Medicare: Hospice wage index,

[Federal Register: October 5, 1998 (Volume 63, Number 192)]

[Notices]

[Page 53446-53456]

From the Federal Register Online via GPO Access [wais.access.gpo.gov]

[DOCID:fr05oc98-87]

[[Page 53446]]

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

[HCFA-1039-N]

RIN 0938-AI87

Medicare Program; Hospice Wage Index

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Notice.

SUMMARY: This notice announces the annual update to the hospice wage index as required by 42 CFR 418.306(c). This update is effective October 1, 1998. The wage index is used to reflect local differences in wage levels. The hospice wage index methodology and values are based on recommendations of a negotiated rulemaking advisory committee and were originally published in the Federal Register on August 8, 1997. This update is the second year of a 3-year transition period. The second transition year begins October 1, 1998 and ends September 30, 1999.

EFFECTIVE DATE: This notice is effective on October 1, 1998.

FOR FURTHER INFORMATION CONTACT: Carol Blackford, (410) 786-5909.

SUPPLEMENTARY INFORMATION:

1. Background

   1. Statute and Regulations

      Hospice Care is an approach to treatment that recognizes that the impending death of an individual warrants a change in the focus from curative care to palliative care (relief of pain and other uncomfortable symptoms). The goal of hospice care is to help terminally ill individuals continue life with minimal disruption to normal activities while remaining primarily in the home environment. A hospice uses an interdisciplinary approach to deliver medical, social, psychological, emotional, and spiritual services through use of a broad spectrum of professional and other caregivers, with the goal of making the individual as physically and emotionally comfortable as possible. Counseling and respite services are available to the family of the hospice patient. Hospice programs consider both the patient and the family as a unit of care.

      Section 1861(dd) of the Social Security Act (the Act) provides for coverage of hospice care for terminally ill Medicare beneficiaries who elect to receive care from a participating hospice. The statutory authority for payment to hospices participating in the Medicare program is contained in section 1814(i) of the Act.

      Our existing regulations under 42 CFR Part 418 (issued on December 16, 1983, effective for hospice services furnished on or after November 1, 1983) establish eligibility requirements and payment standards and procedures, define covered services, and delineate the conditions a hospice must meet to be approved for participation in the Medicare program. Subpart G of Part 418 provides for payment to hospices based on one of four prospectively determined rates for each day in which a qualified Medicare beneficiary is under the care of a hospice. The four rate categories are routine home care, continuous home care, inpatient respite care, and general inpatient care. Payment rates are established for each category.

      The regulations at Sec. 418.306(c), which require the rates to be adjusted by a wage index, were revised on August 8, 1997, through publication of a final rule in the Federal Register (62 FR 42860). This rule implemented a new methodology for calculating the hospice wage index that was based on the recommendations of a negotiated rulemaking committee. The committee reached consensus on a methodology and the resulting committee statement, describing that consensus, was included as an attachment to the August 8, 1997 final hospice wage index rule. The provisions of the final hospice wage index rule are as follows:

      ‹bullet› The revised hospice wage index will be phased in over a 3- year transition period. For the first year of the transition period, a blended index was calculated by adding two-thirds of the 1983 index value for an area to one-third of the revised wage index value for that area. During the second year of the transition period, the calculation is similar, except that the blend is one-third of the 1983 index value and two-thirds of the revised wage index value for that area. During the third transition year the revised wage index will be fully implemented. The first transition year occurred October 1, 1997 through September 30, 1998.

      ‹bullet› All hospice wage index values of 0.8 or greater are subject to a budget neutrality adjustment to ensure that Medicare does not pay any more in the aggregate than it would with the previous wage index. The budget neutrality adjustment is calculated by multiplying the hospice wage index for a given area by the budget neutrality adjustment factor. The budget neutrality adjustment is to be applied annually, both during and after the transition period.

      ‹bullet› All hospice wage index values below 0.8 receive the greater of the following adjustments: the wage index floor, a 15 percent increase, subject to a maximum wage index value of 0.8; or, the budget neutrality adjustment.

      ‹bullet› The wage index is to be updated annually, in the Federal Register, based on the most current available hospital wage data.

      ‹bullet› Because the Virgin Islands is not an area designated under the Prospective Payment System for hospitals, and does not have a hospital wage index, the hospice wage index for the Virgin Islands will be calculated by gathering information from the hospital cost report and comparing hourly wages of the hospital located in the Virgin Islands to the national average, as described in step 9 of item III(A) (computation of the hospice wage index) in the proposed hospice wage index rule published in the Federal Register on September 4, 1996 (61 FR 46583).

      Section 4442 of the Balanced Budget Act of 1997 requires payment for routine and continuous home care to be made based on the geographic location at which the service is furnished. The site of service provision, as it is commonly referred to, was effective October 1, 1997 and was implemented through a Program Memorandum issued in September of 1997. This notice does not address implementation of the site of service provision but merely takes this change into account when analyzing the impact of the annual hospice wage index update.

   2. Update to the Hospice Wage Index

      The second year of the 3-year transition period begins October 1, 1998 and ends September 30, 1999. In accordance with the agreement signed by HCFA and all other members of the Hospice Wage Index Negotiated Rulemaking Committee, we are using the most current HCFA hospital data available, including any changes to the definitions of MSAs, that allow us to publish this notice at least 4 months in advance of the October 1, 1998 effective date. We will be using the 1997 hospital area wage index. Updated wage index values have been calculated by adding one-third of the 1983 index value for each area to two-thirds of the new wage index value. All wage index values are adjusted by a budget neutrality factor of 1.04662 and are subject to the wage index floor adjustment, if applicable. All of the calculations described above have been completed by HCFA and are built into the wage index values

      [[Page 53447]]

      reflected in both Tables A and B below. At this time, there are no Medicare certified hospices located in the Virgin Islands. Therefore, a wage index value for the Virgin Islands has not been calculated.

   3. Tables

      Table A.--Hospice Wage Index for Urban Areas

      Urban area (constituent counties Wage MSA code number

      or county equivalents)

      index

      \1\-- 0040........................ Abilene, TX..................... 0.9066 Taylor, TX 0060........................ Aguadilla, PR................... 0.5905 Aguada, PR Aguadilla, PR Moca, PR 0080........................ Akron, OH....................... 1.0563 Portage, OH Summit, OH 0120........................ Albany, GA...................... 0.8629 Dougherty, GA Lee, GA 0160........................ Albany-Schenectady-Troy, NY..... 0.9030 Albany, NY Montgomery, NY Rensselaer, NY Saratoga, NY Schenectady, NY Schoharie, NY 01606....................... Albany-Schenectady-Troy, NY..... 0.8958 Schoharie, NY 0200........................ Albuquerque, NM................. 0.9737 Sandoval, NM Valencia, NM 02006....................... Albuquerque, NM................. 1.0186 Bernalillo, NM 0220........................ Alexandria, LA.................. 0.9091 Rapides, LA 0240........................ Allentown-Bethlehem-Easton, PA.. 1.0707 Carbon, PA Lehigh, PA Northampton, PA 0280........................ Altoona, PA..................... 0.9951 Blair, PA 0320........................ Amarillo, TX.................... 0.9959 Potter, TX Randall, TX 0380........................ Anchorage, AK................... 1.4074 Anchorage, AK 0440........................ Ann Arbor, MI................... 1.1528 Lenawee, MI 04406....................... Ann Arbor, MI................... 1.2441 Washtenaw, MI 04407....................... Ann Arbor, MI................... 1.2406 Livingston, MI 0450........................ Anniston, AL.................... 0.8776 Calhoun, AL 0460........................ Appleton-Oshkosh-Neenah, WI..... 0.9662 Calumet, WI Outagamie, WI Winnebago, WI 0470........................ Arecibo, PR..................... 0.5905 Arecibo, PR Camuy, PR Hatillo, PR 0480........................ Asheville, NC................... 0.9296 Madison, NC 04806....................... Asheville, NC................... 0.9647 Buncombe, NC 0500........................ Athens, GA...................... 0.9416 Clarke, GA Madison, GA Oconee, GA 0520........................ Atlanta, GA..................... 1.0139 Barrow, GA Cherokee, GA Clayton, GA Cobb, GA Coweta, GA DeKalb, GA Douglas, GA Fayette, GA Forsyth, GA Fulton, GA Gwinnett, GA Henry, GA Newton, GA Paulding, GA Rockdale, GA Spalding, GA Walton, GA 05206....................... Atlanta, GA..................... 0.9820 Bartow, GA Carroll, GA Pickens, GA 0560........................ Atlantic-Cape May, NJ........... 1.1498 Atlantic City, NJ Cape May, NJ 0600........................ Augusta-Aiken, GA-SC............ 0.9866 Columbia, GA McDuffie, GA Richmond, GA Aiken, SC 06006....................... Augusta-Aiken, GA-SC............ 0.9333 Edgefield, SC 0640........................ Austin-San Marcos, TX........... 0.9206 Bastrop, TX Caldwell, TX 06406....................... Austin-San Marcos, TX........... 1.0067 Hays, TX Travis, TX Williamson, TX 0680........................ Bakersfield, CA................. 1.1268 Kern, CA 0720........................ Baltimore, MD................... 1.0549 Anne Arundel, MD Baltimore, MD Baltimore City, MD Carroll, MD Harford, MD Howard, MD Queen Anne's, MD 0733........................ Bangor, ME...................... 0.9847 Penobscot, ME 0743........................ Barnstable-Yarmouth, MA......... 1.3359 Barnstable, MA 0760........................ Baton Rouge, LA................. 0.9398 Ascension, LA East Baton Rouge, LA Livingston, LA West Baton Rouge, LA 0840........................ Beaumont-Port Arthur, TX........ 0.9440 Hardin, TX Jefferson, TX Orange, TX 0860........................ Bellingham, WA.................. 1.1508 Whatcom, WA 0870........................ Benton Harbor, MI............... 0.9273 Berrien, NJ 0875........................ Bergen-Passaic, NJ.............. 1.2072 Bergen, NJ Passaic, NJ 0880........................ Billings, MT.................... 1.0192 Yellowstone, MT 0920........................ Biloxi-Gulfport-Pascagoula, MS.. 0.8910 Hancock, MS Harrison, MS 09206....................... Biloxi-Gulfport-Pascagoula, MS.. 0.9409 Jackson, MS 0960........................ Binghamton, NY.................. 0.9543 Broome, NY Tioga, NY 1000........................ Birmingham, AL.................. 0.9788 Blount, AL Jefferson, AL St. Clair, AL Shelby, AL 1010........................ Bismarck, ND.................... 0.8893 Burleigh, ND Morton, ND 1020........................ Bloomington, IN................. 0.9559 Monroe, IN 1040........................ Bloomington-Normal, IL.......... 0.9630 McLean, IL 1080........................ Boise City, ID.................. 0.9320 Canyon, ID 10806....................... Boise City, ID.................. 0.9931 Ada, ID 1123........................ Boston-Worcester-Lawrence-Lowell- 1.1805 Brockton, MA-NH. Essex, MA Middlesex, MA Norfolk, MA Plymouth, MA Suffolk, MA 11236....................... Boston-Worcester-Lawrence-Lowell- 1.1246 Brockton, MA-NH. Hillsborough, NH Merrimack, NH 11237....................... Boston-Worcester-Lawrence-Lowell- 1.1356 Brockton, MA-NH. Bristol, MA 11238....................... Boston-Worcester-Lawrence-Lowell- 1.0935 Brockton, MA-NH. Rockingham, NH Strafford, NH 11239....................... Boston-Worcester-Lawrence-Lowell- 1.1394 Brockton, MA-NH. Worcester, MA 1125........................ Boulder-Longmont, CO............ 1.0470 Boulder, CO 1145........................ Brazoria, TX.................... 0.9451 Brazoria, TX 1150........................ Bremerton, WA................... 1.0810 Kitsap, WA

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      1240........................ Brownsville-Harlingen-San

      0.9314 Benito, TX. Cameron, TX 1260........................ Bryan-College Station, TX....... 0.9147 Brazos, TX 1280........................ Buffalo-Niagara Falls, NY....... 0.9884 Erie, NY 12806....................... Buffalo-Niagara Falls, NY....... 0.9519 Niagara, NY 1303........................ Burlington, VT.................. 1.1037 Franklin, VT 13036....................... Burlington, VT.................. 1.0444 Chittenden, VT Grand Isle, VT 1310........................ Caguas, PR...................... 0.6085 Caguas, PR Cayey, PR Cidra, PR Gurabo, PR San Lorenzo, PR 1320........................ Canton-Massillon, OH............ 0.9670 Carroll, OH Stark, OH 1350........................ Casper, WY...................... 0.9866 Natrona, WY 1360........................ Cedar Rapids, IA................ 0.9223 Linn, IA 1400........................ Champaign-Urbana, IL............ 0.9731 Champaign, IL 1440........................ Charleston-North Charleston, SC. 0.9725 Berkeley, SC Charleston, SC Dorchester, SC 1480........................ Charleston, WV.................. 1.0228 Kanawha, WV Putnam, WV 1520........................ Charlotte-Gastonia-Rock Hill, NC- 1.0186 SC. Cabarrus, NC Gaston, NC Lincoln, NC Mecklenburg, NC Rowan, NC Stanly, NC Union, NC York, SC 1540........................ Charlottesville, VA............. 1.0824 Albemarle, VA Charlottesville City, VA Fluvanna, VA Greene, VA 1560........................ Chattanooga, TN-GA.............. 0.9415 Catoosa, GA Dade, GA Walker, GA Hamilton, TN Marion, TN 1580........................ Cheyenne, WY.................... 0.9091 Laramie, WY 1600........................ Chicago, IL..................... 1.0607 DeKalb, IL 16006....................... Chicago, IL..................... 1.1051 Kane, IL Kendall, IL 16007....................... Chicago, IL..................... 1.1832 Cook, IL Du Page, IL McHenry, IL 16008....................... Chicago, IL..................... 1.1378 Grundy, IL Will, IL 16009....................... Chicago, IL..................... 1.1445 Lake, IL 1620........................ Chico-Paradise, CA.............. 1.0960 Butte, CA 1640........................ Cincinnati, OH-KY-IN............ 0.9617 Ohio, IN 16406....................... Cincinnati, OH-KY-IN............ 0.9455 Gallatin, KY Grant, KY Pendleton, KY 16407....................... Cincinnati, OH-KY-IN............ 0.9801 Brown, OH 16408....................... Cincinnati, OH-KY-IN............ 1.0294 Dearborn, IN Boone, KY Campbell, KY Kenton, KY Clermont, OH Hamilton, OH Warren, OH 1660........................ Clarksville-Hopkinsville, TN-KY. 0.8389 Christian, KY Montgomery, TN 1680........................ Cleveland-Lorain-Elyria, OH..... 1.0031 Ashtabula, OH 16806....................... Cleveland-Lorain-Elyria, OH..... 1.1037 Cuyahoga, OH Geauga, OH Lake, OH Medina, OH 16807....................... Cleveland-Lorain-Elyria, OH..... 1.0521 Lorain, OH 1720........................ Colorado Springs, CO............ 1.0362 El Paso, CO 1740........................ Columbia, MO.................... 1.0242 Boone, MO 1760........................ Columbia, SC.................... 0.9764 Lexington, SC Richland, SC 1800........................ Harris, GA...................... 0.8749 18006....................... Columbus, GA-AL................. 0.8992 Russell, AL Chattahoochee, GA Muscogee, GA 1840........................ Columbus, OH.................... 1.0469 Delaware, OH Fairfield, OH Franklin, OH Licking, OH Madison, OH Pickaway, OH 1880........................ Corpus Christi, TX.............. 0.9607 Nueces, TX San Patricio, TX 1900........................ Cumberland, MD-WV............... 0.9456 Allegany, MD Mineral, WV 1920........................ Dallas, TX...................... 1.0529 Collin, TX Dallas, TX Denton, TX Ellis, TX Kaufman, TX Rockwall, TX 19206....................... Dallas, TX...................... 0.9604 Henderson, TX Hunt, TX 1950........................ Danville, VA.................... 0.8719 Danville City, VA Pittsylvania, VA 1960........................ Davenport-Moline-Rock Island, IA- 0.9291 IL. Scott, IA Henry, IL Rock Island, IL 2000........................ Dayton-Springfield, OH.......... 1.0565 Clark, OH Greene, OH Miami, OH Montgomery, OH 2020........................ Daytona Beach, FL............... 0.9209 Flagler, FL 20206....................... Daytona Beach, FL............... 0.9548 Volusia, FL 2030........................ Decatur, AL..................... 0.8572 Lawrence, AL Morgan, AL 2040........................ Decatur, IL..................... 0.8952 Macon, IL 2080........................ Denver, CO...................... 1.1482 Adams, CO Arapahoe, CO Denver, CO Douglas, CO Jefferson, CO 2120........................ Des Moines, IA.................. 0.9902 Dallas, IA Polk, IA Warren, IA 2160........................ Detroit, MI..................... 1.1737 Lapeer, MI Macomb, MI Monroe, MI Oakland, MI St. Clair, MI Wayne, MI 2180........................ Dothan, AL...................... 0.8717 Dale, AL Houston, AL 2190........................ Dover, DE....................... 0.9636 Kent, DE 2200........................ Dubuque, IA..................... 0.9230 Dubuque, IA 2240........................ Duluth-Superior, MN-WI.......... 1.0017 St. Louis, MN Douglas, WI 2281........................ Dutchess County, NY............. 1.1228 Dutchess, NY 2290........................ Eau Claire, WI.................. 0.9500 Chippewa, WI Eau Claire, WI 2320........................ El Paso, TX..................... 1.0200 El Paso, TX 2330........................ Elkhart-Goshen, IN.............. 0.9443 Elkhart, IN 2335........................ Elmira, NY...................... 0.9440 Chemung, NY 2340........................ Enid, OK........................ 0.8701

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      Garfield, OK 2360........................ Erie, PA........................ 0.9647 Erie, PA 2400........................ Eugene-Springfield, OR.......... 1.1426 Lane, OR 2440........................ Evansville-Henderson, IN-KY..... 0.9550 Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY 2520........................ Fargo-Moorhead, ND-MN........... 0.9672 Clay, MN Cass, ND 2560........................ Fayetteville, NC................ 0.9347 Cumberland, NC 2580........................ Fayetteville-Springdale-Rogers, 0.8000 AR. Benton, AR 2580........................ Fayetteville-Springdale-Rogers, 0.8102 AR. Washington, AR 2620........................ Flagstaff, AZ-UT................ 0.9482 Coconino, AZ 26206....................... Flagstaff, AZ-UT................ 0.9242 Kane, UT 2640........................ Flint, MI....................... 1.1814 Genesee, MI 2650........................ Florence, AL.................... 0.8029 Colbert, AL Lauderdale, AL 2655........................ Florence, SC.................... 0.8894 Florence, SC 2670........................ Fort Collins-Loveland, CO....... 1.0387 Larimer, CO 2680........................ Ft. Lauderdale, FL.............. 1.1164 Broward, FL 2700........................ Fort Myers-Cape Coral, FL....... 0.9391 Lee, FL 2710........................ Fort Pierce-Port St. Lucie, FL.. 1.0625 Martin, FL St. Lucie, FL 2720........................ Fort Smith, AR-OK............... 0.8806 Crawford, AR Sebastian, AR Sequoyah, OK 2750........................ Fort Walton Beach, FL........... 0.8958 Okaloosa, FL 2760........................ Fort Wayne, IN.................. 0.9217 Adams, IN Huntington, IN Wells, IN 2760........................ Fort Wayne, IN.................. 0.9506 Allen, IN De Kalb, IN Whitley, IN 2800........................ Forth Worth-Arlington, TX....... 0.9797 Hood, TX 28006....................... Forth Worth-Arlington, TX....... 1.0201 Johnson, TX Parker, TX Tarrant, TX 2840........................ Fresno, CA...................... 1.0927 Madera, CA 28406....................... Fresno, CA...................... 1.1570 Fresno, CA 2880........................ Gadsden, AL..................... 0.9372 Etowah, AL 2900........................ Gainesville, FL................. 1.0097 Alachua, FL 2920........................ Galveston-Texas City, TX........ 1.1495 Galveston, TX 2960........................ Gary, IN........................ 1.0636 Lake, IN Porter, IN 2975........................ Glens Falls, NY................. 0.8936 Warren, NY Washington, NY 2980........................ Goldsboro, NC................... 0.8857 Wayne, NC 2985........................ Grand Forks, ND-MN.............. 0.9098 Polk, MN 29856....................... Grand Forks, ND-MN.............. 0.9507 Grand Forks, ND 2995........................ Grand Junction, CO.............. 0.9246 Mesa, CO 3000........................ Grand Rapids-Muskegon-Holland, 1.0385 MI. Allegan, MI 30006....................... Grand Rapids-Muskegon-Holland, 1.0568 MI. Kent, MI Ottawa, MI 30007....................... Grand Rapids-Muskegon-Holland, 1.0333 MI. Muskegon, MI 3040........................ Great Falls, MT................. 0.9738 Cascade, MT 3060........................ Greeley, CO..................... 1.0823 Weld, CO 3080........................ Green Bay, WI................... 0.9827 Brown, WI 3120........................ Greensboro-Winston-Salem-High 0.9866 Point, NC. Davidson, NC Davie, NC Forsyth, NC Guilford, NC Randolph, NC Stokes, NC Yadkin, NC 31206....................... Greensboro-Winston-Salem-High 0.9483 Point, NC. Alamance, NC 3150........................ Greenville, NC.................. 0.9291 Pitt, NC 3160........................ Greenville-Spartanburg-Anderson, 0.9142 SC. Cherokee, SC 31606....................... Greenville-Spartanburg-Anderson, 0.9372 SC. Anderson, SC 31607....................... Greenville-Spartanburg-Anderson, 0.9626 SC. Greenville, SC Pickens, SC Spartanburg, SC 3180........................ Hagerstown, MD.................. 1.0275 Washington, MD 3200........................ Hamilton-Middletown, OH......... 0.9757 Butler, OH 3240........................ Harrisburg-Lebanon-Carlisle, PA. 1.0721 Cumberland, PA Dauphin, PA Lebanon, PA Perry, PA 3283........................ Hartford, CT.................... 1.2533 Hartford, CT Litchfield, CT Middlesex, CT Tolland, CT 3285........................ Hattiesburg, MS................. 0.8007 Forrest, MS Lamar, MS 3290........................ Hickory-Morganton-Lenoir, NC.... 0.9027 Caldwell, NC 32906....................... Hickory-Morganton-Lenoir, NC.... 0.9376 Alexander, NC Burke, NC Catawba, NC 3320........................ Honolulu, HI.................... 1.2246 Honolulu, HI 3350........................ Houma, LA....................... 0.8894 Lafourche, LA Terrebonne, LA 3360........................ Houston, TX..................... 1.0755 Fort Bend, TX Harris, TX Liberty, TX Montgomery, TX Waller, TX 33606....................... Houston, TX..................... 0.9710 Chambers, TX 3400........................ Huntington-Ashland, WV-KY-OH.... 0.9813 Boyd, KY Carter, KY Greenup, KY Lawrence, OH Cabell, WV Wayne, WV 3440........................ Huntsville, AL.................. 0.8711 Limestone, AL 34406....................... Huntsville, AL.................. 0.9057 Madison, AL 3480........................ Indianapolis, IN................ 1.0554 Boone, IN Hamilton, IN Hancock, IN Hendricks, IN Johnson, IN Marion, IN Morgan, IN Shelby, IN 34806....................... Indianapolis, IN................ 1.0252 Madison, IN 3500........................ Iowa City, IA................... 1.0545 Johnson, IA 3520........................ Jackson, MI..................... 0.9903 Jackson, MI 3560........................ Jackson, MS..................... 0.8593 Hinds, MS Madison, MS Rankin, MS 3580........................ Jackson, TN..................... 0.8737 Madison, TN

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      Chester, TN 3600........................ Jacksonville, FL................ 0.9717 Clay, FL Duval, FL Nassau, FL St. Johns, FL 3605........................ Jacksonville, NC................ 0.8625 Onslow, NC 3610........................ Jamestown, NY................... 0.8902 Chautauqua, NY 3620........................ Janesville-Beloit, WI........... 0.9264 Rock, WI 3640........................ Jersey City, NJ................. 1.1770 Hudson, NJ 3660........................ Johnson City-Kingsport-Bristol, 0.9583 TN-VA. Carter, TN Hawkins, TN Sullivan, TN Unicoi, TN Washington, TN Bristol City, VA Scott, VA Washington, VA 3680........................ Johnstown, PA................... 0.9463 Cambria, PA Somerset, PA 3700........................ Jonesboro, AR................... 0.8000 Craighead, AR 3710........................ Joplin, MO...................... 0.8526 Jasper, MO Newton, MO 3720........................ Kalamazoo-Battlecreek, MI....... 1.0749 Van Buren, MI 37206....................... Kalamazoo-Battlecreek, MI....... 1.1141 Calhoun, MI 37207....................... Kalamazoo-Battlecreek, MI....... 1.1724 Kalamazoo, MI 3740........................ Kankakee, IL.................... 0.9227 Kankakee, IL 3760........................ Kansas City, KS-MO.............. 0.9568 Clinton, MO 37606....................... Kansas City, KS-MO.............. 1.0086 Johnson, KS Leavenworth, KS Miami, KS Wyandotte, KS 37607....................... Kansas City, KS-MO.............. 1.0130 Cass, MO Clay, MO Jackson, MO Lafayette, MO Platte, MO Ray, MO 3800........................ Kenosha, WI..................... 1.0224 Kenosha, WI 3810........................ Killeen-Temple, TX.............. 1.0433 Bell, TX Coryell, TX 3840........................ Knoxville, TN................... 0.9366 Anderson, TN Blount, TN Knox, TN Sevier, TN Union, TN 38406....................... Knoxville, TN................... 0.8953 Loudon, TN 3850........................ Kokomo, IN...................... 0.9225 Howard, IN Tipton, IN 3870........................ La Crosse, WI-MN................ 0.9101 Houston, MN La Crosse, WI 38706....................... La Crosse, WI-MN................ 0.9385 La Crosse, WI 3880........................ Lafayette, LA................... 0.8641 Acadia, LA St. Landry, LA 38806....................... Lafayette, LA................... 0.9271 Lafayette, LA St. Martin, LA 3920........................ Lafayette, IN................... 0.9407 Clinton, IN 39206....................... Lafayette, IN................... 0.9580 Tippecanoe, IN 3960........................ Lake Charles, LA................ 0.8894 Calcasieu, LA 3980........................ Lakeland-Winter Haven, FL....... 0.9403 Polk, FL 4000........................ Lancaster, PA................... 1.0234 Lancaster, PA 4040........................ Lansing-East Lansing, MI........ 1.0707 Clinton, MI Eaton, MI Ingham, MI 4080........................ Laredo, TX...................... 0.8187 Webb, TX 4100........................ Las Cruces, NM.................. 0.8982 Dona Ana, NM 4120........................ Las Vegas, NV-AZ................ 1.0512 Mohave, AZ 41206....................... Las Vegas, NV-AZ................ 1.0941 Nye, NV 41207....................... Las Vegas, NV-AZ................ 1.1643 Clark, NV 4150........................ Lawrence, KS.................... 0.9424 Douglas, KS 4200........................ Lawton, OK...................... 0.9547 Comanche, OK 4243........................ Lewiston-Auburn, ME............. 0.9855 Androscoggin, ME 4280........................ Lexington, KY................... 0.9194 Bourbon, KY Clark, KY Fayette, KY Jessamine, KY Scott, KY Woodford, KY 42806....................... Lexington, KY................... 0.8699 Madison, KY 4320........................ Lima, OH........................ 0.9893 Allen, OH Auglaize, OH 4360........................ Lincoln, NE..................... 0.9465 Lancaster, NE 4400........................ Little Rock-North Little Rock, 0.9476 AR. Faulkner, AR Lonoke, AR Pulaski, AR Saline, AR 4420........................ Longview-Marshall, TX........... 0.8843 Upshur, TX 44206....................... Longview-Marshall, TX........... 0.8996 Gregg, TX Harrison, TX 4480........................ Los Angeles-Long Beach, CA...... 1.3083 Los Angeles, CA 4520........................ Louisville, KY-IN............... 1.0420 Clark, IN Floyd, IN Harrison, IN Bullitt, KY Jefferson, KY Oldham, KY 45206....................... Louisville, KY-IN............... 0.9640 Scott, IN 4600........................ Lubbock, TX..................... 0.9380 Lubbock, TX 4640........................ Lynchburg, VA................... 0.8713 Bedford, VA Bedford City, VA 46406....................... Lynchburg, VA................... 0.8964 Amherst, VA Campbell, VA Lynchburg City, VA 4680........................ Macon, GA....................... 0.9874 Bibb, GA Houston, GA Jones, GA Peach, GA 46806....................... Macon, GA....................... 0.9404 Twiggs, GA 4720........................ Madison, WI..................... 1.0595 Dane, WI 4800........................ Mansfield, OH................... 0.9218 Crawford, OH 48006....................... Mansfield, OH................... 0.9229 Richland, OH 4840........................ Mayaguez, PR.................... 0.6098 Anasco, PR Cabo Rojo, PR Hormigueros, PR Mayaguez, PR Sabana Grande, PR San German, PR 4880........................ McAllen-Edinburg-Mission, TX.... 0.8764 Hidalgo, TX 4890........................ Medford-Ashland, OR............. 1.0662 Jackson, OR 4900........................ Melbourne-Titusville-Palm Bay, 0.9423 FL. Brevard, Fl 4920........................ Memphis, TN-AR-MS............... 0.9748 Crittenden, AR DeSoto, MS Shelby, TN Tipton, TN 49206....................... Memphis, TN-AR-MS............... 0.8784 Fayette, TN 4940........................ Merced, CA...................... 1.1164 Merced, CA 5000........................ Miami, FL....................... 1.0888 Dade, FL 5015........................ Middlesex-Somerset-Hunterdon, NJ 1.1426 Hunterdon, NJ Middlesex, NJ Somerset, NJ

      [[Page 53451]]

      5080........................ Milwaukee-Waukesha, WI.......... 1.0522 Milwaukee, WI Ozaukee, WI Washington, WI Waukesha, WI 5120........................ Minneapolis-St. Paul, MN-WI..... 1.0385 Pierce, WI 51206....................... Minneapolis-St. Paul, MN-WI..... 1.1072 Anoka, MN Carver, MN Chisago, MN Dakota, MN Hennepin, MN Isanti, MN Ramsey, MN Scott, MN Washington, MN Wright, MN St. Croix, WI 51207....................... Minneapolis-St. Paul, MN-WI..... 1.0561 Sherburne, MN 5160........................ Mobile, AL...................... 0.9154 Baldwin, AL Mobile, AL 5170........................ Modesto, CA..................... 1.1297 Stanislaus, CA 5190........................ Monmouth-Ocean, NJ.............. 1.1070 Monmouth, NJ Ocean, NJ 5200........................ Monroe, LA...................... 0.9202 Ouachita, LA 5240........................ Montgomery, AL.................. 0.8745 Autauga, AL Elmore, AL Montgomery, AL 5280........................ Muncie, IN...................... 0.9813 Delaware, IN 5330........................ Myrtle Beach, SC................ 0.8453 Horry, SC 5345........................ Naples, FL...................... 1.0096 Collier, FL 5360........................ Nashville, TN................... 1.0693 Cheatham, TN Davidson, TN Dickson, TN Robertson, TN Rutherford, TN Sumner, TN Williamson, TN Wilson, TN 5380........................ Nassau-Suffolk, NY.............. 1.3852 Nassau, NY Suffolk, NY 5483........................ New Haven-Bridgeport-Stamford- 1.2841 Waterbury-Danbury, CT. Fairfield, CT 54836....................... New Haven-Bridgeport-Stamford- 1.2525 Waterbury-Danbury, CT. New Haven, CT 5523........................ New London-Norwich, CT.......... 1.2525 New London, CT 5560........................ New Orleans, LA................. 1.0220 Jefferson, LA Orleans, LA St. Bernard, LA St. Charles, LA St. John The Baptist, LA St. Tammany, LA 55606....................... New Orleans, LA................. 0.9590 Plaquemines, LA St. James, LA 5600........................ New York, NY.................... 1.4545 Bronx, NY Kings, NY New York, NY Putnam, NY Queens, NY Richmond, NY Rockland, NY Westchester, NY 5640........................ Newark, NJ...................... 1.2297 Essex, NJ Morris, NJ Sussex, NJ Union, NJ 5640........................ Newark, NJ...................... 1.2028 Warren, NJ 5660........................ Newburgh, NY-PA................. 1.1476 Pike, PA 56606....................... Newburgh, NY-PA................. 1.1382 Orange, NY 5720........................ Norfolk-Virginia Beach-Newport 0.9215 News, VA-NC. Chesapeake City, VA Gloucester, VA Hampton City, VA James 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 York, VA 57206....................... Norfolk-Virginia Beach-Newport 0.8774 News, VA-NC. Isle of Wight, VA Mathews, VA 57207....................... Norfolk-Virginia Beach-Newport 0.8769 News, VA-NC. Currituck, NC 5775........................ Oakland, CA..................... 1.4914 Alameda, CA Contra Costa, CA 5790........................ Ocala, FL....................... 0.9825 Marion, FL 5800........................ Odessa-Midland, TX.............. 0.9804 Midland, TX 58006....................... Odessa-Midland, TX.............. 0.9453 Ector, TX 5880........................ Oklahoma City, OK............... 0.9606 Canadian, OK Cleveland, OK Logan, OK McClain, OK Oklahoma, OK Pottawatomie, OK 5910........................ Olympia, WA..................... 1.1295 Thurston, WA 5920........................ Omaha, NE-IA.................... 0.9694 Pottawattamie, IA Douglas, NE Sarpy, NE Washington, NE 59206....................... Omaha, NE-IA.................... 0.9364 Cass, NE 5945........................ Orange County, CA............... 1.2439 Orange, CA 5960........................ Orlando, FL..................... 1.0096 Orange, FL Osceola, FL Seminole, FL 59606....................... Orlando, FL..................... 0.9599 Lake, FL 5990........................ Owensboro, KY................... 0.8510 Daviess, KY 6015........................ Panama City, FL................. 0.9333 Bay, FL 6020........................ Parkersburg-Marietta, WV-OH..... 0.9357 Washington, OH Wood, WV 6080........................ Pensacola, FL................... 0.9345 Escambia, FL Santa Rosa, FL 6120........................ Peoria-Pekin, IL................ 0.9883 Peoria, IL Tazewell, IL Woodford, IL 6160........................ Philadelphia, PA-NJ............. 1.2042 Burlington, NJ Camden, NJ Gloucester, NJ Bucks, PA Chester, PA Delaware, PA Montgomery, PA Philadelphia, PA 61606....................... Philadelphia, PA-NJ............. 1.1740 Salem, NJ 6200........................ Phoenix-Mesa, AZ................ 0.9824 Pinal, AZ 62006....................... Phoenix-Mesa, AZ................ 1.0583 Maricopa, AZ 6240........................ Pine Bluff, AR.................. 0.8521 Jefferson, AR 6280........................ Pittsburgh, PA.................. 1.0758 Allegheny, PA Fayette, PA Washington, PA Westmoreland, PA 62806....................... Pittsburgh, PA.................. 1.0575 Beaver, PA 62807....................... Pittsburgh, PA.................. 1.0389 Butler, PA 6323........................ Pittsfield, MA.................. 1.1071 Berkshire, MA 6340........................ Pocatello, ID................... 0.9829 Bannock, ID 6360........................ Ponce, PR....................... 0.6185 Guayanilla, PR Juana Diaz, PR Penuelas, PR Ponce, PR Villalba, PR Yauco, PR

      [[Page 53452]]

      6403........................ Portland, ME.................... 1.0085 Cumberland, ME Sagadahoc, ME York, ME 6440........................ Portland-Vancouver, OR-WA....... 1.1251 Columbia, OR 64406....................... Portland-Vancouver, OR-WA....... 1.1820 Clackamas, OR Multnomah, OR Washington, OR Yamhill, OR 64407....................... Portland-Vancouver, OR-WA....... 1.1693 Clark, WA 6483........................ Providence-Warwick-Pawtucket, RI 1.1119 Bristol, RI Kent, RI Newport, RI Providence, RI Washington, RI 6520........................ Provo-Orem, UT.................. 1.0332 Utah, UT 6560........................ Pueblo, CO...................... 0.9943 Pueblo, CO 6580........................ Punta Gorda, FL................. 0.9209 Charlotte, FL 6600........................ Racine, WI...................... 0.9727 Racine, WI 6640........................ Raleigh-Durham-Chapel Hill, NC.. 0.9817 Chatham, NC Johnston, NC 66406....................... Raleigh-Durham-Chapel Hill, NC.. 1.0388 Durham, NC Franklin, NC Orange, NC Wake, NC 6660........................ Rapid City, SD.................. 0.8614 Pennington, SD 6680........................ Reading, PA..................... 1.0228 Berks, PA 6690........................ Redding, CA..................... 1.1905 Shasta, CA 6720........................ Reno, NV........................ 1.2044 Washoe, NV 6740........................ Richland-Kennewick-Pasco, WA.... 1.0462 Benton, WA Franklin, WA 6760........................ Richmond-Petersburg, VA......... 0.9479 Charles City County, VA Chesterfield, VA Colonial Heights City, VA Dinwiddie, VA Goochland, VA Hanover, VA Henrico, VA Hopewell City, VA New Kent, VA Petersburg City, VA Powhatan, VA Prince George, VA Richmond City, VA 6780........................ Riverside-San Bernardino, CA.... 1.1990 Riverside, CA San Bernardino, CA 6800........................ Roanoke, VA..................... 0.9358 Botetourt, VA Roanoke, VA Roanoke City, VA Salem City, VA 6820........................ Rochester, MN................... 1.0905 Olmsted, MN 6840........................ Rochester, NY................... 1.0266 Livingston, NY Monroe, NY Ontario, NY Orleans, NY Wayne, NY 68406....................... Rochester, NY................... 0.9686 Genesee, NY 6880........................ Rockford, IL.................... 0.9365 Ogle, IL 68806....................... Rockford, IL.................... 0.9976 Boone, IL Winnebago, IL 6895........................ Rocky Mount, NC................. 0.9266 Edgecombe, NC Nash, NC 6920........................ Sacramento, CA.................. 1.2499 El Dorado, CA Placer, CA Sacramento, CA 6960........................ Saginaw-Bay City-Midland, MI.... 1.0493 Bay, MI Midland, MI Saginaw, MI 6980........................ St. Cloud, MN................... 0.9731 Benton, MN Stearns, MN 7000........................ St. Joseph, MO.................. 0.8732 Andrew, MO 70006....................... St. Joseph, MO.................. 0.9283 Buchanan, MO 7040........................ St. Louis, MO-IL................ 0.9265 Lincoln, MO Warren, MO 70406....................... St. Louis, MO-IL................ 0.9715 Jersey, IL Madison, IL 70407....................... St. Louis, MO-IL................ 0.9760 Clinton, IL St. Clair, IL 70408....................... St. Louis, MO-IL................ 1.0109 Franklin, MO Jefferson, MO Monore, IL St. Charles, MO St. Louis City, MO 7080........................ Salem, OR....................... 1.0651 Marion, OR Polk, OR 7120........................ Salinas, CA..................... 1.4579 Monterey, CA 7160........................ Salt Lake City-Ogden, UT........ 1.0251 Davis, UT Salt Lake, UT Weber, UT 7200........................ San Angelo, TX.................. 0.8669 Tom Green, TX 7240........................ San Antonio, TX................. 0.8764 Wilson, TX 72406....................... San Antonio, TX................. 0.9599 Bexar, TX Comal, TX Guadalupe, TX 7320........................ San Diego, CA................... 1.2658 San Diego, CA 7360........................ San Francisco, CA............... 1.4769 Marin, CA San Francisco, CA San Mateo, CA 7400........................ San Jose, CA.................... 1.4519 Santa Clara, CA 7440........................ San Juan-Bayamon, PR............ 0.6207 Aguas Buenas, PR Barceloneta, PR Bayamon, PR Canovanas, PR Carolina, PR Catano, PR Ceiba, PR Comerio, PR Corozal, PR Dorado, PR Fajardo, PR Florida, PR Guaynabo, PR Humacao, PR Juncos, PR Los Piedras, PR Loiza, PR Luguillo, PR Manati, PR Morovis, PR Naguabo, PR Naranjito, PR Rio Grande, PR San Juan, PR Toa Alta, PR Toa Baja, PR Trujillo Alto, PR Vega Alta, PR Vega Baja, PR Yabucoa, PR 7460........................ San Luis Obispo-Atascadero-Paso 1.1462 Robles, CA. San Luis Obispo, CA 7480........................ Santa Barbara-Santa Maria-

      1.1336 Lompoc, CA. Santa Barbara, CA 7485........................ Santa Cruz-Watsonville, CA...... 1.3871 Santa Cruz, CA 7490........................ Santa Fe, NM.................... 1.0451 Los Alamos, NM Santa Fe, NM 7500........................ Santa Rosa, CA.................. 1.3069 Sonoma, CA 7510........................ Sarasota-Bradenton, FL.......... 1.0255 Sarasota, FL 75106....................... Sarasota-Bradenton, FL.......... 1.0017 Manatee, FL 7520........................ Savannah, GA.................... 0.8993 Bryan, GA 75206....................... Savannah, GA.................... 0.9349 Chatham, GA

      [[Page 53453]]

      Effingham, GA 7560........................ Scranton--Wilkes-Barre--

      0.9364 Hazleton, PA. Columbia, PA Lackawanna, PA Luzerne, PA Wyoming, PA 7600........................ Seattle-Bellevue-Everett, WA.... 1.1225 Island, WA 76006....................... Seattle-Bellevue-Everett, WA.... 1.1708 King, WA Snohomish, WA 7610........................ Sharon, PA...................... 0.9498 Mercer, PA 7620........................ Sheboygan, WI................... 0.9000 Sheboygan, WI 7640........................ Sherman-Denison, TX............. 0.9075 Grayson, TX 7680........................ Shreveport-Bossier City, LA..... 0.9461 Webster, LA 76806....................... Shreveport-Bossier City, LA..... 1.0263 Bossier, LA Caddo, LA 7720........................ Sioux City, IA-NE............... 0.9205 Woodbury, IA Dakota, NE 7760........................ Sioux Falls, SD................. 0.8870 Lincoln, SD 77606....................... Sioux Falls, SD................. 0.9375 Minnehaha, SD 7800........................ South Bend, IN.................. 1.0021 St. Joseph, IN 7840........................ Spokane, WA..................... 1.1221 Spokane, WA 7880........................ Springfield, IL................. 1.0062 Menard, IL Sangamon, IL 7920........................ Springfield, MO................. 0.8469 Webster, MO 79206....................... Springfield, MO................. 0.8901 Christian, MO Greene, MO 8003........................ Springfield, MA................. 1.0923 Hampden, MA Hampshire, MA 8050........................ State College, PA............... 1.0411 Centre, PA 8080........................ Steubenville-Weirton, OH-WV..... 0.9438 Jefferson, OH Brooke, WV Hancock, WV 8120........................ Stockton-Lodi, CA............... 1.2084 San Joaquin, CA 8140........................ Sumter, SC...................... 0.8348 Sumter, SC 8160........................ Syracuse, NY.................... 0.9644 Cayuga, NY 81606....................... Syracuse, NY.................... 1.1682 Madison, NY Onondaga, NY Oswego, NY 8200........................ Tacoma, WA...................... 1.1330 Pierce, WA 8240........................ Tallahassee, FL................. 0.9401 Gadsden, FL Leon, FL 8280........................ Tampa-St. Petersburg-Clearwater, 0.9834 FL. Hernando, FL Hillsborough, FL Pasco, FL Pinellas, FL 8320........................ Terre Haute, IN................. 0.9016 Vermillion, IN 83206....................... Terre Haute, IN................. 0.9106 Clay, IN Vigo, IN 8360........................ Texarkana, AR-Texarkana, TX..... 0.9919 Miller, AR Bowie, TX 8400........................ Toledo, OH...................... 1.1202 Fulton, OH Lucas, OH Wood, OH 8440........................ Topeka, KS...................... 1.0468 Shawnee, KS 8480........................ Trenton, NJ..................... 1.0866 Mercer, NJ 8520........................ Tucson, AZ...................... 0.9950 Pima, AZ 8560........................ Tulsa, OK....................... 0.9259 Creek, OK Osage, OK Rogers, OK Tulsa, OK Wagoner, OK 8600........................ Tuscaloosa, AL.................. 0.9266 Tuscaloosa, AL 8640........................ Tyler, TX....................... 1.0174 Smith, TX 8680........................ Utica-Rome, NY.................. 0.9124 Herkimer, NY Oneida, NY 8720........................ Vallejo-Fairfield-Napa, CA...... 1.4234 Napa, CA Solano, CA 8735........................ Ventura, CA..................... 1.1819 Ventura, CA 8750........................ Victoria, TX.................... 0.8925 Victoria, TX 8760........................ Vineland-Millville-Bridgeton, NJ 1.0368 Cumberland, NJ 8780........................ Visalia-Tulare-Porterville, CA.. 1.0922 Tulare, CA 8800........................ Waco, TX........................ 0.8276 McLennan, TX 8840........................ Washington, DC-MD-VA-WV......... 1.1581 District of Columbia, DC Calvert, MD Charles, MD Frederick, MD Montgomery, MD Prince Georges, MD Alexandria City, VA Arlington, VA Fairfax, VA Fairfax City, VA Falls Church City, VA Loudoun, VA Manassas City, VA Manassas Park City, VA Prince William, VA Stafford, VA 88406....................... Washington, DC-MD-VA-WV......... 1.0725 Berkeley, WV Jefferson, WV 88407....................... Washington, DC-MD-VA-WV......... 1.0494 Clarke, VA Culpeper, VA Fauquier, VA Fredericksburg City, VA King George, VA Spotsylvania, VA Warren, VA 8920........................ Waterloo-Cedar Falls, IA........ 0.9203 Black Hawk, IA 8940........................ Wausau, WI...................... 1.0607 Marathon, WI 8960........................ West Palm Beach-Boca Raton, FL.. 1.0658 Palm Beach, FL 9000........................ Wheeling, WV-OH................. 0.9314 Belmont, OH Marshall, WV Ohio, WV 9040........................ Wichita, KS..................... 0.9399 Harvey, KS 90406....................... Wichita, KS..................... 1.0473 Butler, KS Sedgwick, KS 9080........................ Wichita Falls, TX............... 0.8169 Archer, TX 90806....................... Wichita Falls, TX............... 0.8376 Wichita, TX 9140........................ Williamsport, PA................ 0.9544 Lycoming, PA 9160........................ Wilmington-Newark, DE-MD........ 1.1851 New Castle, DE Cecil, MD 9200........................ Wilmington, NC.................. 0.9471 Brunswick, NC 92006....................... Wilmington, NC.................. 0.9649 New Hanover, NC 9260........................ Yakima, WA...................... 1.0634 Yakima, WA 9270........................ Yolo, CA........................ 1.1961 Yolo, CA 9280........................ York, PA........................ 1.0165 York, PA 9320........................ Youngstown-Warren, OH........... 1.0124 Columbiana, OH 93206....................... Youngstown-Warren, OH........... 1.0785 Mahoning, OH Trumbull, OH 9340........................ Yuba City, CA................... 1.0981 Sutter, CA Yuba, CA 9360........................ Yuma, AZ........................ 0.9912

      [[Page 53454]]

      Yuma, AZ

      \1\ Wage index values are based on FY 1997 hospital cost report data prior to reclassification. This wage index is further adjusted. Wage index values greater than 0.8 are subject to a budget neutrality adjustment of 1.04662. Wage index values below 0.8 are adjusted to be the greater of a 15 percent increase, subject to a maximum wage index value of 0.8, or an adjustment by multiplying the hospital wage index value for a given area by the budget neutrality adjustment. All of these adjustments have been completed by HCFA and are built into the wage index values reflected in this table.

      Table B.--Wage Index for Rural Areas

      Wage MSA code number

      Nonurban area

      index

      \2\-- 9901........................ Alabama......................... 0.8000 Alabama 99016....................... Walker, AL.................... 0.8682 9902........................ Alaska.......................... 1.3387 9903........................ Arizona......................... 0.8696 9904........................ Arkansas........................ 0.8000 9905........................ California...................... 1.0488 9906........................ Colorado........................ 0.8575 9907........................ Connecticut Windham, CT................... 1.2283 Delaware 9908........................ Sussex, DE.................... 0.9372 9910........................ Florida......................... 0.9209 Florida 99106....................... Bradford, FL.................. 0.9554 9911........................ Georgia......................... 0.8381 Georgia 99116....................... Butts, GA..................... 0.8700 Georgia 99117....................... Jackson, GA................... 0.8491 9912........................ Hawaii.......................... 1.1244 9913........................ Idaho........................... 0.8877 9914........................ Illinois........................ 0.8363 9915........................ Indiana......................... 0.8700 9916........................ Iowa............................ 0.8058 Iowa 99166....................... Bremer, IA.................... 0.8367 9917........................ Kansas.......................... 0.8045 9918........................ Kentucky........................ 0.8267 Kentucky 99186....................... Shelby, KY.................... 0.9209 9919........................ Louisiana....................... 0.8119 9920........................ Maine........................... 0.8934 9921........................ Maryland........................ 0.9262 9922........................ Massachusetts................... 1.0866 9923........................ Michigan........................ 0.9531 9924........................ Minnesota....................... 0.8703 9925........................ Mississippi..................... 0.7972 9926........................ Missouri........................ 0.8099 9927........................ Montana......................... 0.8828 9928........................ Nebraska........................ 0.8000 9929........................ Nevada.......................... 0.9770 9930........................ New Hampshire................... 1.0380 9931........................ New Jersey \1\.................. ........ 9932........................ New Mexico...................... 0.8873 9933........................ New York........................ 0.8902 New York 99336....................... Greene, NY.................... 0.8975 9934........................ North Carolina.................. 0.8504 9935........................ North Dakota.................... 0.8109 9936........................ Ohio............................ 0.9075 Ohio 99366....................... Union, OH....................... 0.9521 9937........................ Oklahoma........................ 0.8197 9938........................ Oregon.......................... 1.0296 9939........................ Pennsylvania.................... 0.9479 Pennsylvania 99396....................... Monroe, PA.................... 0.9281 Pennsylvania 99397....................... Adams, PA..................... 0.9471 9940........................ Puerto Rico..................... 0.5905 9941........................ Rhode Island \1\................ ........ 9942........................ South Carolina.................. 0.8348 9943........................ South Dakota.................... 0.8000 9944........................ Tennessee

      0.8000 99446....................... Tennessee....................... Sequatchie, TN................ 0.8557 99447....................... Tennessee....................... 0.8395 Grainger, TN Jefferson, TN 9945........................ Texas........................... 0.8041 9946........................ Utah............................ 0.9110 9947........................ Vermont......................... 0.9560 9949........................ Virginia........................ 0.8402 9950........................ Washington...................... 1.0445 9951........................ West Virginia................... 0.8742 9952........................ Wisconsin....................... 0.8807 9953........................ Wyoming......................... 0.9091

      \1\ All counties within the State are classified as urban. \2\ Wage index values are based on FY 1997 hospital cost report data prior to reclassification. This wage index is further adjusted. Wage index values greater than 0.8 are subject to a budget neutrality adjustment of 1.04662. Wage index values below 0.8 are adjusted to be the greater of a 15 percent increase, subject to a maximum wage index value of 0.8, or an adjustment by multiplying the hospital wage index value for a given area by the budget neutrality adjustment. All of these adjustments have been completed by HCFA and are built into the wage index values reflected in this table.

2. Regulatory Impact Statement

   1. Background

      We have examined the impacts of this notice as required by Executive Order 12866, the Unfunded Mandate Reform Act, and the Regulatory Flexibility Act (RFA) (Public Law 96-354). In this notice, we identified an impact on hospices as a result of changes in the way we compute the hospice wage index. The change in the methodology for computing the wage index was determined through a negotiated rulemaking committee and implemented in the August 8, 1997 final rule (62 FR 42860). This notice only described the effects of those changes in conjunction with the annual update to the hospice wage index. Also, we believe these changes to be insignificant. 1. Executive Order 12866 and RFA

      Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects; distributive impacts; and equity). We have determined that this notice is not an economically significant rule under this Executive Order. The RFA requires agencies to analyze options for regulatory relief for small businesses. For purposes of the RFA, States and individuals are not considered small entities. However, most providers, physicians, and health care suppliers are small entities, either by nonprofit status or by having revenues of $5 million or less annually. Approximately 74 percent of Medicare certified hospices are identified as being voluntary, government, or other agency, and therefore are considered small entities. Because the National Hospice Organization estimates that approximately 65 percent of hospice patients are Medicare beneficiaries, we have not considered other sources of revenue in this analysis.

      As discussed below, payments to urban hospices in Puerto Rico will experience the most significant decrease (11.6 percent) in payments under this wage index. Looking at the effects of this rule on Puerto Rico, we see that 21 of the 29 hospices in urban Puerto Rico can be considered small entities that will experience an 11.6 percent decrease in Medicare payments. Therefore, we anticipate this rule will have a significant impact on a substantial number of small entities. However, the methodology for the hospice wage index was previously determined by consensus through a negotiated rulemaking committee that included representatives of national hospice associations; rural, urban, large and small hospices; multi-site hospices; and consumer groups. Based on all of the options considered, the committee determined that the methodology described in the committee statement, and adopted into regulation on August 8, 1997 (62 FR 42860), were favorable for the hospice community as a whole, as well as for the beneficiaries that they serve. Therefore, we believe that mitigating the effects of small entities has been taken into consideration.

      [[Page 53455]]

      2. Congressional Review

      Section 804(2) of Title 5, United States Code (as added by section 251 of Public Law 104-121), specifies that a ``major rule'' is any rule that the Office of Management and Budget finds is likely to result in--

      ‹bullet› An annual effect on the economy of $100 million or more;

      ‹bullet› A major increase in costs or prices for consumers, individual industries, Federal, State, or local government agencies, or geographic regions; or

      ‹bullet› Significant adverse effects on competition, employment, investment, productivity, innovation, or on the ability of United States-based enterprises to compete with foreign-based enterprises in domestic and export markets.

      We estimate that the impact of this notice will not be $100 million or more; therefore, this rule is not a major rule as defined in Title 5, United States Code, section 804(2) and is not being forwarded to Congress for a 60-day review period. 3. Unfunded Mandate

      The Unfunded Mandate Reform Act of 1995 also requires (in section 202) that agencies prepare an assessment of anticipated costs and benefits for any rule that may result in an annual expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more. The notice has no consequential effect on State, local, or tribal governments. We believe the private sector costs of this rule fall below the threshold, as well. 4. Rural Hospital Impact

      Section 1102(b) of the Act requires us to prepare a regulatory impact analysis for any notice that may have a significant impact on the operations of a substantial number of small rural hospitals. Such an analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside a Metropolitan Statistical Area and has fewer than 50 beds.

      Because this notice has no direct impact on small hospitals, in accordance with 5 U.S.C. 604, the Secretary certifies that this notice will not have a significant impact on the operations of a substantial number of small rural hospitals.

   2. Anticipated Effects

      In accordance with the Balanced Budget Act of 1997 (BBA of 1997), hospices are now paid for home care services based on where the service is rendered. This change was effective with FY 1998 and was implemented on October 1, 1997. This impact analysis compares hospice payments under the FY 1998 wage index (Column 4 of the table) to the second transition year blend (Column 5). The wage index blend for the second transition year of the 3-year transition is one-third of the 1983 wage index added to two-thirds of the new wage index. The data used in developing the quantitative analysis for this notice were obtained from the December 1997 update of the national claims history file of all bills submitted during fiscal year 1997. We deleted bills from hospices that have since closed.

      Table C demonstrates the results of our analysis. In Column 2 of the table we indicate the number of routine home care days that were included in our analysis, although the analysis was performed on all types of hospice care. Column 3 of Table C (below) indicates payments that were made using the FY 1998 wage index. Column 5 of Table C is based on FY 1998 claims and estimates payments to be made to hospices using the FY 1999 wage index. For the purposes of this analysis, the payments reflected in Column 3 were adjusted to account for the site of service provision. This adjustment is shown in Column 4 of Table C.

      The final column, which compares Columns 4 and 5, shows the percent change in estimated hospice payments made based on the category of the hospice. The overall percentage change in hospice payments is 0.2 percent. However, the wage index itself is budget neutral to what would have been paid using the 1983 wage index. The 0.2 percent is attributable to the site of service provision, i.e., the effect on payments resulting from the distribution of beneficiaries residing in MSAs with different wage index values than the hospice.

      Table C categorizes hospices by various geographic and provider characteristics. The top row of the table demonstrates the neutral overall payment impact on 2,133 hospices included in the analysis. The next two rows of the table categorize hospices according to their geographic location (urban and rural). There are 1,385 hospices located in urban areas included in our analysis and 748 hospices located in rural areas. The next two groupings in the table indicate the number of hospices by census region, also broken down by urban and rural hospices. The next grouping shows the impact on hospices based on the size of the hospice's program. We determined that the majority of hospice payments are made at the routine home care rate. Therefore, we based the size of each individual hospice's program on the number of routine home care days provided in 1997. The next grouping shows the impact on hospices by type of ownership. The final grouping shows the impact on hospices defined by whether they are provider-based or freestanding.

      The results of our analysis show that the greatest increases are for urban and rural hospices in the New England region, 4.5 percent and 2.8 percent respectively, and for rural hospices in the Pacific regions, with 3.8 percent. The greatest decreases, besides Puerto Rico, are the rural West North Central and rural West South Central regions with 3.1 percent and 4.0 percent respectively. The most dramatic shift occurs in Puerto Rico, where urban payments decrease by 11.6 percent and rural payments decrease by 12.3 percent. Since the wage index values for the Puerto Rico region are more than 15 percent below the 1983 wage index value of 0.8, this region is most affected by the revision to the wage index floor.

      Small hospice programs show small decreases while larger programs show slight increases. Proprietary hospices show slight decreases in payment due to the wage index change while voluntary programs gain slightly. Finally, freestanding hospices show no percent change in their wage index values while provider-based hospice programs show small increases.

      [[Page 53456]]

      Table C.--Impact of Hospice Wage Index Change (1)

      (2)

      (3)

      (4)

      (5)

      (6)

      All...............................

      2,133 19,944 2,211,336 2,195,009 2,200,107

      0.2 Urban Hospices....................

      1,385 16,148 11,868,369 1,849,873 1,855,939

      0.3 Rural Hospices....................

      748

      3,795 342,967 345,136 344,168

      -0.3 Region (Urban):

      New England...................

      102

      568 72,785 72,694 75,979

      4.5

      Middle Atlantic...............

      176

      1,849 226,264 225,095 228,443

      1.5

      South Atlantic................

      182

      3,825 445,473 443,033 445,646

      0.6

      East North Central............

      224

      2,599 300,801 297,570 296,812

      -0.3

      East South Central............

      89

      770 83,503 81,985 81,082

      -1.1

      West North Central............

      99

      937 96,630 94,617 94,224

      -0.4

      West South Central............

      197

      2,373 249,586 243,893 240,371

      -1.4

      Mountain......................

      88

      887 114,857 113,848 113,010

      -0.7

      Pacific.......................

      199

      2,145 263,250 261,968 266,963

      1.9

      Puerto Rico...................

      29

      194 15,221 15,169 13,410

      -11.6 Region (Rural):

      New England...................

      21

      63

      6,341

      6,358

      6,536

      2.8

      Middle Atlantic...............

      34

      261 25,759 25,838 25,384

      -1.8

      South Atlantic................

      115

      549 49,985 50,658 50,932

      0.5

      East North Central............

      121

      442 40,906 41,264 41,511

      0.6

      East South Central............

      76

      1,452 124,526 124,784 125,167

      0.3

      West North Central............

      164

      399 36,089 36,241 35,127

      -3.1

      West South Central............

      82

      255 22,474 22,926 21,999

      -4.0

      Mountain......................

      80

      175 16,739 16,806 16,831

      0.1

      Pacific.......................

      52

      185 19,122 19,229 19,773

      2.8

      Puerto Rico...................

      3

      13

      1,028

      1,034

      907

      -12.3 Size (Routine Home Care Days):

      0-1,752 Days..................

      533

      417 48,237 48,051 47,757

      -0.6

      1,753-4,225 Days..............

      533

      1,524 152,653 151,925 151,578

      -0.2

      4,226-9,422 Days..............

      533

      3,420 352,974 351,698 352,436

      0.2

      9,422+ Days...................

      534 14,583 1,657,472 1,643,334 1,648,336

      0.3 Type of Ownership:

      Voluntary.....................

      1,373 13,516 1,492,335 1,483,835 1,492,700

      0.6

      Proprietary...................

      560

      5,876 664,169 656,650 653,129

      -0.5

      Government....................

      172

      474 47,067 46,818 46,550

      -0.6

      Other.........................

      28

      78

      7,766

      7,705

      7,727

      0.3 Hospice Base:

      Freestanding..................

      793 11,495 1,272,781 1,263,013 1,263,114

      0.0

      Home Health Agency............

      788

      5,235 581,863 577,857 581,728

      0.7

      Hospital......................

      533

      3,123 344,200 341,727 342,789

      0.3

      Skilled Nursing Facility......

      19

      91 12,492 12,411 12,476

      0.5

      *The FY 1997 data used to construct the FY 1998 wage index was adjusted to account for the site of service provision that was included in the Balanced Budget Act of 1997. **Percent change in hospice payments made from 1997, taking into account the site of service change.

      Authority: Section 1814(I) of the Social Security Act (42 U.S.C. 1395f(I)(1))

      (Catalog of Federal Domestic Assistance Program No. 93.773 Medicare--Hospital Insurance Program; and No. 93.774, Medicare-- Supplementary Medical Insurance Program)

      Dated: July 7, 1998. Nancy-Ann Min DeParle, Administrator, Health Care Financing Administration.

      Dated: August 4, 1998. Donna E. Shalala, Secretary.

      [FR Doc. 98-26501Filed9-30-98; 9:53 am]

      BILLING CODE 4120-01-P