ME..
  
  Sagadahoc County, ME...
  
  York County, ME........
  
  38900........................ Portland-Vancouver- 1.1454
  
  Hillsboro, OR-WA.
  
  Clackamas County, OR...
  
  Columbia County, OR....
  
  Multnomah County, OR...
  
  Washington County, OR..
  
  Yamhill County, OR.....
  
  Clark County, WA.......
  
  Skamania County, WA....
  
  38940........................ Port St. Lucie, FL..... 0.9784
  
  Martin County, FL......
  
  St. Lucie County, FL...
  
  39100........................ Poughkeepsie-Newburgh- 1.1339
  
  Middletown, NY.
  
  Dutchess County, NY....
  
  Orange County, NY......
  
  39140........................ Prescott, AZ........... 1.2261
  
  Yavapai County, AZ.....
  
  39300........................ Providence-New Bedford- 1.0639
  
  Fall River, RI-MA.
  
  Bristol County, MA.....
  
  Bristol County, RI.....
  
  Kent County, RI........
  
  Newport County, RI.....
  
  Providence County, RI..
  
  Washington County, RI..
  
  39340........................ Provo-Orem, UT......... 0.9404
  
  Juab County, UT........
  
  Utah County, UT........
  
  39380........................ Pueblo, CO............. 0.8668
  
  Pueblo County, CO......
  
  39460........................ Punta Gorda, FL........ 0.8801
  
  Charlotte County, FL...
  
  39540........................ Racine, WI............. 0.8630
  
  Racine County, WI......
  
  39580........................ Raleigh-Cary, NC....... 0.9648
  
  Franklin County, NC....
  
  Johnston County, NC....
  
  Wake County, NC........
  
  39660........................ Rapid City, SD......... 1.0203
  
  Meade County, SD.......
  
  Pennington County, SD..
  
  39740........................ Reading, PA............ 0.9212
  
  Berks County, PA.......
  
  39820........................ Redding, CA............ 1.5584
  
  Page 47260
  
  Shasta County, CA......
  
  39900........................ Reno-Sparks, NV........ 1.0596
  
  Storey County, NVWashoe
  
  County, NV.
  
  40060........................ Richmond, VA........... 0.9791
  
  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......
  
  40140........................ Riverside-San 1.1463
  
  Bernardino-Ontario, CA.
  
  Riverside County, CA...
  
  San Bernardino County,
  
  CA.
  
  40220........................ Roanoke, VA............ 0.9166
  
  Botetourt County, VA...
  
  Craig County, VA.......
  
  Franklin County, VA....
  
  Roanoke County, VA.....
  
  Roanoke City, VA.......
  
  Salem City, VA.........
  
  40340........................ Rochester, MN.......... 1.0802
  
  Dodge County, MN.......
  
  Olmsted County, MN.....
  
  Wabasha County, MN.....
  
  40380........................ Rochester, NY.......... 0.8602
  
  Livingston County, NY..
  
  Monroe County, NY......
  
  Ontario County, NY.....
  
  Orleans County, NY.....
  
  Wayne County, NY.......
  
  40420........................ Rockford, IL........... 0.9938
  
  Boone County, IL.......
  
  Winnebago County, IL...
  
  40484........................ Rockingham County- 1.0185
  
  Strafford County, NH.
  
  Rockingham County, NH..
  
  Strafford County, NH...
  
  40580........................ Rocky Mount, NC........ 0.9018
  
  Edgecombe County, NC...
  
  Nash County, NC........
  
  40660........................ Rome, GA............... 0.8838
  
  Floyd County, GA.......
  
  40900........................ Sacramento-Arden-Arcade- 1.3777
  
  Roseville, CA.
  
  El Dorado County, CA...
  
  Placer County, CA......
  
  Sacramento County, CA..
  
  Yolo County, CA........
  
  40980........................ Saginaw-Saginaw 0.8512
  
  Township North, MI.
  
  Saginaw County, MI.....
  
  41060........................ St. Cloud, MN.......... 1.0724
  
  Benton County, MN......
  
  Stearns County, MN.....
  
  41100........................ St. George, UT......... 0.9070
  
  Washington County, UT..
  
  41140........................ St. Joseph, MO-KS...... 1.0255
  
  Doniphan County, KS....
  
  Andrew County, MO......
  
  Buchanan County, MO....
  
  Page 47261
  
  DeKalb County, MO......
  
  41180........................ St. Louis, MO-IL....... 0.9165
  
  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.....
  
  41420........................ Salem, OR.............. 1.1224
  
  Marion County, OR......
  
  Polk County, OR........
  
  41500........................ Salinas, CA............ 1.5604
  
  Monterey County, CA....
  
  41540........................ Salisbury, MD.......... 0.9227
  
  Somerset County, MD....
  
  Wicomico County, MD....
  
  41620........................ Salt Lake City, UT..... 0.9415
  
  Salt Lake County, UT...
  
  Summit County, UT......
  
  Tooele County, UT......
  
  41660........................ San Angelo, TX......... 0.8273
  
  Irion County, TX.......
  
  Tom Green County, TX...
  
  41700........................ San Antonio-New 0.9006
  
  Braunfels, 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......
  
  41740........................ San Diego-Carlsbad-San 1.1950
  
  Marcos, CA.
  
  San Diego County, CA...
  
  41780........................ Sandusky, OH........... 0.8167
  
  Erie County, OH........
  
  41884........................ San Francisco-San Mateo- 1.5904
  
  Redwood City, CA.
  
  Marin County, CA.......
  
  San Francisco County,
  
  CA.
  
  San Mateo County, CA...
  
  41900........................ San Germaacuten-Cabo 0.4612
  
  Rojo, PR.
  
  Cabo Rojo Municipio, PR
  
  Lajas Municipio, PR....
  
  Sabana Grande
  
  Municipio, PR.
  
  San Germaacuten
  
  Municipio, PR.
  
  41940........................ San Jose-Sunnyvale- 1.6878
  
  Santa Clara, CA.
  
  San Benito County, CA..
  
  Santa Clara County, CA.
  
  41980........................ San Juan-Caguas- 0.4340
  
  Guaynabo, PR.
  
  Aguas Buenas Municipio,
  
  PR.
  
  Aibonito Municipio, PR.
  
  Arecibo Municipio, PR..
  
  Barceloneta Municipio,
  
  PR.
  
  Barranquitas Municipio,
  
  PR.
  
  Bayamoacuten
  
  Municipio, PR.
  
  Caguas Municipio, PR...
  
  Camuy Municipio, PR....
  
  Canoacutevanas
  
  Municipio, PR.
  
  Carolina Municipio, PR.
  
  Catantildeo
  
  Municipio, PR.
  
  Page 47262
  
  Cayey Municipio, PR....
  
  Ciales Municipio, PR...
  
  Cidra Municipio, PR....
  
  Comeriacuteo
  
  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.
  
  Loiacuteza Municipio,
  
  PR.
  
  Manatiacute
  
  Municipio, PR.
  
  Maunabo Municipio, PR..
  
  Morovis Municipio, PR..
  
  Naguabo Municipio, PR..
  
  Naranjito Municipio, PR
  
  Orocovis Municipio, PR.
  
  Quebradillas Municipio,
  
  PR.
  
  Riacuteo 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..
  
  42020........................ San Luis Obispo-Paso 1.3072
  
  Robles, CA.
  
  San Luis Obispo County,
  
  CA.
  
  42044........................ Santa Ana-Anaheim- 1.2042
  
  Irvine, CA.
  
  Orange County, CA......
  
  42060........................ Santa Barbara-Santa 1.2246
  
  Maria-Goleta, CA.
  
  Santa Barbara County,
  
  CA.
  
  42100........................ Santa Cruz-Watsonville, 1.7111
  
  CA.
  
  Santa Cruz County, CA..
  
  42140........................ Santa Fe, NM........... 1.0660
  
  Santa Fe County, NM....
  
  42220........................ Santa Rosa-Petaluma, CA 1.6102
  
  Sonoma County, CA......
  
  42340........................ Savannah, GA........... 0.9095
  
  Bryan County, GA.......
  
  Chatham County, GA.....
  
  Effingham County, GA...
  
  42540........................ Scranton-Wilkes-Barre, 0.8328
  
  PA.
  
  Lackawanna County, PA..
  
  Luzerne County, PA.....
  
  Wyoming County, PA.....
  
  42644........................ Seattle-Bellevue- 1.1541
  
  Everett, WA.
  
  King County, WA........
  
  Snohomish County, WA...
  
  42680........................ Sebastian-Vero Beach, 0.9032
  
  FL.
  
  Indian River County, FL
  
  43100........................ Sheboygan, WI.......... 0.9303
  
  Sheboygan County, WI...
  
  43300........................ Sherman-Denison, TX.... 0.8011
  
  Grayson County, TX.....
  
  43340........................ Shreveport-Bossier 0.8505
  
  City, LA.
  
  Bossier Parish, LA.....
  
  Caddo Parish, LA.......
  
  De Soto Parish, LA.....
  
  43580........................ Sioux City, IA-NE-SD... 0.9538
  
  Woodbury County, IA....
  
  Dakota County, NE......
  
  Dixon County, NE.......
  
  Union County, SD.......
  
  43620........................ Sioux Falls, SD........ 0.9153
  
  Lincoln County, SD.....
  
  McCook County, SD......
  
  Page 47263
  
  Minnehaha County, SD...
  
  Turner County, SD......
  
  43780........................ South Bend-Mishawaka, 0.9426
  
  IN-MI.
  
  St. Joseph County, IN..
  
  Cass County, MI........
  
  43900........................ Spartanburg, SC........ 0.9325
  
  Spartanburg County, SC.
  
  44060........................ Spokane, WA............ 1.0504
  
  Spokane County, WA.....
  
  44100........................ Springfield, IL........ 0.8958
  
  Menard County, IL......
  
  Sangamon County, IL....
  
  44140........................ Springfield, MA........ 1.0247
  
  Franklin County, MA....
  
  Hampden County, MA.....
  
  Hampshire County, MA...
  
  44180........................ Springfield, MO........ 0.8680
  
  Christian County, MO...
  
  Dallas County, MO......
  
  Greene County, MO......
  
  Polk County, MO........
  
  Webster County, MO.....
  
  44220........................ Springfield, OH........ 0.8981
  
  Clark County, OH.......
  
  44300........................ State College, PA...... 0.9251
  
  Centre County, PA......
  
  44600........................ Steubenville-Weirton, 0.7054
  
  OH-WV.
  
  Jefferson County, OH...
  
  Brooke County, WV......
  
  Hancock County, WV.....
  
  44700........................ Stockton, CA........... 1.3052
  
  San Joaquin County, CA.
  
  44940........................ Sumter, SC............. 0.7551
  
  Sumter County, SC......
  
  45060........................ Syracuse, NY........... 0.9776
  
  Madison County, NY.....
  
  Onondaga County, NY....
  
  Oswego County, NY......
  
  45104........................ Tacoma, WA............. 1.1384
  
  Pierce County, WA......
  
  45220........................ Tallahassee, FL........ 0.8593
  
  Gadsden County, FL.....
  
  Jefferson County, FL...
  
  Leon County, FL........
  
  Wakulla County, FL.....
  
  45300........................ Tampa-St. Petersburg- 0.9072
  
  Clearwater, FL.
  
  Hernando County, FL....
  
  Hillsborough County, FL
  
  Pasco County, FL.......
  
  Pinellas County, FL....
  
  45460........................ Terre Haute, IN........ 0.9209
  
  Clay County, IN........
  
  Sullivan County, IN....
  
  Vermillion County, IN..
  
  Vigo County, IN........
  
  45500........................ Texarkana, TX- 0.7937
  
  Texarkana, AR.
  
  Miller County, AR......
  
  Bowie County, TX.......
  
  45780........................ Toledo, OH............. 0.9148
  
  Fulton County, OH......
  
  Lucas County, OH.......
  
  Ottawa County, OH......
  
  Wood County, OH........
  
  45820........................ Topeka, KS............. 0.8818
  
  Jackson County, KS.....
  
  Jefferson County, KS...
  
  Osage County, KS.......
  
  Shawnee County, KS.....
  
  Wabaunsee County, KS...
  
  45940........................ Trenton-Ewing, NJ...... 1.0062
  
  Mercer County, NJ......
  
  Page 47264
  
  46060........................ Tucson, AZ............. 0.9318
  
  Pima County, AZ........
  
  46140........................ Tulsa, OK.............. 0.8362
  
  Creek County, OK.......
  
  Okmulgee County, OK....
  
  Osage County, OK.......
  
  Pawnee County, OK......
  
  Rogers County, OK......
  
  Tulsa County, OK.......
  
  Wagoner County, OK.....
  
  46220........................ Tuscaloosa, AL......... 0.8664
  
  Greene County, AL......
  
  Hale County, AL........
  
  Tuscaloosa County, AL..
  
  46340........................ Tyler, TX.............. 0.8335
  
  Smith County, TX.......
  
  46540........................ Utica-Rome, NY......... 0.8441
  
  Herkimer County, NY....
  
  Oneida County, NY......
  
  46660........................ Valdosta, GA........... 0.7997
  
  Brooks County, GA......
  
  Echols County, GA......
  
  Lanier County, GA......
  
  Lowndes County, GA.....
  
  46700........................ Vallejo-Fairfield, CA.. 1.4636
  
  Solano County, CA......
  
  47020........................ Victoria, TX........... 0.8434
  
  Calhoun County, TX.....
  
  Goliad County, TX......
  
  Victoria County, TX....
  
  47220........................ Vineland-Millville- 1.0222
  
  Bridgeton, NJ.
  
  Cumberland County, NJ..
  
  47260........................ Virginia Beach-Norfolk- 0.9001
  
  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..
  
  47300........................ Visalia-Porterville, CA 1.0343
  
  Tulare County, CA......
  
  47380........................ Waco, TX............... 0.8559
  
  McLennan County, TX....
  
  47580........................ Warner Robins, GA...... 0.8245
  
  Houston County, GA.....
  
  47644........................ Warren-Troy-Farmington 0.9625
  
  Hills, MI.
  
  Lapeer County, MI......
  
  Livingston County, MI..
  
  Macomb County, MI......
  
  Oakland County, MI.....
  
  St. Clair County, MI...
  
  47894........................ Washington-Arlington- 1.0807
  
  Alexandria, DC-VA-MD-
  
  WV.
  
  District of Columbia,
  
  DC.
  
  Calvert County, MD.....
  
  Charles County, MD.....
  
  Prince George's County,
  
  MD.
  
  Arlington County, VA...
  
  Clarke County, VA......
  
  Fairfax County, VA.....
  
  Fauquier County, VA....
  
  Loudoun County, VA.....
  
  Page 47265
  
  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...
  
  47940........................ Waterloo-Cedar Falls, 0.8372
  
  IA.
  
  Black Hawk County, IA..
  
  Bremer County, IA......
  
  Grundy County, IA......
  
  48140........................ Wausau, WI............. 0.8962
  
  Marathon County, WI....
  
  48300........................ Wenatchee-East 1.0168
  
  Wenatchee, WA.
  
  Chelan County, WA......
  
  Douglas County, WA.....
  
  48424........................ West Palm Beach-Boca 0.9823
  
  Raton-Boynton Beach,
  
  FL.
  
  Palm Beach County, FL..
  
  48540........................ Wheeling, WV-OH........ 0.6735
  
  Belmont County, OH.....
  
  Marshall County, WV....
  
  Ohio County, WV........
  
  48620........................ Wichita, KS............ 0.8696
  
  Butler County, KS......
  
  Harvey County, KS......
  
  Sedgwick County, KS....
  
  Sumner County, KS......
  
  48660........................ Wichita Falls, TX...... 1.0097
  
  Archer County, TX......
  
  Clay County, TX........
  
  Wichita County, TX.....
  
  48700........................ Williamsport, PA....... 0.8084
  
  Lycoming County, PA....
  
  48864........................ Wilmington, DE-MD-NJ... 1.0662
  
  New Castle County, DE..
  
  Cecil County, MD.......
  
  Salem County, NJ.......
  
  48900........................ Wilmington, NC......... 0.9107
  
  Brunswick County, NC...
  
  New Hanover County, NC.
  
  Pender County, NC......
  
  49020........................ Winchester, VA-WV...... 0.9106
  
  Frederick County, VA...
  
  Winchester City, VA....
  
  Hampshire County, WV...
  
  49180........................ Winston-Salem, NC...... 0.8343
  
  Davie County, NC.......
  
  Forsyth County, NC.....
  
  Stokes County, NC......
  
  Yadkin County, NC......
  
  49340........................ Worcester, MA.......... 1.1076
  
  Worcester County, MA...
  
  49420........................ Yakima, WA............. 1.0433
  
  Yakima County, WA......
  
  49500........................ Yauco, PR.............. 0.3757
  
  Guaacutenica
  
  Municipio, PR.
  
  Guayanilla Municipio,
  
  PR.
  
  Pentildeuelas
  
  Municipio, PR.
  
  Yauco Municipio, PR....
  
  49620........................ York-Hanover, PA....... 0.9675
  
  York County, PA........
  
  49660........................ Youngstown-Warren- 0.8328
  
  Boardman, OH-PA.
  
  Mahoning County, OH....
  
  Trumbull County, OH....
  
  Mercer County, PA......
  
  49700........................ Yuba City, CA.......... 1.1808
  
  Sutter County, CA......
  
  Page 47266
  
  Yuba County, CA........
  
  49740........................ Yuma, AZ............... 0.9350
  
  Yuma County, AZ........
  
  ------------------------------------------------------------------------
  
  \1\ At this time, there are no hospitals located in this urban area on
  
  which to base a wage index.
  
  Table 2--FY 2013 Wage Index Based on CBSA Labor Market Areas for Rural
  
  Areas
  
  ------------------------------------------------------------------------
  
  State code Nonurban area Wage index
  
  ------------------------------------------------------------------------
  
  1............................ Alabama................ 0.7260
  
  2............................ Alaska................. 1.2846
  
  3............................ Arizona................ 0.8826
  
  4............................ Arkansas............... 0.7194
  
  5............................ California............. 1.2194
  
  6............................ Colorado............... 1.0126
  
  7............................ Connecticut............ 1.1287
  
  8............................ Delaware............... 1.0008
  
  10........................... Florida................ 0.8361
  
  11........................... Georgia................ 0.7547
  
  12........................... Hawaii................. 1.1200
  
  13........................... Idaho.................. 0.7531
  
  14........................... Illinois............... 0.8426
  
  15........................... Indiana................ 0.8551
  
  16........................... Iowa................... 0.8618
  
  17........................... Kansas................. 0.8041
  
  18........................... Kentucky............... 0.7825
  
  19........................... Louisiana.............. 0.7749
  
  20........................... Maine.................. 0.8581
  
  21........................... Maryland............... 0.9291
  
  22........................... Massachusetts \1\...... 1.3962
  
  23........................... Michigan............... 0.8295
  
  24........................... Minnesota.............. 0.9107
  
  25........................... Mississippi............ 0.7539
  
  26........................... Missouri............... 0.7673
  
  27........................... Montana................ 0.8615
  
  28........................... Nebraska............... 0.8872
  
  29........................... Nevada................. 0.9637
  
  30........................... New Hampshire.......... 1.0441
  
  31........................... New Jersey \1\......... ................
  
  32........................... New Mexico............. 0.8878
  
  33........................... New York............... 0.8152
  
  34........................... North Carolina......... 0.8288
  
  35........................... North Dakota........... 0.7295
  
  36........................... Ohio................... 0.8455
  
  37........................... Oklahoma............... 0.7848
  
  38........................... Oregon................. 1.0337
  
  39........................... Pennsylvania........... 0.8450
  
  40........................... Puerto Rico \1\........ 0.4047
  
  41........................... Rhode Island \1\....... ................
  
  42........................... South Carolina......... 0.8277
  
  43........................... South Dakota........... 0.8300
  
  44........................... Tennessee.............. 0.7734
  
  45........................... Texas.................. 0.7934
  
  46........................... Utah................... 0.8719
  
  47........................... Vermont................ 0.9709
  
  48........................... Virgin Islands......... 0.7505
  
  49........................... Virginia............... 0.7817
  
  50........................... Washington............. 1.0231
  
  51........................... West Virginia.......... 0.7371
  
  52........................... Wisconsin.............. 0.8977
  
  53........................... Wyoming................ 0.9433
  
  65........................... Guam................... 0.9611
  
  ------------------------------------------------------------------------
  
  \1\ All counties within the State are classified as urban, with the
  
  exception of Puerto Rico. Puerto Rico has areas designated as rural;
  
  however, no short-term, acute care hospitals are located in the
  
  area(s) for FY 2013. The rural Massachusetts wage index is calculated
  
  as the average of all contiguous CBSAs. The Puerto Rico wage index is
  
  the same as FY 2012.
  
  FR Doc. 2012-19118 Filed 8-2-12; 4:15 pm
  
  BILLING CODE 4120-01-P

Subscribers can access the reported version of this case.

You can sign up for a trial and make the most of our service including these benefits.

Request your trial

Why Sign-up to vLex?

Over 100 Countries

Search over 120 million documents from over 100 countries including primary and secondary collections of legislation, case law, regulations, practical law, news, forms and contracts, books, journals, and more.
Thousands of Data Sources

Updated daily, vLex brings together legal information from over 750 publishing partners, providing access to over 2,500 legal and news sources from the world’s leading publishers.
Find What You Need, Quickly

Advanced A.I. technology developed exclusively by vLex editorially enriches legal information to make it accessible, with instant translation into 14 languages for enhanced discoverability and comparative research.
Over 2 million registered users

Founded over 20 years ago, vLex provides a first-class and comprehensive service for lawyers, law firms, government departments, and law schools around the world.

Subscribers are able to see a list of all the cited cases and legislation of a document.

You can sign up for a trial and make the most of our service including these benefits.

Request your trial

Why Sign-up to vLex?

Over 100 Countries

Search over 120 million documents from over 100 countries including primary and secondary collections of legislation, case law, regulations, practical law, news, forms and contracts, books, journals, and more.
Thousands of Data Sources

Updated daily, vLex brings together legal information from over 750 publishing partners, providing access to over 2,500 legal and news sources from the world’s leading publishers.
Find What You Need, Quickly

Advanced A.I. technology developed exclusively by vLex editorially enriches legal information to make it accessible, with instant translation into 14 languages for enhanced discoverability and comparative research.
Over 2 million registered users

Founded over 20 years ago, vLex provides a first-class and comprehensive service for lawyers, law firms, government departments, and law schools around the world.

Subscribers are able to see a list of all the documents that have cited the case.

You can sign up for a trial and make the most of our service including these benefits.

Request your trial

Why Sign-up to vLex?

Over 100 Countries

Search over 120 million documents from over 100 countries including primary and secondary collections of legislation, case law, regulations, practical law, news, forms and contracts, books, journals, and more.
Thousands of Data Sources

Updated daily, vLex brings together legal information from over 750 publishing partners, providing access to over 2,500 legal and news sources from the world’s leading publishers.
Find What You Need, Quickly

Advanced A.I. technology developed exclusively by vLex editorially enriches legal information to make it accessible, with instant translation into 14 languages for enhanced discoverability and comparative research.
Over 2 million registered users

Founded over 20 years ago, vLex provides a first-class and comprehensive service for lawyers, law firms, government departments, and law schools around the world.

Subscribers are able to see the revised versions of legislation with amendments.

You can sign up for a trial and make the most of our service including these benefits.

Request your trial

Why Sign-up to vLex?

Over 100 Countries

Search over 120 million documents from over 100 countries including primary and secondary collections of legislation, case law, regulations, practical law, news, forms and contracts, books, journals, and more.
Thousands of Data Sources

Updated daily, vLex brings together legal information from over 750 publishing partners, providing access to over 2,500 legal and news sources from the world’s leading publishers.
Find What You Need, Quickly

Advanced A.I. technology developed exclusively by vLex editorially enriches legal information to make it accessible, with instant translation into 14 languages for enhanced discoverability and comparative research.
Over 2 million registered users

Founded over 20 years ago, vLex provides a first-class and comprehensive service for lawyers, law firms, government departments, and law schools around the world.

Subscribers are able to see any amendments made to the case.

You can sign up for a trial and make the most of our service including these benefits.

Request your trial

Why Sign-up to vLex?

Over 100 Countries

Search over 120 million documents from over 100 countries including primary and secondary collections of legislation, case law, regulations, practical law, news, forms and contracts, books, journals, and more.
Thousands of Data Sources

Updated daily, vLex brings together legal information from over 750 publishing partners, providing access to over 2,500 legal and news sources from the world’s leading publishers.
Find What You Need, Quickly

Advanced A.I. technology developed exclusively by vLex editorially enriches legal information to make it accessible, with instant translation into 14 languages for enhanced discoverability and comparative research.
Over 2 million registered users

Founded over 20 years ago, vLex provides a first-class and comprehensive service for lawyers, law firms, government departments, and law schools around the world.

Subscribers are able to see a visualisation of a case and its relationships to other cases. An alternative to lists of cases, the Precedent Map makes it easier to establish which ones may be of most relevance to your research and prioritise further reading. You also get a useful overview of how the case was received.

Request your trial

Why Sign-up to vLex?

Over 100 Countries

Search over 120 million documents from over 100 countries including primary and secondary collections of legislation, case law, regulations, practical law, news, forms and contracts, books, journals, and more.
Thousands of Data Sources

Updated daily, vLex brings together legal information from over 750 publishing partners, providing access to over 2,500 legal and news sources from the world’s leading publishers.
Find What You Need, Quickly

Advanced A.I. technology developed exclusively by vLex editorially enriches legal information to make it accessible, with instant translation into 14 languages for enhanced discoverability and comparative research.
Over 2 million registered users

Founded over 20 years ago, vLex provides a first-class and comprehensive service for lawyers, law firms, government departments, and law schools around the world.

Subscribers are able to see the list of results connected to your document through the topics and citations Vincent found.

You can sign up for a trial and make the most of our service including these benefits.

Request your trial

Why Sign-up to vLex?

Over 100 Countries

Search over 120 million documents from over 100 countries including primary and secondary collections of legislation, case law, regulations, practical law, news, forms and contracts, books, journals, and more.
Thousands of Data Sources

Updated daily, vLex brings together legal information from over 750 publishing partners, providing access to over 2,500 legal and news sources from the world’s leading publishers.
Find What You Need, Quickly

Advanced A.I. technology developed exclusively by vLex editorially enriches legal information to make it accessible, with instant translation into 14 languages for enhanced discoverability and comparative research.
Over 2 million registered users

Founded over 20 years ago, vLex provides a first-class and comprehensive service for lawyers, law firms, government departments, and law schools around the world.

Medicare Program; Inpatient Psychiatric Facilities Prospective Payment System-Update for Fiscal Year Beginning October 1, 2012 (FY 2013)

You can sign up for a trial and make the most of our service including these benefits.

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users

You can sign up for a trial and make the most of our service including these benefits.

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users

You can sign up for a trial and make the most of our service including these benefits.

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users

You can sign up for a trial and make the most of our service including these benefits.

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users

You can sign up for a trial and make the most of our service including these benefits.

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users

You can sign up for a trial and make the most of our service including these benefits.

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users