Part II

[Federal Register: May 25, 2005 (Volume 70, Number 100)]

[Proposed Rules]

[Page 30187-30327]

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

[DOCID:fr25my05-49]

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Part II

Department of Health and Human Services

Centers for Medicare & Medicaid Services

42 CFR Part 412

Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for FY 2006; Proposed Rule

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 412

[CMS-1290-P]

RIN 0938-AN43

Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for FY 2006

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

ACTION: Proposed rule.

SUMMARY: This proposed rule would update the prospective payment rates for inpatient rehabilitation facilities for Federal fiscal year 2006 as required under section 1886(j)(3)(C) of the Social Security Act (the Act). Section 1886(j)(5) of the Act requires the Secretary to publish in the Federal Register on or before August 1 before each fiscal year, the classification and weighting factors for the inpatient rehabilitation facilities case-mix groups and a description of the methodology and data used in computing the prospective payment rates for that fiscal year.

In addition, we are proposing new policies and are proposing to change existing policies regarding the prospective payment system within the authority granted under section 1886(j) of the Act.

DATES: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on July 18, 2005.

ADDRESSES: In commenting, please refer to file code CMS-1290-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of three ways (no duplicates, please):

1. Electronically. You may submit electronic comments on specific issues in this regulation to http://www.cms.hhs.gov/regulations/ecomments. (Attachments should be in Microsoft Word, WordPerfect, or

Excel; however, we prefer Microsoft Word.)

2. By mail. You may mail written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1290- P, P.O. Box 8010, Baltimore, MD 21244-8010.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to one of the following addresses. If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members. Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201; or 7500 Security Boulevard, Baltimore, MD 21244-1850.

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

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Pete Diaz, (410) 786-1235. Susanne Seagrave, (410) 786-0044. Mollie Knight, (410) 786-7984 for information regarding the market basket and labor-related share. August Nemec, (410) 786-0612 for information regarding the tier comorbidities. Zinnia Ng, (410) 786-4587 for information regarding the wage index and Core- Based Statistical Areas (CBSAs).

SUPPLEMENTARY INFORMATION:

Submitting Comments: We welcome comments from the public on all issues set forth in this rule to assist us in fully considering issues and developing policies. You can assist us by referencing the file code CMS-1290-P and the specific ``issue identifier'' that precedes the section on which you choose to comment.

Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. CMS posts all electronic comments received before the close of the comment period on its public Web site as soon as possible after they have been received. Hard copy comments received timely will be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800- 743-3951.

Table of Contents

1. Background A. General Overview of the Current Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) B. Requirements for Updating the Prospective Payment Rates for IRFs C. Operational Overview of the Current IRF PPS D. Quality of Care in IRFs E. Research to Support Refinements of the Current IRF PPS F. Proposed Refinements to the IRF PPS for Fiscal Year 2006 II. Proposed Refinements to the Patient Classification System A. Proposed Changes to the IRF Classification System 1. Development of the IRF Classification System 2. Description and Methodology Used to Develop the IRF Classification System in the August 7, 2001 Final Rule a. Rehabilitation Impairment Categories b. Functional Status Measures and Age c. Comorbidities d. Development of CMG Relative Weights e. Overview of Development of the CMG Relative Weights B. Proposed Changes to the Existing List of Tier Comorbidities 1. Proposed Changes To Remove Codes That Are Not Positively Related to Treatment Costs 2. Proposed Changes to Move Dialysis to Tier One 3. Proposed Changes to Move Comorbidity Codes Based on Their Marginal Cost C. Proposed Changes to the CMGs 1. Proposed Changes for Updating the CMGs 2. Proposed Use of a Weighted Motor Score Index and Correction to the Treatment of Unobserved Transfer to Toilet Values 3. Proposed Changes for Updating the Relative Weights III. Proposed FY 2006 Federal Prospective Payment Rates A. Proposed Reduction of the Standard Payment Amount to Account for Coding Changes B. Proposed Adjustments to Determine the Proposed FY 2006 Standard Payment Conversion Factor 1. Proposed Market Basket Used for IRF Market Basket Index a. Overview of the Proposed RPL Market Basket b. Proposed Methodology for Operating Portion of the Proposed RPL Market Basket c. Proposed Methodology for Capital Proportion of the RPL Market Basket d. Labor-Related Share 2. Proposed Area Wage Adjustment a. Proposed Revisions of the IRF PPS Geographic Classification b. Current IRF PPS Labor Market Areas Based on MSAs

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   3. Core-Based Statistical Areas (CBSAs) d. Proposed Revisions of the IRF PPS Labor Market Areas i. New England MSAs ii. Metropolitan Divisions iii. Micropolitan Areas e. Implementation of the Proposed Changes to Revise the Labor Market Areas f. Wage Index Data 3. Proposed Teaching Status Adjustment 4. Proposed Adjustment for Rural Location 5. Proposed Adjustment for Disproportionate Share of Low-Income Patients 6. Proposed Update to the Outlier Threshold Amount 7. Proposed Budget Neutrality Factor Methodology for Fiscal Year 2006 8. Description of the Methodology Used to Implement the Proposed Changes in a Budget Neutral Manner 9. Description of the Proposed IRF Standard Payment Conversion Factor for Fiscal Year 2006 10. Example of the Proposed Methodology for Adjusting the Federal Prospective Payment Rates IV. Provisions of the Proposed Regulations V. Collection of Information Requirements VI. Response to Comments VII. Regulatory Impact Analysis

   Acronyms

   Because of the many terms to which we refer by acronym in this propose rule, we are listing the acronyms used and their corresponding terms in alphabetical order below. ADC--Average Daily Census AHA--American Hospital Association AMI--Acute Myocardial Infarction BBA--Balanced Budget Act of 1997 (BBA), Pub. L. 105-33 BBRA--Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999, Pub. L. 106-113 BIPA--Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act of 2000, Pub. L. 106- 554 BLS--Bureau of Labor Statistics CART--Classification and Regression Trees CBSA--Core-Based Statistical Areas CCR--Cost-to-charge ratio CMGs--Case-Mix Groups CMI--Case Mix Index CMSA--Consolidated Metropolitan Statistical Area CPI--Consumer Price Index DSH--Disproportionate Share Hospital ECI--Employment Cost Index FI--Fiscal Intermediary FIM--Functional Independence Measure FIM-FRGs--Functional Independence Measures--Function Related Groups FRG--Function Related Group FTE--Full-time equivalent FY--Federal Fiscal Year GME--Graduate Medical Education HCRIS--Healthcare Cost Report Information System HIPAA--Health Insurance Portability and Accountability Act HHA--Home Health Agency IME--Indirect Medical Education IFMC--Iowa Foundation for Medical Care IPF--Inpatient Psychiatric Facility IPPS--Inpatient Prospective Payment System IRF--Inpatient Rehabilitation Facility IRF-PAI--Inpatient Rehabilitation Facility--Patient Assessment Instrument IRF-PPS--Inpatient Rehabilitation Facility--Prospective Payment System IRVEN--Inpatient Rehabilitation Validation and Entry LIP--Low-income percentage MEDPAR--Medicare Provider Analysis and Review MSA--Metropolitan Statistical Area NECMA--New England County Metropolitan Area NOS--Not Otherwise Specified NTIS--National Technical Information Service OMB--Office of Management and Budget OSCAR--Online Survey, Certification, and Reporting PAI--Patient Assessment Instrument PLI--Professional Liability Insurance PMSA--Primary Metropolitan Statistical Area PPI--Producer Price Index PPS--Prospective Payment System RIC--Rehabilitation Impairment Category RPL--Rehabilitation Hospital, Psychiatric Hospital, and Long-Term Care Hospital Market Basket TEFRA--Tax Equity and Fiscal Responsibility Act TEP--Technical Expert Panel

1. Background

   [If you choose to comment on issues in this section, please include the caption ``Background'' at the beginning of your comments.]

   1. General Overview of the Current Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)

      Section 4421 of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105- 33), as amended by section 125 of the Medicare, Medicaid, and SCHIP

      [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L. 106-113), and by section 305 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Pub. L. 106-554), provides for the implementation of a per discharge prospective payment system (PPS), through section 1886(j) of the Social Security Act (the Act), for inpatient rehabilitation hospitals and inpatient rehabilitation units of a hospital (hereinafter referred to as IRFs).

      Payments under the IRF PPS encompass inpatient operating and capital costs of furnishing covered rehabilitation services (that is, routine, ancillary, and capital costs) but not costs of approved educational activities, bad debts, and other services or items outside the scope of the IRF PPS. Although a complete discussion of the IRF PPS provisions appears in the August 7, 2001 final rule, we are providing below a general description of the IRF PPS.

      The IRF PPS, as described in the August 7, 2001 final rule, uses Federal prospective payment rates across 100 distinct case-mix groups (CMGs). Ninety-five CMGs were constructed using rehabilitation impairment categories, functional status (both motor and cognitive), and age (in some cases, cognitive status and age may not be a factor in defining a CMG). Five special CMGs were constructed to account for very short stays and for patients who expire in the IRF.

      For each of the CMGs, we developed relative weighting factors to account for a patient's clinical characteristics and expected resource needs. Thus, the weighting factors account for the relative difference in resource use across all CMGs. Within each CMG, the weighting factors were ``tiered'' based on the estimated effects that certain comorbidities have on resource use.

      The Federal PPS rates were established using a standardized payment amount (previously referred to as the budget-neutral conversion factor). The standardized payment amount was previously called the budget neutral conversion factor because it reflected a budget neutrality adjustment for FYs 2001 and 2002, as described in Sec. 412.624(d)(2). However, the statute requires a budget neutrality adjustment only for FYs 2001 and 2002. Accordingly, for subsequent years we believe it is more consistent with the statute to refer to the standardized payment as the standardized payment conversion factor, rather than refer to it as a budget neutral conversion factor (see 68 FR 45674, 45684 and 45685). Therefore, we will refer to the standardized payment amount in this proposed rule as the standard payment conversion factor.

      For each of the tiers within a CMG, the relative weighting factors were

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      applied to the standard payment conversion factor to compute the unadjusted Federal prospective payment rates. Under the current system, adjustments that accounted for geographic variations in wages (wage index), the percentage of low-income patients, and location in a rural area were applied to the IRF's unadjusted Federal prospective payment rates. In addition, adjustments were made to account for the early transfer of a patient, interrupted stays, and high cost outliers.

      Lastly, the IRF's final prospective payment amount was determined under the transition methodology prescribed in section 1886(j) of the Act. Specifically, for cost reporting periods that began on or after January 1, 2002 and before October 1, 2002, section 1886(j)(1) of the Act and as specified in Sec. 412.626 provides that IRFs transitioning into the PPS would receive a ``blended payment.'' For cost reporting periods that began on or after January 1, 2002 and before October 1, 2002, these blended payments consisted of 66\2/3\ percent of the Federal IRF PPS rate and 33\1/3\ percent of the payment that the IRF would have been paid had the IRF PPS not been implemented. However, during the transition period, an IRF with a cost reporting period beginning on or after January 1, 2002 and before October 1, 2002 could have elected to bypass this blended payment and be paid 100 percent of the Federal IRF PPS rate. For cost reporting periods beginning on or after October 1, 2002 (FY 2003), the transition methodology expired, and payments for all IRFs consist of 100 percent of the Federal IRF PPS rate.

      We established a CMS Web site that contains useful information regarding the IRF PPS. The Web site URL is http://www.cms.hhs.gov/providers/irfpps/default.asp and may be accessed to download or view

      publications, software, and other information pertinent to the IRF PPS.

   2. Requirements for Updating the Prospective Payment Rates for IRFs

      On August 7, 2001, we published a final rule entitled ``Medicare Program; Prospective Payment System for Inpatient Rehabilitation Facilities'' in the Federal Register (66 FR at 41316), that established a PPS for IRFs as authorized under section 1886(j) of the Act and codified at subpart P of part 412 of the Medicare regulations. In the August 7, 2001 final rule, we set forth the per discharge Federal prospective payment rates for fiscal year (FY) 2002 that provided payment for inpatient operating and capital costs of furnishing covered rehabilitation services (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 IRF PPS. The provisions of the August 7, 2001 final rule were effective for cost reporting periods beginning on or after January 1, 2002. On July 1, 2002, we published a correcting amendment to the August 7, 2001 final rule in the Federal Register (67 FR at 44073). Any references to the August 7, 2001 final rule in this proposed rule include the provisions effective in the correcting amendment.

      Section 1886(j)(5) of the Act and Sec. 412.628 of the regulations require the Secretary to publish in the Federal Register, on or before August 1 of the preceding FY, the classifications and weighting factors for the IRF CMGs and a description of the methodology and data used in computing the prospective payment rates for the upcoming FY. On August 1, 2002, we published a notice in the Federal Register (67 FR at 49928) to update the IRF Federal prospective payment rates from FY 2002 to FY 2003 using the methodology as described in Sec. 412.624. As stated in the August 1, 2002 notice, we used the same classifications and weighting factors for the IRF CMGs that were set forth in the August 7, 2001 final rule to update the IRF Federal prospective payment rates from FY 2002 to FY 2003. We have continued to update the prospective payment rates each year in accordance with the methodology set forth in the August 7, 2001 final rule.

      In this proposed rule, we are proposing to update the IRF Federal prospective payment rates from FY 2005 to FY 2006, and we are proposing revisions to the methodology described in Sec. 412.624. The proposed changes to the methodology are described in more detail in this proposed rule. For example, we are proposing to add a new teaching status adjustment, and we are proposing to implement other changes to existing policies in a budget neutral manner, which requires applying additional budget neutrality factors to the standard payment amount to calculate the standard payment conversion factor for FY 2006. See section III of this proposed rule for further discussion of the proposed FY 2006 Federal prospective payment rates. The proposed FY 2006 Federal prospective payment rates would be effective for discharges on or after October 1, 2005 and before October 1, 2006.

   3. Operational Overview of the Current IRF PPS

      As described in the August 7, 2001 final rule, upon the admission and discharge of a Medicare Part A fee-for-service patient, the IRF is required to complete the appropriate sections of a patient assessment instrument, the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI). All required data must be electronically encoded into the IRF-PAI software product. Generally, the software product includes patient grouping programming called the GROUPER software. The GROUPER software uses specific Patient Assessment Instrument (PAI) data elements to classify (or group) the patient into a distinct CMG and account for the existence of any relevant comorbidities.

      The GROUPER software produces a 5-digit CMG number. The first digit is an alpha-character that indicates the comorbidity tier. The last 4 digits represent the distinct CMG number. (Free downloads of the Inpatient Rehabilitation Validation and Entry (IRVEN) software product, including the GROUPER software, are available at the CMS Web site at http://www.cms.hhs.gov/providers/irfpps/default.asp).

      Once the patient is discharged, the IRF completes the Medicare claim (UB-92 or its equivalent) using the 5-digit CMG number and sends it to the appropriate Medicare fiscal intermediary (FI). (Claims submitted to Medicare must comply with both the Administrative Simplification Compliance Act (ASCA), Pub. L. 107-105, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 104-191. Section 3 of ASCA requires the Medicare Program, subject to subsection (H), to deny payment under Part A or Part B for any expenses for items or services ``for which a claim is submitted other than in an electronic form specified by the Secretary.'' Subsection (h) provides that the Secretary shall waive such denial in two types of cases and may also waive such denial ``in such unusual cases as the Secretary finds appropriate.'' See also, 68 FR at 48805 (August 15, 2003). Section 3 of ASCA operates in the context of the Administrative Simplification provisions of HIPAA, which include, among others, the transactions and code sets standards requirements codified as 45 CFR part 160 and 162, subparts A and I through R (generally known as the Transactions Rule). The Transactions Rule requires covered entities, including covered providers, to conduct covered electronic transactions according to the applicable

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      transaction standards. See the program claim memoranda issued and published by CMS at www.cms.hhs.gov/providers/edi/default.asp, http://www.cms.hhs.gov/provider/edi/default.asp and listed in the addenda to

      the Medicare Intermediary Manual, Part 3, section 3600. Instructions for the limited number of claims submitted to Medicare on paper are located in section 3604 of Part 3 of the Medicare Intermediary Manual.)

      The Medicare Fiscal Intermediary (FI) processes the claim through its software system. This software system includes pricing programming called the PRICER software. The PRICER software uses the CMG number, along with other specific claim data elements and provider-specific data, to adjust the IRF's prospective payment for interrupted stays, transfers, short stays, and deaths and then applies the applicable adjustments to account for the IRF's wage index, percentage of low- income patients, rural location, and outlier payments.

   4. Quality of Care in IRFs

      The IRF-PAI is the patient data collection instrument for IRFs. Currently, the IRF-PAI contains a blend of the functional independence measures items and quality and medical needs questions. The quality and medical needs questions (which are currently collected on a voluntary basis) may need to be modified to encapsulate those data necessary for calculation of quality indicators in the future.

      We awarded a contract to the Research Triangle Institute (RTI) with the primary tasks of identifying quality indicators pertinent to the inpatient rehabilitation setting and determining what information is necessary to calculate those quality indicators. These tasks included reviewing literature and other sources for existing rehabilitation quality indicators. It also involved identifying organizations involved in measuring or monitoring quality of care in the inpatient rehabilitation setting. In addition, RTI was tasked with performing independent testing of the quality indicators identified in their research.

      Once RTI has issued a final report, we will determine which quality-related items should be listed on the IRF-PAI. The revised IRF- PAI will need to be approved by OMB before it is used in IRFs.

      We would like to take this opportunity to discuss our thinking related to broader initiatives in this area related to quality of care. We have supported the development of valid quality measures and have been engaged in a variety of quality improvement efforts focused in other post-acute care settings such as nursing homes. However, as mentioned above, any new quality-related data collected from the IRF- PAI would have to be analyzed to determine the feasibility of developing a payment method that accounts for the performance of the IRF in providing the necessary rehabilitative care.

      Medicare beneficiaries are the primary users of IRF services. Any quality measures must be carefully constructed to address the unique characteristics of this population. Similarly, we need to consider how to design effective incentives; that is, superior performance measured against pre-established benchmarks and/or performance improvements.

      In addition, while our efforts to develop the various post-acute care PPSs, including the IRF PPS, have generated substantial improvements over the preexisting cost-based systems, each of these individual systems was developed independently. As a result, we have focused on phases of a patient's illness as defined by a specific site of service, rather than on the entire post-acute episode. As the differentiation among provider types (such as SNFs and IRFs) becomes less pronounced, we need to investigate a more coordinated approach to payment and delivery of post-acute services that focuses on the overall post-acute episode.

      This could entail a strategy of developing payment policy that is as neutral as possible regarding provider and patient decisions about the use of particular post-acute services. That is, Medicare should provide payments sufficient to ensure that beneficiaries receive high quality care in the most appropriate setting, so that admissions and any transfers between settings occur only when consistent with good care, rather than to generate additional revenues. In order to accomplish this objective, we need to collect and compare clinical data across different sites of service.

      In fact, in the long run, our ability to compare clinical data across care settings is one of the benefits that will be realized as a basic component of the Department's interest in the use of a standardized electronic health record (EHR) across all settings including IRFs. It is also important to recognize the complexity of the effort, not only in developing an integrated assessment tool that is designed using health information standards, but in examining the various provider-centric prospective payment methodologies and considering payment approaches that are based on patient characteristics and outcomes. MedPAC has recently taken a preliminary look at the challenges in improving the coordination of our post-acute care payment methods, and suggested that it may be appropriate to explore additional options for paying for post-acute services. We agree that CMS, in conjunction with MedPAC and other stakeholders, should consider a full range of options in analyzing our post-acute care payment methods, including the IRF PPS.

      We also want to encourage incremental changes that will help us build towards these longer term objectives. For example, medical records tools are now available that could allow better coordinated discharge planning procedures. These tools can be used to ensure communication of a standardized data set that then can be used to establish a comprehensive IRF care plan. Improved communications may reduce the incidence of potentially avoidable rehospitalizations and other negative impacts on quality of care that occur when patients are transferred to IRFs without a full explanation of their care needs. We are looking at ways that Medicare providers can use these tools to generate timely data across settings.

      At this time, we do not offer specific proposals related to the preceding discussion. Finally, some of the ideas discussed here may exceed our current statutory authority. However, we believe that it is useful to encourage discussion of a broad range of ideas for debate of the relative advantages and disadvantages of the various policies affecting this important component of the health care sector. We welcome comments on these and other approaches.

   5. Research To Support Refinements of the Current IRF PPS

      As described in the August 7, 2001 final rule, we contracted with the RAND Corporation (RAND) to analyze IRF data to support our efforts in developing the CMG patient classification system and the IRF PPS. Since then, we have continued our contract with RAND to support us in developing potential refinements to the classification system and the PPS. RAND has also developed a system to monitor the effects of the IRF PPS on patients' access to IRF care and other post-acute care services.

      In 1995, RAND began extensive research, sponsored by us, on the development of a per-discharge based PPS using a patient classification system known as Functional Independence Measures-Function Related Groups (FIM-FRGs) for IRFs. The results of RAND's earliest research, using 1994

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      data, were released in September 1997 and are contained in two reports available through the National Technical Information Service (NTIS). The reports are: Classification System for Inpatient Rehabilitation Patients--A Review and Proposed Revisions to the Function Independence Measure-Function Related Groups, NTIS order number PB98-105992INZ, and Prospective Payment System for Inpatient Rehabilitation, NTIS order number PB98-106024INZ.

      In July 1999, we contracted with RAND to update its earlier research. The update included an analysis of Functional Independence Measure (FIM) data, the Function Related Groups (FRGs), and the model rehabilitation PPS using 1996 and 1997 data. The purpose of updating the earlier research was to develop the underlying data necessary to support the Medicare IRF PPS based on CMGs for the November 3, 2000 proposed rule (65 FR at 66313). RAND expanded the scope of its earlier research to include the examination of several payment elements, such as comorbidities, facility-level adjustments, and implementation issues, including evaluation and monitoring. Then, to develop the provisions of the August 7, 2001 final rule (66 FR 41316, 41323), RAND did similar analysis on calendar year 1998 and 1999 Medicare Provider Analysis and Review (MedPAR) files and patient assessment data.

      We have continued to contract with RAND to help us identify potential refinements to the IRF PPS. RAND conducted updated analyses of the patient classification system, case mix and coding changes, and facility-level adjustments for the IRF PPS using data from calendar year 2002 and FY 2003. This is the first time CMS or RAND has had data generated by IRFs after the implementation of the IRF PPS that are available for data analysis. The refinements we are proposing to make to the IRF PPS are based on the analyses and recommendations from RAND. In addition, RAND sought advice from a technical expert panel (TEP), which reviewed their methodology and findings.

   6. Proposed Refinements to the IRF PPS for Fiscal Year 2006

      Based on analyses by RAND using calendar year 2002 and FY 2003 data, we are proposing refinements to the IRF PPS case-mix classification system (the CMGs and the corresponding relative weights) and the case-level and facility-level adjustments. Several new developments warrant these proposed refinements, including--(1) the availability of more recent 2002 and 2003 data; (2) better coding of comorbidities and patient severity; (3) more complete data; (4) new data sources for imputing missing values; and (5) improved statistical approaches.

      In this proposed rule, we are proposing to make the following revisions:

      Reduce the standard payment amount by 1.9 percent.

      In the August 7, 2001 final rule, we used cost report data from FYs 1998, 1997, and/or 1996 and calendar year 1999 Medicare bill data in calculating the initial PPS payment rates. As discussed in detail in section III.A of this proposed rule, analysis of calendar year 2002 data indicates that the standard payment conversion factor is now at least 1.9 percent higher than it should be to reflect the actual costs of caring for Medicare patients in IRFs. The data demonstrate that this is largely because the implementation of the IRF PPS caused important changes in IRFs' coding practices, including increased accuracy and consistency in coding.

      Make revisions to the comorbidity tiers and the CMGs.

      In the August 7, 2001 final rule, we used FIM and Medicare data from 1998 and 1999 to construct the CMGs and to assign the comorbidity tiers. As discussed in detail in section II of this proposed rule, analysis of calendar year 2002 and FY 2003 data indicates the need to refine the comorbidity tiers and the CMGs to better reflect the costs of Medicare cases in IRFs.

      Adopt the new geographic labor market area definitions based on the definitions created by the Office of Management and Budget (OMB), known as Core-Based Statistical Areas (CBSAs), for purposes of computing the proposed wage index adjustment to IRF payments.

      Historically, Medicare PPSs have used market area definitions developed by OMB. We are proposing to adopt new market area definitions which are based on OMB definitions. As discussed in detail in section III.B.2 of this proposed rule, we believe that these designations more accurately reflect the local economies and wage levels of the areas in which hospitals are located. These are the same labor market area definitions implemented for acute care inpatient hospitals under the hospital inpatient prospective payment system (IPPS) as specified in Sec. 412.64(b)(1)(ii)(A) through (C), which were effective for those hospitals beginning October 1, 2004 as discussed in the August 11, 2004 IPPS final rule (69 FR at 49026 through 49032).

      Implement a teaching status adjustment to payments for services provided in IRFs that are, or are part of, teaching hospitals.

      In previous rules, including the August 7, 2001 final rule, we noted that analyses of the data did not support a teaching adjustment. However, analysis of the more recent calendar year 2002 and fiscal year 2003 data supports a teaching status adjustment. For the first time, as discussed in detail in section III.B.3 of this proposed rule, the data analysis has demonstrated a statistically significant relationship between an IRF's teaching status and the costs of caring for patients in that IRF. We believe this may suggest the need to account for the higher costs associated with major teaching programs. For reasons discussed in detail in section III.B.3 of this proposed rule, we are proposing to implement the new teaching status adjustment in a budget neutral manner. However, we have some concerns about proposing a teaching status adjustment for IRFs at this time (as discussed in detail in section III.B.3 of this proposed rule). Because of these concerns, we are specifically soliciting comments on our consideration of an IRF teaching status adjustment.

      Update the formulas used to compute the rural and the low- income patient (LIP) adjustments to IRF payments.

      In the August 7, 2001 final rule, we implemented an adjustment to account for the higher costs in rural IRFs by multiplying their payments by 1.1914. As discussed in detail in section III.B.4 of this proposed rule, the regression analysis RAND performed on fiscal year 2003 data suggests that this rural adjustment should be updated to 1.241 to account for the differences in costs between rural and urban IRFs.

      Similarly, in the August 7, 2001 final rule, we implemented an adjustment to payments to reflect facilities' low-income patient percentage calculated as (1+ the disproportionate share hospital (DSH) patient percentage) raised to the power of 0.4838. As discussed in detail in section III.B.5 of this proposed rule, the regression analysis RAND performed on fiscal year 2003 data indicates that the LIP adjustment should now be calculated as (1 + DSH patient percentage) raised to the power of 0.636. For reasons discussed in detail in section III.B.5 of this proposed rule, we are proposing to implement the changes to these adjustments in a budget neutral manner.

      Update the outlier threshold amount from $11,211 (FY 2005) to $4,911 (FY 2006) to maintain total estimated outlier payments at 3 percent of total estimated payments.

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      In the August 7, 2001 final rule, we describe the process by which we calculate the outlier threshold, which involves simulating payments and then determining a threshold that would result in outlier payments being equal to 3 percent of total payments under the simulation. As discussed in detail in section III.B.6 of this proposed rule, we believe based on RAND's regression analysis that all of the other proposed updates to the IRF PPS, including the structure of the CMGs and the tiers, the relative weights, and the facility-level adjustments (such as the rural adjustment, the LIP adjustment, and the proposed teaching status adjustment) make it necessary to propose to adjust the outlier threshold amount.

2. Proposed Refinements to the Patient Classification System

   [If you choose to comment on issues in this section, please include the caption ``Proposed Refinements to the Patient Classification System'' at the beginning of your comments.]

   1. Proposed Changes to the IRF Classification System

      1. Development of the IRF Classification System

      Section 1886(j)(2)(A)(i) of the Act, as amended by section 125 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 requires the Secretary to establish ``classes of patient discharges of rehabilitation facilities by functional-related groups (each referred to as a case-mix group or CMG), based on impairment, age, comorbidities, and functional capability of the patients, and such other factors as the Secretary deems appropriate to improve the explanatory power of functional independence measure-function related groups.'' In addition, the Secretary is required to establish a method of classifying specific patients in IRFs within these groups as specified in Sec. 412.620.

      In the August 7, 2001 final rule (66 FR at 41342), we implemented a methodology to establish a patient classification system using CMGs. The CMGs are based on the FIM-FRG methodology and reflect refinements to that methodology.

      In general, a patient is first placed in a major group called a rehabilitation impairment category (RIC) based on the patient's primary reason for inpatient rehabilitation, (for example, a stroke). The patient is then placed into a CMG within the RIC, based on the patient's ability to perform specific activities of daily living, and sometimes the patient's cognitive ability and/or age. Other special circumstances, such as the occurrence of very short stays, or cases where the patient expired, are also considered in determining the appropriate CMG.

      We explained in the August 7, 2001 final rule that further analysis of FIM and Medicare data may result in refinements to CMGs. In the August 7, 2001 final rule, we used the most recent FIM and Medicare data available at that time (that is 1998 and 1999 data). Developing the CMGs with the 1998 and 1999 data resulted in 95 CMGs based on the FIM-FRG methodology. The data also supported the establishment of five additional special CMGs that improved the explanatory power of the FIM- FRGs. We established one additional special CMG to account for very short stays and four additional special CMGs to account for cases where the patient expired. In addition, we established a payment of an additional amount for patients with at least one relevant comorbidity in certain CMGs. 2. Description and Methodology Used to Develop the IRF Classification System in the August 7, 2001 Final Rule a. Rehabilitation Impairment Categories

      In the first step to develop the CMGs, the FIM data from 1998 and 1999 were used to group patients into RICs. Specifically, the impairment code from the assessment instrument used by clients of UDSmr and Healthsouth indicates the primary reason for the inpatient rehabilitation admission. This impairment code is used to group the patient into a RIC. Currently, we use 21 RICs for the IRF PPS. b. Functional Status Measures and Age

      After using the RIC to define the first division among the inpatient rehabilitation groups, we used functional status measures and age to partition the cases further. In the August 7, 2001 final rule, we used 1998 and 1999 Medicare bills with corresponding FIM data to create the CMGs and more thoroughly examine each item of the motor and cognitive measures. Based on the data used for the August 7, 2001 final rule, we found that we could improve upon the CMGs by making a slight modification to the motor measure. We modified the motor measure by removing the transfer to tub/shower item because we found that an increase in a patient's ability to perform functional tasks with less assistance for this item was associated with an increase in cost, whereas an increase in other functional items decreased costs. We describe below the statistical methodology (Classification and Regression Trees (CART)) that we used to incorporate a patient's functional status measures (modified motor score and cognitive score) and age into the construction of the CMGs in the August 7, 2001 final rule.

      We used the CART methodology to divide the rehabilitation cases further within each RIC. (Further information regarding the CART methodology can be found in the seminal literature on CART (Classification and Regression Trees, Leo Breiman, Jerome Friedman, Richard Olshen, Charles Stone, Wadsworth Inc., Belmont CA, 1984: pp. 78-80).) We chose to use the CART method because it is useful in identifying statistical relationships among data and, using these relationships, constructing a predictive model for organizing and separating a large set of data into smaller, similar groups. Further, in constructing the CMGs, we analyzed the extent to which the independent variables (motor score, cognitive score, and age) helped predict the value of the dependent variable (the log of the cost per case). The CART methodology creates the CMGs that classify patients with clinically distinct resource needs into groups. CART is an iterative process that creates initial groups of patients and then searches for ways to divide the initial groups to decrease the clinical and cost variances further and to increase the explanatory power of the CMGs. Our current CMGs are based on historical data. In order to develop a separate CMG, we need to have data on a sufficient number of cases to develop coherent groups. Currently, we use 95 CMGs as well as 5 special CMGs for scenarios involving short stays or the expiration of the patient. c. Comorbidities

      Under the statutory authority of section 1886(j)(2)(C)(i) of the Act, we are proposing to make several changes to the comorbidity tiers associated with the CMGs for comorbidities that are not positively related to treatment costs, or their excessive use is questionable, or their condition could not be differentiated from another condition. Specifically, section 1886(j)(2)(C)(i) of the Act provides the following: The Secretary shall from time to time adjust the classifications and weighting factors established under this paragraph as appropriate to reflect changes in treatment patterns, technology, case mix, number of payment units for which payment is made under this title and other factors that may affect the relative use of resources. The adjustments shall be made in a manner so that changes in aggregate payments under the

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      classification system are a result of real changes and are not a result of changes in coding that are unrelated to real changes in case mix.

      A comorbidity is a specific patient condition that is secondary to the patient's principal diagnosis or impairment that is used to place a patient into a RIC. A patient could have one or more comorbidities present during the inpatient rehabilitation stay. Our analysis for the August 7, 2001 final rule found that the presence of a comorbidity could have a major effect on the cost of furnishing inpatient rehabilitation care. We also stated that the effect of comorbidities varied across RICs, significantly increasing the costs of patients in some RICs, while having no effect in others. Therefore, for the August 7, 2001 final rule, we linked frequently occurring comorbidities to impairment categories in order to ensure that all of the chosen comorbidities were not an inherent part of the diagnosis that assigns the patient to the RIC.

      Furthermore, in the August 7, 2001 final rule, we indicated that comorbidities can affect cost per case for some of the CMGs, but not all. When comorbidities substantially increased the average cost of the CMG and were determined to be clinically relevant (not inherent in the diagnosis in the RIC), we developed CMG relative weights adjusted for comorbidities (Sec. 412.620(b)). d. Development of CMG Relative Weights

      Section 1886(j)(2)(B) of the Act requires that an appropriate relative weight be assigned to each CMG. Relative weights account for the variance in cost per discharge and resource utilization among the payment groups and are a primary element of a case-mix adjusted PPS. The establishment of relative weights helps ensure that beneficiaries have access to care and receive the appropriate services that are commensurate to other beneficiaries that are classified in the same CMG. In addition, prospective payments that are based on relative weights encourage provider efficiency and, hence, help ensure a fair distribution of Medicare payments. Accordingly, as specified in Sec. 412.620(b)(1), we calculate a relative weight for each CMG that is proportional to the resources needed by an average inpatient rehabilitation case in that CMG. For example, cases in a CMG with a relative weight of 2, on average, will cost twice as much as cases in a CMG with a relative weight of 1. We discuss the details of developing the relative weights below.

      As indicated in the August 7, 2001 final rule, we believe that the RAND analysis has shown that CMGs based on function-related groups (adjusted for comorbidities) are effective predictors of resource use as measured by proxies such as length of stay and costs. The use of these proxies is necessary in developing the relative weights because data that measure actual nursing and therapy time spent on patient care, and other resource use data, are not available. e. Overview of Development of the CMG Relative Weights

      As indicated in the August 7, 2001 final rule, to calculate the relative weights, we estimate operating (routine and ancillary services) and capital costs of IRFs. For this proposed rule, we use the same method for calculating the cost of a case that we outlined in the August 7, 2001 final (66 FR at 41351 through 43153). We obtained cost- to-charge ratios for ancillary services and per diem costs for routine services from the most recent available cost report data. We then obtain charges from Medicare bill data and derived corresponding functional measures from the FIM data. We omit data from rehabilitation facilities that are classified as all-inclusive providers from the calculation of the relative weights, as well as from the parameters that we use to define transfer cases, because these facilities are paid a single, negotiated rate per discharge and therefore do not maintain a charge structure. For ancillary services, we calculate both operating and capital costs by converting charges from Medicare claims into costs using facility-specific, cost-center specific cost-to-charge ratios obtained from cost reports. Our data analysis for the August 7, 2001 final rule showed that some departmental cost-to-charge ratios were missing or found to be outside a range of statistically valid values. For anesthesiology, a value greater than 10, or less than 0.01, is found not to be statistically valid. For all other cost centers, values greater than 10 or less than 0.5 are found not to be statistically valid. In the August 7, 2001 final rule, we replaced individual cost- to-charge ratios outside of these thresholds. The replacement value that we used for these aberrant cost-to-charge ratios was the mean value of the cost-to-charge ratio for the cost-center within the same type of hospital (either freestanding or unit). For routine services, per diem operating and capital costs are used to develop the relative weights. In addition, per diem operating and capital costs for special care services are used to develop the relative weights. (Special care services are furnished in intensive care units. We note that fewer than 1 percent of rehabilitation days are spent in intensive care units.) Per diem costs are obtained from each facility's Medicare cost report data. We use per diem costs for routine and special care services because, unlike for ancillary services, we could not obtain cost-to- charge ratios for these services from the cost report data. To estimate the costs for routine and special care services included in developing the relative weights, we sum the product of routine cost per diem and Medicare inpatient days and the product of the special care per diem and the number of Medicare special care days.

      In the August 7, 2001 final rule, we used a hospital specific relative value method to calculate relative weights. We used the following basic steps to calculate the relative weights as indicated in the August 7, 2001 final rule (at 66 FR 41316, 41351 through 41352).

      The first step in calculating the CMG weights is to estimate the effect that comorbidities have on costs. The second step required us to adjust the cost of each Medicare discharge (case) to reflect the effects found in the first step. In the third step, the adjusted costs from the second step were used to calculate ``relative adjusted weights'' in each CMG using the hospital-specific relative value method. The final steps are to calculate the CMG relative weights by modifying the ``relative adjusted weight'' with the effects of the existence of the comorbidity tiers (explained below) and normalizing the weights to 1.

   2. Proposed Changes to the Existing List of Tier Comorbidities

      1. Proposed Changes to Remove Codes That Are Not Positively Related to Treatment Costs

      While our methodology for this proposed rule for determining the tiers remains unchanged from the August 7, 2001 final rule, RAND's analysis indicates that 1.6 percent of FY 2003 cases received a tier payment (often in tier one) that was not justified by any higher cost for the case. Therefore, under statutory authority section 1886(j)(2)(C)(i) of the Act, we are proposing several technical changes to the comorbidity tiers associated with the CMGs. Specifically, the RAND analysis found that the first 17 diagnoses shown in Table 1 below are no longer positively related to treatment cost after controlling for CMG. The

      [[Page 30195]]

      additional two codes were also problematic. According to RAND, code 410.91 (AMI, NOS, Initial) was too unspecific to be differentiated from other related codes and code 260, Kwashiorkor, was found to be unrealistically represented in the data according to a RAND technical expert panel.

      With respect to the eighteenth code in Table One, (410.X1) Specific AMI, initial), we note that RAND found there is not clinical reason to believe that this code differs in a rehabilitation environment from all of the specific codes for initial AMI of the form 410.X, where X is an numeric digit. In other words, this code is indistinguishable from the seventeenth code in Table One (410.91 AMI, NOS, initial). Following this observation, RAND tested the other initial AMI codes as a single group and found that they have no positive effect on case cost. Since we are proposing to remove ``AMI, NOS, initial'' from the tier list because it is not positively related to treatment cost after controlling for the CMG, we believe that ``Specific AMI, initial'' similarly should be removed from the tier list since it is indistinguishable from ``AMI, NOS, initial.''

      With respect to the last code in Table One (Kwashiorkor), we are proposing to remove this code from the tier list as well. This comorbidity is positively related to cost in our data. However, RAND's technical expert panel (TEP) found the large number of cases coded with this rare disease to be unrealistic and recommended that it be removed from the tier list.

      Table 1 contains two malnutrition codes, and removing these two malnutrition codes where use is concentrated in specific hospitals is particularly important because these hospitals are likely receiving unwarrantedly high payments due to the tier one assignment of these cases. Thus, because we believe the excess use of these two comorbid conditions is inappropriate based on the findings of RAND's TEP, we are proposing their removal.

      The data indicate large variation in the rate of increase from the 1999 data to the 2003 data across the conditions that make up the tiers. The greatest increases were for miscellaneous throat conditions and malnutrition, each of which were more than 10 times as frequent in 2003 as in 1999. The growth in these two conditions was far larger than for any other condition. Many conditions, however, more than doubled in frequency, including dialysis, cachexia, obesity, and the non-renal complications of diabetes. The condition with the least growth, renal complications of diabetes, may have been affected by improved coding of dialysis.

      The remaining proposed changes to our initial list of diagnoses in Table 1 deal with tracheostomy cases. These rare cases were excluded from the pulmonary RIC 15 in the August 7, 2001 final rule. The new data indicate that they are more expensive than other cases in the same CMG in RIC 15, as well as in other RICs. Therefore, we believe the data demonstrate that tracheostomy cases should be added to the tier list for RIC 15. Finally, DX V55.0, ``attention to tracheostomy'' should initially have been part of this condition as these cases were and are as expensive as other tracheostomy cases. Thus, since ``attention to tracheostomy'' is as expensive as other tracheostomy cases, it is logical to group such similar cases together.

      We believe that the data provided by RAND support the removal of the codes in Table 1 below because they either have no impact on cost after controlling for their CMG or are indistinguishable from other codes or are unrealistically overrepresented. Therefore, we are proposing to remove these codes from the tier list.

      Table 1.--Proposed List of Codes To Be Removed From the Tier List

      ICD-9-CM code

      Abbreviated code title

      Condition

      235.1.................... Unc behav neo oral/phar...... Miscellaneous throat conditions. 933.1.................... Foreign body in larynx....... Miscellaneous throat conditions. 934.1.................... Foreign body bronchus........ Miscellaneous throat conditions. 530.0.................... Achalasia & cardiospasm...... Esophegeal conditions. 530.3.................... Esophageal stricture......... Esophegeal conditions. 530.6.................... Acquired esophag diverticulum Esophegeal conditions. V46.1.................... Dependence on respirator..... Ventilator status. 799.4.................... Cachexia..................... Cachexia. V49.75................... Status amputation below knee. Amputation of LE. V49.76................... Status amputation above knee. Amputation of LE. V497.7................... Status amputation hip........ Amputation of LE. 356.4.................... Idiopathic progressive

      Meningitis and encephalitis. polyneuropathy. 250.90................... Diabetes II, w unspecified Non-renal Complications of Diabetes. complications, not stated as uncontrolled. 250.93................... Diabetes I, w unspecified Non-renal Complications of Diabetes. complications, uncontrolled. 261...................... Nutritional Marasmus......... Malnutrition. 262...................... Other severe protein calorie Malnutrition. deficiency. 410.91................... AMI, NOS, initial............ Major comorbidities. 410.X1................... Specific AMI, initial........ Major comorbidities. 260...................... Kwashiorkor.................. Malnutrition.

      2. Proposed Changes To Move Dialysis To Tier One

      We are proposing the movement of dialysis to tier one, which is the tier associated with the highest payment. The data from the RAND analysis show that patients on dialysis cost substantially more than current payments for these patients and should be moved into the highest paid tier because this tier would more closely align payment with the cost of a case. Based on RAND's analysis using 2003 data, a patient with dialysis costs 31 percent more than a non-dialysis patient in the same CMG and with the same other accompanying comorbidities.

      Overall, the largest increase in the cost of a condition occurs among patients on dialysis, where the coefficient in the cost regression increases by 93 percent, from 0.1400 to 0.2697. Part of the explanation for the increased coefficient could be that some IRFs had not borne all dialysis costs for their patients in the pre-PPS period

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      (because providers were previously permitted to bill for dialysis separately). Dialysis is currently in tier two. However, it is likely that, in the 1999 data, some IRFs had not borne all dialysis costs for their patients. Because the fraction of cases coded with dialysis increased by 170 percent, it is also likely that improved coding was part of the explanation for the increased coefficient. We believe a 170 percent increase is such a dramatic increase that it would be highly unlikely that in one short time, 170 percent more patients need dialysis than they did before the implementation of the IRF PPS. We also believe that the improved coding is likely due to the fact that higher costs are associated with dialysis patients and therefore IRFs, in an effort to ensure that their payments cover these higher expenses will better and more carefully code comorbidities whose presence will result in higher PPS payments.

      Moving dialysis patients to tier one will more adequately compensate hospitals for the extra cost of those patients and thereby maintain or increase access to these services. 3. Proposed Changes To Move Comorbidity Codes Based on Their Marginal Cost

      Under statutory authority section 1886(j)(2)(C)(i) of the Act, we are proposing to move comorbidity codes based on their marginal cost. Another limitation with the existing tiers is that costs for several conditions would be more accurately predicted if their tier assignments were changed. After examining RAND's data, we believe that a full 4 percent of FY 2003 cases should be moved down to tiers with lower payment.

      We propose that tier assignments be based on the results of statistical analyses RAND has performed under contract with CMS, using as independent variables only the proposed CMGs and conditions that we are proposing for tiers (for example, the CMGs and conditions that remain after the proposed changes have been made). We are proposing that the tier assignments of each of these conditions be decided based on the magnitude of their coefficients in RAND's statistical analysis.

      We believe the IRF PPS led to substantial changes in coding of comorbidities between 1999 (pre-implementation of the IRF PPS) and 2003 (post-implementation of the IRF PPS). The percentage of cases with one or more comorbidities increased from 16.79 percent in the data in which tiers were defined (1998 through 1999) to 25.51 percent in FY 2003. This is an increase of 52 percent in tier incidence (52 = 100 x (25.51- 16.79)/16.79). The presence of a tier one comorbidity, the highest paid of the tiers, almost quadrupled during this same time period. Although, coding likely improved, the presence of upcoding for a higher payment may play a factor as well.

      The 2003 data provide a more accurate explanation of the costs that are associated with each of the comorbidities, largely due to having 100 percent of the Medicare-covered IRF cases in the later data versus slightly more than half of the cases in 1999 data. Therefore, using the 2003 data to propose to assign each diagnosis or condition will considerably improve the matching of payments to their relative costs.

   3. Proposed Changes to the CMGs

      Section 1886(j)(2)(C)(i) of the Act requires the Secretary from time to time to adjust the classifications and weighting factors of patients under the IRF PPS to reflect changes in treatment patterns, technology, case mix, number of payment units for which payment is made, and other factors that may affect the relative use of resources. These adjustments shall be made in a manner so that changes in aggregate payments under the classification system are the result of real changes and not the result of changes in coding that are unrelated to real changes in case mix.

      In accordance with section 1886(j)(2)(C)(i) of the Act and as specified in Sec. 412.620(c) and based on the research conducted by RAND, we are proposing to update the CMGs used to classify IRF patients for purposes of establishing payment amounts. We are also proposing to update the relative weights associated with the payment groups based on FY 2003 Medicare bill and patient assessment data. We are proposing to replace the current unweighted motor score index used to assign patients to CMGs with a weighted motor score index that would improve our ability to accurately predict the costs of caring for IRF patients, as described in detail below. However, we are not proposing to change the methodology for computing the cognitive score index.

      As described in the August 7, 2001 final rule, we contracted with RAND to analyze IRF data to support our efforts in developing our patient classification system and the IRF PPS. We have continued our contract with RAND to support us in developing potential refinements to the classification system and the PPS. As part of this research, we asked RAND to examine possible refinements to the CMGs to identify potential improvements in the alignment between Medicare payments and actual IRF costs. In conducting its research, RAND used a technical expert panel (TEP) made up of experts from industry groups, other government entities, academia, and other interested parties. The technical expert panel reviewed RAND's methodologies and advised RAND on many technical issues.

      Several recent developments make significant improvements in the alignment between Medicare payments and actual IRF costs possible. First, when the IRF PPS was implemented in 2002, a new recording instrument was used to collect patient data, the IRF Patient Assessment Instrument (or the IRF PAI). The new instrument contained questions that improved the quality of the patient-level information available to researchers.

      Second, more recent data are available on a larger patient population. Until now, the design of the IRF PPS was based entirely on 1999 data on Medicare rehabilitation patients from just a sample of hospitals. Now, we have post-PPS data from 2002 and 2003 that describe the entire universe of Medicare-covered rehabilitation patients.

      Finally, we believe that proposed improvements in the algorithms that produced the initial CMGs, as described below, should lead to new CMGs that better predict treatment costs in the IRF PPS.

      Using FIM (the inpatient rehabilitation facility assessment instrument before the PPS) and Medicare data from 1998 and 1999, RAND helped us develop the original structure of the IRF PPS. IRFs became subject to the PPS beginning with cost reporting periods on or after January 1, 2002. The PPS is based on assigning patients to particular CMGs that are designed to predict the costs of treating particular Medicare patients according to how well they function in four general categories: transfers, sphincter control, self-care (for example, grooming, eating), and locomotion. Patient functioning is measured according to 18 categories of activity: 13 motor tasks, such as climbing stairs, and 5 cognitive tasks, such as recall. The PPS is intended to align payments to IRFs as closely as possible with the actual costs of treating patients. If the PPS ``underpays'' for some kinds of care, IRFs have incentives to limit access for patients requiring that kind of care because payments would be less than the costs of providing care for a particular case so an IRF may try to

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      limit its financial ``losses''; conversely, if the PPS overpays, resources are wasted because IRFs' payments exceed the costs of providing care for a particular case.

      The fiscal year 2003 data file currently available for refining the CMGs is better than the 1999 data RAND originally used to construct the IRF PPS because it contains many more IRF cases and represents the universe of Medicare-covered IRF cases, rather than a sample. The best available data that CMS and RAND had for analysis in 1999 contained 390,048 IRF cases, representing 64 percent of all Medicare-covered patients in participating IRF hospitals. The more recent data contain 523,338 IRF cases (fiscal year 2003), representing all Medicare-covered patients in participating IRF hospitals. The larger file enables RAND to obtain greater precision in the analysis and ensures a more balanced and complete picture of patients under the IRF PPS.

      Also, the fiscal year 2003 data are better than the 1999 data used to design the IRF PPS because they include more detailed information about patients' level of functioning. For example, new variables are included in the more recent data that provide further details on patient functioning. Standard bowel and bladder scores on the FIM instrument (used to assess patients before the IRF PPS), for example, measured some combination of the level of assistance required and the frequency of accidents (that is, soiling of clothes and surroundings). New variables on the IRF-PAI instrument measure the level and the frequency separately. Since measures of the level of assistance required and the frequency of accidents contain slightly different information about the expected costliness of an IRF patient, having measures for these two variables separately provides additional information to researchers.

      Furthermore, additional optional information is recorded on the health status of patients in the more recent data (for example, shortness of breath, presence of ulcers, inability to balance). 1. Proposed Changes for Updating the CMGs

      As described in the August 7, 2001 final rule, RAND developed the original list of CMGs using FIM data from 1998 and 1999 to group patients into RICs. Table 2 below shows the final set of 95 CMGs based on the FIM-FRG methodology, the 5 special CMGs, and their descriptions. Impairment codes from the assessment instrument used by UDSmr and Healthsouth indicated the primary reasons for inpatient rehabilitation admissions. The impairment codes were used to group patients into RICs. Table 3 below shows each RIC and its associated impairment code. BILLING CODE 4120-01-P

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      Given the availability of more recent, post-PPS data, we asked RAND to examine possible refinements to the CMGs to identify potential

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      improvements in the alignment between Medicare payments and actual IRF costs. In addition to analyzing fiscal year 2003 data, RAND also convened a TEP, made up of researchers from industry, provider organizations, government, and academia, to provide support and guidance through the process of developing possible refinements to the PPS. Members of the TEP reviewed drafts of RAND's reports, offered suggestions for additional analyses, and provided clinicians' views of the importance and significance of various findings.

      RAND's analysis of the FY 2003 data, along with the support and guidance of the TEP, strongly suggest the need to update the CMGs to better align payments with costs under the IRF PPS. The other option we considered before deciding to propose to update the CMGs with the fiscal year 2003 data was to maintain the same CMG structure but recalculate the relative weights for the current CMGs using the 2003 data. After carefully reviewing the results of RAND's regression analysis, which compared the predictive ability of the CMGs under 3 scenarios (not updating the CMGs or the relative weights, updating only the relative weights and not the CMGs, and updating both the relative weights and the CMGs), we believe (based on RAND's analysis) that updating both the relative weights and the CMGs will allow the classification system to do a much better job of reflecting changes in treatment patterns, technology, case mix, and other factors which may affect the relative use of resources.

      We believe it is appropriate to update the CMGs and the relative weights at this time because the 2003 data we now have represent a substantial improvement over the 1999 data. The more recent data include all Medicare-covered IRF cases rather than a subset, allowing us to base the proposed CMG changes on a complete picture of the types of patients in IRFs. In designing the IRF PPS, we used the best available data, but those data did not allow us to have a complete picture of the types of patients in IRFs. Also, the clinical coding of patient conditions in IRFs is vastly improved in the more recent data than it was in the best available data we had to design the IRF PPS. In addition, changes in treatment patterns, technology, case mix, and other factors affecting the relative use of resources in IRFs since the IRF PPS was implemented likely require an update to the classification system.

      We are currently paying IRFs based on 95 CMGs and 5 special CMGs developed using the CART algorithm applied to 1999 data. The CART algorithm that was used in designing the IRF PPS assigned patients to RICs according to their age and their motor and cognitive FIM scores. CART produced the partitions so that the reported wage-adjusted rehabilitation cost of the patients was relatively constant within partitions. Then, a subjective decision-making process was used to decrease the number of CMGs (to ensure that the payment system did not become unduly complicated), to enforce certain constraints on the CMGs (to ensure that, for instance, IRFs were not paid more for patients who had fewer comorbidities than for patients with more comorbidities), and to fit the comorbidity tiers. Although the use of a subjective decision-making process (rather than a computer algorithm) was very useful, there were limitations. For example, it made it difficult to explore the implications of variations to the CART models because a computer program can examine many more variations of a model in a much shorter time than an individual person. Furthermore, the computer is more efficient at accounting for all of the possible combinations and interactions between important variables that affect patient costs.

      In analyzing potential refinements to the IRF PPS, RAND created a new algorithm that would be very useful in constructing the proposed CMGs (the new algorithm would be based on the CART methodology described in detail earlier in this section of the proposed rule). RAND applied the new algorithm to the fiscal year 2003 IRF data. We are proposing to use RAND's new algorithm for refinements to the CMGs. The proposed algorithm would be based entirely on an iterative computerized process to decrease the number of CMGs, enforce constraints on the CMGs, and assign the comorbidity tiers. At each step in the process, the proposed new CART algorithm would produce all of the possible combinations of CMGs using all available variables. It would then select the variables and the CMG constructions that offer the best predictive ability, as measured by the greatest decrease in the mean- squared error. We propose that the following constraints be placed on the algorithm, based on RAND's analysis: (1) Neighboring CMGs would have to differ by at least $1,500, unless eliminating the CMG would change the estimated costs of patients in that CMG by more than $1,000; (2) estimated costs for patients with lower motor or cognitive index scores (more functionally dependent) would always have to be higher than estimated costs for patients with higher motor or cognitive index scores (less functionally dependent). We believe that the PPS should not pay more for a patient who is less functionally dependent than for one who is more functionally dependent; and (3) each CMG must contain at least 50 observations (for statistical validity).

      RAND's technical expert panel, which included representatives from industry groups, other government entities, academia, and other researchers, reviewed and commented on these constraints and the rest of RAND's proposed methodology (developed based on RAND's analysis of the data) for updating the CMGs as RAND developed the improvements to the CART methodology.

      The following would be the most substantial differences between the existing CMGs and the proposed new CMGs:

      Fewer CMGs than before (87 compared with 95 in the current system).

      The number of CMGs under the RIC for stroke patients (RIC 1) would decrease from 14 to 10.

      The cognitive index score would affect patient classification in two of the RICs (RICs 1 and 2), whereas it currently affects RICs 1, 2, 5, 8, 12, and 18.

      A patient's age would now affect assignment for CMGs in RICs 1, 4 and 8, whereas it currently affects assignment for CMGs in RICs 1 and 4.

      In Table 2 above, we provided the CMGs that are currently being used to pay IRFs. Table 4 below shows the proposed new CMGs. BILLING CODE 4120-01-P

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      Note: CMG definitions use proposed weighted motor scores, as defined below.

      The primary objective in updating the CMGs is to better align IRF payments with the costs of caring for IRF patients, given better, more recent information. This requires that we improve the ability of the system to predict patient costs. RAND's analysis suggests that the proposed new CMGs clearly improve the ability of the payment system to predict patient costs. The proposed new CMGs would greatly improve the explanation of the variance in the system. 2. Proposed Use of a Weighted Motor Score Index and Correction to the Treatment of Unobserved Transfer to Toilet Values

      As described in detail below, we are proposing to use a weighted motor score index in assigning patients to CMGs, instead of the current motor score index that treats all components equally. We are also proposing to change the motor score value for the transfer to toilet variable to 2 rather than 1 when it is unobserved. However, we are not proposing changes to the cognitive score index. As described in detail below, we believe that a weighted motor score index, with the correction to the treatment of unobserved transfer to toilet values would improve the classification of patients into CMGs, which in turn would improve the accuracy of payments to IRFs.

      In order to classify a patient into a CMG, IRFs use the admission assessment data from the IRF-PAI to score a patient's functional independence measures. The functional independence measures consist of what are termed ``motor'' items and ``cognitive'' items. In addition to the functional independence measures, the patient's age may also influence the patient's CMG classification. The motor items are generally indications of the patient's physical functioning level. The cognitive items are generally indications of the patient's mental functioning level, and are related to the patient's ability to process and respond to empirical factual information, use judgment, and accurately perceive what is happening. The motor items are eating, grooming, bathing, dressing upper body, dressing lower body, toileting, bladder management, bowel management, transfer to bed/chair/wheelchair, transfer to toilet, walking or wheelchair use, and stair climbing. The cognitive items are comprehension, expression, social interaction, problem solving, and memory. (The CMS IRF-PAI manual includes more information on these items.) Each item is generally recorded on a patient assessment instrument and scored on a scale of 1 to 7, with a 7 indicating complete independence in this area of functioning, and a 1 indicating that a patient is very impaired in this area of functioning.

      As explained in the August 7, 2001 final rule (66 FR at 41349), the

      [[Page 30211]]

      instructions for the IRF-PAI require that providers record an 8 for an item to indicate that the activity did not occur (or was not observed), as opposed to a 1 through 7 indicating that the activity occurred and the estimated level of function connected with that activity.

      Please note that when the IRF-PAI form went through the approval process, the code 8 was removed and replaced with the code 0. Therefore, a 0 is now the code facilities use to record when an activity does not occur (or is not observed).

      In order to determine the appropriate payment for patients for whom an activity is coded as 0 (that is, either not performed or not observed), we needed to decide an appropriate way of changing the 0 to another code for which payment could be assigned. As discussed in the August 7, 2001 final rule (66 FR at 41349), we decided to assign a code of 1 (indicating that the patient needed ``maximal assistance'') whenever a code of 0 appeared for one of the items on the IRF-PAI used to determine payment. This was the most conservative approach we could have taken based on the best available data at the time because a value of 1 indicates that the patient needed maximal assistance performing the task. Thus, providers would receive the highest payment available for that item (although it might not be the highest payment overall, depending on the patient's CMG, other functional abilities, and/or comorbidities).

      We are proposing to change the way we treat a code of 0 on the IRF- PAI for the transfer to toilet item. This is the only item for which we are proposing this change at this time because RAND's regression analysis demonstrated that of all the motor score values, the evidence supporting a change in the motor score values was the strongest with respect to this item. We propose to assign a code of 2, instead of a code of 1, to patients for whom a 0 is recorded on the IRF-PAI for the transfer to toilet item (as discussed below) because RAND's analysis of calendar year 2002 and FY 2003 data indicates that patients for whom a 0 is recorded are more similar in terms of their characteristics and costliness to patients with a recorded score of 2 than to patients with a recorded score of 1. We are proposing to make this change in order to provide the most accurate payment for each patient.

      Using regression analysis on the calendar year 2002 and FY 2003 data, which is more complete and provides more detailed information on patients' functional abilities than the FY 1999 data used to construct the IRF PPS (even though the 1999 data were the best available data at the time), RAND analyzed whether the assignment of 1 to items for which a 0 is recorded on the IRF-PAI continues to correctly assign payments based on patients' expected costliness. RAND examined all of the items in the motor score index, focusing on how often a code of 0 appears for the item, how similar patients with a code of 0 are to other patients with the same characteristics that have a score of 1 though 7, and how much a change in the item's score affects the prediction of a patient's expected costliness. Based on RAND's regression analysis, we believe it is appropriate to change the assignment of 0 on the transfer to toilet item from a 1 to a 2 for the purposes of determining IRF payments.

      Until now, the IRF PPS has used standard motor and cognitive scores, the sum of either 12 or 13 motor items and the sum of 5 cognitive items, to assign patients to CMGs. This summing equally weights the components of the indices. These indices have been accepted and used for many years. Although the weighted motor score is an option that has been considered before, most experts believed that the data were not complete and accurate enough before the IRF PPS (although they were the most complete and accurate data available at the time). Now, it is believed that the data are complete and accurate enough to support proposing to use a weighted motor score index.

      In developing candidate indices that would weight the items in the score, RAND had competing goals: to develop indices that would increase the predictive power of the system while at the same time maintaining simplicity and transparency in the payment system. For example, they found that an ``optimal'' weighting methodology from the standpoint of predictive power would require computing 378 different weights (18 different weights for the motor and cognitive indices that could all differ across 21 RICs). Rather than introduce this level of complexity to the system, RAND decided to explore simpler weighting methodologies that would still increase the predictive power of the system.

      RAND used regression analysis to explore the relationship of the FIM motor and cognitive scores to cost. The idea of these models was to determine the impact of each of the FIM items on cost and then weight each item in the index according to its relative impact on cost. Based on the regression analysis, RAND was able to design a weighting methodology for the motor score that could potentially be applied uniformly across all RICs.

      RAND assessed different weighting methodologies for both the motor score index and the cognitive score index. They discovered that weighting the motor score index improved the predictive ability of the system, whereas weighting the cognitive score index did not. Furthermore, the cognitive score index has never had much of an effect (in some RICs, it has no effect) on the assignment of patients to CMGs because the motor score tends to be much stronger at predicting a patient's expected costs in an IRF than the cognitive score.

      For these reasons, we are proposing a weighting methodology for the motor score index at this time. We propose to continue using the same methodology we have been using since the IRF PPS was first implemented to compute the cognitive score index (that is, summing the components of the index) because, among other things, a change in methodology for calculating this component of the system failed to improve the accuracy of the IRF PPS payments. Therefore, it would be futile to expend resources on changing this method when it would not benefit the program.

      Table 5 below shows the proposed optimal weights for the components of the motor score, averaged across all RICs and normalized to sum to 100.0, obtained through the regression analysis. The weights relate to the FIM items' relative ability to predict treatment costs. Table 5 indicates that dressing lower, toilet, bathing, and eating are the most effective self-care items for predicting costs; bowel and bladder control may not be effective at predicting costs; and that the items grouped in the transfer and locomotion categories might be somewhat more effective at predicting costs than the other categories.

      Table 5.--Proposed Optimal Weights, Averaged Across Rehabilitation Impairment Categories (RICs): Motor Items

      Average Item type

      Functional independence item optimal weight

      Self.......................... Dressing lower...............

      1.4 Self.......................... Toilet.......................

      1.2 Self.......................... Bathing......................

      0.9 Self.......................... Eating.......................

      0.6 Self.......................... Dressing upper...............

      0.2 Self.......................... Grooming.....................

      0.2 Sphincter..................... Bladder......................

      0.5 Sphincter..................... Bowel........................

      0.2 Transfer...................... Transfer to bed..............

      2.2 Transfer...................... Transfer to toilet...........

      1.4 Transfer...................... Transfer to tub..............

      Not included

      [[Page 30212]]

      Locomotion.................... Walking......................

      1.6 Locomotion.................... Stairs.......................

      1.6

      Based on RAND's analysis, we considered a number of different candidate indices before proposing a weighted index. We considered proposing to define some simple combinations of the four item types that make up the motor score index and assigning weights to the groups of items instead of to the individual items. For example, we considered proposing to sum the three transfer items together to form a group with a weight of two, since they contributed about twice as much in the cost regression as the self-care items. We also considered proposing to assign the self-care items a weight of one and the bladder and bowel items as a group a weight close to zero, since they contributed little to predicting cost in the regression analysis. We tried a number of variations and combinations of this, but RAND's TEP generally rejected these weighting schemes. They believed that introducing elements of subjectivity into the development of the weighting scheme may invite controversy, and that it is better to use an objective algorithm to derive the appropriate weights. We agree that an objective weighting scheme is best because it is based on regression analysis of the amount that various components of the motor score index contribute to predicting patient costs, using the best available data we have. Therefore, we are proposing a weighting scheme that applies the average optimal weights. To develop the proposed weighting scheme, RAND used regression analysis to estimate the relative contribution of each item to the prediction of costs. Based on this analysis, we are proposing to use the weighting scheme indicated in Table 5 above and in the following simple equation:

      Motor score index=1.4*dressing lower + 1.2*toilet + 0.9*bathing + 0.6*eating + 0.2*dressing upper + 0.2*grooming + 0.5*bladder + 0.2*bowel + 2.2*transfer to bed + 1.4*transfer to toilet + 1.6*walking + 1.6*stairs.

      Another reason we are proposing to use a weighted motor score index to assign patients to CMGs is that RAND's regression analysis showed that it predicts costs better than the current unweighted motor score index. Across all 21 RICs, the proposed weighted motor score index improves the explanation of variance within each RIC by 9.5 percent, on average. 3. Proposed Changes for Updating the Relative Weights

      Section 1886(j)(2)(B) of the Act requires that an appropriate relative weight be assigned to each CMG. Relative weights that account for the variance in cost per discharge and resource utilization among payment groups are a primary element of a case-mix adjusted prospective payment system. The accuracy of the relative weights helps to ensure that payments reflect as much as possible the relative costs of IRF patients and, therefore, that beneficiaries have access to care and receive the appropriate services.

      Section 1886(j)(2)(C)(i) of the Act requires the Secretary from time to time to adjust the classifications and weighting factors to reflect changes in treatment patterns, technology, case mix, number of payment units for which payment to IRFs is made, and other factors which may affect the relative use of resources. In accordance with this section of the Act, we are proposing to recalculate a relative weight for each CMG that is proportional to the resources needed by an average inpatient rehabilitation case in that CMG. For example, cases in a CMG with a relative weight of 2, on average, would cost twice as much as cases in a CMG with a relative weight of 1. We are not proposing any changes to the methodology we are using for calculating the relative weights, as described in the August 7, 2001 final rule (66 FR 41316, 41351 through 41353); we are only proposing to update the relative weights themselves.

      As previously stated, we believe that improved coding of data, the availability of more complete data, proposed changes to the tier comorbidities and CMGs, and changes in IRF cost structures make it very unlikely that the relative weights assigned to the CMGs when the IRF PPS was first implemented still accurately represent the differences in costs across CMGs and across tiers. Therefore, we are proposing to recalculate the relative weights. However, we are not proposing any changes to the methodology for calculating the relative weights. Instead, we are proposing to update the relative weights (the relative weights that are multiplied by the standard payment conversion factor to assign relative payments for each CMG and tier) using the same methodology as described in the August 7, 2001 final rule (66 FR 41316, 41351 through 41353) and as described in detail at the beginning of this section of this proposed rule, applied to FY 2003 Medicare billing data. To summarize, we are proposing to use the following basic steps to update the relative weights: The first step in calculating the CMG weights is to estimate the effects that comorbidities have on costs. The second step is to adjust the cost of each Medicare discharge (case) to reflect the effects found in the first step. In the third step, the adjusted costs from the second step are used to calculate ``relative adjusted weights'' in each CMG using the hospital-specific relative value method. The final steps are to calculate the CMG relative weights by modifying the ``relative adjusted weight'' with the effects of the existence of the comorbidity tiers (explained below) and normalize the weights to 1. Table 6 below shows the proposed relative weights, based on the 2003 data.

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      BILLING CODE 4120-01-C

      We are proposing to make the tier and the CMG changes in such a way that total estimated aggregate payments to IRFs for FY 2006 are the same with and without the proposed changes (that is, in a budget neutral manner) for the following reasons. First, we believe that the results of RAND's analysis of 2002 and 2003 IRF cost data suggest that additional money does not need to be added to the IRF PPS. RAND's analysis found, for example, that if all IRFs had been paid based on 100 percent of the IRF PPS payment rates throughout all of 2002 (some IRFs were still transitioning to PPS payments during 2002), PPS payments during 2002 would have been 17 percent higher than IRFs' costs. Furthermore, RAND did not find evidence that the overall costliness of patients (average case mix) in IRFs increased substantially in 2002 compared with 1999. As discussed in detail in section III.A of this proposed rule, RAND found that real case mix increased by at most 1.5 percent, and may have decreased by as much as 2.4 percent. The available evidence, therefore, suggests that resources in the IRF PPS are likely adequate to care for the types of patients IRFs treat. We are open to examining other evidence regarding the amount of aggregate payments in the system and the types of patients IRFs are currently treating.

      The purpose of the CMG and tier changes is to ensure that the existing resources already in the IRF PPS are distributed better among IRFs according to the relative costliness of the types of patient they treat. Section 1886(j)(2)(C)(i) of the Act confers broad statutory authority upon the Secretary to adjust the classification and weighting factors in order to account for relative resource use. Consistent with that broad statutory authority, we are proposing to redistribute aggregate payments to more accurately reflect the IRF case mix.

      To ensure that total estimated aggregate payments to IRFs do not change, we propose to apply a factor to the standard payment amount to ensure that estimated aggregate payments under this subsection in the FY are not greater or less than those that would

      [[Page 30220]]

      have been made in the year without such adjustment. In section III.B.7 and section III.B.8 of this proposed rule, we discuss the methodology and factor we are proposing to apply to the standard payment amount.

3. Proposed FY 2006 Federal Prospective Payment Rates

   (If you choose to comment on issues in this section, please include the caption ``Proposed FY 2006 Federal Prospective Payment Rates'' at the beginning of your comments.)

   1. Proposed Reduction of the Standard Payment Amount to Account for Coding Changes

      Section 1886(j)(2)(C)(ii) of the Act requires the Secretary to adjust the per payment unit payment rate for IRF services to eliminate the effect of coding or classification changes that do not reflect real changes in case mix if the Secretary determines that changes in coding or classification of patients have resulted or will result in changes in aggregate payments under the classification system. As described below, in accordance with this section of the Act and based on research conducted by RAND under contract with us, we are proposing to reduce the standard payment amount for patients treated in IRFs by 1.9 percent. However, as discussed below, RAND found a range of possible estimates that likely accounts for the amount of case mix change that was due to coding. In light of the range of estimates that may be appropriate, we are continuing to work with RAND to further analyze the data and are considering adoption of an alternative percentage reduction. Accordingly, we solicit comments on whether the proposed 1.9 percent is the percentage reduction that ought to be made, or if another percentage reduction (for example, the 3.4 percent observed case mix change or the 5.8 percent that RAND found in its study, detailed below, to be the maximum amount of change due to coding) should be applied.

      We are proposing to reduce the standard payment amount by 1.9 percent because RAND's regression analysis of calendar year 2002 data found that payments to IRFs were about $140 million more than expected during 2002 because of changes in the classification of patients in IRFs, and that a portion of this increase in payments was due to coding changes that do not reflect real changes in case mix. If IRF patients have more costly impairments, lower functional status, or more comorbidities, and thus require more resources in the IRF in 2002 than in 1999, we would consider this a real change in case mix. Conversely, if IRF patients have the same impairments, functional status, and comorbidities in 2002 as they did in 1999 but are coded differently resulting in higher payment, we consider this a case mix increase due to coding. We believe that changes in payment amounts should accurately reflect changes in IRFs' patient case mix (that is, the true cost of treating patients), and should not be influenced by changes in coding practices.

      Under the IRF PPS, payments for each Medicare rehabilitation patient are determined using a multi-step process. First, a patient is assigned to a particular CMG and a tier based on four patient characteristics at admission: impairment, functional independence, comorbidities, and age. The amount of the payment for each patient is then calculated by taking the standard payment conversion factor ($12,958 in FY 2005) and adjusting it by multiplying by a relative weight, which depends on each patient's CMG and tier assignment.

      For example, an 80-year old hip replacement patient with a motor score between 47 and 54 and no comorbidities would be assigned to a particular CMG and tier based on these characteristics. The CMG and tier to which he is assigned would have an associated relative weight, in this case 0.5511 in FY 2005 (69 FR at 45725). This relative weight would be multiplied by the standard payment conversion factor of $12,958 to equal the payment of $7,141 in FY 2005 (0.5511 x $12,958 = $7,141). Based on the following discussion, we are proposing lowering the standard payment amount by 1.9 percent to account for coding changes that have increased payments to IRFs. However, we solicit comments regarding other possible percentage reductions within the range RAND identified, as discussed below.

      As described in the August 7, 2001 final rule, we contracted with RAND to analyze IRF data to support our efforts in developing the classification system and the IRF PPS. We have continued our contract with RAND to support us in developing potential refinements to the classification system and the PPS for this proposed rule. As part of this research, we asked RAND to examine changes in case mix and coding since the IRF PPS. To examine these changes, RAND compared 2002 data from the first year of implementation of the PPS with the 1999 (pre- PPS) data used to construct the IRF PPS.

      RAND's analysis of the 2002 data, as described in more detail below, demonstrates that changes in the types of patients going to IRFs and changes in coding both caused increases in payments to IRFs between 1999 and 2002. The 2002 data are more complete than the 1999 data that were first used to design the IRF PPS because they include all Medicare-covered IRF cases. Although the 1999 data we used in designing the original standard payment rate for the IRF PPS were the best available data we had at the time, they were based on a sample (64 percent) of IRF cases.

      In addition, such review was necessary because, as explained below, we believe that the implementation of the IRF PPS caused important changes in coding. The IRF PPS likely improved the accuracy and consistency of coding across IRFs, because of the educational programs that were implemented in 2001 and 2002 and because items that previously did not affect payments (such as comorbidities) became important factors for determining the PPS payments. Since these items now affect payments, there is greater incentive to code for them. There were also changes to the IRF-PAI instructions given for coding some of the items on the patient assessment instrument, so that the same patient may have been correctly coded differently in 2002 than in 1999.

      Furthermore, implementation of the IRF PPS may have caused changes in case mix because it increased incentives for IRFs to take patients with greater impairment, lower function, or comorbidities. Under the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) (Pub. L. 97- 248), IRFs were paid on the basis of Medicare reasonable costs limited by a facility-specific target amount per discharge. IRFs were paid on a per discharge basis without per discharge adjustments being made for the impairments, functional status, or comorbidities of patients. Thus, IRFs had a strong incentive to admit less costly patients to ensure that the costs of treating patients did not exceed their TEFRA payments. Under the IRF PPS, however, IRFs' PPS payments are tied directly to the principle diagnosis and accompanying comorbidities of the patient. Thus, based on the characteristics of the patients (that is, impairments, functional status, and comorbidities), the more costly the patient is expected to be, the higher the PPS payment. Therefore, IRFs may have greater incentives than they had under TEFRA to admit more costly patients.

      Thus, in light of these concerns, RAND performed an analysis using IRF Medicare claims data matched with FIM and IRF-PAI data and comparing 2002 data (post-PPS) with 1999 data (pre-

      [[Page 30221]]

      PPS), RAND found that the observed case mix--the expected costliness of patients--in IRFs increased by 3.4 percent between the two time periods. Thus, we paid 3.4 percent, or about $140 million, more than expected during 2002 because of changes in the classification of cases in IRFs. However, RAND found little evidence that the patients admitted to IRFs in 2002 had higher resource needs (that is, more impairments, lower functioning, or more comorbidities) than the patients admitted in 1999. In fact, most of the changes in case mix that RAND documented from the acute care hospital records implied that IRF patients should have been less costly to treat in 2002 than in 1999. For example, RAND found a 16 percent decrease in the proportion of patients treated in IRFs following acute hospitalizations for stroke, when it compared the results of the 2002 data with the 1999 data. Stroke patients tend to be relatively more costly than other types of patients for IRFs because they tend to require more intensive services than other types of patients. A decrease in the proportion of stroke patients relative to other types of patients, therefore, would likely contribute to a decrease in the overall expected costliness of IRF patients. RAND also found a 22 percent increase in the proportion of cases treated in IRFs following a lower extremity joint replacement. Lower extremity joint replacement patients tend to be relatively less costly for IRFs than other types of patients because their care needs tend to be less intensive than other types of patients. For this reason, the increase in the proportion of these patients treated in IRFs would suggest a decrease in the overall expected costliness of IRF patients.

      We asked RAND to quantify the amount of the case mix change that was due to real case mix change (that is, the extent to which IRF patients had more impairments, lower functioning, or more comorbidities) and the amount that was due to coding. However, while the data permit RAND to observe the total change in expected costliness of patients over time with some precision, estimating the amount of this total change that is real and the amount that is due to coding generally cannot be done with the same level of precision. Therefore, in order to quantify the amounts that were due to real case mix change and the amounts that were due to coding, RAND used two approaches to give a range of estimates within which the correct estimates would logically fall--(1) one that potentially underestimates the amount of real case mix change and overestimates the amount of case mix change due to coding; and (2) one that potentially overestimates real change and underestimates change due to coding. These two approaches give us a range of estimates, which we are confident should logically border the actual amount of real case mix and coding change. The first approach uses the following assumptions:

      Changes over time in characteristics recorded during the acute hospitalizations preceding the inpatient rehabilitation facility stay were real case mix changes (as acute care hospitals had little incentive to change their coding of patients in response to the IRF PPS); and

      Changes over time in IRF coding that did not correspond with changes in the characteristics recorded during the acute hospitalizations were attributable to changes in IRF coding practices.

      To illustrate this point, suppose, for example, that the IRF records showed that there were a greater number of patients with a pulmonary condition in IRFs in 2002 than in 1999. Patients with a pulmonary condition tend to be relatively more costly for IRFs to treat than other types of patients, so an increase in the number of these patients would indicate an increase in the costliness of IRF patients (that is, an increase in IRFs' case mix). However, in 2002 IRFs had a much greater incentive to record if patients had a pulmonary condition than they did in 1999 because they got paid more for this condition in 2002, whereas they did not in 1999. Therefore, it is reasonable to expect that some of the increase in the number of patients with a pulmonary condition was due to the fact that IRFs were recording that condition for patients more frequently, not that there were really more patients of that type (although there may also have been some more patients of that type). To determine the extent to which IRFs may have just been coding that condition more often versus the extent to which there actually may have been more patients with a pulmonary condition going to IRFs than before, RAND looked at the one source of information that we believe was least likely to be influenced by the incentive to code patients with this condition more frequently in the IRF: the acute care hospital record from the stay preceding the IRF stay. We believe that the acute care hospitals are not likely to be influenced by IRF PPS policies that only affect IRF payments (that is, changes in IRF payment policies would not likely result in monetary benefits to the acute care hospitals). Thus, if RAND found a substantial increase in the number of IRF patients with a pulmonary condition in the acute care hospital before going to the IRF, it would be reasonable to assume that more patients with a pulmonary condition were going to IRFs (a real increase in case mix). However, if there was little change in the number of IRF patients with a pulmonary condition in the acute care hospital before going to the IRF, then we believe it is reasonable to assume that a portion of the increase in patients with a pulmonary condition in IRFs was due to the incentives to code more of these patients in the IRFs.

      We believe that this first approach shows that both factors, real case mix change and coding change, contributed to the amount of observed change in 2002, the first IRF PPS rate year. However, these estimates (based on the best available data) do not fully address all of the variables that may have contributed to the change in case mix. For example, the model does not account for the possibility that patients could develop impairments, functional problems, or comorbidities after they leave the acute care hospital (prior to the IRF admission) that would make them more costly when they are in the IRF. We note that the introduction of a new payment system may have interrelated effects on providers as they adapt to new (or perceived) program incentives. Thus, an analysis of first year experience may not be fully representative of providers' behavior under a fully implemented system. In addition, hospital coding practices may change at a different rate in facilities where the IRF is a unit of an acute care hospital compared with freestanding IRF hospitals. Although we attempted to identify all of the factors that cause the variation in costs among the IRFs' patient population, this may not have been possible given that the data are from the transitional year of the new PPS. Finally, we want to ensure that the rate reduction will not have an adverse effect on beneficiaries' access to IRF care.

      For the reasons described above, we believe we should provide some flexibility to account for the possibility that some of the observed changes may be attributable to other than coding changes. Thus, in determining the amount of the proposed reduction in the standard payment amount, we examined RAND's second approach that recognizes the difficulty of precise measurement of real case mix and coding changes. Using this second approach, RAND developed an analytical procedure that allowed them to distinguish more fully between real case mix change and coding change

      [[Page 30222]]

      based on patient characteristics. In part, this second approach involves analyzing some specific examples of coding that we know have changed over time, such as direct indications of improvements in impairment coding, changes in coding instruction for bladder and bowel functioning, and dramatic increases in coding of certain conditions that affect patients' placement into tiers (resulting in higher payments).

      Using the two approaches, RAND found that real case mix changes in IRFs over this period ranged from a decrease of 2.4 percent (using the first approach) to an increase of 1.5 percent (using the second approach). This suggests that coding changes accounted for between 1.9 percent (if real case mix increased by 1.5 percent (that is, 3.4 percent minus 1.5 percent)) and 5.8 percent (if real case mix decreased by 2.4 percent (that is, 3.4 percent plus 2.4 percent)) of the increase in aggregate payments for 2002 compared with 1999. Thus, RAND recommended decreasing the standard per discharge payment amount by between 1.9 and 5.8 percent to adjust for the coding changes. We are proposing to reduce the standard payment amount by the lower of these two numbers, 1.9 percent, because we believe it is a reasonable estimate for the amount of coding change, based on RAND's analysis of direct indications of coding change.

      We considered proposing a reduction to the standard payment amount by an amount up to 5.8 percent because RAND's first approach suggested that coding changes could possibly have been responsible for up to 5.8 percent of the observed increase in IRFs' case mix. Furthermore, a separate analysis by RAND found that if all IRFs had been paid based on 100 percent of the IRF PPS payment rates throughout all of 2002 (some IRFs were still transitioning to PPS payments during 2002), PPS payments during 2002 would have been 17 percent higher than IRFs' costs. This suggests that we could potentially have proposed a reduction greater than 1.9 and up to 5.8 percent.

      We decided to propose a reduction of 1.9 percent, the lowest possible amount of change attributable to coding change. However, we are continuing to work with RAND to further analyze the data and are soliciting comments on the following factors which may have an effect on the amount of the reduction. First, whether changes that occurred within the transitional IRF PPS rate year could have impacted coding and patient selection and affected these analyses. Second, since we feel it is crucial to maintain access to IRF care, we are soliciting comments on the effect of the proposed range of reductions on access to IRF care, particularly for patients with greater resource needs. The analyses described here are only the first of an ongoing series of studies to evaluate the existence and extent of payment increases due to coding changes. We will continue to review the need for any further reduction in the standard payment amount in subsequent years as part of our overall monitoring and evaluation of the IRF PPS.

      Therefore, for FY 2006, we are proposing to reduce the standard payment amount by the lowest amount (1.9 percent) attributable to coding changes. We believe this approach, which is supported by RAND's analysis of the data, would adequately adjust for the increased payments to IRFs caused by purely coding changes, but would still provide the flexibility to account for the possibility that some of the observed changes in case mix may be attributed to other than coding changes. Furthermore, we chose the amount of the proposed reduction in the standard payment amount in order to recognize that IRFs' current cost structures may be changing as they strive to comply with other recent Medicare policy changes, such as the criteria for IRF classification commonly known as the ``75 percent rule.'' We are continuing to work with RAND to analyze the data and are soliciting comments on whether the proposed 1.9 percent is the percentage reduction that ought to be made, or if another percentage reduction (for example, the 3.4 percent observed case mix change or the 5.8 percent that RAND found to be maximum amount of change due to coding) should be applied.

      To accomplish the proposed reduction of the standard payment conversion factor by 1.9 percent, we first propose to update the FY 2005 standard payment conversion factor by the estimated market basket of 3.1 percent to get the standard payment amount for FY 2006 ($12,958*1.031 = $13,360). Next, we propose to multiply the FY 2006 standard payment amount by 0.981, which reduces the standard payment amount by 1.9 percent ($13,360*0.981 = $13,106). In section III.B.7 of this proposed rule, we propose to further adjust the $13,106 by the proposed budget neutrality factors for the wage index and the other proposed refinements outlined in this proposed rule that would result in the proposed FY 2006 standard payment conversion factor. In section III.B.7 of this proposed rule, we provide a step-by-step calculation that results in the FY 2006 standard payment conversion factor.

   2. Proposed Adjustments to Determine the Proposed FY 2006 Standard Payment Conversion Factor

      1. Proposed Market Basket Used for IRF Market Basket Index

      Under the broad authority of section 1886(j)(3)(C) of the Act, the Secretary establishes an increase factor that reflects changes over time in the prices of an appropriate mix of goods and services included in covered IRF services, which is referred to as a market basket index. The market basket needs to include both operating and capital. Thus, although the Secretary is required to develop an increase factor under section 1886(j)(3)(C) of the Act, this provision gives the Secretary discretion in the design of such factor.

      The index currently used to update payments for rehabilitation facilities is the Excluded hospital including capital market basket. This market basket is based on 1997 Medicare cost report data and includes Medicare-participating rehabilitation (IRF), LTCH, psychiatric (IPF), cancer, and children's hospitals.

      We are unable to create a separate market basket specifically for rehabilitation hospitals due to the small number of facilities and the limited data that are provided (for instance, only about 25 percent of rehabilitation facility cost reports reported contract labor cost data for 2002). Since all IRFs are paid under the IRF PPS, nearly all LTCHs are paid under the LTCH PPS, and IPFs for cost reporting periods beginning on or after January 1, 2005 will be paid under the IPF PPS, we propose to update payments for rehabilitation facilities using a market basket reflecting the operating and capital cost structures for IRFs, IPFs, and LTCHs, hereafter referred to as the RPL (rehabilitation, psychiatric, long-term care) market basket. We propose to exclude children's and cancer hospitals from the RPL market basket because their payments are based entirely on reasonable costs subject to rate-of-increase limits established under the authority of section 1886(b) of the Act, which is implemented in Sec. 413.40 of the regulations. They are not reimbursed under a prospective payment system. Also, the FY 2002 cost structures for children's and cancer hospitals are noticeably different than the cost structures of the IRFs, IPFs, and LTCHs. The services offered in IRFs, IPFs, and LTCHs are typically more labor-intensive than those offered in cancer and children's hospitals. Therefore, the compensation cost weights for IRFs, IPFs, and LTCHs are larger than those in cancer and children's hospitals. In addition, the depreciation cost weights

      [[Page 30223]]

      for IRFs, IPFs, and LTCHs are noticeably smaller than those for children's and cancer hospitals.

      In the following discussion, we provide a background on market baskets and describe the methodologies used to determine the operating and capital portions of the proposed FY 2002-based RPL market basket. a. Overview of the Proposed RPL Market Basket

      The proposed RPL market basket is a fixed weight, Laspeyres-type price index that is constructed in three steps. First, a base period is selected (in this case, FY 2002), and total base period expenditures are estimated for a set of mutually exclusive and exhaustive spending categories based upon type of expenditure. Then the proportion of total operating costs that each category represents is determined. These proportions are called cost or expenditure weights. Second, each expenditure category is matched to an appropriate price or wage variable, referred to as a price proxy. In nearly every instance, these price proxies are price levels derived from publicly available statistical series that are published on a consistent schedule, preferably at least on a quarterly basis.

      Finally, the expenditure weight for each cost category is multiplied by the level of its respective price proxy for a given period. The sum of these products (that is, the expenditure weights multiplied by their price levels) for all cost categories yields the composite index level of the market basket in a given period. Repeating this step for other periods produces a series of market basket levels over time. Dividing an index level for a given period by an index level for an earlier period produces a rate of growth in the input price index over that time period.

      A market basket is described as a fixed-weight index because it answers the question of how much it would cost, at another time, to purchase the same mix of goods and services purchased to provide hospital services in a base period. The effects on total expenditures resulting from changes in the quantity or mix of goods and services (intensity) purchased subsequent to the base period are not measured. In this manner, the market basket measures only the pure price change. Only when the index is rebased would the quantity and intensity effects be captured in the cost weights. Therefore, we rebase the market basket periodically so the cost weights reflect changes in the mix of goods and services that hospitals purchase (hospital inputs) to furnish patient care between base periods.

      The terms rebasing and revising, while often used interchangeably, actually denote different activities. Rebasing means moving the base year for the structure of costs of an input price index (for example, shifting the base year cost structure from FY 1997 to FY 2002). Revising means changing data sources, methodology, or price proxies used in the input price index. We are proposing to rebase and revise the market basket used to update the IRF PPS. b. Proposed Methodology for Operating Portion of the Proposed RPL Market Basket

      The operating portion of the proposed FY 2002-based RPL market basket consists of several major cost categories derived from the FY 2002 Medicare cost reports for IRFs, IPFs, and LTCHs: Wages, drugs, professional liability insurance and a residual. We choose FY 2002 as the base year because we believe this is the most recent, relatively complete year of Medicare cost report data. Due to insufficient Medicare cost report data for IRFs, IPFs, and LTCHs, cost weights for benefits, contract labor, and blood and blood products were developed using the proposed FY 2002-based IPPS market basket (Section IV. Proposed Rebasing and Revision of the Hospital Market Baskets IPPS Hospital Proposed Rule for FY 2006), which we explain in more detail later in this section. For example, less than 30 percent of IRFs, IPFs, and LTCHs reported benefit cost data in FY 2002. We have noticed an increase in cost data for these expense categories over the last 4 years. The next time we rebase the RPL market basket, there may be sufficient IRFs, IPFs, and LTCHs cost report data to develop the weights for these expenditure categories.

      Since the cost weights for the RPL market basket are based on facility costs, we are proposing to limit our sample to hospitals with a Medicare average length of stay within a comparable range of the total facility average length of stay. We believe this provides a more accurate reflection of the structure of costs for Medicare treatments. Our goal is to measure cost shares that are reflective of case mix and practice patterns associated with providing services to Medicare beneficiaries.

      We propose to use those cost reports for IRFs and LTCHs whose Medicare average length of stay is within 15 percent (that is, 15 percent higher or lower) of the total facility average length of stay for the hospital. This is the same edit applied to the FY 1992 and FY 1997 excluded hospital with capital market baskets. We propose 15 percent because it includes those LTCHs and IRFs whose Medicare LOS is within approximately 5 days of the facility length of stay.

      We propose to use a less stringent measure of Medicare length of stay for IPFs whose average length of stay is within 30 or 50 percent (depending on the total facility average length of stay) of the total facility length of stay. This less stringent edit allows us to increase our sample size by over 150 reports and produce a cost weight more consistent with the overall facility. The edit we applied to IPFs when developing the FY-1997 based excluded hospital with capital market basket was based on the best available data at the time.

      The detailed cost categories under the residual (that is, the remaining portion of the market basket after excluding wages and salaries, drugs, and professional liability cost weights) are derived from the proposed FY 2002-based IPPS market basket and the 1997 Benchmark Input-Output Tables published by the Bureau of Economic Analysis, U.S. Department of Commerce. The proposed FY 2002-based IPPS market basket is developed using FY 2002 Medicare hospital cost reports with the most recent and detailed cost data. The 1997 Benchmark I-O is the most recent, comprehensive source of cost data for all hospitals. Proposed cost weights for benefits, contract labor, and blood and blood products were derived using the proposed FY 2002-based IPPS market basket. For example, the ratio of the benefit cost weight to the wages and salaries cost weight in the proposed FY 2002-based IPPS market basket was applied to the RPL wages and salaries cost weight to derive a benefit cost weight for the RPL market basket. The remaining proposed operating cost categories were derived using the 1997 Benchmark Input- Output Tables aged to 2002 using relative price changes. (The methodology we used to age the data involves applying the annual price changes from the price proxies to the appropriate cost categories. We repeat this practice for each year.) Therefore, using this methodology roughly 59 percent of the proposed RPL market basket is accounted for by wages, drugs and professional liability insurance data from FY 2002 Medicare cost report data for IRFs, LTCHs, and IPFs.

      Table 7 below sets forth the complete proposed FY 2002-based RPL market basket including cost categories, weights, and price proxies. For comparison purposes, the corresponding FY 1997-based excluded hospital with capital market basket is listed as well.

      [[Page 30224]]

      Wages and salaries are 52.895 percent of total costs for the proposed FY 2002-based RPL market basket compared to 47.335 percent for FY 1997-based excluded hospital with capital market basket. Employee benefits are 12.982 percent for the proposed FY 2002-based RPL market basket compared to 10.244 percent for FY 1997-based excluded hospital with capital market basket. As a result, compensation costs (wages and salaries plus employee benefits) for the proposed FY 2002-based RPL market basket are 65.877 percent of costs compared to 57.579 percent for the FY 1997-based excluded hospital with capital market basket. Of the 8 percentage point difference between the compensation shares, approximately 3 percentage points are due to the proposed new base year (FY 2002 instead of FY 1997), 3 percentage points are due to the revised length of stay edit and the remaining 2 percentage points are due to the proposed exclusion of other hospitals (that is, only including IRFs, IPFs, and LTCHs in the market basket).

      Following the table is a summary outlining the choice of the proxies used for the operating portion of the proposed market basket. The price proxies for the proposed capital portion are described in more detail in the capital methodology section. (See section III.B.1.c of this proposed rule.) BILLING CODE 4120-01-P

      [[Page 30225]]

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      BILLING CODE 4120-01-C

      Below we provide the proxies that we are proposing to use for the FY 2002-based RPL market basket. With the exception of the Professional Liability proxy, all the proposed price proxies for the operating portion of the proposed RPL market basket are based on Bureau of Labor Statistics (BLS) data and are grouped into one of the following BLS categories:

      Producer Price Indexes--Producer Price Indexes (PPIs) measure price changes for goods sold in other than retail markets. PPIs are preferable price proxies for goods that hospitals purchase as inputs in producing their outputs because the PPIs would better reflect the prices faced by hospitals. For example, we use a special PPI for prescription drugs, rather than the Consumer Price Index (CPI) for prescription drugs because hospitals generally purchase drugs directly from the wholesaler. The PPIs that we use measure price change at the final stage of production.

      Consumer Price Indexes--Consumer Price Indexes (CPIs) measure change in the prices of final goods and services bought by the typical consumer. Because they may not represent the price faced by a producer,

      [[Page 30228]]

      we used CPIs only if an appropriate PPI was not available, or if the expenditures were more similar to those of retail consumers in general rather than purchases at the wholesale level. For example, the CPI for food purchased away from home is used as a proxy for contracted food services.

      Employment Cost Indexes--Employment Cost Indexes (ECIs) measure the rate of change in employee wage rates and employer costs for employee benefits per hour worked. These indexes are fixed-weight indexes and strictly measure the change in wage rates and employee benefits per hour. Appropriately, they are not affected by shifts in employment mix.

      We evaluated the price proxies using the criteria of reliability, timeliness, availability, and relevance. Reliability indicates that the index is based on valid statistical methods and has low sampling variability. Timeliness implies that the proxy is published regularly, at least once a quarter. Availability means that the proxy is publicly available. Finally, relevance means that the proxy is applicable and representative of the cost category weight to which it is applied. The CPIs, PPIs, and ECIs selected by us to be proposed in this regulation meet these criteria.

      We note that the proposed proxies are the same as those used for the FY 1997-based excluded hospital with capital market basket. Because these proxies meet our criteria of reliability, timeliness, availability, and relevance, we believe they continue to be the best measure of price changes for the cost categories. For further discussion on the FY 1997-based excluded hospital with capital market basket, see the IPPS final rule (67 FR at 50042), published in the Federal Register on August 1, 2002.

      Wages and Salaries

      For measuring the price growth of wages in the proposed FY 2002- based RPL market basket, we propose to use the ECI for wages and salaries for civilian hospital workers as the proxy for wages.

      Employee Benefits

      The proposed FY 2002-based RPL market basket would use the ECI for employee benefits for civilian hospital workers.

      Nonmedical Professional Fees

      The ECI for compensation for professional and technical workers in private industry would be applied to this category since it includes occupations such as management and consulting, legal, accounting and engineering services.

      Fuel, Oil, and Gasoline

      The percentage change in the price of gas fuels as measured by the PPI (Commodity Code 0552) would be applied to this component.

      Electricity

      The percentage change in the price of commercial electric power as measured by the PPI (Commodity Code 0542) would be applied to this component.

      Water and Sewage

      The percentage change in the price of water and sewage maintenance as measured by the Consumer Price Index (CPI) for all urban consumers (CPI Code CUUR0000SEHG01) would be applied to this component.

      Professional Liability Insurance

      The proposed FY 2002-based RPL market basket would use the percentage change in the hospital professional liability insurance (PLI) premiums as estimated by the CMS Hospital professional liability index for the proxy of this category. In the FY 1997-based excluded hospital with capital market basket, the same price proxy was used.

      We continue to research options for improving our proxy for professional liability insurance. This research includes exploring various options for expanding our current survey, including the identification of another entity that would be willing to work with us to collect more complete and comprehensive data. We are also exploring other options such as third party or industry data that might assist us in creating a more precise measure of PLI premiums. At this time we have not identified a preferred option, therefore, no change is proposed for the proxy in this proposed rule.

      Pharmaceuticals

      The percentage change in the price of prescription drugs as measured by the PPI (PPI Code PPI32541DRX) would be used as a proxy for this category. This is a special index produced by BLS and is the same proxy used in the 1997-based excluded hospital with capital market basket.

      Food, Direct Purchases

      The percentage change in the price of processed foods and feeds as measured by the PPI (Commodity Code 02) would be applied to this component.

      Food, Contract Services

      The percentage change in the price of food purchased away from home as measured by the CPI for all urban consumers (CPI Code CUUR0000SEFV) would be applied to this component.

      Chemicals

      The percentage change in the price of industrial chemical products as measured by the PPI (Commodity Code 061) would be applied to this component. While the chemicals hospital's purchase include industrial as well as other types of chemicals, the industrial chemicals component constitutes the largest proportion by far. Thus, we believe that commodity Code 061 is the appropriate proxy.

      Medical Instruments

      The percentage change in the price of medical and surgical instruments as measured by the PPI (Commodity Code 1562) would be applied to this component

      Photographic Supplies

      The percentage change in the price of photographic supplies as measured by the PPI (Commodity Code 1542) would be applied to this component.

      Rubber and Plastics

      The percentage change in the price of rubber and plastic products as measured by the PPI (Commodity Code 07) would be applied to this component.

      Paper Products

      The percentage change in the price of converted paper and paperboard products as measured by the PPI (Commodity Code 0915) would be used.

      Apparel

      The percentage change in the price of apparel as measured by the PPI (Commodity Code 381) would be applied to this component.

      Machinery and Equipment

      The percentage change in the price of machinery and equipment as measured by the PPI (Commodity Code 11) would be applied to this component.

      Miscellaneous Products

      The percentage change in the price of all finished goods less food and energy as measured by the PPI (Commodity Code SOP3500) would be applied to this component. Using this index would remove the double-counting of food and energy prices, which are captured elsewhere in the market basket. The weight for this cost category is higher than in the 1997-based index because the weight for blood and blood products (1.322) is added to it. In the 1997-based excluded hospital with capital market basket we included a separate cost

      [[Page 30229]]

      category for blood and blood products, using the BLS Producer Price Index for blood and derivatives as a price proxy. A review of recent trends in the PPI for blood and derivatives suggests that its movements may not be consistent with the trends in blood costs faced by hospitals. While this proxy did not match exactly with the product hospitals are buying, its trend over time appears to be reflective of the historical price changes of blood purchased by hospitals. However, an apparent divergence in trends in the PPI for blood and derivatives and trends in blood costs faced by hospitals over recent years led us to reevaluate whether the PPI for blood and derivatives was an appropriate measure of the changing price of blood. We ran test market baskets classifying blood in 3 separate cost categories: blood and blood products, contained within chemicals as was done for the 1992- based excluded hospital with capital market basket, and within miscellaneous products. These categories use as proxies the following PPIs: the PPI for blood and blood products, the PPI for chemicals, and the PPI for finished goods less food and energy, respectively. Of these three proxies, the PPI for finished goods less food and energy moved most like the recent blood cost and price trends. In addition, the impact on the overall market basket by using different proxies for blood was negligible, mostly due to the relatively small weight for blood in the market basket.

      Therefore, we are proposing to use the PPI for finished goods less food and energy for the blood proxy because we believe it would best be able to proxy only price changes rather than nonprice factors such as changes in quantities or required tests associated with blood purchased by hospitals. We will continue to evaluate this proxy for its appropriateness and will explore the development of alternative price indexes to proxy the price changes associated with this cost.

      Telephone

      The percentage change in the price of telephone services as measured by the CPI for all urban consumers (CPI Code CUUR0000SEED) would be applied to this component.

      Postage

      The percentage change in the price of postage as measured by the CPI for all urban consumers (CPI Code CUUR0000SEEC01) would be applied to this component.

      Proposed Changes for All Other Services, Labor Intensive

      The percentage change in the ECI for compensation paid to service workers employed in private industry would be applied to this component.

      All Other Services, Nonlabor Intensive

      The percentage change in the all-items component of the CPI for all urban consumers (CPI Code CUUR0000SA0) would be applied to this component. c. Proposed Methodology for Capital Portion of the RPL Market Basket

      Unlike for the operating costs of the proposed FY 2002-based RPL market basket, we did not have IRFs, IPFs, and LTCHs FY 2002 Medicare cost report data for the capital cost weights, due to a change in the FY 2002 cost reporting requirements. Rather, we used these hospitals' expenditure data for the capital cost categories of depreciation, interest, and other capital expenses for the most recent year available (FY 2001), and aged the data to a FY 2002 base year using relevant price proxies.

      We calculated weights for the RPL market basket capital costs using the same set of Medicare cost reports used to develop the operating share for IRFs, IPFs, and LTCHs. The resulting proposed capital weight for the FY 2002 base year is 10.149 percent. This is based on FY 2001 Medicare cost report data for IRFs, IPFs, and LTCHs, aged to FY 2002 using relevant price proxies.

      Lease expenses are not a separate cost category in the market basket, but are distributed among the cost categories of depreciation, interest, and other, reflecting the assumption that the underlying cost structure of leases is similar to capital costs in general. We assumed 10 percent of lease expenses are overhead and assigned them to the other capital expenses cost category as overhead. We base this assignment of 10 percent of lease expenses to overhead on the common assumption that overhead is 10 percent of costs. The remaining lease expenses were distributed to the three cost categories based on the weights of depreciation, interest, and other capital expenses not including lease expenses.

      Depreciation contains two subcategories: building and fixed equipment and movable equipment. The split between building and fixed equipment and movable equipment was determined using the FY 2001 Medicare cost reports for IRFs, IPFs, and LTCHs. This methodology was also used to compute the 1997-based index (67 FR at 50044).

      Total interest expense cost category is split between the government/nonprofit and for-profit hospitals. The 1997-based excluded hospital with capital market basket allocated 85 percent of the total interest cost weight to the government/nonprofit interest, proxied by average yield on domestic municipal bonds, and 15 percent to for-profit interest, proxied by average yield on Moody's Aaa bonds.

      We propose to derive the split using the relative FY 2001 Medicare cost report data for IPPS hospitals on interest expenses for the government/nonprofit and for-profit hospitals. Due to insufficient Medicare cost report data for IRFs, IPFs and LTCHs, we propose to use the same split used in the IPPS capital input price index, which is 75- 25. We believe it is important that this split reflects the latest relative cost structure of interest expenses for hospitals. Therefore, we propose to use a 75-25 split to allocate interest expenses to government/nonprofit and for-profit. See the Proposed IPPS Rule for FY 2006, Section IV.D, Capital Input Price Index Section.

      Since capital is acquired and paid for over time, capital expenses in any given year are determined by both past and present purchases of physical and financial capital. The vintage-weighted capital index is intended to capture the long-term consumption of capital, using vintage weights for depreciation (physical capital) and interest (financial capital). These vintage weights reflect the purchase patterns of building and fixed equipment and movable equipment over time. Depreciation and interest expenses are determined by the amount of past and current capital purchases. Therefore, we are proposing to use the vintage weights to compute vintage-weighted price changes associated with depreciation and interest expense.

      Vintage weights are an integral part of the proposed FY 2002-based RPL market basket. Capital costs are inherently complicated and are determined by complex capital purchasing decisions, over time, based on such factors as interest rates and debt financing. In addition, capital is depreciated over time instead of being consumed in the same period it is purchased. The capital portion of the proposed FY 2002-based RPL market basket would reflect the annual price changes associated with capital costs, and would be a useful simplification of the actual capital investment process. By accounting for the vintage nature of capital, we are able to provide an accurate, stable annual measure of price changes. Annual non-vintage price changes for capital are unstable due to the volatility of interest rate changes and, therefore, do not reflect the actual annual price changes

      [[Page 30230]]

      for Medicare capital-related costs. The capital component of the proposed FY 2002-based RPL market basket would reflect the underlying stability of the capital acquisition process and provide hospitals with the ability to plan for changes in capital payments.

      To calculate the vintage weights for depreciation and interest expenses, we needed a time series of capital purchases for building and fixed equipment and movable equipment. We found no single source that provides the best time series of capital purchases by hospitals for all of the above components of capital purchases. The early Medicare Cost Reports did not have sufficient capital data to meet this need because these data were not required. While the AHA Panel Survey provided a consistent database back to 1963, it did not provide annual capital purchases. The AHA Panel Survey provided a time series of depreciation expenses through 1997 which could be used to infer capital purchases over time. From 1998 to 2001, total hospital depreciation expenses were calculated by multiplying the AHA Annual Survey total hospital expenses by the ratio of depreciation to total hospital expenses from the Medicare cost reports. Beginning in 2001, the AHA Annual survey began collecting depreciation expenses. We hope to be able to use this data in future rebasings.

      In order to estimate capital purchases from AHA data on depreciation and interest expenses, the expected life for each cost category (building and fixed equipment, movable equipment, and debt instruments) is needed. Due to insufficient Medicare cost report data for IRFs, IPFs and LTCHs, we propose to use FY 2001 Medicare cost reports for IPPS hospitals to determine the expected life of building and fixed equipment and movable equipment. The expected life of any piece of equipment can be determined by dividing the value of the asset (excluding fully depreciated assets) by its current year depreciation amount. This calculation yields the estimated useful life of an asset if depreciation were to continue at current year levels, assuming straight-line depreciation. From the FY 2001 Medicare cost reports for IPPS hospitals the expected life of building and fixed equipment was determined to be 23 years, and the expected life of movable equipment was determined to be 11 years.

      Although we are proposing to use this methodology for deriving the useful life of an asset, we plan to review it between the publication of the proposed and final rules. We plan to review alternate data sources, if available, and analyze in more detail the hospital's capital cost structure reported in the Medicare cost reports.

      We also propose to use the fixed and movable weights derived from FY 2001 Medicare cost reports for IRFs, IPFs and LTCHs to separate the depreciation expenses into annual amounts of building and fixed equipment depreciation and movable equipment depreciation. By multiplying the annual depreciation amounts by the expected life calculations from the FY 2001 Medicare cost reports, year-end asset costs for building and fixed equipment and movable equipment could be determined. We then calculated a time series back to 1963 of annual capital purchases by subtracting the previous year asset costs from the current year asset costs. From this capital purchase time series we were able to calculate the vintage weights for building and fixed equipment, movable equipment, and debt instruments. Each of these sets of vintage weights are explained in detail below.

      For proposed building and fixed equipment vintage weights, the real annual capital purchase amounts for building and fixed equipment derived from the AHA Panel Survey were used. The real annual purchase amount was used to capture the actual amount of the physical acquisition, net of the effect of price inflation. This real annual purchase amount for building and fixed equipment was produced by deflating the nominal annual purchase amount by the building and fixed equipment price proxy, the Boeckh Institutional Construction Index. This is the same proxy used for the FY 1997-based excluded hospital with capital market basket. We believe this proxy continues to meet our criteria of reliability, timeliness, availability, and relevance. Since building and fixed equipment has an expected life of 23 years, the vintage weights for building and fixed equipment are deemed to represent the average purchase pattern of building and fixed equipment over 23-year periods. With real building and fixed equipment purchase estimates available back to 1963, sixteen 23-year periods could be averaged to determine the average vintage weights for building and fixed equipment that are representative of average building and fixed equipment purchase patterns over time. Vintage weights for each 23-year period are calculated by dividing the real building and fixed capital purchase amount in any given year by the total amount of purchases in the 23-year period. This calculation is done for each year in the 23- year period, and for each of the sixteen 23-year periods. The average of each year across the sixteen 23-year periods is used to determine the 2002 average building and fixed equipment vintage weights.

      For proposed movable equipment vintage weights, the real annual capital purchase amounts for movable equipment derived from the AHA Panel Survey were used to capture the actual amount of the physical acquisition, net of price inflation. This real annual purchase amount for movable equipment was calculated by deflating the nominal annual purchase amount by the movable equipment price proxy, the Producer Price Index for Machinery and Equipment. This is the same proxy used for the FY 1997-based excluded hospital with capital market basket. We believe this proxy, which meets our criteria, is the best measure of price changes for this cost category. Since movable equipment has an expected life of 11 years, the vintage weights for movable equipment are deemed to represent the average purchase pattern of movable equipment over 11-year periods. With real movable equipment purchase estimates available back to 1963, twenty-eight 11-year periods could be averaged to determine the average vintage weights for movable equipment that are representative of average movable equipment purchase patterns over time. Vintage weights for each 11-year period would be calculated by dividing the real movable capital purchase amount for any given year by the total amount of purchases in the 11-year period. This calculation is done for each year in the 11-year period, and for each of the twenty-eight 11-year periods. The average of each year across the twenty-eight 11-year periods would be used to determine the FY 2002 average movable equipment vintage weights.

      For proposed interest vintage weights, the nominal annual capital purchase amounts for total equipment (building and fixed, and movable) derived from the AHA Panel and Annual Surveys were used. Nominal annual purchase amounts were used to capture the value of the debt instrument. Since hospital debt instruments have an expected life of 23 years, the vintage weights for interest are deemed to represent the average purchase pattern of total equipment over 23-year periods. With nominal total equipment purchase estimates available back to 1963, sixteen 23- year periods could be averaged to determine the average vintage weights for interest that are representative of average capital purchase patterns over time. Vintage weights for each 23-year period would be calculated by dividing the nominal total capital purchase

      [[Page 30231]]

      amount for any given year by the total amount of purchases in the 23- year period. This calculation would be done for each year in the 23- year period and for each of the sixteen 23-year periods. The average of the sixteen 23-year periods would be used to determine the FY 2002 average interest vintage weights. The vintage weights for the index are presented in Table 8 below.

      In addition to the proposed price proxies for depreciation and interest costs described above in the vintage weighted capital section, we propose to use the CPI-U for Residential Rent as a price proxy for other capital-related costs. The price proxies for each of the capital cost categories are the same as those used for the IPPS final rule (67 FR at 50044) capital input price index. BILLING CODE 4120-01-P

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      BILLING CODE 4120-01-C

      The proposed FY 2006 update for IRF PPS using the proposed FY 2002- based RPL market basket and Global Insight's 4th quarter 2004 forecast is be 3.1 percent. This includes increases in both the operating section and the capital section. Global Insight, Inc. is a nationally recognized economic and financial forecasting firm that contracts with CMS to forecast the components of the market baskets. Using the current FY 1997-based excluded hospital with capital market basket (66 FR at 41427), Global Insight's fourth quarter 2004

      [[Page 30233]]

      forecast for FY 2006 is also 3.1 percent. Table 4 below compares the proposed FY 2002-based RPL market basket and the FY 1997-based excluded hospital with capital market basket percent changes. For both the historical and forecasted periods between FY 2000 and FY 2008, the difference between the two market baskets is minor with the exception of FY 2002 where the proposed FY 2002-based RPL market basket increased three tenths of a percentage point higher than the FY 1997-based excluded hospital with capital market basket. This is primarily due to the proposed FY 2002-based RPL market basket having a larger compensation (that is, the sum of wages and salaries and benefits) cost weight than the FY 1997-based index and the price changes associated with compensation costs increasing much faster than the prices of other market basket components. Also contributing is the ``all other nonlabor intensive'' cost weight, which is smaller in the proposed FY 2002-based RPL market basket than in the FY 1997-based index, and the slower price changes associated with these costs.

      TABLE 9.--Proposed FY 2002-based RPL Market Basket and FY 1997-based Excluded Hospital With Capital Market Basket Percent Changes, FY 2000-FY 2008

      FY 1997-based Proposed rebased excluded hospital Fiscal year (FY)

      FY 2002-based RPL market basket with market basket

      capital

      Historical data:

      FY 2000.............................................................

      3.1

      3.1

      FY 2001.............................................................

      4.0

      4.0

      FY 2002.............................................................

      3.9

      3.6

      FY 2003.............................................................

      3.8

      3.7

      FY 2004.............................................................

      3.6

      3.6

      Average FYs 2000-2004...............................................

      3.7

      3.6 Forecast:

      FY 2005.............................................................

      3.7

      3.8

      FY 2006.............................................................

      3.1

      3.1

      FY 2007.............................................................

      2.9

      2.8

      FY 2008.............................................................

      2.9

      2.8

      Average FYs 2005-2008...............................................

      3.2

      3.1

      4. Labor-Related Share

         Section 1886(j)(6) of the Act specifies that the Secretary shall adjust the proportion (as estimated by the Secretary from time to time) of rehabilitation facilities' costs which are attributable to wages and wage-related costs, of the prospective payment rates computed under paragraph (3) for area differences in wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the rehabilitation facility compared to the national average wage level for such facilities. Not later than October 1, 2001 (and at least every 36 months thereafter), the Secretary shall update the factor under the preceding sentence on the basis of information available to the Secretary (and updated as appropriate) of the wages and wage-related costs incurred in furnishing rehabilitation services. Any adjustments or updates made under this paragraph for a fiscal year shall be made in a manner that assures that the aggregated payments under this subsection in the fiscal year shall be made in a manner that assures that the aggregated payments under this subsection in the fiscal year are not greater or less than those that would have been made in the year without such adjustment.

         The labor-related share is determined by identifying the national average proportion of operating costs that are related to, influenced by, or vary with the local labor market. Using our current definition of labor-related, the labor-related share is the sum of the relative importance of wages and salaries, fringe benefits, professional fees, labor-intensive services, and a portion of the capital share from an appropriate market basket. We used the proposed FY 2002-based RPL market basket costs to determine the proposed labor-related share for the IRF PPS. The proposed labor-related share for FY 2006 would be the sum of the proposed FY 2006 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 2002) and FY 2006. The sum of the proposed relative importance for FY 2006 for operating costs (wages and salaries, employee benefits, professional fees, and labor-intensive services) would be 71.782 percent, as shown in the chart below. The portion of capital that is influenced by local labor markets would estimated to be 46 percent, which is the same percentage currently used in the IRF prospective payment system. Since the relative importance for capital would be 9.079 percent of the proposed FY 2002-based RPL market basket in FY 2006, we are proposing to take 46 percent of 9.079 percent to determine the proposed capital labor- related share for FY 2006. The result would be 4.176 percent, which we propose to add to 71.782 percent for the operating cost amount to determine the total proposed labor-related share for FY 2006. Thus, the labor-related share that we propose to use for IRF PPS in FY 2006 would be 75.958 percent. This proposed labor-related share is determined using the same methodology as employed in calculating all previous IRF labor-related shares (66 FR at 41357).

         Table 10 below shows the proposed FY 2006 relative importance labor-related share using the proposed 2002-based RPL market basket and the FY 1997-based excluded hospital with capital market.

         [[Page 30234]]

         Table 10.--Proposed Total Labor-Related Share

         FY 1997 excluded Proposed FY 2002- hospital with based RPL market capital market Cost category

         basket relative basket relative importance

         importance (percent) FY 2006 (percent) FY 2006

         Wages and salaries......................................................

         52.823

         48.432 Employee benefits.......................................................

         13.863

         11.415 Professional fees.......................................................

         2.907

         4.540 All other labor intensive services......................................

         2.189

         4.496

         Subtotal............................................................

         71.782

         68.883 Labor-related share of capital costs....................................

         4.176

         3.307

         Total...............................................................

         75.958

         72.190

         We are currently continuing an evaluation of our labor-related share methodology used in the IPPS (see 67 FR at 31447 for discussion of our previous analysis). Our evaluation includes regression analysis and reviewing the makeup of cost categories based on our current labor- related definition. A complete discussion of our research is provided in the FY 2006 IPPS proposed rule (See FY 2006 IPPS proposed rule, Section IV, B, 3). The labor-related share used in the IPPS was the first labor-related share used in a prospective payment system. Our methodology for calculating the proposed labor-related share for the IRF PPS is based upon the methodology used in the IPPS. 2. Proposed Area Wage Adjustment

         Section 1886(j)(6) of the Act requires the Secretary to adjust the proportion (as estimated by the Secretary from time to time) of rehabilitation facilities' costs that are attributable to wages and wage-related costs by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the rehabilitation facility compared to the national average wage level for those facilities. Not later than October 1, 2001 and at least every 36 months thereafter, the Secretary is required to update the factor under the preceding sentence on the basis of information available to the Secretary (and updated as appropriate) of the wages and wage- related costs incurred in furnishing rehabilitation services. Any adjustments or updates made under section 1886(j)(6) of the Act for a FY shall be made in a manner that assures the aggregated payments under section 1886(j)(6) of the Act are not greater or less than those that would have been made in the year without such adjustment.

         In our August 1, 2003 final rule, we acknowledged that on June 6, 2003, the Office of Management and Budget (OMB) issued ``OMB Bulletin No.03-04,'' announcing revised definitions of Metropolitan Statistical Areas, and new definitions of Micropolitan Statistical Areas and Combined Statistical Areas. A copy of the Bulletin may be obtained at the following Internet address: http://www.whitehouse.gov/omb/bulletins/b03-04.html. At that time, we did not propose to apply these

         new definitions known as the Core-Based Statistical Areas (CBSAs). After further analysis and discussed in detail below, we are proposing to use revised labor market area definitions as a result of the OMB revised definitions to adjust the FY 2006 IRF PPS payment rate. In addition, the IPPS is applying these revised definitions as discussed in the August 11, 2004 final rule (69 FR at 49207).

      1. Proposed Revisions of the IRF PPS Geographic Classification

         As discussed in the August 7, 2001 final rule, which implemented the IRF PPS (66 FR at 41316), in establishing an adjustment for area wage levels under Sec. 412.624(e)(1), the labor-related portion of an IRF's Federal prospective payment is adjusted by using an appropriate wage index. As set forth in Sec. 412.624(e)(1), an IRF's wage index is determined based on the location of the IRF in an urban or rural area as defined in Sec. 412.602 and further defined in Sec. 412.62(f)(1)(ii) and Sec. 412.62(f)(1)(iii) as urban and rural areas, respectively. An urban area, under the IRF PPS, is defined in Sec. 412.62(f)(1)(ii) as a Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA) as defined by the Office of Management and Budget (OMB). Under Sec. 412.62(f)(1)(iii), a rural area is defined as any area outside of an urban area. In general, an urban area is defined as a Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA) as defined by the Office of Management and Budget. Under Sec. 412.62(f)(1)(iii), a rural area is defined as any area outside of an urban area. The urban and rural area geographic classifications defined in Sec. 412.62(f)(1)(ii) and (f)(1)(iii), respectively, were used under the IPPS from FYs 1985 through 2004 (as specified in Sec. 412.63(b)), and have been used under the IRF PPS since it was implemented for cost reporting periods beginning on or after January 1, 2002.

         The wage index used for the IRF PPS is calculated by using the acute care IPPS wage index data on the basis of the labor market area in which the acute care hospital is located, but without taking into account geographic reclassification under sections 1886(d)(8) and (d)(10) of the Act and without applying the ``rural floor'' under section 4410 of Pub. L. 105-33 (BBA). In addition, Section 4410 of Pub. L. 105-33 (BBA) provides that for the purposes of section 1886(d)(3)(E) of the Act, that the area wage index applicable to hospitals located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in the State. Consistent with past IRF policy, we treat this provision, commonly referred to as the ``rural floor'', as applicable to the acute inpatient hospitals and not IRFs. Therefore, the hospital wage index used for IRFs is commonly referred to as ``pre-floor'' indicating that ``rural floor'' provision is not applied. As a result, the applicable IRF wage index value is assigned to the IRF on the basis of the labor market area in which the IRF is geographically located.

         Below, we will provide a description of the current labor markets that have been used for area wage adjustments under the IRF PPS since its implementation of cost reporting periods beginning on or after January 1, 2002. Previously, we have not described the labor market areas used under the IRF PPS in detail, although we have published each area's wage index in tables, in the IRF PPS final rules and

         [[Page 30235]]

         update notices, each year and noted the use of the geographic area in applying the wage index adjustment in IRF PPS payment examples in the final regulation implementing the IRF PPS (69 FR at 41367 through 41368). The IRF industry has also understood that the same labor market areas in use under the IPPS (from the time the IRF PPS was implemented, for cost reporting periods beginning on or after January 1, 2002) would be used under the IRF PPS. The OMB has adopted new statistical area definitions (as discussed in greater detail below) and we are proposing to adopt new labor market area definitions based on these areas under the IRF PPS (as discussed in greater detail below). Therefore, we believe it is helpful to provide a more detailed description of the current IRF PPS labor market areas, in order to better understand the proposed change to the IRF PPS labor market areas presented below in this proposed rule.

         The current IRF PPS labor market areas are defined based on the definitions of MSAs, Primary MSAs (PMSAs), and NECMAs issued by the OMB (commonly referred to collectively as ``MSAs''). These MSA definitions, which are discussed in greater detail below, are currently used under the IRF PPS and other prospective payment systems, such as LTCH, IPF, Home Health Agency (HHA), and SNF (Skilled Nursing Facility) PPSs. In the IPPS final rule (67 FR at 49026 through 49034), revised labor market area definitions were adopted under the hospital IPPS (Sec. 412.64(b)), which were effective October 1, 2004 for acute care hospitals. These new CBSAs standards were announced by the OMB late in 2000. b. Current IRF PPS Labor Market Areas Based on MSAs

         As mentioned earlier, since the implementation of the IRF PPS in the August 7, 2001 IRF PPS final rule, we have used labor market areas to further characterize urban and rural areas as determined under Sec. 412.602 and further defined in Sec. 412.62(f)(1)(ii) and (f)(1)(iii). To this end, we have defined labor market areas under the IRF PPS based on the definitions of MSAs, PMSAs, and NECMAs issued by the OMB, which is consistent with the IPPS approach. The OMB also designates Consolidated MSAs (CMSAs). A CMSA is a metropolitan area with a population of 1 million or more, comprising two or more PMSAs (identified by their separate economic and social character). For purposes of the wage index, we use the PMSAs rather than CMSAs because they allow a more precise breakdown of labor costs (as further discussed in section III.B.2.d.ii of this proposed rule). If a metropolitan area is not designated as part of a PMSA, we use the applicable MSA.

         These different designations use counties as the building blocks upon which they are based. Therefore, IRFs are assigned to either an MSA, PMSA, or NECMA based on whether the county in which the IRF is located is part of that area. All of the counties in a State outside a designated MSA, PMSA, or NECMA are designated as rural. For the purposes of calculating the wage index, we combine all of the counties in a State outside a designated MSA, PMSA, or NECMA together to calculate the statewide rural wage index for each State. c. Core-Based Statistical Areas (CBSAs)

         OMB reviews its Metropolitan Area definitions preceding each decennial census. As discussed in the IPPS final rule (69 FR at 49027), in the fall of 1998, OMB chartered the Metropolitan Area Standards Review Committee to examine the Metropolitan Area standards and develop recommendations for possible changes to those standards. Three notices related to the review of the standards, providing an opportunity for public comment on the recommendations of the Committee, were published in the Federal Register on the following dates: December 21, 1998 (63 FR at 70526); October 20, 1999 (64 FR at 56628); and August 22, 2000 (65 FR at 51060).

         In the December 27, 2000 Federal Register (65 FR at 82228 through 82238), OMB announced its new standards. In that notice, OMB defines CBSA, beginning in 2003, as ``a geographic entity associated with at least one core of 10,000 or more population, plus adjacent territory that has a high degree of social and economic integration with the core as measured by commuting ties.'' The standards designate and define two categories of CBSAs: MSAs and Micropolitan Statistical Areas (65 FR at 82235 through 82238).

         According to OMB, MSAs are based on urbanized areas of 50,000 or more population, and Micropolitan Statistical Areas (referred to in this discussion as Micropolitan Areas) are based on urban clusters of at least 10,000 population, but less than 50,000 population. Counties that do not fall within CBSAs (either MSAs or Micropolitan Areas) are deemed ``Outside CBSAs.'' In the past, OMB defined MSAs around areas with a minimum core population of 50,000, and smaller areas were ``Outside MSAs.'' On June 6, 2003, OMB announced the new CBSAs, comprised of MSAs and the new Micropolitan Areas based on Census 2000 data. (A copy of the announcement may be obtained at the following Internet address: http://www.whitehouse.gov/omb/bulletins/fy04/b04-03.html. )

         The new CBSA designations recognize 49 new MSAs and 565 new Micropolitan Areas, and revise the composition of many of the existing MSAs. There are 1,090 counties in MSAs under the new CBSA designations (previously, there were 848 counties in MSAs). Of these 1,090 counties, 737 are in the same MSA as they were prior to the change in designations, 65 are in a different MSA, and 288 were not previously designated to any MSA. There are 674 counties in Micropolitan Areas. Of these, 41 were previously in an MSA, while 633 were not previously designated to an MSA. There are five counties that previously were designated to an MSA but are no longer designated to either an MSA or a new Micropolitan Area: Carter County, KY; St. James Parish, LA; Kane County, UT; Culpepper County, VA; and King George County, VA. For a more detailed discussion of the conceptual basis of the new CBSAs, refer to the IPPS final rule (67 FR at 49026 through 49034). d. Proposed Revisions to the IRF PPS Labor Market Areas

         In its June 6, 2003 announcement, OMB cautioned that these new definitions ``should not be used to develop and implement Federal, State, and local nonstatistical programs and policies without full consideration of the effects of using these definitions for such purposes. These areas should not serve as a general-purpose geographic framework for nonstatistical activities, and they may or may not be suitable for use in program funding formulas.''

         We currently use MSAs to define labor market areas for purposes of the wage index. In fact, MSAs are also used to define labor market areas for purposes of the wage index for many of the other Medicare prospective payment systems (for example, LTCH, SNF, HHA, IPF, and Outpatient). While we recognize MSAs are not designed specifically to define labor market areas, we believe they represent a reasonable and appropriate proxy for this purpose, because they are based upon characteristics we believe also generally reflect the characteristics of unified labor market areas. For example, CBSAs reflect a core population plus an adjacent territory that reflects a high degree of social and economic integration. This integration is measured by commuting ties, thus demonstrating that these areas may draw workers from

         [[Page 30236]]

         the same general areas. In addition, the most recent CBSAs reflect the most up to date information. The OMB reviews its MA definitions preceding each decennial census to reflect recent population changes and the CBSAs are based on the Census 2000 data. Our analysis and discussion here are focused on issues related to adopting the new CBSA designations to define labor market areas for the purposes of the IRF PPS.

         Historically, Medicare PPSs have utilized Metropolitan Area (MA) definitions developed by OMB. The labor market areas currently used under the IRF PPS are based on the MA definitions issued by OMB. OMB reviews its MA definitions preceding each decennial census to reflect more recent population changes. Thus, the CBSAs are OMB's latest MA definitions based on the Census 2000 data. Because we believe that the OMB's latest MA designations more accurately reflect the local economies and wage levels of the areas in which hospitals are currently located, we are proposing to adopt the revised labor market area designations based on the OMB's CBSA designations.

         As specified in Sec. 412.624(e)(1), we explained in the August 7, 2001 final rule that the IRF PPS wage index adjustment was intended to reflect the relative hospital wage levels in the geographic area of the hospital as compared to the national average hospital wage level. Since OMB's CBSA designations are based on Census 2000 data and reflect the most recent available geographic classifications, we are proposing to revise the labor market area definitions used under the IRF PPS. Specifically, we are proposing to revise the IRF PPS labor market definitions based on the OMB's new CBSA designations effective for IRF PPS discharges occurring on or after October 1, 2005. Accordingly, we are proposing to revise Sec. 412.602 to specify that for discharges occurring on or after October 1, 2005, the application of the wage index under the IRF PPS would be made on the basis of the location of the facility in an urban or rural area as defined in Sec. 412.64(b)(1)(ii)(A) through (C). (As a conforming change, we are also proposing to revise Sec. 412.602, definitions for rural and urban areas effective for discharges occurring on or after October 1, 2005 would be defined in Sec. 412.64(b)(1)(ii)(A) through (C). To further clarify, we will revise the regulation text to explicitly reference urban and rural definitions for a cost-reporting period beginning on or after January 1, 2002, with respect to discharges occurring during the period covered by such cost reports but before October 1, 2005 under Sec. 412.62(f)(1)(ii) and Sec. 412.62(f)(1)(iii)).

         We note that these are the same labor market area definitions (based on the OMB's new CBSA designations) implemented under the IPPS at Sec. 412.64(b), which were effective for those hospitals beginning October 1, 2004 as discussed in the IPPS final rule (69 FR at 49026 through 49034). The similarity between the IPPS and the IRF PPS includes the adoption in the initial implementation of the IRF PPS of the same labor market area definitions under the IRF PPS that existed under the IPPS at that time, as well as the use of acute care hospitals' wage data in calculating the IRF PPS wage index. In addition, the OMB's CBSA-based designations reflect the most recent available geographic classifications and more accurately reflects current labor markets. Therefore, we believe that proposing to revise the IRF PPS labor market area definitions based on OMB's CBSA-based designations are consistent with our historical practice of modeling IRF PPS policy after IPPS policy.

         Below, we discuss the composition of the proposed IRF PPS labor market areas based on the OMB's new CBSA designations. i. New England MSAs

         As stated above, in the August 7, 2001 final rule, we currently use NECMAs to define labor market areas in New England, because these are county-based designations rather than the 1990 MSA definitions for New England, which used minor civil divisions such as cities and towns. Under the current MSA definitions, NECMAs provided more consistency in labor market definitions for New England compared with the rest of the country, where MSAs are county-based. Under the new CBSAs, OMB has now defined the MSAs and Micropolitan Areas in New England on the basis of counties. The OMB also established New England City and Town Areas, which are similar to the previous New England MSAs.

         In order to create consistency among all labor market areas and to maintain these areas on the basis of counties, we are proposing to use the county-based areas for all MSAs in the nation, including those in New England. Census has now defined the New England area based on counties, creating a city- and town-based system as an alternative. We believe that adopting county-based labor market areas for the entire country except those in New England would lead to inconsistencies in our designations. Adopting county-based labor market areas for the entire country provides consistency and stability in Medicare program payment because all of the labor market areas throughout the country, including New England, would be defined using the same system (that is, counties) rather than different systems in different areas of the country, and minimizes programmatic complexity.

         In addition, we have consistently employed a county-based system for New England for precisely that reason: to maintain consistency with the labor market area definitions used throughout the country. Because we have never used cities and towns for defining IRF labor market areas, employing a county-based system in New England maintains that consistent practice. We note that this is consistent with the implementation of the CBSA-based designations under the IPPS for New England (see 69 FR at 49028). Accordingly, in this proposed rule, we are proposing to use the New England MSAs as determined under the proposed new CBSA-based labor market area definitions in defining the proposed revised IRF PPS labor market areas. ii. Metropolitan Divisions

         Under OMB's new CBSA designations, a Metropolitan Division is a county or group of counties within a CBSA that contains a core population of at least 2.5 million, representing an employment center, plus adjacent counties associated with the main county or counties through commuting ties. A county qualifies as a main county if 65 percent or more of its employed residents work within the county and the ratio of the number of jobs located in the county to the number of employed residents is at least 0.75. A county qualifies as a secondary county if 50 percent or more, but less than 65 percent, of its employed residents work within the county and the ratio of the number of jobs located in the county to the number of employed residents is at least 0.75. After all the main and secondary counties are identified and grouped, each additional county that already has qualified for inclusion in the MSA falls within the Metropolitan Division associated with the main/secondary county or counties with which the county at issue has the highest employment interchange measure. Counties in a Metropolitan Division must be contiguous (65 FR at 82236).

         The construct of relatively large MSAs being comprised of Metropolitan Divisions is similar to the current construct of the CMSAs comprised of PMSAs. As noted above, in the past, OMB designated CMSAs as

         [[Continued on page 30237]]

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

         [[pp. 30237-30286]] Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for FY 2006

         [[Continued from page 30236]]

         [[Page 30237]]

         Metropolitan Areas with a population of 1 million or more and comprised of two or more PMSAs. Under the IRF PPS, we currently use the PMSAs rather than CMSAs to define labor market areas because they comprise a smaller geographic area with potentially varying labor costs due to different local economies. We believe that CMSAs may be too large of an area with a relatively large number of hospitals, to accurately reflect the local labor costs of all the individual hospitals included in that relatively ``large'' area. A large market area designation increased the likelihood of including many hospitals located in areas with very different labor market conditions within the same market area designation. This variation could increase the difficulty in calculating a single wage index that would be relevant for all hospitals within the market area designation. Similarly, we believe that MSAs with a population of 2.5 million or greater may be too large of an area to accurately reflect the local labor costs of all the individual hospitals included in that relatively ``large'' area. Furthermore, as indicated above, Metropolitan Divisions represent the closest approximation to PMSAs, the building block of the current IRF PPS labor market area definitions, and therefore, would most accurately maintain our current structuring of the IRF PPS labor market areas. Therefore, as implemented under the IPPS (69 FR at 49029), we are proposing to use the Metropolitan Divisions where applicable (as describe below) under the proposed new CBSA-based labor market area definitions.

         In addition to being comparable to the organization of the labor market areas under the current MSA designations (that is, the use of PMSAs rather than CMSAs), we believe that proposing to use Metropolitan Divisions where applicable (as described below) under the IRF PPS would result in a more accurate adjustment for the variation in local labor market areas for IRFs. Specifically, if we would recognize the relatively ``larger'' CBSA that comprises two or more Metropolitan Divisions as an independent labor market area for purposes of the wage index, it would be too large and would include the data from too many hospitals to compute a wage index that would accurately reflect the various local labor costs of all the individual hospitals included in that relatively ``large'' CBSA. As mentioned earlier, a large market area designation increases the likelihood of including many hospitals located in areas with very different labor market conditions within the same market area designation. This variation could increase the difficulty in calculating a single wage index that would be relevant for all hospitals within the market area designation. Rather, by proposing to recognize Metropolitan Divisions where applicable (as described below) under the proposed new CBSA-based labor market area definitions under the IRF PPS, we believe that in addition to more accurately maintaining the current structuring of the IRF PPS labor market areas, the local labor costs would be more accurately reflected, thereby resulting in a wage index adjustment that better reflects the variation in the local labor costs of the local economies of the IRFs located in these relatively ``smaller'' areas.

         Below we describe where Metropolitan Divisions would be applicable under the proposed new CBSA-based labor market area definitions under the IRF PPS.

         Under the OMB's CBSA-based designations, there are 11 MSAs containing Metropolitan Divisions: Boston; Chicago; Dallas; Detroit; Los Angeles; Miami; New York; Philadelphia; San Francisco; Seattle; and Washington, DC. Although these MSAs were also CMSAs under the prior definitions, in some cases their areas have been altered. Under the current IRF PPS MSA designations, Boston is a single NECMA. Under the proposed CBSA-based labor market area designations, it would be comprised of four Metropolitan Divisions. Los Angeles would go from four PMSAs under the current IRF PPS MSA designations to two Metropolitan Divisions under the proposed CBSA-based labor market area designations. The New York CMSA would go from 15 PMSAs under the current IRF PPS MSA designations to only four Metropolitan Divisions under the proposed CBSA-based labor market area designations. The five PMSAs in Connecticut under the current IRF PPS MSA designations would become separate MSAs under the proposed CBSA-based labor market area designations because two MSAs became separate MSAs. The number of PMSAs in New Jersey, under the current IRF PPS MSA designations would go from five to two, with the consolidation of two New Jersey PMSAs (Bergen- Passaic and Jersey City) into the New York-Wayne-White Plains, NY-NJ Division, under the proposed CBSA-based labor market area designations. In San Francisco, under the proposed CBSA-based labor market area designations there are only two Metropolitan Divisions. Currently, there are six PMSAs, some of which are now separate MSAs under the current IRF PPS labor market area designations.

         Under the current IRF PPS labor market area designations, Cincinnati, Cleveland, Denver, Houston, Milwaukee, Portland, Sacramento, and San Juan are all designated as CMSAs, but would no longer be designated as CMSAs under the proposed CBSA-based labor market area designations. As noted previously, the population threshold to be designated a CMSA under the current IRF PPS labor market area designations is 1 million. In most of these cases, counties currently in a PMSA would become separate, independent MSAs under the proposed CBSA-based labor market area designations, leaving only the MSA for the core area under the proposed CBSA-based labor market area designations. iii. Micropolitan Areas

         Under the new OMB's CBSA-based designations, Micropolitan Areas are essentially a third area definition consisting primarily of areas that are currently rural, but also include some or all of areas that are currently designated as urban MSA. As discussed in greater detail in the IPPS final rule (69 FR at 49029 through 49032), how these areas are treated would have significant impacts on the calculation and application of the wage index. Specifically, whether or not Micropolitan Areas are included as part of the respective statewide rural wage indices would impact the value of the statewide rural wage index of any State that contains a Micropolitan Area because a hospital's classification as urban or rural affects which hospitals' wage data are included in the statewide rural wage index. As discussed above in section III.B.2.b of this proposed rule, we combine all of the counties in a State outside a designated urban area to calculate the statewide rural wage index for each State.

         Including Micropolitan Areas as part of the statewide rural labor market area would result in an increase to the statewide rural wage index because hospitals located in those Micropolitan Areas typically have higher labor costs than other rural hospitals in the State. Alternatively, if Micropolitan Areas were to be recognized as independent labor market areas, because there would be so few hospitals in those areas to complete a wage index, the wage indices for IRFs in those areas could become relatively unstable as they might change considerably from year to year.

         We currently use MSAs to define urban labor market areas and group all the hospitals in counties within each

         [[Page 30238]]

         State that are not assigned to an MSA into a statewide rural labor market area. Therefore, we used the terms ``urban'' and ``rural'' wage indices in the past for ease of reference. However, the introduction of Micropolitan Areas by the OMB potentially complicates this terminology because these areas include many hospitals that are currently included in the statewide rural labor market areas.

         We are proposing to treat Micropolitan Areas as rural labor market areas under the IRF PPS for the reasons outlined below. That is, counties that are assigned to a Micropolitan Area under the CBSA-based designations would be treated the same as other ``rural'' counties that are not assigned to either an MSA or a Micropolitan Area. Therefore, in determining an IRF's applicable wage index (based on IPPS hospital wage index data) we are proposing that an IRF in a Micropolitan Area under OMB's CBSA designations would be classified as ``rural'' and would be assigned the statewide rural wage index for the State in which it resides.

         In the IPPS final rule (69 FR at 49029 through 49032), we discuss our evaluation of the impact of treating Micropolitan areas as part of the statewide rural labor market area instead of treating Micropolitan Areas as independent labor market areas for hospitals paid under the IPPS. As an alternative to treating Micropolitan Areas as part of the statewide rural labor market area for purposes of the IRF PPS, we examined treating Micropolitan Areas as separate (urban) labor market areas, just as we did when implementing the revised labor market areas under the IPPS. As discussed in greater detail in that same final rule, the designation of Micropolitan Areas as separate urban areas for wage index purposes would have a dramatic impact on the calculation of the wage index. This is because Micropolitan areas encompass smaller populations than MSAs, and tend to include fewer hospitals per Micropolitan area. Currently, there are only 25 MSAs with one hospital in the MSA. However, under the new proposed CBSA-based definitions, there are 373 Micropolitan Areas with one hospital, and 49 MSAs with only one hospital.

         Since Micropolitan Areas encompass smaller populations than MSAs, they tend to include fewer hospitals per Micropolitan Area, recognizing Micropolitan Areas as independent labor market areas would generally increase the potential for dramatic shifts in those areas' wage indices from one year to the next because a single hospital (or group of hospitals) could have a disproportionate effect on the wage index of the area. The large number of labor market areas with only one hospital and the increased potential for dramatic shifts in the wage indexes from one year to the next is a problem for several reasons. First, it creates instability in the wage index from year to year for a large number of hospitals. Second, it reduces the averaging effect (this averaging effect allows for more data points to be used to calculate the representative standard of measured labor costs within a market area) lessening some of the incentive for hospitals to operate efficiently. This incentive is inherent in a system based on the average hourly wages for a large number of hospitals, as hospitals could profit more by operating below that average. In labor market areas with a single hospital, high wage costs are passed directly into the wage index with no counterbalancing averaging with lower wages paid at nearby competing hospitals. Third, it creates an arguably inequitable system when so many hospitals have wage indexes based solely on their own wages, while other hospitals' wage indexes are based on an average hourly wage across many hospitals. Therefore, in order to minimize the potential instability in payment levels from year to year, we believe it would be appropriate to treat Micropolitan Areas as part of the statewide rural labor market area under the IRF PPS.

         For the reasons noted above, and consistent with the treatment of these areas under the IPPS, we are proposing not to adopt Micropolitan Areas as independent labor market areas under the IRF PPS. Under the proposed new CBSA-based labor market area definitions, we are proposing that Micropolitan Areas be considered a part of the statewide rural labor market area. Accordingly, we are proposing that the IRF PPS statewide rural wage index be determined using the acute-care IPPS hospital wage data (the rational for using IPPS hospital wage data is discussed in section III.B.2.f of this proposed rule) from hospitals located in non-MSA areas and that the statewide rural wage index be assigned to IRFs located in those areas. e. Implementation of the Proposed Changes To Revise the Labor Market Areas

         Under section 1886(j) of the Act, as added by section 4421 of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33) and as amended by section 125 of the Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L. 106-113) and section 305 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Pub. L. 106- 554), which requires the implementation of such prospective payment system, the Secretary generally has broad authority in developing the IRF PPS, including whether and how to make adjustments to the IRF PPS.

         To facilitate an understanding of the proposed policies related to the proposed change to the IRF PPS labor market areas discussed above, in Table 3 of the Addendum of this proposed rule, we are providing a listing of each IRF's state and county location; existing MSA labor market area designation; and its proposed new CBSA designation based on county information from our online survey, certification, and reporting (OSCAR) database, and an Iowa Foundation for Medical Care (IFMC) report listing providers and their state and county location that submitted IRF-PAIs during the past 18 months (report request made in February 2005). We encourage IRFs to review the county location and both the current and proposed labor market area assignments for accuracy. Any questions or corrections (including additions or deletions) to the information provided in Table 3 of the Addendum should be emailed to the following CMS Web address: IRFPPSInfo@cms.hhs.gov. A link to this address can be found on the following CMS Web page http://www.cms.hhs.gov/providers/irfpps/ .

         When the revised labor market areas based on OMB's new CBSA-based designations were adopted under the IPPS beginning on October 1, 2004, a transition to the new designations was established due to the scope and substantial implications of these new boundaries and to buffer the subsequent substantial impacts on numerous hospitals. As discussed in the IPPS final rule (69 FR at 49032), during FY 2005, a blend of wage indices is calculated for those acute care IPPS hospitals experiencing a drop in their wage indices because of the adoption of the new labor market areas. The most substantial decrease in wage index impacts urban acute-care hospitals that were designated as rural under the CBSA-based designations.

         While we recognize that, just like IPPS hospitals, IRFs may experience decreases in their wage index as a result of the proposed labor market area changes, our data analysis showed that a majority of IRFs either expect no change in wage index or an increase in wage index based on CBSA definitions.

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         In addition, a very small number of IRFs (3 percent) would experience a decline of 5 percent or more in the wage index based on CBSA designations. A 5 percent decrease in the wage index for an IRF may result in a noticeable decrease in their wage index compared to what their wage index would have been for FY 2006 under the MSA-based designations. We also found that a very small number of IRFs (4 percent) would experience a change in either rural or urban designation under the CBSA-based definitions. Since a majority of IRFs would not be significantly impacted by the proposed labor market areas, we believe it is not necessary to propose a transition to the proposed new CBSA- based labor market area for the purposes of the IRF PPS wage index. The main purpose of a transition is to buffer hospitals that would be significantly impacted by a proposed policy. Since the impact of the proposed labor market areas upon IRFs would be minimal, the need to transition is absent. We recognize that there would be many alternatives to efficiently implement the proposed CBSA-based geographic designations. The statute confers broad authority to the Secretary under 1886(j)(6) of the Act to establish factor for area wage differences by a factor such that budget neutral wage index options may be considered. Thus, we considered three budget neutral alternatives that could implement the adoption of the proposed CBSA-based designations as discussed below. Even though a majority of IRFs would not be significantly impacted by the proposed labor market areas, we wanted to be diligent and at least examine transition policies and the affect on the system. We needed to conduct the analysis to determine how IRFs fare under such a proposed policy.

         One alternative we considered institutes a one-year transition with a blended wage index, equal to 50 percent of the FY 2006 MSA-based wage index and 50 percent of the FY 2006 CBSA-based wage index (both based on the FY 2001 hospital wage data), for all providers. In this scenario, a blended wage index of 50 percent of the FY 2006 MSA-based wage index and 50 percent of the FY 2006 CBSA-based wage index was used because in the IPPS final rule (69 FR at 49033) a blended wage index employed 50 percent of the FY 2001 hospital wage index data and the old labor market definitions, and 50 percent of the wage index employing FY 2001 wage index data and the new labor market definitions. However, we found that while this would help some IRFs that are adversely affected by the changes to the MSAs, it would also reduce the wage index values (compared to fully adopting the CBSA wage index value) for IRFs that would be positively affected by the changes. Thus, the unadjusted payment rate for all providers would be slightly reduced. Therefore, a majority of the IRFs would not benefit if all providers are given a blended wage index in a budget neutral manner (such that estimated aggregate, overall payments to IRFs would not change under the proposed labor market area definitions).

         A second alternative we considered consists of a one-year transition with a blended wage index, equal to 50 percent of the FY 2006 MSA wage index and 50 percent of the FY 2006 CBSA-based wage index (both based on the FY 2001 hospital wage data), only for providers that would experience a decrease due solely to the changes in the labor market definitions. In this second alternative, a blended wage index of 50 percent of the FY 2006 MSA wage index and 50 percent of the FY 2006 CBSA-based wage index was determined because in the IPPS final rule (69 FR at 49033) a blended wage index employed 50 percent of the FY 2001 hospital wage index data and the old labor market definitions, and 50 percent of the wage index employing FY 2001 wage index data and the new labor market definitions. Therefore, providers that would experience a decrease in their FY 2006 wage index under the CBSA-based definitions compared to the wage index they would have received under the MSA-based definitions (in both cases using FY 2001 hospital wage data) would receive a blended wage index as described above.

         When we performed our analysis, we found that the unadjusted payment amounts decreased substantially more under this option than they did either by using the first option discussed above or by fully adopting the CBSA-based designations. As with the first alternative, the positive impact of blending in order decrease the impacts for a relatively small number of IRFs would require reduced payment rates for all providers, including the IRFs receiving a blended wage index.

         As discussed in the August 11, 2004 IPPS final rule (69 FR at 49032), during FY 2005, a hold harmless policy was implemented to minimize the overall impact of hospitals that were in FY 2004 designated as urban under the MSA designations, but would become rural under the CBSA designations. In the same final rule, hospitals were afforded a three-year hold harmless policy because the IPPS determined that acute-care hospitals that changed designations from urban to rural would be substantially impacted by the significant change in wage index. Although we considered a hold harmless policy for IRFs that would be substantially impacted from the change in wage index due to the CBSA-based designation, we found that an extremely small number of IRFs (4.4 percent) would change designations. In addition, currently urban facilities that become rural under the CBSA-based definitions would receive the rural facility adjustment, which we are proposing to increase from 19.14 percent to 24.1 percent (discussed in further detail in section III.B.4 of this proposed rule). Thus, the impact on urban facilities that become rural would be mitigated by the rural adjustment.

         We also found that 91 percent of rural facilities that would be designated as urban under the CBSA-based definitions would experience an increase in the wage index. Furthermore, a majority (74 percent) of rural facilities that become urban would experience at least a 5 percent to 10 percent or more increase in wage index. Thus, we do not believe it is appropriate or necessary to adopt a hold harmless policy for facilities that would experience a change in designation under the CBSA-based definitions.

         Finally, we note that section 505 of the MMA established new section 1886(d)(13) of the Act. The new section 1886(d)(13) requires that the Secretary establish a process to make adjustments to the hospital wage index based on commuting patterns of hospital employees. We believe that this requirement for an ``out-commuting'' or ``out- migration'' adjustment applies specifically to the IPPS. Therefore, we will not be proposing such an adjustment for the IRF PPS.

         We are not proposing a transition, a hold harmless policy, nor an ``out-commuting'' adjustment under the IRF PPS from the current MSA- based labor market areas designations to the new CBSA-based labor market area designations as discussed below. We are proposing to adopt the new CBSA-based labor market area definitions beginning with the 2006 IRF PPS fiscal year without a transition period, without a hold harmless policy, and without an ``out-commuting'' adjustment. We believe that this proposed policy is appropriate because despite significant similarities between the IRF PPS and the IPPS, there are clear distinctions between the payment systems, particularly regarding wage index issues.

         The most significant distinction upon which we have based this proposed

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         policy determination is that where acute care hospitals have been paid using full wage index adjusted payments since 1983 and have used the previous IPPS MSA-based labor market area designations for over 10 years, under the IRF PPS we have been using the excluded pre- reclassification and pre-floor MSA-based wage index for cost reporting periods beginning on or after January 1, 2002. Since the implementation of the IRF PPS has only used the MSA-based labor market area designations since 2002 of which the first year was a transition year, many IRFs received a blended payment that consisted of a percentage of TEFRA and a percentage of the IRF PPS rate (as described below). Since many IRFs were initially under the transition period whereby many IRFs received a blend of TEFRA payments and the adjusted Federal prospective payment rates in accordance with section 1886(j)(1) of the Act and as specified in Sec. 412.626, IRFs may still be adjusting to the changes in wage index and thus has not established a long history of an expected wage index from year to year. We may reasonably expect that IRFs would not experience a substantial impact on their respective wage indices because under a relatively new IRF PPS, IRFs are adjusting to the change of being paid a Federal prospective payment rate. Our data analysis also shows that a minimal number of IRFs would experience a decrease of more than 5 percent in the wage index. A 5 percent decrease in the wage index for an IRF would possibly result in a noticeable decrease in their wage index compared to what their wage index would have been for FY 2006 under the MSA-based designations. In addition, under the CBSA designation, a small number of IRFs would experience a change from their current urban or rural designation. Therefore, the overall impact of IRFs under the MSA-based designations versus the CBSA-based designations did not result in a dramatic change overall.

         Although the wage index has been a stable feature of the acute care hospital IPPS since its 1983 implementation and has utilized the prior MSA-based labor market area designation for over 10 years, this is not the case for the IRF PPS which has only been implemented for cost reporting periods beginning on or after January 1, 2002. Therefore, if the proposed CBSA-based labor market area designations were adopted they would have a negligible impact on IRFs because the adoption of the CBSA-based designations are proposed in a budget neutral manner (as discussed in detail in section IV of this proposed rule).

         The impact of adopting the proposed CBSA-based wage index has shown in our impact analysis to have very little impact on the overall payment rates to the extent the proposed refinements to the overall system are also implemented (as discussed below). In addition, unlike other post-acute care payment systems, the IRF PPS payments apply a rural facility adjustment to account for higher costs in rural facilities (as discussed in 66 FR at 41359). We are proposing to increase the current rural adjustment from 19.14 percent to 24.1 percent (as discussed in section III.4 of this proposed rule). Therefore, IRFs that are designated as urban under the MSA-based definitions, but that would be classified as rural under the proposed CBSA-based definitions, will receive a facility add-on of 24.1 percent.

         In sum, the IRF PPS has only been implemented for hospital cost reporting periods beginning on or after January 1, 2002 (which means that payment to IRFs have only been governed by the IRF PPS for slightly more than 3 years). In addition, a small number of IRFs would experience a change in rural or urban designations under the CBSA-based designations. To the extent the proposed changes in this rule are adopted, the change in labor market area for an urban facility to a rural facility is expected to be offset by the rural adjustment we are proposing to increase from 19.14 to 24.1 percent as discussed below. We also found that a majority of IRFs would experience no change in wage index or an increase. Thus, we are proposing to fully adopt the CBSA- based designations without a hold harmless policy. We believe that it is not appropriate or necessary to propose a transition to the proposed new CBSA-based labor market area for the purpose of the IRF PPS wage index adjustment as specified under Sec. 412.624 as explained previously in this section. In addition, as explained above, we believe there are not sufficient data to support a transition from MSA-based designations to the proposed CBSA-based designations. f. Wage Index Data

         In the August 7, 2001 final rule, we established an IRF wage index based on FY 1997 acute care hospital wage data to adjust the FY 2002 IRF payment rates. For the FY 2003 IRF PPS payment rates, we applied the same wage adjustment as used for FY 2002 IRF PPS rates because we determined that the application of the wage index and labor-related share used in FY 2002 provided an appropriate adjustment to account for geographic variation in wage levels that was consistent with the statute. For the FY 2004 IRF PPS payment rates, we used the hospital wage index based on FY 1999 acute care hospital wage data. For the FY 2005 IRF PPS payment rates, we used the hospital wage index based on FY 2000 acute care hospital wage data. We are proposing to use FY 2001 acute care hospital wage data for FY 2006 IRF PPS payment rates because it is the most recent final data available. We believe that a wage index based on acute care hospital wage data is the best proxy and most appropriate wage index to use in adjusting payments to IRFs, since both acute care hospitals and IRFs compete in the same labor markets. Since acute care hospitals compete in the same labor market areas as IRFs, the wage data of acute care hospitals should accurately capture the relationship of wages and wage-related costs of IRF in an area as comparable to the national average. In the August 1, 2001 final rule (66 FR at 41358) we established FY 2002 IRF PPS wage index values for the 2002 IRF PPS fiscal year calculated from the same data used to compute the FY 2001 acute care hospital inpatient wage index data without taking into account geographic reclassification under sections 1886(d)(8) and (d)(10) of the Act and without applying the ``rural floor'' under section 4410 of Pub. L. 105-33 (BBA) (as discussed in section III.B.2.a of this proposed rule). Acute care hospital inpatient wage index data is also used to establish the wage index adjustment used in other PPSs (for example, LTCH, IPF, HHA, and SNF). As we discussed in the August 7, 2001 final rule (66 FR at 41316, 41358), since hospitals that are excluded from the IPPS are not required to provide wage-related information on the Medicare cost report and because we would need to establish instructions for the collection of this IRF data it is not appropriate at this time to propose a wage index specific to IRF facilities. Because we do not have an IRF specific wage index that we can compare to the hospital wage index, we are unable to determine at this time the degree to which the acute care hospital data fully represent IRF wages or if a geographic reclassification adjustment under the IRF PPS is appropriate. However, we believe that a wage index based on acute care hospital data is the best and most appropriate wage index to use in adjusting payments to IRFs, since both acute care hospitals and IRFs compete in the same labor markets. Also, we propose to continue to use the same method for calculating wage indices as was indicated in the August 7, 2001 final rule (69 FR at 41357 through 41358). In addition, 1886(d)(8) and

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         1886(d)(10) of the Act which permits reclassification is applicable only to inpatient acute care hospitals at this time. The wage adjustment established under the IRF PPS is based on an IRF's actual location without regard to the urban or rural designation of any related or affiliated provider.

         In proposing to adopt the CBSA-based designations, we recognize that there may be geographic areas where there are no hospitals, and thus no hospital wage data on which to base the calculation of the IRF PPS wage index. We found that this occurred in two States-- Massachusetts and Puerto Rico--where, using the CBSA-based designations, there were no hospitals located in rural areas. At present, no IRFs are affected by this lack of data, because currently there are no rural IRFs in these two States. If, rural IRFs open in these two States, we propose, for FY 2006, to use the rural FY 2001 MSA-based hospital wage data for that State to determine the wage index of such IRFs. In other words, we would use the same wage data (the FY 2001 hospital wage data) used to calculate the FY 2006 IRF wage index. However, rather than using CBSA-based designations, we would use MSA- based designations to determine the rural wage index of the State. Using such MSA-based designations there would be rural wage indices for both Massachusetts and Puerto Rico. We believe this is the most reasonable approach, as we would be using the same hospital wage data used to calculate the CBSA-based wage indices.

         In the event this occurs in urban areas where IRFs are located, we are proposing to use the average of the urban hospital wage data throughout the State as a reasonable proxy for the urban areas without hospital wage data. Therefore, urban IRFs located in geographic areas without any hospital wage data would receive a wage index based on the average wage index for all urban areas within the State. This does not presently affect any urban IRFs for FY 2006 because there are no IRFs located in urban areas without hospital wage data. However, the policy would apply to future years when there may be urban IRFs located in geographic areas with no corresponding hospital wage data.

         We believe this policy is reasonable because it maintains a CBSA- based wage index system, while creating an urban proxy for IRFs located in urban areas without corresponding hospital wage data. We note that we could not apply a similar averaging in rural areas, because in the rural areas there is no State rural hospital wage data available for averaging on a State-wide basis. For example, in Massachusetts and Puerto Rico, using a CBSA-based designation system, there are simply no rural hospitals in the State upon which we could base an average.

         In addition, we note that the Secretary has broad authority under 1886(j)(6) to update the wage index on the basis of information available to the Secretary (and updated as appropriate) of the wages and wage-related costs incurred in furnishing rehabilitation services. Therefore, for FY 2006 we propose to use FY 2001 MSA-based hospital wage data for rural Massachusetts and rural Puerto Rico in the event there are rural IRFs in such States. In addition, for FY 2006 and thereafter, we propose to calculate a statewide urban average in the event that there exist urban IRFs in geographic areas with no corresponding hospital wage data. We solicit comments on these approaches to calculate the wage index values for areas without hospital wage data for this and subsequent fiscal years. We note that for fiscal years 2007 and thereafter, we likely will not calculate the MSA-based rural area indices, as the acute care hospital IPPS will no longer publish MSA-based wage tables. Thus, we specifically request comments on the approach to be used for IRFs in rural areas without corresponding hospital wage data for fiscal years 2007 and thereafter.

         For the reasons discussed above, we are proposing to continue the use of the acute care hospital inpatient wage index data generated from cost reporting periods beginning during FY 2001 without taking into account geographic reclassification as specified under sections 1886(d)(8) and (d)(10) of the Act and without applying the ``rural floor'' under section 4410 of Pub. L. 105-33 (BBA) (as discussed in section III.B.2.a of this proposed rule). We believe that cost reporting period FY 2001 would be used to determine the applicable wage index values under the IRF PPS because these are the best available data. These data are the same FY 2001 acute care hospital inpatient wage data that were used to compute the FY 2005 wage indices. The proposed full wage index values that would be applicable for IRF PPS discharges occurring on or after October 1, 2005 are shown in Addendum 1, Tables 2a (for urban areas) and 2b (for rural areas) in the Addendum of this proposed rule.

         In addition, any proposed adjustment or update to the IRF wage index made as specified under section 1886(j)(6) of the Act would be made in a budget neutral manner that assures that the estimated aggregated payments under this subsection in the FY year are not greater or less than those that would have been made in the year without such adjustment. Therefore, we are proposing to calculate a budget-neutral wage adjustment factor as established in the July 30, 2004 notice and as specified in Sec. 412.624(e)(1). We will continue to use the following steps to ensure that the proposed FY 2006 IRF standard payment conversion factor reflects the update to the proposed CBSA wage indices and to the proposed labor-related share in a budget neutral manner:

         Step 1: Determine the total amount of the estimated FY 2005 IRF PPS rates using the FY 2005 standard payment conversion factor and the labor-related share and the wage indices from FY 2005 (as published in the July 30, 2004 final notice).

         Step 2: Calculate the total amount of estimated IRF PPS payments using the FY 2005 standard payment conversion factor and the proposed updated CBSA-based FY 2006 labor-related share and wage indices described above.

         Step 3: Divide the amount calculated in step 1 by the amount calculated in step 2, which equals the proposed FY 2006 budget-neutral wage adjustment factor of 0.9996.

         Step 4: Apply the proposed FY 2006 budget-neutral wage adjustment factor from step 3 to the FY 2005 IRF PPS standard payment conversion factor after the application of the market basket update, described above, to determine the proposed FY 2006 standard payment conversion factor. 3. Proposed Teaching Status Adjustment

         Section 1886(j)(3)(A)(v) of the Act requires the Secretary to adjust the prospective payment rates for the IRF PPS by such factors as the Secretary determines are necessary to properly reflect variations in necessary costs of treatment among rehabilitation facilities. Under this authority, in the August 7, 2001 final rule (66 FR 41316, 41359), we considered implementing an adjustment for IRFs that are, or are part of, teaching institutions. However, because the results of our regression analysis, using FY 1999 data, showed that the indirect teaching cost variable was not significant, we did not implement a payment adjustment for indirect teaching costs in that final rule. The regression analysis conducted by RAND for this proposed rule, using FY 2003 data, shows that the indirect teaching cost variable is significant in explaining the higher costs of IRFs that have teaching programs. Therefore, we are proposing to establish a facility level adjustment to the Federal per discharge base rate for IRFs that are, or are part of,

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         teaching institutions for the reasons discussed below (the ``teaching status adjustment''). However, as discussed below, we have some concerns about proposing a teaching status adjustment. The policy implications of implementing a teaching status adjustment on the basis of the results of RAND's recent analysis oblige us to seek assurance that these results do not reflect an aberration based on only a single year's data and that the teaching status adjustment can be implemented in such a way that it would be equitable to all IRFs. Analysis of future data (FY 2004 or later) would give us such assurance because it would allow the effects of the other proposed changes outlined in this proposed rule to be realized and allow us to determine whether the significant coefficient on the teaching variable continues to be present in the future data.

         The purpose of the proposed teaching status adjustment would be to account for the higher indirect operating costs experienced by facilities that participate in graduate medical education programs.

         We are proposing to implement the proposed teaching status adjustment in a budget neutral manner (that is, keeping aggregate payments for FY 2006 with the proposed teaching adjustment the same as aggregate payments for FY 2006 without the proposed teaching adjustment) for the reasons discussed below. (As a conforming change, we are proposing to revise Sec. 412.624 to add a new section (e)(4) as the teaching status adjustment. Specifically, Sec. 412.624(e)(4) would be for discharges on or after October 1, 2005. We propose to adjust the Federal prospective payment on a facility basis by a factor as specified by CMS for facilities that are teaching institutions or units of teaching institutions. This adjustment would be made on a claim basis as an interim payment and the final payment in full for the claim would be made during the final settlement of the cost report. Thus, we would redesignate the current (e)(4) and (e)(5) as (e)(5) and (e)(6)).

         Medicare makes direct graduate medical education (GME) payments (for direct costs such as resident and teaching physician salaries, and other direct teaching costs) to all teaching hospitals including those paid under the IPPS, and those that were once paid under the TEFRA rate of increase limits but are now paid under other PPSs. These direct GME payments are made separately from payments for hospital operating costs and are not part of the PPSs. However, the direct GME payments may not address the higher indirect operating costs which may often be experienced by teaching hospitals. For teaching hospitals paid under the TEFRA rate-of-increase limits, Medicare did not make separate medical education payments because payments to these hospitals were based on the hospitals' reasonable costs. Because payments under TEFRA were based on hospitals' reasonable costs, the higher indirect costs that might be associated with teaching programs would automatically have been factored into the TEFRA payments.

         When the IRF PPS was implemented, we did not adjust payments to IRFs for indirect medical education costs because we did not find that adjustments for such costs were supported by the regression analyses or by the impact analyses. As discussed in the August 7, 2001 final rule (69 FR 41316, 41359), the indirect teaching variable was not significant for either the fully specified regression or the payment regression in RAND's analysis. Furthermore, the impacts among the various classes of facilities reflecting the fully phased-in IRF PPS illustrated that IRFs with the highest measure of indirect teaching would lose approximately 2 percent of estimated payments under the IRF PPS when compared with payments under TEFRA rate-of-increase limits. These impacts did not account for changes in behavior that facilities were likely to adopt in response to the inherent incentives of the IRF PPS, and we believed that IRFs could change their behavior to mitigate any potential reduction in payments.

         The earlier research conducted by RAND was based on 1999 data and on a sample of IRFs. RAND recently conducted research to support us in developing potential refinements to the IRF classification system and the PPS. The regression analysis conducted by RAND for this proposed rule, using FY 2003 data, showed that the indirect teaching cost variable is significant in explaining the higher costs of IRFs that have teaching programs.

         In conducting the analysis on the FY 2003 data, RAND used the resident counts that were reported on the hospital cost reports (worksheet S-3, line 25, column 9 for freestanding IRF hospitals and worksheet S-3, Part 1, line 14 (or line 14.01 for subprovider 2), column 9 for rehabilitation units of acute care hospitals). That is, for the freestanding rehabilitation hospitals, RAND used the number of residents and interns reported for the entire hospital. For the rehabilitation units of acute care hospitals, RAND used the number of residents and interns reported for the rehabilitation unit (reported separately on the cost report from the number reported for the rest of the hospital). RAND did not distinguish between different types of resident specialties, nor did they distinguish among the different types of services residents provide, because this information is not reported on the cost reports.

         RAND used regression analysis (with the logarithm of costs as the dependent variable) to re-examine the effect of IRFs' teaching status on the costs of care. With FY 2003 data that include all Medicare- covered IRF discharges, RAND found a statistically significant difference in costs between IRFs with teaching programs and those without teaching programs in the regression analysis. The different results obtained using the FY 2003 data (compared with the 1999 data) may be due to improvements in IRF coding after implementation of the IRF PPS. More accurately coded data may have allowed RAND to determine better the differences in case mix among hospitals with and without teaching programs, which would then have allowed the effect of whether or not an IRF has a teaching program to become significant in the regression analysis. There are two main reasons that indirect operating costs may be higher in teaching hospitals: (1) Because the teaching activities themselves result in inefficiencies that increase costs, and (2) because patients needing more costly services tend to be treated more often in teaching hospitals than in non-teaching hospitals, that is, the case mix that is drawn to teaching hospitals. Quantifying more precisely the amount of cost increase that is due to teaching hospitals' case mix allows RAND to more precisely quantify the amount of increase due to the inefficiencies associated with a teaching program.

         We would propose to treat the teaching status adjustment as an additional payment to the Federal prospective payment rate, similar to the IME payments made under the IPPS (see Sec. 412.105). Any such teaching status adjustments for the IRF PPS facilities would be made on a claim basis as interim payments, but the final payment in full for the cost reporting period would be made through the cost report. The difference between those interim payments and the actual teaching status adjustment amount computed in the cost report would be adjusted through lump sum payments/recoupments when the cost report is filed and later settled.

         As in the IPF PPS, we would propose to calculate a teaching adjustment based on the IRF's ``teaching variable,'' which would be one plus the ratio of the number of FTE residents training in the IRF (subject to limitations described

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         further below) to the IRF's average daily census (ADC). In RAND's most recent cost regressions using data from FY 2003, the logarithm of the teaching variable has a coefficient value of 1.083. We would propose to convert this cost effect to a teaching status payment adjustment by treating the regression coefficient as an exponent and raising the teaching variable to a power equal to the coefficient value--currently 1.083 (that is, the teaching status adjustment would be calculated by raising the teaching variable (1 + FTE residents/ADC) to the 1.083 power). For a facility with a teaching variable of 0.10, and using a coefficient based upon the coefficient value (1.083) from the FY 2003 data, this method would yield a 10.9 percent increase in the per discharge payment; for a facility with a teaching variable of 0.05, the payment would increase by 5.4 percent. We note that the coefficient value of 1.083 is based on regression analysis holding all other components of the payment system constant. Because we are proposing a number of other revisions to the payment system in this proposed rule, the coefficient value is subject to change for the final rule depending on the other revisions included in the final rule. Moreover, we are concerned that IRFs' responses to other proposed changes described in this proposed rule will influence the effects of a teaching variable on IRFs' costs.

         In addition, the teaching adjustment we would propose would limit the incentives for IRFs to add FTE residents for the purpose of increasing their teaching adjustment, as has been done in the payment systems for psychiatric facilities and acute inpatient hospitals. Thus, we would propose to impose a cap on the number of FTE residents that may be counted for purposes of calculating the teaching adjustment, similar to that established by sections 4621 (IME FTE cap for IPPS hospitals) and 4623 (direct GME FTE cap for all hospitals) of the BBA. We note that the FTE resident cap already applies to teaching hospitals, including IRFs, for purposes of direct GME payments as specified in Sec. 413.75 through Sec. 413.83. The proposed cap would limit the number of residents that teaching hospitals may count for the purposes of calculating the IRF PPS teaching status adjustment, not the number of residents teaching institutions can hire or train.

         The proposed FTE resident cap would be identical in freestanding teaching rehabilitation hospitals and in distinct part rehabilitation units with GME programs. Similar to the regulations for counting FTE residents under the IPPS as described in Sec. 412.105(f), we are proposing to calculate a number of FTE residents that trained in the IRF during a ``base year'' and use that FTE resident number as the cap. An IRF's FTE resident cap would ultimately be determined based on the final settlement of the IRF's most recent cost reporting period ending on or before November 15, 2003. We would also propose that, similar to new IPPS teaching hospitals, IRFs that first begin training residents after November 15, 2003 would initially receive an FTE cap of ``0''. The FTE caps for new IRFs (as well as existing IRFs) that start training residents in a new GME program (as defined in Sec. 413.79(l)) may be subsequently adjusted in accordance with the policies that are being applied in the IPF PPS (as described in Sec. 412.424(d)(1)(iii)(B)(2)), which in turn are made in accordance with the policies described in 42 CFR 413.79(e) for IPPS hospitals. However, contrary to the policy for IME FTE resident caps under the IPPS, we would not allow IRFs to aggregate the FTE resident caps used to compute the IRF PPS teaching status adjustment through affiliation agreements. We are proposing these policies because we believe it is important to limit the total pool of resident FTE cap positions within the IRF community and avoid incentives for IRFs to add FTE residents in order to increase their payments. We also want to avoid the possibility of hospitals transferring residents between IPPS and IRF training settings in order to increase Medicare payments. We recognize that under the regulations applicable to the IPPS IME adjustment, a new teaching hospital that trains residents from an existing program (not a new program as defined in 42 CFR 413.79(l)) can receive an adjustment to its IME FTE cap by entering into a Medicare GME affiliation agreement (see Sec. 412.105(f)(1)(vi), Sec. 413.75(b), and Sec. 413.79(f)) with other hospitals. However, this option would not be available to new teaching IRFs because, as noted above, we would propose not to allow IRFs to aggregate the FTE resident caps used to compute the IRF PPS teaching adjustment through affiliation agreements.

         We would propose that residents with less than full-time status and residents rotating through the rehabilitation hospital or unit for less than a full year be counted in proportion to the time they spend in their assignment with the IRF (for example, a resident on a full-time, 3-month rotation to the IRF would be counted as 0.25 FTEs for purposes of counting residents to calculate the ratio). No FTE resident time counted for purposes of the IPPS IME adjustment would be allowed to be counted for purposes of the teaching status adjustment for the IRF PPS.

         The denominator that we would propose to use to calculate the teaching status adjustment under the IPF PPS would be the IRF's average daily census (ADC) from the current cost reporting period because it is closely related to the IRF's patient load, which determines the number of interns and residents the IRF can train. We also believe the ADC is a measure that can be defined precisely and is difficult to manipulate. Although the IPPS IME adjustment uses the hospital's number of beds as the denominator, the capital PPS (as specified at Sec. 412.322) and the IPF PPS (as specified at Sec. 412.424) both use the ADC as the denominator for the indirect graduate medical education adjustments.

         If a rehabilitation hospital or unit has more FTE residents in a given year than in the base year (the base year being used to establish the cap), we would base payments in that year on the lower number (the cap amount). This approach would be consistent with the IME adjustment under the IPPS and the IPF PPS. The IRF would be free to add FTE residents above the cap amount, but it would not be allowed to count the number of FTE residents above the cap for purposes of calculating the teaching adjustment. This means that the cap would be an upper limit on the number of FTE residents that may be counted for purposes of calculating the teaching status adjustment. IRFs could adjust their number of FTE residents counted for purposes of calculating the teaching adjustment as long as they remained under the cap.

         On the other hand, if a rehabilitation hospital or unit were to have fewer FTE residents in a given year than in the base year (that is, fewer residents than its FTE resident cap), an adjustment in payments in that year would be based on the lower number (the actual number of FTE residents the facility hires and trains).

         We would propose to implement a teaching status adjustment in such a way that total estimated aggregate payments to IRFs for FY 2006 would be the same with and without the proposed adjustment (that is, in a budget neutral manner). This is because we believe that the results of RAND's analysis of 2002 and 2003 IRF cost data suggest that additional money does not need to be added to the IRF PPS. RAND's analysis found, for example, that if all IRFs had been paid based on 100 percent of the IRF PPS payment rates throughout all of 2002 (some IRFs were still transitioning to PPS payments during 2002), PPS

         [[Page 30244]]

         payments during 2002 would have been 17 percent higher than IRFs' costs. We are open to examining other evidence regarding the amount of aggregate payments in the system.

         Consideration of an adjustment to payments based on an IRF's teaching status is consistent with section 1886 (j)(3)(A)(v) of the Act, which confers broad statutory authority upon the Secretary to adjust the per payment unit payment rate by such factors as the Secretary determines are necessary to properly reflect variations in necessary costs of treatment among rehabilitation facilities.

         As mentioned above and discussed below, we have some concerns with implementing a teaching status adjustment for IRFs at this time. We are concerned about volatility in the data given the many changes to the IRF PPS that have been made in recent years and may be adopted in this rulemaking process. Other proposed payment policy changes have the potential to change the magnitude or even the effect of a teaching variable on costs once IRFs have fully responded to the other proposed policy changes in this proposed rule. We also believe it is important to ensure that the data accurately counts residents who provide services to IRF patients.

         We note that the significant coefficient we found in the analysis of the FY 2003 data contrasts with the statistically insignificant coefficient we found in the analysis of the 1999 data used to construct the initial IRF PPS. Although we currently believe it may be appropriate to propose a teaching status adjustment for IRFs based on analysis of the FY 2003 data, we recognize that we may need to examine new data (that is, FY 2004 or later) to help us to reconcile these contradictory findings. We also believe the analysis of this new data could potentially lead us to conclude that a teaching status adjustment is not needed.

         The results of RAND's analysis using FY 2003 data also show that certain refinements to the IRF case mix system (as discussed in section II of this proposed rule) would improve the system by more appropriately accounting for the variation in costs among different types of IRF patients. In this proposed rule, we propose numerous changes to the CMGs and tiers, and to the threshold amount used to determine whether cases qualify for outlier payments, in order to better align IRF payments with the costs of providing care to Medicare beneficiaries in IRFs. In addition, this proposed rule proposes substantial changes to the wage index (the adoption of CBSA market area definitions) and to the rural and the LIP adjustments. We believe that these proposed changes may have an impact on cost differences between teaching and non-teaching IRFs, and that we will be able to assess their impact on teaching and non-teaching IRFs only after the proposed changes have been implemented.

         Furthermore, we believe it is important to ensure that the data accurately count residents who participate in managing the rehabilitation of IRF patients. We are particularly interested in ensuring that the FTE resident counts used for the proposed IRF teaching status adjustment do not duplicate resident counts used for purposes of the IPPS IME adjustment, and that hospitals do not have incentives to shift residents from the acute care hospital to the hospital's rehabilitation unit for purposes of computing the proposed IRF teaching adjustment. We are soliciting comments on the most valid and reliable method of counting residents for purposes of a proposed teaching status adjustment. We note that any changes we may make, based on our further investigation of this issue or on comments we receive on this proposed rule, to the methodology for counting residents could affect the magnitude of the proposed teaching adjustment or even whether the data continue to indicate that the proposed teaching status adjustment is appropriate.

         In addition, we recognize that the proposed new teaching status adjustment, especially if implemented in a budget-neutral manner, is an important issue for all providers because it involves a redistribution of resources among facilities. That is, under the proposal, IRFs with teaching programs would receive additional payments, while IRFs without teaching programs would have their payments lowered to maintain total estimated payments for FY 2006 at the same level as without the proposed adjustment. For this reason, we believe caution is warranted in this case.

         We are specifically soliciting comments on our consideration of the IRF teaching status adjustment. 4. Proposed Adjustment for Rural Location

         Consistent with the broad statutory authority conferred upon the Secretary in section 1886(j)(3)(A)(v) of the Act, we adjust the Federal prospective payment amount associated with a CMG to account for an IRF's geographic wage variation, low-income patients and, if applicable, location in a rural area, as described in Sec. 412.624(e).

         Under the broad statutory authority conferred upon the Secretary in section 1886(j)(3)(A)(v) of the Act, we are proposing to increase the adjustment to the Federal prospective payment amount for IRFs located in rural areas from 19.14 percent to 24.1 percent. We are proposing this change because RAND's regression analysis, using the best available data we have (FY 2003), indicates that rural facilities now have 24.1 percent higher costs of caring for Medicare patients than urban facilities. We note that we propose to use the same statistical approach, as described in the November 3, 2000 proposed rule (65 FR 66304, 66356 through 66357) and adopted in the August 7, 2001 final rule (66 FR at 41359) to estimate the proposed update to the rural adjustment. The statistical approach RAND used both when the PPS was first implemented and for the proposed update described in this proposed rule relies on the coefficient determined from the regression analysis. The 19.14 percent rural adjustment has been applied to payments for IRFs located in rural areas since the implementation of the IRF PPS. We note that the FY 2003 data are the best available data we have, just as the 1998 and 1999 data used in the initial development of the IRF PPS were the best available data at that time.

         We are proposing to implement the proposed update to the rural adjustment so that total estimated aggregate payments for FY 2006 are the same with the proposed update to the adjustment as they would have been without the proposed update to the adjustment (that is, in a budget neutral manner). We are proposing to make this proposed update to the rural adjustment in a budget neutral manner because we believe that the results of RAND's analysis of 2002 and 2003 IRF cost data (as discussed previously in this proposed rule) suggest that additional money does not need to be added to the IRF PPS. RAND's analysis found, for example, that if all IRFs had been paid based on 100 percent of the IRF PPS payment rates throughout all of 2002 (some IRFs were still transitioning to PPS payments during 2002), PPS payments during 2002 would have been 17 percent higher than IRFs' costs. We are open to examining other evidence regarding the amount of estimated aggregate payments in the system.

         This is consistent with section 1886(j)(3)(A)(v) of the Act which confers broad statutory authority upon the Secretary to adjust the per payment unit payment rate by such factors as the Secretary determines are necessary to properly reflect variations in necessary costs of treatment among rehabilitation

         [[Page 30245]]

         facilities. To ensure that total estimated aggregate payments to IRFs do not change, we propose to apply a factor to the standard payment conversion factor to assure that the estimated aggregate payments under this subsection in the FY are not greater or less than those that would have been made in the year without the proposed update to the adjustment. In sections III.B.7 and III.B.8 of this proposed rule, we discuss the methodology and factor we are proposing to apply to the standard payment amount. 5. Proposed Adjustment for Disproportionate Share of Low-Income Patients

         Consistent with the broad statutory authority conferred upon the Secretary in section 1886(j)(3)(A)(v) of the Act, we adjust the Federal prospective payment amount associated with a CMG to account for an IRF's geographic wage variation, low-income patients and, if applicable, location in a rural area, as described in Sec. 412.624(e).

         Under the broad statutory authority conferred upon the Secretary in section 1886(j)(3)(A)(v) of the Act, we are proposing to update the low-income patient (LIP) adjustment to the Federal prospective payment rate to account for differences in costs among IRFs associated with differences in the proportion of low-income patients they treat. RAND's regression analysis of 2003 data indicates that the LIP formula could be updated to better distribute current payments among facilities according to the proportion of low-income patients they treat. Although the current formula appropriately distributed LIP-adjusted payments among facilities when the IRF PPS was first implemented, we believe the formula should be updated from time to time to reflect changes in the costs of caring for low-income patients.

         The proposed LIP adjustment is based on the formula used to account for the costs of furnishing care to low-income patients as discussed in the August 7, 2001 final rule (67 FR at 41360). We propose to update the LIP adjustment from the power of 0.4838 to the power of 0.636. Therefore, the proposed formula to calculate the LIP adjustment would be as follows: (1 + DSH patient percentage) raised to the power of (.636) Where DSH patient percentage =

         [GRAPHIC] [TIFF OMITTED] TP25MY05.023

         We note that we propose to use the same statistical approach, as described in the August 7, 2001 final rule (66 FR at 41359 through 41360), that was used to develop the original LIP adjustment. We note that the FY 2003 data we propose to use in calculating this adjustment are the best available data, just as the 1998 and 1999 data used in the initial development of the IRF PPS were the best available data at that time.

         We are proposing to implement the proposed update to the LIP adjustment so that total estimated aggregate payments for FY 2006 are the same with the proposed update to the adjustment as they would have been without the proposed update to the adjustment (that is, in a budget neutral manner). We are proposing to make this proposed update to the LIP adjustment in a budget neutral manner because we believe that the results of RAND's analysis of 2002 and 2003 IRF cost data (as discussed previously in this proposed rule) suggest that additional money does not need to be added to the IRF PPS. RAND's analysis found, for example, that if all IRFs had been paid based on 100 percent of the IRF PPS payment rates throughout all of 2002 (some IRFs were still transitioning to PPS payments during 2002), PPS payments during 2002 would have been 17 percent higher than IRFs' costs. We are open to examining other evidence regarding the amount of estimated aggregate payments in the system.

         This is consistent with section 1886 (j)(3)(A)(v) of the Act which confers broad statutory authority upon the Secretary to adjust the per payment unit payment rate by such factors as the Secretary determines are necessary to properly reflect variations in necessary costs of treatment among rehabilitation facilities. To ensure that total estimated aggregate payments to IRFs do not change, we propose to apply a factor to the standard payment conversion factor to assure that the estimated aggregate payments under this subsection in the FY are not greater or less than those that would have been made in the year without the proposed update to the adjustment. In sections III.B.7 and III.B.8 of this proposed rule, we discuss the methodology and factor we are proposing to apply to the standard payment amount. 6. Proposed Update to the Outlier Threshold Amount

         Consistent with the broad statutory authority conferred upon the Secretary in sections 1886(j)(4)(A)(i) and 1886(j)(4)(A)(ii) of the Act, we are proposing to update the outlier threshold amount from the $11,211 threshold amount for FY 2005 to $4,911 in FY 2006 to maintain total estimated outlier payments at 3 percent of total estimated payments. In the August 7, 2001 final rule, we discuss our rationale for setting estimated outlier payments at 3 percent of total estimated payments (66 FR at 41362). We continue to propose to use 3 percent for the same reasons outlined in the August 7, 2001 final rule. We believe it is necessary to update the outlier threshold amount because RAND's analysis of the calendar year 2002 and FY 2003 data indicates that total estimated outlier payments will not equal 3 percent of total estimated payments unless we update the outlier loss threshold. We will continue to analyze the estimated outlier payments for subsequent years and adjust as appropriate in order to maintain estimated outlier payments at 3 percent of total estimated payments. The reasons for estimated outlier payments not equaling 3 percent of total estimated payments are discussed in more detail below.

         Section 1886(j)(4) of the Act provides the Secretary with the authority to make payments in addition to the basic IRF prospective payments for cases incurring extraordinarily high costs. In the August 7, 2001 final rule, we codified at Sec. 412.624(e)(4) of the regulations (which would be redesignated as Sec. 412.624(e)(5)) the provision to make an adjustment for additional payments for outlier cases that have extraordinarily high costs relative to the costs of most discharges. Providing additional payments for outliers strongly improves the accuracy of the IRF PPS in determining resource costs at the patient and facility level because facilities receive additional compensation over and above the adjusted Federal prospective payment amount for uniquely high-cost cases. These additional payments reduce the financial losses that would otherwise be caused by treating patients who require more costly care and, therefore, reduce the incentives to underserve these patients.

         [[Page 30246]]

         Under Sec. 412.624(e)(4) (which would be redesignated as Sec. 412.624(e)(5)), we make outlier payments for any discharges if the estimated cost of a case exceeds the adjusted IRF PPS payment for the CMG plus the adjusted threshold amount (we are proposing to make this $4,911, which is then adjusted for each IRF by the facility's wage adjustment, its LIP adjustment, its rural adjustment, and its teaching status adjustment, if applicable). We calculate the estimated cost of a case by multiplying the IRF's overall cost-to-charge ratio by the Medicare allowable covered charge. In accordance with Sec. 412.624(e)(4), we pay outlier cases 80 percent of the difference between the estimated cost of the case and the outlier threshold (the sum of the adjusted IRF PPS payment for the CMG and the adjusted fixed threshold dollar amount).

         Consistent with the broad statutory authority conferred upon the Secretary in sections 1886(j)(4)(A)(i) and 1886(j)(4)(A)(ii) of the Act, and in accordance with the methodology stated in the August 1, 2003 final rule (68 FR at 45692 through 45693), we propose to continue to apply a ceiling to an IRF's cost-to-charge ratios (CCR). Also, in the August 1, 2003 final rule (68 FR at 45693 through 45694), we stated the methodology we use to adjust IRF outlier payments and the methodology we use to make these adjustments. We indicated that the methodology is codified in Sec. 412.624(e)(4) (which would be redesignated as Sec. 412.624(e)(5)) and Sec. 412.84(i)(3).

         On February 6, 2004, we issued manual instructions in Change Request 2998 stating that we would set forth the upper threshold (ceiling) and the national CCRs applicable to IRFs in each year's annual notice of prospective payment rates published in the Federal Register. The upper threshold CCR for IRFs that we are proposing for FY 2006 would be 1.52 based on CBSA-based geographic designations. We are proposing to base this upper threshold CCR on the CBSA-based geographic designations because the CBSAs are the geographic designations we are proposing to adopt for purposes of computing the proposed wage index adjustment to IRF payments for FY 2006. If, instead, we were to use the MSA geographic designations, the upper threshold CCR amount would likely be different than the 1.52 we are proposing above. In addition, this is an estimated threshold and is subject to change in the final rule based on more recent data.

         In addition, we are proposing to update the national urban and rural CCRs for IRFs. Under Sec. 412.624(e)(4) (which would be redesignated as Sec. 412.624(e)(5)) and Sec. 412.84(i)(3), we are proposing to apply the national CCRs to the following situations:

         New IRFs that have not yet submitted their first Medicare cost report.

         IRFs whose operating or capital CCR is in excess of 3 standard deviations above the corresponding national geometric mean.

         Other IRFs for whom the fiscal intermediary obtains accurate data with which to calculate either an operating or capital CCR (or both) are not available.

         The national CCR based on the facility location of either urban or rural would be used in each of the three situations cited above. Specifically, for FY 2006, we have estimated a proposed national CCR of 0.631 for rural IRFs and 0.518 for urban IRFs. For new facilities, we are proposing to use these national ratios until the facility's actual CCR can be computed using the first tentative settled or final settled cost report data, which will then be used for the subsequent cost report period.

         In the August 7, 2001 final rule (66 FR at 41362 through 41363), we describe the process by which we calculate the outlier threshold. We continue to use this process for this proposed rule. We begin by simulating aggregate payments with and without an outlier policy, and applying an iterative process to determine a threshold that would result in outlier payments being equal to 3 percent of total simulated payments under the simulation. We note that the simulation analysis used to calculate the proposed $4,911 outlier threshold includes all of the proposed changes to the PPS discussed in this proposed rule, and is therefore subject to change in the final rule depending on the policies contained in the final rule. In addition, we will continue to analyze the estimated outlier payments for subsequent years and adjust as appropriate in order to maintain estimated outlier payments at 3 percent of total estimated payments.

         In this proposed rule, we are proposing to update the threshold amount to $4,911 so that outlier payments will continue to equal 3 percent of total estimated payments under the IRF PPS. RAND found that 2002 outlier payments were equal to 3.1 percent of total payments in 2002. Nevertheless, the outlier loss threshold is affected by cost-to- charge ratios because the cost-to-charge ratios are used to compute the estimated cost of a case, which in turn is used to determine if a particular case qualifies for an outlier payment or not. For example, if the cost-to-charge ratio decreases, then the estimated costs of a case with the same reported charges would decrease. Thus, the chances that the case would exceed the outlier loss threshold and qualify for an outlier payment would decrease, decreasing the likelihood that the case would qualify for an outlier payment. If fewer cases were to qualify for outlier payments, then total estimated outlier payments could fall below 3 percent of total estimated payments.

         Our analyses of cost report data from FY 1999 through FY 2002 (and projections for FY 2004 though FY 2006) indicate that the overall cost- to-charge ratios in IRFs have been falling since the IRF PPS was implemented. We are still analyzing possible reasons for this finding. However, because cost-to-charge ratios are used to determine whether a particular case qualifies for an outlier payment, this drop in the cost-to-charge ratios is likely responsible for much of the drop in total estimated outlier payments below 3 percent of total estimated payments. Thus, the outlier threshold would need to be lowered from $11,211 to $4,911 for FY 2006 in order that total estimated outlier payments would equal 3 percent of total estimated payments.

         In addition, we are proposing to adjust the outlier threshold for FY 2006 because RAND's analysis of calendar year 2002 and FY 2003 data indicates that many of the other proposed changes discussed in this proposed rule would affect what the outlier threshold would need to be in order for total estimated outlier payments to equal 3 percent of total estimated payments. The outlier loss threshold is affected by the definitions of all other elements of the IRF PPS, including the structure of the CMGs and the tiers, the relative weights, the policies for very short-stay cases and for cases in which the patient expires in the facility (that is, cases that qualify for the special CMG assignments), and the facility-level adjustments (such as the rural adjustment, the LIP adjustment, and the proposed teaching status adjustment). In this proposed rule, we are proposing to change many of these components of the IRF PPS. For the reasons discussed above, then, we believe it is appropriate to update the outlier loss threshold for FY 2006. We expect to continue to adjust the outlier threshold in the future when the data indicate that total estimated outlier payments would deviate from equaling 3 percent of total estimated payments. 7. Proposed Budget Neutrality Factor Methodology for Fiscal Year 2006

         We are proposing to make a one-time revision (for FY 2006) to the methodology found in Sec. 412.624(d) in

         [[Page 30247]]

         order to make the proposed changes to the tiers and CMGs, the rural adjustment, the LIP adjustment, and the proposed teaching status adjustment in a budget neutral manner. Accordingly, we are proposing to revise Sec. 412.624(d) by adding a section Sec. 412.624(d)(4) for fiscal year 2006. Specifically, we are proposing to revise the methodology found in Sec. 412.624(d) by adding a new paragraph (d)(4). The addition of this paragraph would provide for the application of a factor, as specified by the Secretary, which would be applied to the standard payment amount in order to make the proposed changes described in this preamble in a budget neutral manner for FY 2006. In addition, this paragraph would be used in future years if we propose refinements to the above-cited adjustments. According to the revised methodology, we propose to apply the market basket increase factor (3.1 percent) to the standard payment conversion factor for FY 2005 ($12,958), which equals $13,360. Then, we propose a one-time reduction to the standard payment amount of 1.9 percent to adjust for coding changes that increased payment to IRFs (as discussed in section III.A of this proposed rule), which equals $13,106. We then propose to apply the budget neutral wage adjustment (as discussed in section III.B.2.f of this proposed rule) of 0.9996 to $13,106, which would result in a standard payment amount of $13,101. For FY 2006 only, we propose to change the methodology for computing the standard payment conversion factor by applying budget neutrality factors for the proposed changes to the tiers and CMGs, the rural adjustment, the LIP adjustment, and the proposed teaching status adjustment. The next section contains a detailed explanation of these proposed budget neutrality factors, including the steps for computing these factors and how they affect total estimated aggregate payments and payments to individual IRF providers. The factors we are proposing to apply (as discussed in the next section) are 0.9994 for the proposed tier and CMG changes, 0.9865 for the proposed teaching status adjustment, 0.9963 for the proposed change to the rural adjustment, and 0.9836 for the proposed change to the LIP adjustment. These factors are subject to change as we analyze more current data. We have combined these factors, by multiplying the four factors together, into one budget neutrality factor for all four of these proposed changes (0.9994 * 0.9865 * 0.9963 * 0.9836 = 0.9662). We apply this overall budget neutrality factor to $13,101, resulting in a standard payment conversion factor for FY 2006 of $12,658. Note that the FY 2006 standard payment conversion factor is lower than it was in FY 2005 because it needed to be reduced to ensure that estimated aggregate payments for FY 2006 would remain the same as they otherwise would have been without the proposed changes. If we did not proposed to decrease the standard payment conversion factor, each of the proposed changes would increase total estimated aggregate payments by increasing payments to rural and teaching facilities, and to facilities with a higher average case mix of patients and facilities that treat a higher proportion of low-income patients. To assess how overall payments to a particular type of IRF would likely be affected by the proposed budget- neutral changes, please see Table 13 of this proposed rule.

         The FY 2006 standard payment conversion factor would be applied to each CMG relative weight shown in Table 6, Proposed Relative Weights for Case-Mix Groups, to compute the proposed unadjusted IRF prospective payment rates for FY 2006 shown in Table 12. To further clarify, the proposed one-time budget neutrality factors described above will only be applied for FY 2006. In addition, if no further refinements are proposed for subsequent fiscal years, we will use the methodology as described in Sec. 412.624(c)(3)(ii). 8. Description of the Methodology Used To Implement the Proposed Changes in a Budget Neutral Manner

         Section 1886(j)(2)(C)(i) of the Act confers broad statutory authority upon the Secretary to adjust the classification and weighting factors in order to account for relative resource use. In addition, section 1886(j)(2)(C)(ii) provides that insofar as the Secretary determines that such adjustments for a previous fiscal year (or estimates of such adjustments for a future fiscal year) did (or are likely to) result in a change in aggregated payments under the classification system during the fiscal year that are a result of changes in the coding or classification of patients that do not reflect real changes in case mix, the Secretary shall adjust the per payment unit payment rate for subsequent years to eliminate the effect of such coding or classification changes. Similarly, section 1886(j)(3)(A)(v) of the Act confers broad statutory authority upon the Secretary to adjust the per discharge payment rate by such factors as the Secretary determines are necessary to properly reflect variations in necessary costs of treatment among IRFs. Consistent with this broad statutory authority, we are proposing to better distribute aggregate payments among IRFs to more accurately reflect their case mix and the increased costs associated with IRFs that have teaching programs, are located in rural areas, or treat a high proportion of low-income patients.

         To ensure that total estimated aggregate payments to IRFs do not change with these proposed changes, we propose to apply a factor to the standard payment amount for each of the proposed changes to ensure that estimated aggregate payments in FY 2006 are not greater or less than those that would have been made in the year without the proposed changes. We propose to calculate these four factors using the following steps:

         Step 1: Determine the FY 2006 IRF PPS standard payment amount using the FY 2005 standard payment conversion factor increased by the estimated market basket of 3.1 percent and reduced by 1.9 percent to account for coding changes (as discussed in section III.A of this proposed rule).

         Step 2: Multiply the CBSA-based budget neutrality factor discussed in this preamble by the standard payment amount computed in step 1 to account for the wage index and labor-related share (0.9996), as discussed in section III.B.2.f of this proposed rule.

         Step 3: Calculate the estimated total amount of IRF PPS payments for FY 2006 (with no change to the tiers and CMGs, no teaching status adjustment, and no changes to the rural and LIP adjustments).

         Step 4: Apply the proposed new tier and CMG assignments (as discussed in section II) to calculate the estimated total amount of IRF PPS payments for FY 2006.

         Step 5: Divide the amount calculated in step 3 by the amount calculated in step 4 to determine the factor (currently estimated to be 0.9994) that maintains the same total estimated aggregate payments in FY 2006 with and without the proposed changes to the tier and CMG assignments.

         Step 6: Apply the factor computed in step 5 to the standard payment amount from step 2, and calculate estimated total IRF PPS payment for FY 2006.

         Step 7: Apply the proposed change to the rural adjustment (as discussed in section III.B.4 of this proposed rule) to calculate the estimated total amount of IRF PPS payments for FY 2006.

         Step 8: Divide the amount calculated in step 6 by the amount calculated in step 7 to determine the factor (currently estimated to be 0.9963) that keeps total estimated payments in FY 2006 the

         [[Page 30248]]

         same with and without the proposed change to the rural adjustment.

         Step 9: Apply the factor computed in step 8 to the standard payment amount from step 6, and calculate estimated total IRF PPS payment for FY 2006.

         Step 10: Apply the proposed change to the LIP adjustment (as discussed in section III.B.5 of this proposed rule) to calculate the estimated total amount of IRF PPS payments for FY 2006.

         Step 11: Divide the amount calculated in step 9 by the amount calculated in step 10 to determine the factor (currently estimated to be 0.9836) that maintains the same total estimated aggregate payments in FY 2006 with and without the proposed change to the LIP adjustment.

         Step 12: Apply the factor computed in step 11 to the standard payment amount from step 9, and calculate estimated total IRF PPS payment for FY 2006.

         Step 13: Apply the proposed teaching status adjustment (as discussed in section III.B.5 of this proposed rule) to calculate the estimated total amount of IRF PPS payments for FY 2006.

         Step 14: Divide the amount calculated in step 12 by the amount calculated in step 13 to determine the factor (currently estimated to be 0.9865) that maintains the same total estimated aggregate payments in FY 2006 with and without the proposed teaching status adjustment.

         As discussed in section III.B.9 of this proposed rule, the proposed FY 2006 IRF PPS standard payment conversion factor that accounts for the proposed new tier and CMG assignments, the proposed changes to the rural and the LIP adjustments, and the proposed teaching status adjustment applies the following factors: the market basket update, the reduction of 1.9 percent to account for coding changes, the budget- neutral CBSA-based wage index and labor-related share budget neutrality factor of 0.9996, the proposed tier and CMG changes budget neutrality factor of 0.9994, the proposed rural adjustment budget neutrality factor of 0.9963, the proposed LIP adjustment budget neutrality factor of 0.9836, and the proposed teaching status adjustment budget neutrality factor of 0.9865.

         Each of these proposed budget neutrality factors lowers the proposed standard payment amount. The budget neutrality factor for the proposed tier and CMG changes lowers the standard payment amount from $13,101 to $13,093. The budget neutrality factor for the proposed change to the rural adjustment lowers the standard payment amount from $13,093 to $13,045. The budget neutrality factor for the proposed change to the LIP adjustment lowers the standard payment amount from $13,045 to $12,831. Finally, the budget neutrality factor for the proposed teaching status adjustment lowers the standard payment amount from $12,831 to $12,658. As indicated previously, the standard payment conversion factor would need to be lowered in order to ensure that total estimated payments for FY 2006 with the proposed changes equal total estimated payments for FY 2006 without the proposed changes. This is because these four proposed changes would result in an increase, on average, to total estimated aggregate payments to IRFs, because IRFs with teaching programs, IRFs located in rural areas, IRFs with higher case mix, and IRFs with higher proportions of low-income patients would receive higher payments. To maintain the same total estimated aggregate payments to all IRFs, then, we are proposing to redistribute payments among IRFs. Thus, some redistribution of payments occurs among facilities, while total estimated aggregate payments do not change. To determine how these proposed changes are estimated to affect payments among different types of facilities, please see Table 13 in this proposed rule. 9. Description of the Proposed IRF Standard Payment Conversion Factor for Fiscal Year 2006

         In the August 7, 2001 final rule, we established a standard payment amount referred to as the budget neutral conversion factor under Sec. 412.624(c). In accordance with the methodology described in Sec. 412.624(c)(3)(i), the budget neutral conversion factor for FY 2002, as published in the August 7,2001 final rule, was $11,838.00. Under Sec. 412.624(c)(3)(i), this amount reflects, as appropriate, any adjustments for outlier payments, budget neutrality, and coding and classification changes as described in Sec. 412.624(d).

         The budget neutral conversion factor is a standardized payment amount and the amount reflects the budget neutrality adjustment for FY 2002. The statute required a budget neutrality adjustment only for FYs 2001 and 2002. Accordingly, we believed it was more consistent with the statute to refer to the standard payment as a standard payment conversion factor, rather than refer to it as a budget neutral conversion factor. Consequently, we changed all references to budget neutral conversion factor to ``standard payment conversion factor.''

         Under Sec. 412.624(c)(3)(i), the standard payment conversion factor for FY 2002 of $11,838.00 reflected the budget neutrality adjustment described in Sec. 412.624(d)(2). Under the then existing Sec. 412.624(c)(3)(ii), we updated the FY 2002 standard payment conversion factor ($11,838.00) to FY 2003 by applying an increase factor (the market basket) of 3.0 percent, as described in the update notice published in the August 1, 2002 Federal Register (67 FR at 49931). This yielded the FY 2003 standard payment conversion factor of $12,193.00 that was published in the August 1, 2002 update notice (67 FR at 49931). The FY 2003 standard payment conversion factor ($12,193) was used to update the FY 2004 standard payment conversion factor by applying an increase factor (the market basket) of 3.2 percent and budget neutrality factor of 0.9954, as described in the August 1, 2003 Federal Register (68 FR at 45689). This yielded the FY 2004 standard payment conversion factor of $12,525 that was published in the August 1, 2003 Federal Register (68 FR at 45689). The FY 2004 standard payment conversion factor ($12,525) was used to update the FY 2005 standard payment conversion factor by applying an increase factor (the market basket) of 3.1 percent and budget neutrality factor of 1.0035, as described in the July 30, 2004 Federal Register (69 FR at 45766). This yielded the FY 2005 standard payment conversion factor of $12,958 as published in the July 30, 2004 Federal Register (69 FR at 45766).

         We propose to use the revised methodology in accordance with Sec. 412.624(c)(3)(ii)and as described in section III.B.7 of this proposed rule. To calculate the standard payment conversion factor for FY 2006, we are proposing to apply the market basket increase factor (3.1 percent) to the standard payment conversion factor for FY 2005 ($12,958), which equals $13,360. Then, we propose a one-time reduction to the standard payment amount of 1.9 percent to adjust for coding changes that increased payment to IRFs, which equals $13,106. We then propose to apply the budget neutral wage adjustment of 0.9996 to $13,106, which would result in a standard payment amount of $13,101. Next, we propose to apply a one-time budget neutrality factor (for FY 2006 only) for the proposed budget neutral refinements to the tiers and CMGs, the teaching status adjustment, the rural adjustment, and the adjustment for the proportion of low-income patients (of 0.9662) to $13,101, which would result in a standard payment conversion factor for FY 2006 of $12,658. The FY 2006 standard payment conversion factor would be applied to each CMG weight

         [[Page 30249]]

         shown in Table 6, Proposed Relative Weights for Case-Mix Groups, to compute the unadjusted IRF prospective payment rates for FY 2006 shown in Table 12. 10. Example of the Proposed Methodology for Adjusting the Federal Prospective Payment Rates

         To illustrate the methodology that we propose to use to adjust the Federal prospective payments (as described in section III.B.7 and section III.B.8 of this proposed rule), we provide an example in Table 11 below.

         One beneficiary is in Facility A, an IRF located in rural Montana, and another beneficiary is in Facility B, an IRF located in the New York City core-based statistical area. Facility A, a non-teaching hospital, has a disproportionate share hospital (DSH) adjustment of 5 percent, with a low-income patient adjustment of (1.0315), a wage index of (0.8701), and an applicable rural area adjustment (24.1 percent). Facility B, a teaching hospital, has a DSH of 15 percent, with a LIP adjustment of (1.0929), a wage index of (1.3311), and an applicable teaching status adjustment of (1.109).

         Both Medicare beneficiaries are classified to CMG 0110 (without comorbidities). To calculate each IRF's total proposed adjusted Federal prospective payment, we compute the wage-adjusted Federal prospective payment and multiply the result by the appropriate low-income patient adjustment, the rural adjustment (if applicable), and the teaching hospital adjustment (if applicable). Table 11 illustrates the components of the proposed adjusted payment calculation. BILLING CODE 4120-01-P

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         Thus, the proposed adjusted payment for Facility A would be $31,671.57, and the adjusted payment for Facility B would be $41,637.65.

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         BILLING CODE 4120-01-C

4. Provisions of the Proposed Regulations

   (If you choose to comment on issues in this section, please include the caption ``Provisions of the Proposed Regulations'' at the beginning of your comments.)

   We are proposing to make revisions to the regulation in order to implement the proposed prospective payment for IRFs for FY 2006 and subsequent fiscal years. Specifically, we are proposing to make conforming changes in 42 CFR part 412. These proposed revisions and others are discussed in detail below.

   1. Section 412.602 Definitions

      In Sec. 412.602, we are proposing to revise the definitions of ``Rural area'' and ``Urban area'' to read as follows:

      Rural area means: For cost-reporting periods beginning on or after January 1, 2002, with respect to discharges occurring during the period covered by such cost reports but before October 1, 2005, an area as defined in Sec. 412.62(f)(1)(iii). For discharges occurring on or after October 1, 2005, rural area means an area as defined in Sec. 412.64(b)(1)(ii)(C).

      Urban area means: For cost-reporting periods beginning on or after January 1, 2002, with respect to discharges occurring during the period covered by such cost reports but before October 1, 2005, an area as defined in Sec. 412.62(f)(1)(ii). For discharges occurring on or after October 1, 2005, urban area means an area as defined in Sec. 412.64(b)(1)(ii)(A) and Sec. 412.64(b)(1)(ii)(B).

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   2. Section 412.622 Basis of payment

      In this section, we are proposing to correct the cross references in paragraphs (b)(1) and (b)(2)(i). In paragraph (b)(1), we are proposing to remove the cross references ``Sec. Sec. 413.85 and 413.86 of this chapter'' and add in their place ``Sec. 413.75 and Sec. 413.85 of this chapter.'' In paragraph (b)(2)(i), we are proposing to remove the cross reference ``Sec. 413.80 of this chapter'' and add in its place ``Sec. 413.89 of this chapter.''

   3. Section 412.624 Methodology for calculating the Federal prospective payment rates.

      In paragraph (d)(1), removing the cross reference to ``paragraph (e)(4)'' and adding in its place ``paragraph (e)(5).''

      Adding a new paragraph (d)(4).

      Redesignating paragraphs (e)(4) and (e)(5) as paragraphs (e)(5) and (e)(6).

      Adding a new paragraph (e)(4).

      Revising newly redesignated paragraph (e)(5).

      Revising newly redesignated paragraph (e)(6).

      In paragraph (f)(2)(v), removing the cross references to ``paragraphs (e)(1), (e)(2), and (e)(3) of this section'' and adding in their place ``paragraphs (e)(1), (e)(2), (e)(3), and (e)(4) of this section.''

   4. Additional Changes

      Reduce the standard payment conversion factor by 1.9 percent to account for coding changes.

      Revise the comorbidity tiers and CMGs.

      Use a weighted motor score index in assigning patients to CMGs.

      Update the relative weights.

      Update payments for rehabilitation facilities using a market basket reflecting the operating and capital cost structures for the RPL market basket.

      Provide the weights and proxies to use for the FY 2002- based RPL market basket.

      Indicate the methodology for the capital portion of the RPL market basket.

      Adopt the new geographic labor market area definitions as specified in Sec. 412.64(b)(1)(ii)(A)-(C).

      Use the New England MSAs as determined under the proposed new CBSA-based labor market area definitions.

      Use FY 2001 acute care hospital wage data in computing the FY 2006 IRF PPS payment rates.

      Implement a teaching status adjustment.

      Update the formulas used to compute the rural and the LIP adjustments to IRF payments.

      Update the outlier threshold amount to maintain total outlier payments at 3 percent of total estimated payments.

      Revise the methodology for computing the standard payment conversion factor (for FY 2006 only) to make the proposed CMG and tier changes, the proposed teaching status adjustment, and the proposed updates to the rural and LIP adjustments in a budget neutral manner.

5. Collection of Information Requirements

   This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995.

6. Response to Comments

   Because of the large number of public comments we normally receive on Federal Register documents, we are not able to acknowledge or respond to them individually. We will consider all comments we receive by the date and time specified in the DATES section of this preamble, and, when we proceed with a subsequent document, we will respond to the comments in the preamble to that document.

7. Regulatory Impact Analysis

   [If you choose to comment on issues in this section, please include the caption ``Regulatory Impact Analysis'' at the beginning of your comments.]

   1. Introduction

      The August 7, 2001 final rule established the IRF PPS for the payment of Medicare services for cost reporting periods beginning on or after January 1, 2002. We incorporated a number of elements into the IRF PPS, such as case-level adjustments, a wage adjustment, an adjustment for the percentage of low-income patients, a rural adjustment, and outlier payments. This proposed rule sets forth updates of the IRF PPS rates contained in the August 7, 2001 final rule and proposes policy changes with regard to the IRF PPS based on analyses conducted by RAND under contract with us on calendar year 2002 and FY 2003 data (updated from the 1999 data used to design the IRF PPS).

      In constructing these impacts, we do not attempt to predict behavioral responses, nor do we make adjustments for future changes in such variables as discharges or case-mix. We note that certain events may combine to limit the scope or accuracy of our impact analysis, because such an analysis is future-oriented and, thus, susceptible to forecasting errors due to other changes in the forecasted impact time period. Some examples of such possible events are newly legislated general Medicare program funding changes by the Congress, or changes specifically related to IRFs. In addition, changes to the Medicare program may continue to be made as a result of the BBA, the BBRA, the BIPA, or new statutory provisions. Although these changes may not be specific to the IRF PPS, the nature of the Medicare program is such that the changes may interact, and the complexity of the interaction of these changes could make it difficult to predict accurately the full scope of the impact upon IRFs.

      We have examined the impacts of this proposed rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review) and the Regulatory Flexibility Act (RFA) and Impact on Small Hospitals (September 16, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132. 1. Executive Order 12866

      Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibility of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year).

      We estimate that the cost to the Medicare program for IRF services in FY 2006 will increase by $180 million over FY 2005 levels. The updates to the IRF labor-related share and wage indices are made in a budget neutral manner. We are proposing to make changes to the CMGs and the tiers, the teaching status adjustment, and the rural and LIP adjustments in a budget neutral manner (that is, in order that total estimated aggregate payments with the changes equal total estimated aggregate payments without the changes). This means that we are proposing to improve the distribution of payments among facilities depending on the mix of patients they treat, their teaching status, their geographic location (rural vs. urban), and the percentage of low- income patients they treat, without changing total estimated aggregate

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      payments. To accomplish this redistribution of payments among facilities, we lower the base payment amount, which then gets adjusted upward for each facility according to the facility's characteristics. This proposed redistribution would not, however, affect aggregate payments to facilities. Thus, the proposed changes to the IRF labor- related share and the wage indices, the proposed changes to the CMGs, the tiers, and the motor score index, the proposed teaching status adjustment, the proposed update to the rural adjustment, and the proposed update to the LIP adjustment would have no overall effect on estimated costs to the Medicare program. Therefore, the estimated increased cost to the Medicare program is due to the updated IRF market basket of 3.1 percent, the 1.9 percent reduction to the standard payment conversion factor to account for changes in coding that affect total aggregate payments, and the update to the outlier threshold amount. We have determined that this proposed rule is a major rule as defined in 5 U.S.C. 804(2). Based on the overall percentage change in payments per case estimated using our payment simulation model (a 2.9 percent increase), we estimate that the total impact of these proposed changes for FY 2006 payments compared to FY 2005 payments would be approximately a $180 million increase. This amount does not reflect changes in IRF admissions or case-mix intensity, which would also affect overall payment changes. 2. Regulatory Flexibility Act (RFA)

      The RFA requires agencies to analyze the economic impact of our regulations on small entities. If we determine that the proposed regulation would impose a significant burden on a substantial number of small entities, we must examine options for reducing the burden. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and government agencies. Most IRFs and most other providers and suppliers are considered small entities, either by nonprofit status or by having revenues of $6 million to $29 million in any 1 year. (For details, see the Small Business Administration's regulation that set forth size standards for health care industries at 65 at FR 69432.) Because we lack data on individual hospital receipts, we cannot determine the number of small proprietary IRFs. Therefore, we assume that all IRFs (approximate total of 1,200 IRFs, of which approximately 60 percent are nonprofit facilities) are considered small entities for the purpose of the analysis that follows. Medicare fiscal intermediaries and carriers are not considered to be small entities. Individuals and States are not included in the definition of a small entity. 3. Impact on Rural Hospitals

      Section 1102(b) of the Act requires us to prepare a regulatory impact analysis for any proposed rule that may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. With the exception of hospitals located in certain New England counties, for purposes of section 1102(b) of the Act, we previously defined a small rural hospital as a hospital with fewer than 100 beds that is located outside of a Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA). However, under the new labor market definitions that we are proposing to adopt, we would no longer employ NECMAs to define urban areas in New England. Therefore, for purposes of this analysis, we now define a small rural hospital as a hospital with fewer than 100 beds that is located outside of a Metropolitan Statistical Area (MSA).

      As discussed in detail below, the rates and policies set forth in this proposed rule would not have an adverse impact on rural hospitals based on the data of the 169 rural units and 21 rural hospitals in our database of 1,188 IRFs for which data were available. 4. Unfunded Mandates Reform Act

      Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4) also requires that agencies assess anticipated costs and benefits before issuing any proposed rule that may result in an expenditure in any 1 year by State, local, or tribal governments, in the aggregate, or by the private sector, of at least $110 million. This proposed rule would not mandate any requirements for State, local, or tribal governments, nor would it affect private sector costs. 5. Executive Order 13132

      Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. We have reviewed this proposed rule in light of Executive Order 13132 and have determined that it would not have any negative impact on the rights, roles, or responsibilities of State, local, or tribal governments. 6. Overall Impact

      The following analysis, in conjunction with the remainder of this document, demonstrates that this proposed rule is consistent with the regulatory philosophy and principles identified in Executive Order 12866, the RFA, and section 1102(b) of the Act. We have determined that the proposed rule would have a significant economic impact on a substantial number of small entities or a significant impact on the operations of a substantial number of small rural hospitals.

   2. Anticipated Effects of the Proposed Rule

      We discuss below the impacts of this proposed rule on the budget and on IRFs. 1. Basis and Methodology of Estimates

      In this proposed rule, we are proposing policy changes and payment rate updates for the IRF PPS. Based on the overall percentage change in payments per discharge estimated using a payment simulation model developed by RAND under contract with CMS (a 2.9 percent increase), we estimate the total impact of these proposed changes for FY 2006 payments compared to FY 2005 payments to be approximately a $180 million increase. This amount does not reflect changes in hospital admissions or case-mix intensity, which would also affect overall payment changes.

      We have prepared separate impact analyses of each of the proposed changes to the IRF PPS. RAND's payment simulation model relies on the most recent available data (FY 2003) to enable us to estimate the impacts on payments per discharge of certain changes we are proposing in this proposed rule.

      The data used in developing the quantitative analyses of changes in payments per discharge presented below are taken from the FY 2003 MedPAR file and the most current Provider-Specific File that is used for payment purposes. Data from the most recently available IRF cost reports were used to estimate costs and to categorize hospitals. Our analysis has several qualifications. First, we do not make adjustments for behavioral changes that hospitals may adopt in response to the proposed policy changes, and we do not adjust for future changes in such variables as admissions, lengths of stay, or case-mix. Second, due to the interdependent nature of the IRF PPS payment components, it is very difficult to precisely quantify the impact associated with each proposed change.

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      Using cases in the FY 2003 MedPAR file, we simulated payments under the IRF PPS given various combinations of payment parameters.

      The proposed changes discussed separately below are the following:

      The effects of the proposed annual market basket update (using the proposed rehabilitation hospital, psychiatric hospital, and long-term care hospital (RPL) market basket) to IRF PPS payment rates required by sections 1886(j)(3)(A)(i) and 1886(j)(3)(C) of the Act.

      The effects of applying the proposed budget-neutral labor- related share and wage index adjustment, as required under section 1886(j)(6) of the Act.

      The effects of the proposed decrease to the standard payment conversion factor to account for the increase in estimated aggregate payments due to changes in coding, as required under section 1886(j)(2)(C)(ii) of the Act.

      The effects of the proposed budget-neutral changes to the tier comorbidities, CMGs, motor score index, and relative weights, under the authority of section 1886(j)(2)(C)(i) of the Act.

      The effects of the proposed adoption of new CBSAs based on the new geographic area definitions announced by OMB in June 2003.

      The effects of the proposed implementation of a budget- neutral teaching status adjustment, as permitted under section 1886(j)(3)(A)(v) of the Act.

      The effects of the proposed budget-neutral update to the percentage amount by which payments are adjusted for IRFs located in rural areas, as permitted under section 1886(j)(3)(A)(v) of the Act.

      The effects of the proposed budget-neutral update to the formula used to calculate the payment adjustment for IRFs based on the percentage of low-income patients they treat, as permitted under section 1886(j)(3)(A)(v) of the Act.

      The effects of the proposed change to the outlier loss threshold amount to maintain total estimated outlier payments at 3 percent of total estimated payments to IRFs in FY 2006, consistent with section 1886(j)(4) of the Act.

      The total change in payments based on the proposed FY 2006 policies relative to payments based on FY 2005 policies.

      To illustrate the impacts of the proposed FY 2006 changes, our analysis begins with a FY 2005 baseline simulation model using: IRF charges inflated to FY 2005 using the market basket; the FY 2005 PRICER; the estimated percent of outlier payments in FY 2005; the FY 2005 CMG GROUPER (version 1.22); the MSA designations for IRFs based on OMB's MSA definitions prior to June 2003; the FY 2005 wage index; the FY 2005 labor-market share; the FY 2005 formula for the LIP adjustment; and the FY 2005 percentage amount of the rural adjustment.

      Each proposed policy change is then added incrementally to this baseline model, finally arriving at a FY 2006 model incorporating all of the proposed changes to the IRF PPS. This allows us to isolate the effects of each change. Note that, in computing estimated payments per discharge for each of the proposed policy changes, the outlier loss threshold has been adjusted so that estimated outlier payments are 3 percent of total estimated payments.

      Our final comparison illustrates the percent change in payments per discharge from FY 2005 to FY 2006. One factor that affects the proposed changes in IRFs' payments from FY 2005 to FY 2006 is that we currently estimate total outlier payments during FY 2005 to be 1.2 percent of total estimated payments. As discussed in the August 7, 2001 final rule (66 FR at 41362), our policy is to set total estimated outlier payments at 3 percent of total estimated payments. Because estimated outlier payments during FY 2005 were below 3 percent of total payments, payments in FY 2006 would increase by an additional 1.8 percent over payments in FY 2005 because of the proposed change in the outlier loss threshold to achieve the 3 percent target. 2. Analysis of Table 13

      Table 13 displays the results of our analysis. The table categorizes IRFs by geographic location, including urban or rural location and location with respect to CMS' nine regions of the country. In addition, the table divides IRFs into those that are separate rehabilitation hospitals (otherwise called freestanding hospitals in this section), those that are rehabilitation units of a hospital (otherwise called hospital units in this section), rural or urban facilities by ownership (otherwise called for-profit, non-profit, and government), and by teaching status. The top row of the table shows the overall impact on the 1,188 IRFs included in the analysis.

      The next twelve rows of Table 13 contain IRFs categorized according to their geographic location, designation as either a freestanding hospital or a unit of a hospital, and by type of ownership: all urban, which is further divided into urban units of a hospital, urban freestanding hospitals, by type of ownership, and rural, which is further divided into rural units of a hospital, rural freestanding hospitals, and by type of ownership. There are 998 IRFs located in urban areas included in our analysis. Among these, there are 802 IRF units of hospitals located in urban areas and 196 freestanding IRF hospitals located in urban areas. There are 190 IRFs located in rural areas included in our analysis. Among these, there are 169 IRF units of hospitals located in rural areas and 21 freestanding IRF hospitals located in rural areas. There are 354 for-profit IRFs. Among these, there are 295 IRFs in urban areas and 59 IRFs in rural areas. There are 708 non-profit IRFs. Among these, there are 603 urban IRFs and 105 rural IRFs. There are 126 government owned IRFs. Among these, there are 100 urban IRFs and 26 rural IRFs.

      The following three parts of Table 13 show IRFs grouped by their geographic location within a region, and the last part groups IRFs by teaching status. First, IRFs located in urban areas are categorized with respect to their location within a particular one of nine geographic regions. Second, IRFs located in rural areas are categorized with respect to their location within a particular one of the nine CMS regions. In some cases, especially for rural IRFs located in the New England, Mountain, and Pacific regions, the number of IRFs represented is small. Finally, IRFs are grouped by teaching status, including non- teaching IRFs, IRFs with an intern and resident to ADC ratio less than 10 percent, IRFs with an intern and resident to ADC ratio greater than or equal to 10 percent and less than or equal to 19 percent, and IRFs with an intern and resident to ADC ratio greater than 19 percent. BILLING CODE 4120-01-P

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      3. Impact of the Proposed Market Basket Update to the IRF PPS Payment Rates (Using the RPL Market Basket) (Column 6, Table 13)

      In column 6 of Table 13, we present the effects of the proposed market basket update to the IRF PPS payment rates, as discussed in section III.B.1 of this proposed rule. Section 1886(j)(3)(A)(i) of the Act requires us annually to update the per discharge prospective payment rate for IRFs by an increase factor specified by the Secretary and based on an appropriate percentage increase in a market basket of goods and services comprising services for which payment is made to IRFs, as specified in section 1886(j)(3)(C) of the Act.

      As discussed in detail in section III.B.1 of this proposed rule, we are proposing to use a new market basket that reflects the operating and capital cost structures of inpatient rehabilitation facilities, inpatient psychiatric facilities, and long-term care hospitals, referred to as the rehabilitation hospital, psychiatric hospital, and long-term care hospital (RPL) market basket. The proposed FY 2006 update for IRF PPS payments using the proposed FY 2002-based RPL market basket and the Global Insight's 4th quarter 2004 forecast would be 3.1 percent.

      In the aggregate, and across all hospital groups, the proposed update would result in a 3.1 percent increase in overall payments to IRFs. 4. Impact of Updating the Budget-Neutral Labor-Related Share and MSA- Based Wage Index Adjustment (Column 4, Table 14)

      In column 4 of Table 14, we present the effects of a budget-neutral update to the labor-related share and the wage index adjustment (using the geographic area definitions developed by OMB before June 2003), as discussed in section III.B.2 of this proposed rule. Since we are not proposing to use the MSA labor market definitions, table 14 is for reference purposes only.

      Section 1886(j)(6) of the Act requires us annually to adjust the proportion of rehabilitation facilities' costs that are attributable to wages and wage-related costs, of the prospective payment rates under the IRF PPS for area differences in wage levels by a factor reflecting the relative hospital wage level in the geographic area of the rehabilitation facility compared to the national average wage level for such facilities. This section of the Act also requires any such adjustments to be made in a budget-neutral manner.

      In accordance with section 1886(j)(6) of the Act, we are proposing to update the labor-related share and adopt the wage index adjustment based on CBSA designations in a budget neutral manner. However, if we do not adopt the CBSA-based designations, this would not change aggregated payments to IRF as indicated in the first row of column 4 in Table 14. If we only update the MSA-based wage index and labor-related share, there would be small distributional effects among different categories of IRFs. For example, rural IRFs would experience a 1.0 percent decrease while urban facilities would experience a 0.1 percent increase in payments based on the RLP labor-related share and MSA-based wage index. Rural IRFs in the East South Central region would experience the largest decrease of 1.8 percent based on the proposed FY 2006 labor-related share and MSA-based wage index. Urban IRFs in the Pacific region would experience the largest increase in payments of 0.8 percent.

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      BILLING CODE 4120-01-C 5. Impact of the Proposed 1.9 Percent Decrease in the Standard Payment Amount to Account for Coding Changes (Column 11, Table 13)

      In column 11 of Table 13, we present the effects of the proposed decrease in the standard payment amount to account for the increase in aggregate payments due to changes in coding that do not reflect real changes in case mix, as discussed in section III.A of this proposed rule. Section 1886(j)(2)(C)(ii) of the Act requires us to adjust the per discharge PPS payment rate to eliminate the effect of coding or classification changes that do not reflect real changes in case mix if we determine that such changes result in a change in aggregate payments under the classification system.

      In the aggregate, and across all hospital groups, the proposed update would result in a 1.9 percent decrease in overall payments to IRFs. Thus, we estimate that the 1.9 percent reduction in the standard payment amount would result in a cost savings to the Medicare program of approximately $120 million.

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      6. Impact of the Proposed Changes to the CMG Reclassifications and Recalibration of Relative Weights (Column 7, Table 13)

      In column 7 of Table 13, we present the effects of the proposed changes to the tier comorbidities, the CMGs, the motor score index, and the proposed recalibration of the relative weights, as discussed in section II.A of this proposed rule. Section 1886(j)(2)(C)(i) of the Act requires us to adjust from time to time the classifications and weighting factors as appropriate to reflect changes in treatment patterns, technology, case mix, number of payment units for which payment under the IRF PPS is made, and any other factors which may affect the relative use of resources.

      As described in section II.A.3 of this proposed rule, we are proposing to update the tier comorbidities to remove condition codes from the list that we believe no longer merit additional payments, move dialysis patients to tier one to increase payments for these patients, and to align payments with the comorbidity conditions according to their effects on the relative costliness of patients. We are also proposing to update the CMGs and the relative weights for the CMGs so that they better reflect the relative costliness of different types of IRF patients. We are also proposing to replace the current motor score index with a weighted motor score index that better estimates the relative costliness of IRF patients. Finally, we are proposing to change the coding of patients with missing information for the transfer to toilet item in the motor score index from 1 to 2.

      To assess the impact of these proposed changes, we compared aggregate payments using the FY 2005 CMG relative weights (GROUPER version 1.22) to aggregate payments using the proposed FY 2006 CMG relative weights (GROUPER version 1.30). We note that, under the authority in section 1886(j)(2)(C)(i) of the Act and consistent with our rationale as described in section II.B.4 of this proposed rule, we have applied a budget neutrality factor to ensure that the overall payment impact of the proposed CMG changes is budget neutral (that is, in order that total estimated aggregate payments for FY 2006 with the change are equal to total estimated aggregate payment for FY 2006 without the change). Because we found that the proposed relative weights we would use for calculating the FY 2006 payment rates are slightly higher, on average, than the relative weights we are currently using, and that the effect of this would be to increase aggregate payments, the proposed budget neutrality factor for the CMG and tier changes lowers the standard payment amount somewhat. Because the lower standard payment amount is balanced by the higher average weights, the effect is no change in overall payments to IRFs. However, the distribution of payments among facilities is affected, with some facilities receiving higher payments and some facilities receiving lower payments as a result of the tier and CMG changes, as shown in column 7 of Table 13.

      Although, in the aggregate, these proposed changes would not change overall payments to IRFs, as shown in the zero impact in the first row of column 7, there are distributional effects of these changes. On average, the impacts of these proposed changes on any particular group of IRFs are very small, with urban IRFs experiencing a 0.1 percent decrease and rural IRFs experiencing a 1.2 percent increase in aggregate payments. The largest impacts are a 2.7 percent increase among rural IRFs in the West North Central region and a 2.7 percent decrease among rural IRFs in the Pacific region. 7. Impact of the Proposed Changes to New Labor Market Areas (Column 4, Table 13)

      In accordance with the broad discretion under section 1886(j)(6) of the Act, we currently define hospital labor market areas based on the definitions of Metropolitan Statistical Areas (MSAs), Primary MSAs (PMSAs), and New England County Metropolitan Areas (NECMAs) issued by OMB as discussed in section III.B.2 of this proposed rule. On June 6, 2003, OMB announced new Core-Based Statistical Areas (CBSAs), comprised of MSAs and the new Micropolitan Statistical Areas based on Census 2000 data. We are proposing to adopt the new MSA definitions, consistent with the inpatient prospective payment system, including the 49 new Metropolitan areas designated under the new definitions. We are also proposing to adopt MSA definitions in New England in place of NECMAs. We are proposing not to adopt the newly defined Micropolitan Statistical Areas for use in the payment system, as Micropolitan Statistical Areas would remain part of the statewide rural areas for purposes of the IRF PPS payments, consistent with payments under the inpatient prospective payment system.

      The effects of these proposed changes to the new CBSA-based designations are isolated in column 4 of Table 13 by holding all other payment parameters constant in this simulation. That is, column 4 shows the percentage changes in payments when going from a model using the current MSA designations to a model using the proposed new CBSA designations (for Metropolitan areas only).

      Table 15 below compares the shifts in proposed wage index values for IRFs for FY 2006 relative to FY 2005. A small number of IRFs (1.6 percent) would experience an increase of between 5 and 10 percent and 1.5 percent of IRFs would experience an increase of more than 10 percent. A small number of IRFs (2.5 percent) would experience decreases in their wage index values of at least 5 percent, but less than 10 percent. Furthermore, IRFs that would experience decreases in their wage index values of greater than 10 percent would be 0.7 percent.

      The following table shows the projected impact for IRFs.

      Table 15.--Proposed Impact of the Proposed FY 2006 CBSA-based Area Wage Index

      Percent Percent change in area wage index

      of IRFs

      Decrease Greater Than 10.0.................................... 0.7 Decrease Between 5.0 and 10.0................................. 2.5 Decrease Between 2.0 and 5.0.................................. 5.7 Decrease Between 0 and 2.0.................................... 25.6 No Change..................................................... 37.2 Increase Between 0 and 2.0.................................... 22.1 Increase Between 2.0 and 5.0.................................. 3.3 Increase Between 5.0 and 10.0................................. 1.6 Increase Greater Than 10.0.................................... 1.5

      Total \1\................................................... 100.0

      \1\ May not exactly equal 100 percent due to rounding.

      8. Impact of the Proposed Adjustment to the Outlier Threshold Amount (Column 5, Table 13)

      We estimate total outlier payments in FY 2005 to be approximately 1.2 percent of total estimated payments, so we are proposing to update the threshold from $11,211 in FY 2005 to $4,911 in FY 2006 in order to set total estimated outlier payments in FY 2006 equal to 3 percent of total estimated payments in FY 2006.

      The impact of this proposed change (as shown in column 5 of table 13) is to increase total estimated payments to IRFs by about 1.8 percent.

      The effect on payments to rural IRFs would be to increase payments by 3.9 percent, and the effect on payments to urban IRFs would be to increase payments by 1.6 percent. The largest effect would be a 9.5 percent increase in payments to rural IRFs in the Mountain region, and the smallest effect would be

      [[Page 30265]]

      no change in payments for urban IRFs located in the East South Central region. 9. Impact of the Proposed Budget-Neutral Teaching Status Adjustment (Column 10, Table 13)

      In column 10 of Table 13, we present the effects of the proposed budget-neutral implementation of a teaching status adjustment to the Federal prospective payment rate for IRFs that have teaching programs, as discussed in section III.B.3 of this proposed rule. Section 1886(j)(3)(A)(v) of the Act requires the Secretary to adjust the Federal prospective payment rates for IRFs under the IRF PPS for such factors as the Secretary determines are necessary to properly reflect variations in necessary costs of treatment among rehabilitation facilities. Under the authority of section 1886 (j)(3)(A)(v) of the Act, we are proposing to apply a budget neutrality factor to ensure that the overall payment impact of the proposed teaching status adjustment is budget neutral (that is, in order that total estimated aggregate payments for FY 2006 with the proposed adjustment would equal total estimated aggregate payments for FY 2006 without the proposed adjustment). Because IRFs with teaching programs would receive additional payments from the implementation of this proposed new teaching status adjustment, the effect of the proposed budget neutrality factor would be to reduce the standard payment amount, therefore reducing payments to IRFs without teaching programs. By design, however, the increased payments to teaching facilities would balance the decreased payments to non-teaching facilities, and total estimated aggregate payments to all IRFs would remain unchanged. Therefore, the first row of column 10 of Table 13 indicates a zero impact in the aggregate. However, the rest of column 10 gives the distributional effects among different types of providers of this change. Some providers' payments increase and some decrease with this change.

      On average, the impacts of this proposed change on any particular group of IRFs are very small, with urban IRFs experiencing a 0.1 percent increase and rural IRFs experiencing a 1.1 percent decrease. The largest impacts are a 2.0 percent increase among urban IRFs in the Middle Atlantic region and 1.2 percent decreases among rural IRFs in the Middle Atlantic, South Atlantic, and West South Central regions.

      Overall, non-teaching hospitals would experience a 1.1 percent decrease. The largest impacts are a 24.3 percent increase among teaching facilities with intern and resident to ADC ratios greater than 19 percent. Teaching facilities that have intern and resident to ADC ratios greater than or equal to 10 percent and less than or equal to 19 percent would experience an increase of 11 percent. Teaching facilities with resident and intern to ADC ratios less than 10 percent would experience an increase of 2.6 percent. 10. Impact of the Proposed Update to the Rural Adjustment (Column 8, Table 13)

      In column 8 of Table 13, we present the effects of the proposed budget-neutral update to the percentage adjustment to the Federal prospective payment rates for IRFs located in rural areas, as discussed in section III.B.4 of this proposed rule. Section 1886(j)(3)(A)(v) of the Act requires the Secretary to adjust the Federal prospective payment rates for IRFs under the IRF PPS for such factors as the Secretary determines are necessary to properly reflect variations in necessary costs of treatment among rehabilitation facilities.

      In accordance with section 1886(j)(3)(A)(v) of the Act, we are proposing to change the rural adjustment percentage, based on FY 2003 data, from 19.14 percent to 24.1 percent.

      Because we are proposing to make this proposed update to the rural adjustment in a budget neutral manner under the broad authority conferred by section 1886(j)(3)(A)(v) of the Act, payments to urban facilities would decrease in proportion to the total increase in payments to rural facilities. To accomplish this redistribution of resources between urban and rural facilities, we propose to apply a budget neutrality factor to reduce the standard payment amount. Rural facilities would receive an increase in payments to this amount, and urban facilities would not. Overall, aggregate payments to IRFs would not change, as indicated by the zero impact in the first row of column 8. However, payments would be redistributed among rural and urban IRFs, as indicated by the rest of the column. On average, because there are a relatively small number of rural facilities, the impacts of this proposed change on urban IRFs are relatively small, with all urban IRFs experiencing a 0.3 percent decrease. The impact on rural IRFs is somewhat larger, with rural IRFs experiencing a 3.4 percent increase. The largest impacts are a 3.6 percent increase among rural IRFs in the Middle Atlantic region. 11. Impact of the Proposed Update to the LIP Adjustment (Column 9, Table 13)

      In column 9 of Table 13, we present the effects of the proposed budget-neutral update to the adjustment to the Federal prospective payment rates for IRFs according to the percentage of low-income patients they treat, as discussed in section III.B.5 of this proposed rule. Section 1886(j)(3)(A)(v) of the Act requires the Secretary to adjust the Federal prospective payment rates for IRFs under the IRF PPS for such factors as the Secretary determines are necessary to properly reflect variations in necessary costs of treatment among rehabilitation facilities.

      In accordance with section 1886(j)(3)(A)(v) of the Act, we are proposing to change the formula for the LIP adjustment, based on FY 2003 data, to raise the amount of 1 plus the DSH patient percentage to the power of 0.636 instead of the power of 0.4838. Therefore, the formula to calculate the low-income patient or LIP adjustment would be as follows:

      (1 + DSH patient percentage) raised to the power of (.636) Where DSH patient percentage =

      [GRAPHIC] [TIFF OMITTED] TP25MY05.035

      Because we are proposing to make this proposed update to the LIP adjustment in a budget neutral manner, payments would be redistributed among providers, according to their low-income percentages, but total estimated aggregate payments to facilities would not change. To do this, we propose to apply a budget neutrality factor that lowers the standard payment amount in proportion to the amount of payment increase that is attributable to the increased LIP adjustment payments. This would result in no change to aggregate payments, which is reflected in the zero impact shown in the first row of column 9 of Table 13. The remaining rows of the column show the

      [[Page 30266]]

      impacts on different categories of providers. On average, the impacts of this proposed change on any particular group of IRFs are small, with urban IRFs experiencing no change in aggregate payments and rural IRFs experiencing a 0.1 percent decrease in aggregate payments. The largest impacts are a 1.2 percent increase among IRFs with 10 percent or higher intern and resident to ADC ratios and 0.9 percent decrease among rural IRFs in the Pacific region. 12. All Proposed Changes (Column 12, Table 13)

      Column 12 of Table 13 compares our estimates of the proposed payments per discharge, incorporating all proposed changes reflected in this proposed rule for FY 2006, to our estimates of payments per discharge in FY 2005 (without these proposed changes). This column includes all of the proposed policy changes.

      Column 12 reflects all FY 2006 proposed changes relative to FY 2005, shown in columns 4 though 11. The average increase for all IRFs is approximately 2.9 percent. This increase includes the effects of the proposed 3.1 percent market basket update. It also reflects the 1.8 percentage point difference between the estimated outlier payments in FY 2005 (1.2 percent of total estimated payments) and the proposed estimate of the percentage of outlier payments in FY 2006 (3 percent), as described in the introduction to the Addendum to this proposed rule. As a result, payments per discharge are estimated to be 1.8 percent lower in FY 2005 than they would have been had the 3 percent target outlier payment percentage been met, resulting in a 1.8 percent greater increase in total FY 2006 payments than would otherwise have occurred.

      It also includes the impact of the proposed one-time 1.9 percent reduction in the standard payment conversion factor to account for changes in coding that increased payments to IRFs. Because we propose to make the remainder of the proposed changes outlined in this proposed rule in a budget-neutral manner, they do not affect total IRF payments in the aggregate. However, as described in more detail in each section, they do affect the distribution of payments among providers.

      There might also be interactive effects among the various proposed factors comprising the payment system that we are not able to isolate. For these reasons, the values in column 12 may not equal the sum of the proposed changes described above.

      The proposed overall change in payments per discharge for IRFs in FY 2006 would increase by 2.9 percent, as reflected in column 12 of Table 13. IRFs in urban areas would experience a 2.6 percent increase in payments per discharge compared with FY 2005. IRFs in rural areas, meanwhile, would experience a 6.8 percent increase. Rehabilitation units in urban areas would experience a 5 percent increase in payments per discharge, while freestanding rehabilitation hospitals in urban areas would experience a 1.1 percent decrease in payments per discharge. Rehabilitation units in rural areas would experience a 6.5 percent increase in payments per discharge, while freestanding rehabilitation hospitals in rural areas would experience a 8.1 percent increase in payments per discharge.

      Overall, the largest payment increase would be 32.1 percent among teaching IRFs with an intern and resident to ADC ratio greater than 19 percent and 15.8 percent among teaching IRFs with an intern and resident to ADC ratio greater than or equal to 10 percent and less than or equal to 19 percent. This is largely due to the proposed teaching status adjustment. Other than for teaching IRFs, the largest payment increase would be 12.3 percent among rural IRFs located in the Middle Atlantic region. This is due largely to the change in the proposed CBSA-based designation from urban to rural, whereby the number of cases in the rural Middle Atlantic Region that would receive the proposed new rural adjustment of 24.1 percent would increase. The only overall decreases in payments would occur among all urban freestanding IRFs and urban IRFs located in the New England, East South Central, and Mountain census regions. The largest of these overall payment decreases would be 1.3 percent among all urban freestanding hospitals. This is due largely to the proposed change in the CBSA-based designation from rural to urban. For non-profit IRFs, we found that rural non-profit facilities would receive the largest payment increase of 8 percent. Conversely, for-profit urban facilities would experience a 1.1 percent overall decrease. 13. Accounting Statement

      As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf ), in Table 16 below, we

      have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this proposed rule. This table provides our best estimate of the increase in Medicare payments under the IRF PPS as a result of the proposed changes presented in this proposed rule based on the data for 1,188 IRFs in our database. All expenditures are classified as transfers to Medicare providers (that is, IRFs).

      Table 16.--Accounting Statement: Classification of Estimated Expenditures, From FY 2005 to FY 2006 (In millions)

      Category

      Transfers

      Annualized Monetized Transfers............ $180 From Whom To Whom?

      Federal Government To IRF Medicare Providers.

      List of Subjects in 42 CFR Part 412

      Administrative practice and procedure, Health facilities, Medicare, Puerto Rico, Reporting and recordkeeping requirements.

      For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services proposes to amend 42 CFR chapter IV as follows:

      PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES

      1. The authority citation for part 412 continues to read as follows:

      Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

      Subpart P--Prospective Payment for Inpatient Rehabilitation Hospitals and Rehabilitation Units

      2. Section 412.602 is amended by revising the definitions of ``Rural area'' and ``Urban area'' to read as follows:

      Sec. 412.602 Definitions.

      * * * * *

      Rural area means: For cost-reporting periods beginning on or after January 1, 2002, with respect to discharges occurring during the period covered by such cost reports but before October 1, 2005, an area as defined in Sec. 412.62(f)(1)(iii). For discharges occurring on or after October 1, 2005, rural area means an area as defined in Sec. 412.64(b)(1)(ii)(C). * * * * *

      Urban area means: For cost-reporting periods beginning on or after January 1, 2002, with respect to discharges occurring during the period covered by such cost reports but before October 1, 2005, an area as defined in Sec. 412.62(f)(1)(ii). For discharges occurring on or after October 1, 2005,

      [[Page 30267]]

      urban area means an area as defined in Sec. 412.64(b)(1)(ii)(A) and Sec. 412.64(b)(1)(ii)(B).

      Sec. 412.622 [Amended]

      3. Section 412.622 is amended by--

   1. In paragraph (b)(1), removing the cross references ``Sec. Sec. 413.85 and 413.86 of this chapter'' and adding in their place ``Sec. 413.75 and Sec. 413.85 of this chapter''.

   2. In paragraph (b)(2)(i), removing the cross reference to ``Sec. 413.80 of this chapter'' and adding in its place ``Sec. 413.89 of this chapter''.

      4. Section 412.624 is amended by--

      1. In paragraph (d)(1), removing the cross reference to ``paragraph (e)(4)'' and adding in its place ``paragraph (e)(5)''.

      2. Adding a new paragraph (d)(4).

      3. Redesignating paragraphs (e)(4) and (e)(5) as paragraphs (e)(5) and (e)(6).

      4. Adding a new paragraph (e)(4).

      5. Revising newly redesignated paragraph (e)(5).

      6. Revising newly redesignated paragraph (e)(6).

      7. In paragraph (f)(2)(v), removing the cross references to ``paragraphs (e)(1), (e)(2), and (e)(3) of this section'' and adding in their place ``paragraphs (e)(1), (e)(2), (e)(3), and (e)(4) of this section''.

      The revisions and additions read as follows:

      Sec. 412.624 Methodology for calculating the Federal prospective payment rates.

      * * * * *

      (d) * * *

      (4) Payment adjustment for Federal fiscal year 2006 and subsequent Federal fiscal years. CMS adjusts the standard payment conversion factor based on any updates to the adjustments specified in paragraph (e)(2), (e)(3), and (e)(4), of this section, and to any revision specified in Sec. 412.620(c).

      (e) * * *

      (4) Adjustments for teaching hospitals. For discharges on or after October 1, 2005, CMS adjusts the Federal prospective payment on a facility basis by a factor as specified by CMS for facilities that are teaching institutions or units of teaching institutions. This adjustment is made on a claim basis as an interim payment and the final payment in full for the claim is made during the final settlement of the cost report.

      (5) Adjustment for high-cost outliers. CMS provides for an additional payment to an inpatient rehabilitation facility if its estimated costs for a patient exceed a fixed dollar amount (adjusted for area wage levels and factors to account for treating low-income patients, for rural location, and for teaching programs) as specified by CMS. The additional payment equals 80 percent of the difference between the estimated cost of the patient and the sum of the adjusted Federal prospective payment computed under this section and the adjusted fixed dollar amount. Effective for discharges occurring on or after October 1, 2003, additional payments made under this section will be subject to the adjustments at Sec. 412.84(i), except that national averages will be used instead of statewide averages. Effective for discharges occurring on or after October 1, 2003, additional payments made under this section will also be subject to adjustments at Sec. 412.84(m).

      (6) Adjustments related to the patient assessment instrument. An adjustment to a facility's Federal prospective payment amount for a given discharge will be made, as specified under Sec. 412.614(d), if the transmission of data from a patient assessment instrument is late. * * * * * (Catalog of Federal Domestic Assistance Program No. 93.773, Medicare--Hospital Insurance; and Program No. 93.774, Medicare-- Supplementary Medical Insurance Program)

      Dated: April 14, 2005. Mark B. McClellan, Administrator, Centers for Medicare & Medicaid Services.

      Approved: May 4, 2005. Michael O. Leavitt, Secretary.

      The following addendum will not appear in the Code of Federal Regulations.

      Addendum

      This addendum contains the tables referred to throughout the preamble to this proposed rule. The tables presented below are as follows:

      Table 1A.--FY 2006 IRF PPS MSA Labor Market Area Designations for Urban Areas for the purposes of comparing Wage Index values with Table 2A.

      Table 1B.--FY 2006 IRF PPS MSA Labor Market Area Designations for Rural Areas for the purposes of comparing Wage Index values with Table 2B.

      Table 2A.--Proposed Inpatient Rehabilitation Facility (IRF) wage index for urban areas based on proposed CBSA labor market areas for discharges occurring on or after October 1, 2005.

      Table 2B.--Proposed Inpatient Rehabilitation Facility (IRF) wage index based on proposed CBSA labor market areas for rural areas for discharges occurring on or after October 1, 2005.

      Table 3--Inpatient Rehabilitation Facilities with Corresponding State and County Location; Current Labor Market Area Designation; and Proposed New CBSA-based Labor Market Area Designation.

      Table 1A.--FY 2006 IRF PPS MSA Labor Market Area Designations for Urban Areas for the Purposes of Comparing Wage Index Values with Table 2a

      Urban area (Constituent Counties Wage MSA

      or County Equivalents)

      index

      0040...................... Abilene, TX...................... 0.8009 Taylor, TX 0060...................... Aguadilla, PR.................... 0.4294 Aguada, PR Aguadilla, PR Moca, PR 0080...................... Akron, OH........................ 0.9055 Portage, OH Summit, OH 0120...................... Albany, GA....................... 1.1266 Dougherty, GA Lee, GA 0160...................... Albany-Schenectady-Troy, NY...... 0.8570 Albany, NY Montgomery, NY Rensselaer, NY

      [[Page 30268]]

      Saratoga, NY Schenectady, NY Schoharie, NY 0200...................... Albuquerque, NM.................. 1.0485 Bernalillo, NM Sandoval, NM Valencia, NM 0220...................... Alexandria, LA................... 0.8171 Rapides, LA 0240...................... Allentown-Bethlehem-Easton, PA... 0.9536 Carbon, PA Lehigh, PA Northampton, PA 0280...................... Altoona, PA...................... 0.8462 Blair, PA 0320...................... Amarillo, TX..................... 0.9178 Potter, TX Randall, TX 0380...................... Anchorage, AK.................... 1.2109 Anchorage, AK 0440...................... Ann Arbor, MI.................... 1.0816 Lenawee, MI Livingston, MI Washtenaw, MI 0450...................... Anniston,AL...................... 0.7881 Calhoun, AL 0460...................... Appleton-Oshkosh-Neenah, WI...... 0.9115 Calumet, WI Outagamie, WI Winnebago, WI 0470...................... Arecibo, PR...................... 0.3757 Arecibo, PR Camuy, PR Hatillo, PR 0480...................... Asheville, NC.................... 0.9501 Buncombe, NC Madison, NC 0500...................... Athens, GA....................... 1.0202 Clarke, GA Madison, GA Oconee, GA 0520...................... Atlanta, GA...................... 0.9971 Barrow, GA Bartow, GA Carroll, GA Cherokee, GA Clayton, GA Cobb, GA Coweta, GA De Kalb, GA Douglas, GA Fayette, GA Forsyth, GA Fulton, GA Gwinnett, GA Henry, GA Newton, GA Paulding, GA Pickens, GA Rockdale, GA Spalding, GA Walton, GA 0560...................... Atlantic City-Cape May, NJ....... 1.0907 Atlantic City, NJ Cape May, NJ 0580...................... Auburn-Opelika, AL............... 0.8215 Lee, AL 0600...................... Augusta-Aiken, GA-SC............. 0.9208 Columbia, GA McDuffie, GA

      [[Page 30269]]

      Richmond, GA Aiken, SC Edgefield, SC 0640...................... Austin-San Marcos, TX............ 0.9595 Bastrop, TX Caldwell, TX Hays, TX Travis, TX Williamson, TX 0680...................... Bakersfield, CA.................. 1.0036 Kern, CA 0720...................... Baltimore, MD.................... 0.9907 Anne Arundel, MD Baltimore, MD Baltimore City, MD Carroll, MD Harford, MD Howard, MD Queen Annes, MD 0733...................... Bangor, ME....................... 0.9955 Penobscot, ME 0743...................... Barnstable-Yarmouth, MA.......... 1.2335 Barnstable, MA 0760...................... Baton Rouge, LA.................. 0.8354 Ascension, LA East Baton Rouge Livingston, LA West Baton Rouge, LA 0840...................... Beaumont-Port Arthur, TX......... 0.8616 Hardin, TX Jefferson, TX Orange, TX 0860...................... Bellingham, WA................... 1.1642 Whatcom, WA 0870...................... Benton Harbor, MI................ 0.8847 Berrien, MI 0875...................... Bergen-Passaic, NJ............... 1.1967 Bergen, NJ Passaic, NJ 0880...................... Billings, MT..................... 0.8961 Yellowstone, MT 0920...................... Biloxi-Gulfport-Pascagoula, MS... 0.8649 Hancock, MS Harrison, MS Jackson, MS 0960...................... Binghamton, NY................... 0.8447 Broome, NY Tioga, NY 1000...................... Birmingham, AL................... 0.9198 Blount, AL Jefferson, AL St. Clair, AL Shelby, AL 1010...................... Bismarck, ND..................... 0.7505 Burleigh, ND Morton, ND 1020...................... Bloomington, IN.................. 0.8587 Monroe, IN 1040...................... Bloomington-Normal, IL........... 0.9111 McLean, IL 1080...................... Boise City, ID................... 0.9352 Ada, ID Canyon, ID 1123...................... Boston-Worcester-Lawrence-Lowell- 1.1290 Brockton, MA-NH. Bristol, MA Essex, MA Middlesex, MA Norfolk, MA Plymouth, MA Suffolk, MA

      [[Page 30270]]

      Worcester, MA Hillsborough, NH Merrimack, NH Rockingham, NH Strafford, NH 1125...................... Boulder-Longmont, CO............. 1.0046 Boulder, CO 1145...................... Brazoria, TX..................... 0.8524 Brazoria, TX 1150...................... Bremerton, WA.................... 1.0614 Kitsap, WA 1240...................... Brownsville-Harlingen-San Benito, 1.0125 TX. Cameron, TX 1260...................... Bryan-College Station, TX........ 0.9243 Brazos, TX 1280...................... Buffalo-Niagara Falls, NY........ 0.9339 Erie, NY Niagara, NY 1303...................... Burlington, VT................... 0.9322 Chittenden, VT Franklin, VT Grand Isle, VT 1310...................... Caguas, PR....................... 0.4061 Caguas, PR Cayey, PR Cidra, PR Gurabo, PR San Lorenzo, PR 1320...................... Canton-Massillon, OH............. 0.8895 Carroll, OH Stark, OH 1350...................... Casper, WY....................... 0.9243 Natrona, WY 1360...................... Cedar Rapids, IA................. 0.8975 Linn, IA 1400...................... Champaign-Urbana, IL............. 0.9527 Champaign, IL 1440...................... Charleston-North Charleston, SC.. 0.9420 Berkeley, SC Charleston, SC Dorchester, SC 1480...................... Charleston, WV................... 0.8876 Kanawha, WV Putnam, WV 1520...................... Charlotte-Gastonia-Rock Hill, NC- 0.9711 SC. Cabarrus, NC Gaston, NC Lincoln, NC Mecklenburg, NC Rowan, NC Union, NC York, SC 1540...................... Charlottesville, VA.............. 1.0294 Albemarle, VA Charlottesville City, VA Fluvanna, VA Greene, VA 1560...................... Chattanooga, TN-GA............... 0.9207 Catoosa, GA Dade, GA Walker, GA Hamilton, TN Marion, TN 1580...................... Cheyenne, WY..................... 0.8980 Laramie, WY 1600...................... Chicago, IL...................... 1.0851 Cook, IL De Kalb, IL Du Page, IL Grundy, IL

      [[Page 30271]]

      Kane, IL Kendall, IL Lake, IL McHenry, IL Will, IL 1620...................... Chico-Paradise, CA............... 1.0542 Butte, CA 1640...................... Cincinnati, OH-KY-IN............. 0.9595 Dearborn, IN Ohio, IN Boone, KY Campbell, KY Gallatin, KY Grant, KY Kenton, KY Pendleton, KY Brown, OH Clermont, OH Hamilton, OH Warren, OH 1660...................... Clarksville-Hopkinsville, TN-KY.. 0.8022 Christian, KY Montgomery, TN 1680...................... Cleveland-Lorain-Elyria, OH...... 0.9626 Ashtabula, OH Geauga, OH Cuyahoga, OH Lake, OH Lorain, OH Medina, OH 1720...................... Colorado Springs, CO............. 0.9792 El Paso, CO 1740...................... Columbia MO...................... 0.8396 Boone, MO 1760...................... Columbia, SC..................... 0.9450 Lexington, SC Richland, SC 1800...................... Columbus, GA-AL.................. 0.8690 Russell, AL Chattanoochee, GA Harris, GA Muscogee, GA 1840...................... Columbus, OH..................... 0.9753 Delaware, OH Fairfield, OH Franklin, OH Licking, OH Madison, OH Pickaway, OH 1880...................... Corpus Christi, TX............... 0.8647 Nueces, TX San Patricio, TX 1890...................... Corvallis, OR.................... 1.0545 Benton, OR 1900...................... Cumberland, MD-WV................ 0.8662 Allegany MD Mineral WV 1920...................... Dallas, TX....................... 1.0054 Collin, TX Dallas, TX Denton, TX Ellis, TX Henderson, TX Hunt, TX Kaufman, TX Rockwall, TX 1950...................... Danville, VA..................... 0.8643 Danville City, VA Pittsylvania, VA 1960...................... Davenport-Moline-Rock Island, IA- 0.8773 IL.

      [[Page 30272]]

      Scott, IA Henry, IL Rock Island, IL 2000...................... Dayton-Springfield, OH........... 0.9231 Clark, OH Greene, OH Miami, OH Montgomery, OH 2020...................... Daytona Beach, FL................ 0.8900 Flagler, FL Volusia, FL 2030...................... Decatur, AL...................... 0.8894 Lawrence, AL Morgan, AL 2040...................... Decatur, IL...................... 0.8122 Macon, IL 2080...................... Denver, CO....................... 1.0904 Adams, CO Arapahoe, CO Broomfield, CO Denver, CO Douglas, CO Jefferson, CO 2120...................... Des Moines, IA................... 0.9266 Dallas, IA Polk, IA Warren, IA 2160...................... Detroit, MI...................... 1.0227 Lapeer, MI Macomb, MI Monroe, MI Oakland, MI St. Clair, MI Wayne, MI 2180...................... Dothan, AL....................... 0.7596 Dale, AL Houston, AL 2190...................... Dover, DE........................ 0.9825 Kent, DE 2200...................... Dubuque, IA...................... 0.8748 Dubuque, IA 2240...................... Duluth-Superior, MN-WI........... 1.0356 St. Louis, MN Douglas, WI 2281...................... Dutchess County, NY.............. 1.1657 Dutchess, NY 2290...................... Eau Claire, WI................... 0.9139 Chippewa, WI Eau Claire, WI 2320...................... El Paso, TX...................... 0.9181 El Paso, TX 2330...................... Elkhart-Goshen, IN............... 0.9278 Elkhart, IN 2335...................... Elmira, NY....................... 0.8445 Chemung, NY 2340...................... Enid, OK......................... 0.9001 Garfield, OK 2360...................... Erie, PA......................... 0.8699 Erie, PA 2400...................... Eugene-Springfield, OR........... 1.0940 Lane, OR 2440...................... Evansville-Henderson, IN-KY...... 0.8395 Posey, IN Vanderburgh, IN Warrick, IN Henderson, KY 2520...................... Fargo-Moorhead, ND-MN............ 0.9114 Clay, MN Cass, ND 2560...................... Fayetteville, NC................. 0.9363

      [[Page 30273]]

      Cumberland, NC 2580...................... Fayetteville-Springdale-Rogers, 0.8636 AR. Benton, AR Washington, AR 2620...................... Flagstaff, AZ-UT................. 1.0611 Coconino, AZ Kane, UT 2640...................... Flint, MI........................ 1.1178 Genesee, MI 2650...................... Florence, AL..................... 0.7883 Colbert, AL Lauderdale, AL 2655...................... Florence, SC..................... 0.8960 Florence, SC 2670...................... Fort Collins-Loveland, CO........ 1.0218 Larimer, CO 2680...................... Ft. Lauderdale, FL............... 1.0165 Broward, FL 2700...................... Fort Myers-Cape Coral, FL........ 0.9371 Lee, FL 2710...................... Fort Pierce-Port St. Lucie, FL... 1.0046 Martin, FL St. Lucie, FL 2720...................... Fort Smith, AR-OK................ 0.8303 Crawford, AR Sebastian, AR Sequoyah, OK 2750...................... Fort Walton Beach, FL............ 0.8786 Okaloosa, FL 2760...................... Fort Wayne, IN................... 0.9737 Adams, IN Allen, IN De Kalb, IN Huntington, IN Wells, IN Whitley, IN 2800...................... Forth Worth-Arlington, TX........ 0.9520 Hood, TX Johnson, TX Parker, TX Tarrant, TX 2840...................... Fresno, CA....................... 1.0407 Fresno, CA Madera, CA 2880...................... Gadsden, AL...................... 0.8049 Etowah, AL 2900...................... Gainesville, FL.................. 0.9459 Alachua, FL 2920...................... Galveston-Texas City, TX......... 0.9403 Galveston, TX 2960...................... Gary, IN......................... 0.9342 Lake, IN Porter, IN 2975...................... Glens Falls, NY.................. 0.8467 Warren, NY Washington, NY 2980...................... Goldsboro, NC.................... 0.8778 Wayne, NC 2985...................... Grand Forks, ND-MN............... 0.9091 Polk, MN Grand Forks, ND 2995...................... Grand Junction, CO............... 0.9900 Mesa, CO 3000...................... Grand Rapids-Muskegon-Holland, MI 0.9519 Allegan, MI Kent, MI Muskegon, MI Ottawa, MI 3040...................... Great Falls, MT.................. 0.8810 Cascade, MT

      [[Page 30274]]

      3060...................... Greeley, CO...................... 0.9444 Weld, CO 3080...................... Green Bay, WI.................... 0.9586 Brown, WI 3120...................... Greensboro-Winston-Salem-High

      0.9312 Point, NC. Alamance, NC Davidson, NC Davie, NC Forsyth, NC Guilford, NC Randolph, NC Stokes, NC Yadkin, NC 3150...................... Greenville, NC................... 0.9183 Pitt, NC 3160...................... Greenville-Spartanburg-Anderson, 0.9400 SC. Anderson, SC Cherokee, SC Greenville, SC Pickens, SC Spartanburg, SC 3180...................... Hagerstown, MD................... 0.9940 Washington, MD 3200...................... Hamilton-Middletown, OH.......... 0.9066 Butler, OH 3240...................... Harrisburg-Lebanon-Carlisle, PA.. 0.9286 Cumberland, PA Dauphin, PA Lebanon, PA Perry, PA 3283...................... Hartford, CT..................... 1.1054 Hartford, CT Litchfield, CT Middlesex, CT Tolland, CT 3285...................... Hattiesburg, MS.................. 0.7362 Forrest, MS Lamar, MS 3290...................... Hickory-Morganton-Lenoir, NC..... 0.9502 Alexander, NC Burke, NC Caldwell, NC Catawba, NC 3320...................... Honolulu, HI..................... 1.1013 Honolulu, HI 3350...................... Houma, LA........................ 0.7721 Lafourche, LA Terrebonne, LA 3360...................... Houston, TX...................... 1.0117 Chambers, TX Fort Bend, TX Harris, TX Liberty, TX Montgomery, TX Waller, TX 3400...................... Huntington-Ashland, WV-KY-OH..... 0.9564 Boyd, KY Carter, KY Greenup, KY Lawrence, OH Cabell, WV Wayne, WV 3440...................... Huntsville, AL................... 0.8851 Limestone, AL Madison, AL 3480...................... Indianapolis, IN................. 1.0039 Boone, IN Hamilton, IN Hancock, IN Hendricks, IN

      [[Page 30275]]

      Johnson, IN Madison, IN Marion, IN Morgan, IN Shelby, IN 3500...................... Iowa City, IA.................... 0.9654 Johnson, IA 3520...................... Jackson, MI...................... 0.9146 Jackson, MI 3560...................... Jackson, MS...................... 0.8406 Hinds, MS Madison, MS Rankin, MS 3580...................... Jackson, TN...................... 0.8900 Chester, TN Madison, TN 3600...................... Jacksonville, FL................. 0.9548 Clay, FL Duval, FL Nassau, FL St. Johns, FL 3605...................... Jacksonville, NC................. 0.8401 Onslow, NC 3610...................... Jamestown, NY.................... 0.7589 Chautaqua, NY 3620...................... Janesville-Beloit, WI............ 0.9583 Rock, WI 3640...................... Jersey City, NJ.................. 1.0923 Hudson, NJ 3660...................... Johnson City-Kingsport-Bristol, 0.8202 TN-VA. Carter, TN Hawkins, TN Sullivan, TN Unicoi, TN Washington, TN Bristol City, VA Scott, VA Washington, VA 3680...................... Johnstown, PA.................... 0.7980 Cambria, PA Somerset, PA 3700...................... Jonesboro, AR.................... 0.8144 Craighead, AR 3710...................... Joplin, MO....................... 0.8721 Jasper, MO Newton, MO 3720...................... Kalamazoo-Battlecreek, MI........ 1.0350 Calhoun, MI Kalamazoo, MI Van Buren, MI 3740...................... Kankakee, IL..................... 1.0603 Kankakee, IL 3760...................... Kansas City, KS-MO............... 0.9641 Johnson, KS Leavenworth, KS Miami, KS Wyandotte, KS Cass, MO Clay, MO Clinton, MO Jackson, MO Lafayette, MO Platte, MO Ray, MO 3800...................... Kenosha, WI...................... 0.9772 Kenosha, WI 3810...................... Killeen-Temple, TX............... 0.9242 Bell, TX Coryell, TX 3840...................... Knoxville, TN.................... 0.8508

      [[Page 30276]]

      Anderson, TN Blount, TN Knox, TN Loudon, TN Sevier, TN Union, TN 3850...................... Kokomo, IN....................... 0.8986 Howard, IN Tipton, IN 3870...................... La Crosse, WI-MN................. 0.9289 Houston, MN La Crosse, WI 3880...................... Lafayette, LA.................... 0.8105 Acadia, LA Lafayette, LA St. Landry, LA St. Martin, LA 3920...................... Lafayette, IN.................... 0.9067 Clinton, IN Tippecanoe, IN 3960...................... Lake Charles, LA................. 0.7972 Calcasieu, LA 3980...................... Lakeland-Winter Haven, FL........ 0.8930 Polk, FL 4000...................... Lancaster, PA.................... 0.9883 Lancaster, PA 4040...................... Lansing-East Lansing, MI......... 0.9658 Clinton, MI Eaton, MI Ingham, MI 4080...................... Laredo, TX....................... 0.8747 Webb, TX 4100...................... Las Cruces, NM................... 0.8784 Dona Ana, NM 4120...................... Las Vegas, NV-AZ................. 1.1121 Mohave, AZ Clark, NV Nye, NV 4150...................... Lawrence, KS..................... 0.8644 Douglas, KS 4200...................... Lawton, OK....................... 0.8212 Comanche, OK 4243...................... Lewiston-Auburn, ME.............. 0.9562 Androscoggin, ME 4280...................... Lexington, KY.................... 0.9219 Bourbon, KY Clark, KY Fayette, KY Jessamine, KY Madison, KY Scott, KY Woodford, KY 4320...................... Lima, OH......................... 0.9258 Allen, OH Auglaize, OH 4360...................... Lincoln, NE...................... 1.0208 Lancaster, NE 4400...................... Little Rock-North Little, AR..... 0.8826 Faulkner, AR Lonoke, AR Pulaski, AR Saline, AR 4420...................... Longview-Marshall, TX............ 0.8739 Gregg, TX Harrison, TX Upshur, TX 4480...................... Los Angeles-Long Beach, CA....... 1.1732 Los Angeles, CA 4520...................... Louisville, KY-IN................ 0.9162 Clark, IN

      [[Page 30277]]

      Floyd, IN Harrison, IN Scott, IN Bullitt, KY Jefferson, KY Oldham, KY 4600...................... Lubbock, TX...................... 0.8777 Lubbock, TX 4640...................... Lynchburg, VA.................... 0.9017 Amherst, VA Bedford City, VA Bedford, VA Campbell, VA Lynchburg City, VA 4680...................... Macon, GA........................ 0.9596 Bibb, GA Houston, GA Jones, GA Peach, GA Twiggs, GA 4720...................... Madison, WI...................... 1.0395 Dane, WI 4800...................... Mansfield, OH.................... 0.9105 Crawford, OH Richland, OH 4840...................... Mayaguez, PR..................... 0.4769 Anasco, PR Cabo Rojo, PR Hormigueros, PR Mayaguez, PR Sabana Grande, PR San German, PR 4880...................... McAllen-Edinburg-Mission, TX..... 0.8602 Hidalgo, TX 4890...................... Medford-Ashland, OR.............. 1.0534 Jackson, OR 4900...................... Melbourne-Titusville-Palm Bay, FL 0.9633 Brevard, FL 4920...................... Memphis, TN-AR-MS................ 0.9234 Crittenden, AR De Soto, MS Fayette, TN Shelby, TN Tipton, TN 4940...................... Merced, CA....................... 1.0575 Merced, CA 5000...................... Miami, FL........................ 0.9870 Dade, FL 5015...................... Middlesex-Somerset-Hunterdon, NJ. 1.1360 Hunterdon, NJ Middlesex, NJ Somerset, NJ 5080...................... Milwaukee-Waukesha, WI........... 1.0076 Milwaukee, WI Ozaukee, WI Washington, WI Waukesha, WI 5120...................... Minneapolis-St. Paul, MN-WI...... 1.1066 Anoka, MN Carver, MN Chisago, MN Dakota, MN Hennepin, MN Isanti, MN Ramsey, MN Scott, MN Sherburne, MN Washington, MN Wright, MN Pierce, WI

      [[Page 30278]]

      St. Croix, WI 5140...................... Missoula, MT..................... 0.9618 Missoula, MT 5160...................... Mobile, AL....................... 0.7932 Baldwin, AL Mobile, AL 5170...................... Modesto, CA...................... 1.1966 Stanislaus, CA 5190...................... Monmouth-Ocean, NJ............... 1.0888 Monmouth, NJ Ocean, NJ 5200...................... Monroe, LA....................... 0.7913 Ouachita, LA 5240...................... Montgomery, AL................... 0.8300 Autauga, AL Elmore, AL Montgomery, AL 5280...................... Muncie, IN....................... 0.8580 Delaware, IN 5330...................... Myrtle Beach, SC................. 0.9022 Horry, SC 5345...................... Naples, FL....................... 1.0558 Collier, FL 5360...................... Nashville, TN.................... 1.0108 Cheatham, TN Davidson, TN Dickson, TN Robertson, TN Rutherford, TN Sumner, TN Williamson, TN Wilson, TN 5380...................... Nassau-Suffolk, NY............... 1.2907 Nassau, NY Suffolk, NY 5483...................... New Haven-Bridgeport-Stamford-

      1.2254 Waterbury-Danbury, CT. Fairfield, CT New Haven, CT 5523...................... New London-Norwich, CT........... 1.1596 New London, CT 5560...................... New Orleans, LA.................. 0.9103 Jefferson, LA Orleans, LA Plaquemines, LA St. Bernard, LA St. Charles, LA St. James, LA St. John The Baptist, LA St. Tammany, LA 5600...................... New York, NY..................... 1.3586 Bronx, NY Kings, NY New York, NY Putnam, NY Queens, NY Richmond, NY Rockland, NY Westchester, NY 5640...................... Newark, NJ....................... 1.1625 Essex, NJ Morris, NJ Sussex, NJ Union, NJ Warren, NJ 5660...................... Newburgh, NY-PA.................. 1.1170 Orange, NY Pike, PA 5720...................... Norfolk-Virginia Beach-Newport

      0.8894 News, VA-NC. Currituck, NC Chesapeake City, VA

      [[Page 30279]]

      Gloucester, VA Hampton City, VA Isle of Wight, VA James City, VA Mathews, 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 5775...................... Oakland, CA...................... 1.5220 Alameda, CA Contra Costa, CA 5790...................... Ocala, FL........................ 0.9153 Marion, FL 5800...................... Odessa-Midland, TX............... 0.9632 Ector, TX Midland, TX 5880...................... Oklahoma City, OK................ 0.8966 Canadian, OK Cleveland, OK Logan, OK McClain, OK Oklahoma, OK Pottawatomie, OK 5910...................... Olympia, WA...................... 1.1006 Thurston, WA 5920...................... Omaha, NE-IA..................... 0.9754 Pottawattamie, IA Cass, NE Douglas, NE Sarpy, NE Washington, NE 5945...................... Orange County, CA................ 1.1611 Orange, CA 5960...................... Orlando, FL...................... 0.9742 Lake, FL Orange, FL Osceola, FL Seminole, FL 5990...................... Owensboro, KY.................... 0.8434 Daviess, KY 6015...................... Panama City, FL.................. 0.8124 Bay, FL 6020...................... Parkersburg-Marietta, WV-OH...... 0.8288 Washington, OH Wood, WV 6080...................... Pensacola, FL.................... 0.8306 Escambia, FL Santa Rosa, FL 6120...................... Peoria-Pekin, IL................. 0.8886 Peoria, IL Tazewell, IL Woodford, IL 6160...................... Philadelphia, PA-NJ.............. 1.0824 Burlington, NJ Camden, NJ Gloucester, NJ Salem, NJ Bucks, PA Chester, PA Delaware, PA Montgomery, PA Philadelphia, PA 6200...................... Phoenix-Mesa, AZ................. 0.9982 Maricopa, AZ Pinal, AZ

      [[Page 30280]]

      6240...................... Pine Bluff, AR................... 0.8673 Jefferson, AR 6280...................... Pittsburgh, PA................... 0.8756 Allegheny, PA Beaver, PA Butler, PA Fayette, PA Washington, PA Westmoreland, PA 6323...................... Pittsfield, MA................... 1.0439 Berkshire, MA 6340...................... Pocatello, ID.................... 0.9601 Bannock, ID 6360...................... Ponce, PR........................ 0.4954 Guayanilla, PR Juana Diaz, PR Penuelas, PR Ponce, PR Villalba, PR Yauco, PR 6403...................... Portland, ME..................... 1.0112 Cumberland, ME Sagadahoc, ME York, ME 6440...................... Portland-Vancouver, OR-WA........ 1.1403 Clackamas, OR Columbia, OR Multnomah, OR Washington, OR Yamhill, OR Clark, WA 6483...................... Providence-Warwick-Pawtucket, RI. 1.1061 Bristol, RI Kent, RI Newport, RI Providence, RI Washington, RI 6520...................... Provo-Orem, UT................... 0.9613 Utah, UT 6560...................... Pueblo, CO....................... 0.8752 Pueblo, CO 6580...................... Punta Gorda, FL.................. 0.9441 Charlotte, FL 6600...................... Racine, WI....................... 0.9045 Racine, WI 6640...................... Raleigh-Durham-Chapel Hill, NC... 1.0258 Chatham, NC Durham, NC Franklin, NC Johnston, NC Orange, NC Wake, NC 6660...................... Rapid City, SD................... 0.8912 Pennington, SD 6680...................... Reading, PA...................... 0.9215 Berks, PA 6690...................... Redding, CA...................... 1.1835 Shasta, CA 6720...................... Reno, NV......................... 1.0456 Washoe, NV 6740...................... Richland-Kennewick-Pasco, WA..... 1.0520 Benton, WA Franklin, WA 6760...................... Richmond-Petersburg, VA.......... 0.9397 Charles City County, VA Chesterfield, VA Colonial Heights City, VA Dinwiddie, VA Goochland, VA Hanover, VA

      [[Page 30281]]

      Henrico, VA Hopewell City, VA New Kent, VA Petersburg City, VA Powhatan, VA Prince George, VA Richmond City, VA 6780...................... Riverside-San Bernardino, CA..... 1.0970 Riverside, CA San Bernardino, CA 6800...................... Roanoke, VA...................... 0.8428 Botetourt, VA Roanoke, VA Roanoke City, VA Salem City, VA 6820...................... Rochester, MN.................... 1.1504 Olmsted, MN 6840...................... Rochester, NY.................... 0.9196 Genesee, NY Livingston, NY Monroe, NY Ontario, NY Orleans, NY Wayne, NY 6880...................... Rockford, IL..................... 0.9626 Boone, IL Ogle, IL Winnebago, IL 6895...................... Rocky Mount, NC.................. 0.8998 Edgecombe, NC Nash, NC 6920...................... Sacramento, CA................... 1.1848 El Dorado, CA Placer, CA Sacramento, CA 6960...................... Saginaw-Bay City-Midland, MI..... 0.9696 Bay, MI Midland, MI Saginaw, MI 6980...................... St. Cloud, MN.................... 1.0215 Benton, MN Stearns, MN 7000...................... St. Joseph, MO................... 1.0013 Andrews, MO Buchanan, MO 7040...................... St. Louis, MO-IL................. 0.9081 Clinton, IL Jersey, IL Madison, IL Monroe, IL St. Clair, IL Franklin, MO Jefferson, MO Lincoln, MO St. Charles, MO St. Louis, MO St. Louis City, MO Warren, MO Sullivan City, MO 7080...................... Salem, OR........................ 1.0556 Marion, OR Polk, OR 7120...................... Salinas, CA...................... 1.3823 Monterey, CA 7160...................... Salt Lake City-Ogden, UT......... 0.9487 Davis, UT Salt Lake, UT Weber, UT 7200...................... San Angelo, TX................... 0.8167 Tom Green, TX

      [[Page 30282]]

      7240...................... San Antonio, TX.................. 0.9023 Bexar, TX Comal, TX Guadalupe, TX Wilson, TX 7320...................... San Diego, CA.................... 1.1267 San Diego, CA 7360...................... San Francisco, CA................ 1.4712 Marin, CA San Francisco, CA San Mateo, CA 7400...................... San Jose, CA..................... 1.4744 Santa Clara, CA 7440...................... San Juan-Bayamon, PR............. 0.4802 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 1.1118 Robles, CA. San Luis Obispo, CA 7480...................... Santa Barbara-Santa Maria-Lompoc, 1.0771 CA. Santa Barbara, CA 7485...................... Santa Cruz-Watsonville, CA....... 1.4779 Santa Cruz, CA 7490...................... Santa Fe, NM..................... 1.0590 Los Alamos, NM Santa Fe, NM 7500...................... Santa Rosa, CA................... 1.2961 Sonoma, CA 7510...................... Sarasota-Bradenton, FL........... 0.9629 Manatee, FL Sarasota, FL 7520...................... Savannah, GA..................... 0.9460 Bryan, GA Chatham, GA Effingham, GA 7560...................... Scranton--Wilkes-Barre--Hazleton, 0.8522 PA. Columbia, PA Lackawanna, PA Luzerne, PA Wyoming, PA 7600...................... Seattle-Bellevue-Everett, WA..... 1.1479 Island, WA King, WA

      [[Page 30283]]

      Snohomish, WA 7610...................... Sharon, PA....................... 0.7881 Mercer, PA 7620...................... Sheboygan, WI.................... 0.8948 Sheboygan, WI 7640...................... Sherman-Denison, TX.............. 0.9617 Grayson, TX 7680...................... Shreveport-Bossier City, LA...... 0.9111 Bossier, LA Caddo, LA Webster, LA 7720...................... Sioux City, IA-NE................ 0.9094 Woodbury, IA Dakota, NE 7760...................... Sioux Falls, SD.................. 0.9441 Lincoln, SD Minnehaha, SD 7800...................... South Bend, IN................... 0.9447 St. Joseph, IN 7840...................... Spokane, WA...................... 1.0660 Spokane, WA 7880...................... Springfield, IL.................. 0.8738 Menard, IL Sangamon, IL 7920...................... Springfield, MO.................. 0.8597 Christian, MO Greene, MO Webster, MO 8003...................... Springfield, MA.................. 1.0173 Hampden, MA Hampshire, MA 8050...................... State College, PA................ 0.8461 Centre, PA 8080...................... Steubenville-Weirton, OH-WV...... 0.8280 Jefferson, OH Brooke, WV Hancock, WV 8120...................... Stockton-Lodi, CA................ 1.0564 San Joaquin, CA 8140...................... Sumter, SC....................... 0.8520 Sumter, SC 8160...................... Syracuse, NY..................... 0.9394 Cayuga, NY Madison, NY Onondaga, NY Oswego, NY 8200...................... Tacoma, WA....................... 1.1078 Pierce, WA 8240...................... Tallahassee, FL.................. 0.8655 Gadsden, FL Leon, FL 8280...................... Tampa-St. Petersburg-Clearwater, 0.9024 FL. Hernando, FL Hillsborough, FL Pasco, FL Pinellas, FL 8320...................... Terre Haute, IN.................. 0.8582 Clay, IN Vermillion, IN Vigo, IN 8360...................... Texarkana, AR-Texarkana, TX...... 0.8413 Miller, AR Bowie, TX 8400...................... Toledo, OH....................... 0.9524 Fulton, OH Lucas, OH Wood, OH 8440...................... Topeka, KS....................... 0.8904 Shawnee, KS 8480...................... Trenton, NJ...................... 1.0276

      [[Page 30284]]

      Mercer, NJ 8520...................... Tucson, AZ....................... 0.8926 Pima, AZ 8560...................... Tulsa, OK........................ 0.8729 Creek, OK Osage, OK Rogers, OK Tulsa, OK Wagoner, OK 8600...................... Tuscaloosa, AL................... 0.8440 Tuscaloosa, AL 8640...................... Tyler, TX........................ 0.9502 Smith, TX 8680...................... Utica-Rome, NY................... 0.8295 Herkimer, NY Oneida, NY 8720...................... Vallejo-Fairfield-Napa, CA....... 1.3517 Napa, CA Solano, CA 8735...................... Ventura, CA...................... 1.1105 Ventura, CA 8750...................... Victoria, TX..................... 0.8469 Victoria, TX 8760...................... Vineland-Millville-Bridgeton, NJ. 1.0573 Cumberland, NJ 8780...................... Visalia-Tulare-Porterville, CA... 0.9975 Tulare, CA 8800...................... Waco, TX......................... 0.8146 McLennan, TX 8840...................... Washington, DC-MD-VA-WV.......... 1.0971 District of Columbia, DC Calvert, MD Charles, MD Frederick, MD Montgomery, MD Prince Georges, MD Alexandria City, VA Arlington, VA Clarke, VA Culpepper, VA Fairfax, VA Fairfax City, VA Falls Church City, VA Fauquier, VA Fredericksburg City, VA King George, VA Loudoun, VA Manassas City, VA Manassas Park City, VA Prince William, VA Spotsylvania, VA Stafford, VA Warren, VA Berkeley, WV Jefferson, WV 8920...................... Waterloo-Cedar Falls, IA......... 0.8633 Black Hawk, IA 8940...................... Wausau, WI....................... 0.9570 Marathon, WI 8960...................... West Palm Beach-Boca Raton, FL... 1.0362 Palm Beach, FL 9000...................... Wheeling, OH-WV.................. 0.7449 Belmont, OH Marshall, WV Ohio, WV 9040...................... Wichita, KS...................... 0.9486 Butler, KS Harvey, KS Sedgwick, KS 9080...................... Wichita Falls, TX................ 0.8395

      [[Page 30285]]

      Archer, TX Wichita, TX 9140...................... Williamsport, PA................. 0.8485 Lycoming, PA 9160...................... Wilmington-Newark, DE-MD......... 1.1121 New Castle, DE Cecil, MD 9200...................... Wilmington, NC................... 0.9237 New Hanover, NC Brunswick, NC 9260...................... Yakima, WA....................... 1.0322 Yakima, WA 9270...................... Yolo, CA......................... 0.9378 Yolo, CA 9280...................... York, PA......................... 0.9150 York, PA 9320...................... Youngstown-Warren, OH............ 0.9517 Columbiana, OH Mahoning, OH Trumbull, OH 9340...................... Yuba City, CA.................... 1.0363 Sutter, CA Yuba, CA 9360...................... Yuma, AZ......................... 0.8871 Yuma, AZ

      Table 1B.--FY 2006 IRF PPS MSA Labor Market Area Designations for Rural Areas for the Purposes of Comparing Wage Index Values With Table 2B

      Wage Nonurban area

      Index

      Alabama...................................................... 0.7637 Alaska....................................................... 1.1637 Arizona...................................................... 0.9140 Arkansas..................................................... 0.7703 California................................................... 1.0297 Colorado..................................................... 0.9368 Connecticut.................................................. 1.1917 Delaware..................................................... 0.9503 Florida...................................................... 0.8721 Georgia...................................................... 0.8247 Guam......................................................... 0.9611 Hawaii....................................................... 1.0522 Idaho........................................................ 0.8826 Illinois..................................................... 0.8340 Indiana...................................................... 0.8736 Iowa......................................................... 0.8550 Kansas....................................................... 0.8087 Kentucky..................................................... 0.7844 Louisiana.................................................... 0.7290 Maine........................................................ 0.9039 Maryland..................................................... 0.9179 Massachusetts................................................ 1.0216 Michigan..................................................... 0.8740 Minnesota.................................................... 0.9339 Mississippi.................................................. 0.7583 Missouri..................................................... 0.7829 Montana...................................................... 0.8701 Nebraska..................................................... 0.9035 Nevada....................................................... 0.9832 New Hampshire................................................ 0.9940 New Jersey \1\............................................... ......... New Mexico................................................... 0.8529 New York..................................................... 0.8403 North Carolina............................................... 0.8500 North Dakota................................................. 0.7743 Ohio......................................................... 0.8759 Oklahoma..................................................... 0.7537 Oregon....................................................... 1.0049 Pennsylvania................................................. 0.8348 Puerto Rico.................................................. 0.4047 Rhode Island \1\............................................. ......... South Carolina............................................... 0.8640 South Dakota................................................. 0.8393 Tennessee.................................................... 0.7876 Texas........................................................ 0.7910 Utah......................................................... 0.8843 Vermont...................................................... 0.9375 Virginia..................................................... 0.8479 Virgin Islands............................................... 0.7456 Washington................................................... 1.0072 West Virginia................................................ 0.8083 Wisconsin.................................................... 0.9498 Wyoming...................................................... 0.9182

      \1\ All counties within the State are classified urban.

      Table 2a.--Proposed Inpatient Rehabilitaion Facility Wage Index for Urban Areas Based on Proposed CBSA Labor Market Areas For Discharges Occurring on or After October 1, 2005

      Urban area (Constituent Full wage CBSA code

      counties)

      Index

      10180..................... Abilene, TX...................... 0.7850 Callahan County, TX Jones County, TX Taylor County, TX 10380..................... Aguadilla-Isabela-San

      0.4280 Sebasti[aacute]n, PR. Aguada Municipio, PR

      [[Page 30286]]

      Aguadilla Municipio, PR Aasco Municipio, PR Isabela Municipio, PR Lares Municipio, PR Moca Municipio, PR Rinc[iacute]n Municipio, PR San Sebasti[aacute]n Municipio, PR 10420..................... Akron, OH........................ 0.9055 Portage County, OH Summit County, OH 10500..................... Albany, GA....................... 1.1266 Baker County, GA Dougherty County, GA Lee County, GA Terrell County, GA Worth County, GA 10580..................... Albany-Schenectady-Troy, NY...... 0.8650 Albany County, NY Rensselaer County, NY Saratoga County, NY Schenectady County, NY Schoharie County, NY 10740..................... Albuquerque, NM.................. 1.0485 Bernalillo County, NM Sandoval County, NM Torrance County, NM Valencia County, NM 10780..................... Alexandria, LA................... 0.8171 Grant Parish, LA Rapides Parish, LA 10900..................... Allentown-Bethlehem-Easton, PA-NJ 0.9501 Warren County, NJ Carbon County, PA Lehigh County, PA Northampton County, PA 11020..................... Altoona, PA...................... 0.8462 Blair County, PA 11100..................... Amarillo, TX..................... 0.9178 Armstrong County, TX Carson County, TX Potter County, TX Randall County, TX 11180..................... Ames, IA......................... 0.9479 Story County, IA 11260..................... Anchorage, AK.................... 1.2165 Anchorage Municipality, AK Matanuska-Susitna Borough, AK 11300..................... Anderson, IN..................... 0.8713 Madison County, IN 11340..................... Anderson, SC..................... 0.8670 Anderson County, SC 11460..................... Ann Arbor, MI.................... 1.1022 Washtenaw County, MI 11500..................... Anniston-Oxford, AL.............. 0.7881 Calhoun County, AL 11540..................... Appleton, WI..................... 0.9131 Calumet County, WI Outagamie County, WI 11700..................... Asheville, NC.................... 0.9191 Buncombe County, NC Haywood County, NC Henderson County, NC Madison County, NC 12020..................... Athens-Clarke County, GA......... 1.0202 Clarke County, GA Madison County, GA Oconee County, GA Oglethorpe County, GA 12060..................... Atlanta-Sandy Springs-Marietta, 0.9971 GA. Barrow County, GA

      [[Continued on page 30287]]

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

      [[pp. 30287-30327]] Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for FY 2006

      [[Continued from page 30286]]

      [[Page 30287]]

      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, NJ................ 1.0931 Atlantic County, NJ 12220..................... Auburn-Opelika, AL............... 0.8215 Lee County, AL 12260..................... Augusta-Richmond County, GA-SC... 0.9154 Burke County, GA Columbia County, GA McDuffie County, GA Richmond County, GA Aiken County, SC Edgefield County, SC 12420..................... Austin-Round Rock, TX............ 0.9595 Bastrop County, TX Caldwell County, TX Hays County, TX Travis County, TX Williamson County, TX 12540..................... Bakersfield, CA.................. 1.0036 Kern County, CA 12580..................... Baltimore-Towson, MD............. 0.9907 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....................... 0.9955 Penobscot County, ME 12700..................... Barnstable Town, MA.............. 1.2335 Barnstable County, MA 12940..................... Baton Rouge, LA.................. 0.8319 Ascension Parish, LA East Baton Rouge Parish, LA East Feliciana Parish, LA Iberville Parish, LA Livingston Parish, LA Pointe Coupee Parish, LA St. Helena Parish, LA West Baton Rouge Parish, LA West Feliciana Parish, LA 12980..................... Battle Creek, MI................. 0.9366 Calhoun County, MI

      [[Page 30288]]

      13020..................... Bay City, MI..................... 0.9574 Bay County, MI 13140..................... Beaumont-Port Arthur, TX......... 0.8616 Hardin County, TX Jefferson County, TX Orange County, TX 13380..................... Bellingham, WA................... 1.1642 Whatcom County, WA 13460..................... Bend, OR......................... 1.0603 Deschutes County, OR 13644..................... Bethesda-Frederick-Gaithersburg, 1.0956 MD. Frederick County, MD Montgomery County, MD 13740..................... Billings, MT..................... 0.8961 Carbon County, MT Yellowstone County, MT 13780..................... Binghamton, NY................... 0.8447 Broome County, NY Tioga County, NY 13820..................... Birmingham-Hoover, AL............ 0.9157 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..................... 0.7505 Burleigh County, ND Morton County, ND 13980..................... Blacksburg-Christiansburg-

      0.7951 Radford, VA. Giles County, VA Montgomery County, VA Pulaski County, VA Radford City, VA 14020..................... Bloomington, IN.................. 0.8587 Greene County, IN Monroe County, IN Owen County, IN 14060..................... Bloomington-Normal, IL........... 0.9111 McLean County, IL 14260..................... Boise City-Nampa, ID............. 0.9352 Ada County, ID Boise County, ID Canyon County, ID Gem County, ID Owyhee County, ID 14484..................... Boston-Quincy, MA................ 1.1771 Norfolk County, MA Plymouth County, MA Suffolk County, MA 14500..................... Boulder, CO...................... 1.0046 Boulder County, CO 14540..................... Bowling Green, KY................ 0.8140 Edmonson County, KY Warren County, KY 14740..................... Bremerton-Silverdale, WA......... 1.0614 Kitsap County, WA 14860..................... Bridgeport-Stamford-Norwalk, CT.. 1.2835 Fairfield County, CT 15180..................... Brownsville-Harlingen, TX........ 1.0125 Cameron County, TX 15260..................... Brunswick, GA.................... 1.1933 Brantley County, GA Glynn County, GA McIntosh County, GA 15380..................... Buffalo-Niagara Falls, NY........ 0.9339 Erie County, NY Niagara County, NY 15500..................... Burlington, NC................... 0.8967

      [[Page 30289]]

      Alamance County, NC 15540..................... Burlington-South Burlington, VT.. 0.9322 Chittenden County, VT Franklin County, VT Grand Isle County, VT 15764..................... Cambridge-Newton-Framingham, MA.. 1.1189 Middlesex County, MA 15804..................... Camden, NJ....................... 1.0675 Burlington County, NJ Camden County, NJ Gloucester County, NJ 15940..................... Canton-Massillon, OH............. 0.8895 Carroll County, OH Stark County, OH 15980..................... Cape Coral-Fort Myers, FL........ 0.9371 Lee County, FL 16180..................... Carson City, NV.................. 1.0352 Carson City, NV 16220..................... Casper, WY....................... 0.9243 Natrona County, WY 16300..................... Cedar Rapids, IA................. 0.8975 Benton County, IA Jones County, IA Linn County, IA 16580..................... Champaign-Urbana, IL............. 0.9527 Champaign County, IL Ford County, IL Piatt County, IL 16620..................... Charleston, WV................... 0.8876 Boone County, WV Clay County, WV Kanawha County, WV Lincoln County, WV Putnam County, WV 16700..................... Charleston-North Charleston, SC.. 0.9420 Berkeley County, SC Charleston County, SC Dorchester County, SC 16740..................... Charlotte-Gastonia-Concord, NC-SC 0.9743 Anson County, NC Cabarrus County, NC Gaston County, NC Mecklenburg County, NC Union County, NC York County, SC 16820..................... Charlottesville, VA.............. 1.0294 Albemarle County, VA Fluvanna County, VA Greene County, VA Nelson County, VA Charlottesville City, VA 16860..................... Chattanooga, TN-GA............... 0.9207 Catoosa County, GA Dade County, GA Walker County, GA Hamilton County, TN Marion County, TN Sequatchie County, TN 16940..................... Cheyenne, WY..................... 0.8980 Laramie County, WY 16974..................... Chicago-Naperville-Joliet, IL.... 1.0868 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........................ 1.0542

      [[Page 30290]]

      Butte County, CA 17140..................... Cincinnati-Middletown, OH-KY-IN.. 0.9516 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............... 0.8022 Christian County, KY Trigg County, KY Montgomery County, TN Stewart County, TN 17420..................... Cleveland, TN.................... 0.7844 Bradley County, TN Polk County, TN 17460..................... Cleveland-Elyria-Mentor, OH...... 0.9650 Cuyahoga County, OH Geauga County, OH Lake County, OH Lorain County, OH Medina County, OH 17660..................... Coeur d'Alene, ID................ 0.9339 Kootenai County, ID 17780..................... College Station-Bryan, TX........ 0.9243 Brazos County, TX Burleson County, TX Robertson County, TX 17820..................... Colorado Springs, CO............. 0.9792 El Paso County, CO Teller County, CO 17860..................... Columbia, M...................... 0.8396 Boone County, MO Howard County, MO 17900..................... Columbia, SC..................... 0.9392 Calhoun County, SC Fairfield County, SC Kershaw County, SC Lexington County, SC Richland County, SC Saluda County, SC 17980..................... Columbus, GA-AL.................. 0.8690 Russell County, AL Chattahoochee County, GA Harris County, GA Marion County, GA Muscogee County, GA 18020..................... Columbus, IN..................... 0.9388 Bartholomew County, IN 18140..................... Columbus, OH..................... 0.9737 Delaware County, OH 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............... 0.8647 Aransas County, TX Nueces County, TX

      [[Page 30291]]

      San Patricio County, TX 18700..................... Corvallis, OR.................... 1.0545 Benton County, OR 19060..................... Cumberland, MD-WV................ 0.8662 Allegany County, MD Mineral County, WV 19124..................... Dallas-Plano-Irving, TX.......... 1.0074 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....................... 0.9558 Murray County, GA Whitfield County, GA 19180..................... Danville, IL..................... 0.8392 Vermilion County, IL 19260..................... Danville, VA..................... 0.8643 Pittsylvania County, VA Danville City, VA 19340..................... Davenport-Moline-Rock Island, IA- 0.8773 IL. Henry County, IL Mercer County, IL Rock Island County, IL Scott County, IA 19380..................... Dayton, OH....................... 0.9303 Greene County, OH Miami County, OH Montgomery County, OH Preble County, OH 19460..................... Decatur, AL...................... 0.8894 Lawrence County, AL Morgan County, AL 19500..................... Decatur, IL...................... 0.8122 Macon County, IL 19660..................... Deltona-Daytona Beach-Ormond

      0.8898 Beach, FL. Volusia County, FL 19740..................... Denver-Aurora, CO................ 1.0904 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, IA................... 0.9266 Dallas County, IA Guthrie County, IA Madison County, IA Polk County, IA Warren County, IA 19804..................... Detroit-Livonia-Dearborn, MI..... 1.0349 Wayne County, MI 20020..................... Dothan, AL....................... 0.7537 Geneva County, AL Henry County, AL Houston County, AL 20100..................... Dover, DE........................ 0.9825 Kent County, DE 20220..................... Dubuque, IA...................... 0.8748 Dubuque County, IA 20260..................... Duluth, MN-WI.................... 1.0340 Carlton County, MN St. Louis County, MN

      [[Page 30292]]

      Douglas County, WI 20500..................... Durham, NC....................... 1.0363 Chatham County, NC Durham County, NC Orange County, NC Person County, NC 20740..................... Eau Claire, WI................... 0.9139 Chippewa County, WI Eau Claire County, WI 20764..................... Edison, NJ....................... 1.1136 Middlesex County, NJ Monmouth County, NJ Ocean County, NJ Somerset County, NJ 20940..................... El Centro, CA.................... 0.8856 Imperial County, CA 21060..................... Elizabethtown, KY................ 0.8684 Hardin County, KY Larue County, KY 21140..................... Elkhart-Goshen, IN............... 0.9278 Elkhart County, IN 21300..................... Elmira, NY....................... 0.8445 Chemung County, NY 21340..................... El Paso, TX...................... 0.9181 El Paso County, TX 21500..................... Erie, PA......................... 0.8699 Erie County, PA 21604..................... Essex County, MA................. 1.0662 Essex County, MA 21660..................... Eugene-Springfield, OR........... 1.0940 Lane County, OR 21780..................... Evansville, IN-KY................ 0.8372 Gibson County, IN Posey County, IN Vanderburgh County, IN Warrick County, IN Henderson County, KY Webster County, KY 21820..................... Fairbanks, AK.................... 1.1146 Fairbanks North Star Borough, AK 21940..................... Fajardo, PR...................... 0.3939 Ceiba Municipio, PR Fajardo Municipio, PR Luquillo Municipio, PR 22020..................... Fargo, ND-MN..................... 0.9114 Cass County, ND Clay County, MN 22140..................... Farmington, NM................... 0.8049 San Juan County, NM 22180..................... Fayetteville, NC................. 0.9363 Cumberland County, NC Hoke County, NC 22220..................... Fayetteville-Springdale-Rogers, 0.8636 AR-MO. Benton County, AR Madison County, AR Washington County, AR McDonald County, MO 22380..................... Flagstaff, AZ.................... 1.0787 Coconino County, AZ 22420..................... Flint, MI........................ 1.1178 Genesee County, MI 22500..................... Florence, SC..................... 0.8833 Darlington County, SC Florence County, SC 22520..................... Florence-Muscle Shoals, AL....... 0.7883 Colbert County, AL Lauderdale County, AL 22540..................... Fond du Lac, WI.................. 0.9897 Fond du Lac County, WI 22660..................... Fort Collins-Loveland, CO........ 1.0218

      [[Page 30293]]

      Larimer County, CO 22744..................... Fort Lauderdale-Pompano Beach-

      1.0165 Deerfield Beach, FL. Broward County, FL 22900..................... Fort Smith, AR-OK................ 0.8283 Crawford County, AR Franklin County, AR Sebastian County, AR Le Flore County, OK Sequoyah County, OK 23020..................... Fort Walton Beach-Crestview-

      0.8786 Destin, FL. Okaloosa County, FL 23060..................... Fort Wayne, IN................... 0.9807 Allen County, IN Wells County, IN Whitley County, IN 23104..................... Fort Worth-Arlington, TX......... 0.9472 Johnson County, TX Parker County, TX Tarrant County, TX Wise County, TX 23420..................... Fresno, CA....................... 1.0536 Fresno County, CA 23460..................... Gadsden, AL...................... 0.8049 Etowah County, AL 23540..................... Gainesville, FL.................. 0.9459 Alachua County, FL Gilchrist County, FL 23580..................... Gainesville, GA.................. 0.9557 Hall County, GA 23844..................... Gary, IN......................... 0.9310 Jasper County, IN Lake County, IN Newton County, IN Porter County, IN 24020..................... Glens Falls, NY.................. 0.8467 Warren County, NY Washington County, NY 24140..................... Goldsboro, NC.................... 0.8778 Wayne County, NC 24220..................... Grand Forks, ND-MN............... 0.9091 Polk County, MN Grand Forks County, ND 24300..................... Grand Junction, CO............... 0.9900 Mesa County, CO 24340..................... Grand Rapids-Wyoming, MI......... 0.9420 Barry County, MI Ionia County, MI Kent County, MI Newaygo County, MI 24500..................... Great Falls, MT.................. 0.8810 Cascade County, MT 24540..................... Greeley, CO...................... 0.9444 Weld County, CO 24580..................... Green Bay, WI.................... 0.9590 Brown County, WI Kewaunee County, WI Oconto County, WI 24660..................... Greensboro-High Point, NC........ 0.9190 Guilford County, NC Randolph County, NC Rockingham County, NC 24780..................... Greenville, NC................... 0.9183 Greene County, NC Pitt County, NC 24860..................... Greenville, SC................... 0.9557 Greenville County, SC Laurens County, SC Pickens County, SC 25020..................... Guayama, PR...................... 0.4005 Arroyo Municipio, PR

      [[Page 30294]]

      Guayama Municipio, PR Patillas Municipio, PR 25060..................... Gulfport-Biloxi, MS.............. 0.8950 Hancock County, MS Harrison County, MS Stone County, MS 25180..................... Hagerstown-Martinsburg, MD-WV.... 0.9715 Washington County, MD Berkeley County, WV Morgan County, WV 25260..................... Hanford-Corcoran, CA............. 0.9296 Kings County, CA 25420..................... Harrisburg-Carlisle, PA.......... 0.9359 Cumberland County, PA Dauphin County, PA Perry County, PA 25500..................... Harrisonburg, VA................. 0.9275 Rockingham County, VA Harrisonburg City, VA 25540..................... Hartford-West Hartford-East

      1.1054 Hartford, CT. Hartford County, CT Litchfield County, CT Middlesex County, CT Tolland County, CT 25620..................... Hattiesburg, MS.................. 0.7362 Forrest County, MS Lamar County, MS Perry County, MS 25860..................... Hickory-Lenoir-Morganton, NC..... 0.9502 Alexander County, NC Burke County, NC Caldwell County, NC Catawba County, NC 25980..................... Hinesville-Fort Stewart, GA...... 0.7715 Liberty County, GA Long County, GA 26100..................... Holland-Grand Haven, MI.......... 0.9388 Ottawa County, MI 26180..................... Honolulu, HI..................... 1.1013 Honolulu County, HI 26300..................... Hot Springs, AR.................. 0.9249 Garland County, AR 26380..................... Houma-Bayou Cane-Thibodaux, LA... 0.7721 Lafourche Parish, LA Terrebonne Parish, LA 26420..................... Houston-Baytown-Sugar Land, TX... 0.9973 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-KY-OH..... 0.9564 Boyd County, KY Greenup County, KY Lawrence County, OH Cabell County, WV Wayne County, WV 26620..................... Huntsville, AL................... 0.8851 Limestone County, AL Madison County, AL 26820..................... Idaho Falls, ID.................. 0.9059 Bonneville County, ID Jefferson County, ID 26900..................... Indianapolis, IN................. 1.0113 Boone County, IN

      [[Page 30295]]

      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.................... 0.9654 Johnson County, IA Washington County, IA 27060..................... Ithaca, NY....................... 0.9589 Tompkins County, NY 27100..................... Jackson, MI...................... 0.9146 Jackson County, MI 27140..................... Jackson, MS...................... 0.8291 Copiah County, MS Hinds County, MS Madison County, MS Rankin County, MS Simpson County, MS 27180..................... Jackson, TN...................... 0.8900 Chester County, TN Madison County, TN 27260..................... Jacksonville, FL................. 0.9537 Baker County, FL Clay County, FL Duval County, FL Nassau County, FL St. Johns County, FL 27340..................... Jacksonville, NC................. 0.8401 Onslow County, NC 27500..................... Janesville, WI................... 0.9583 Rock County, WI 27620..................... Jefferson City, MO............... 0.8338 Callaway County, MO Cole County, MO Moniteau County, MO Osage County, MO 27740..................... Johnson City, TN................. 0.8146 Carter County, TN Unicoi County, TN Washington County, TN 27780..................... Johnstown, PA.................... 0.8380 Cambria County, PA 27860..................... Jonesboro, AR.................... 0.8144 Craighead County, AR Poinsett County, AR 27900..................... Joplin, MO....................... 0.8721 Jasper County, MO Newton County, MO 28020..................... Kalamazoo-Portage, MI............ 1.0676 Kalamazoo County, MI Van Buren County, MI 28100..................... Kankakee-Bradley, IL............. 1.0603 Kankakee County, IL 28140..................... Kansas City, MO-KS............... 0.9629 Franklin County, KS Johnson County, KS Leavenworth County, KS Linn County, KS Miami County, KS Wyandotte County, KS Bates County, MO Caldwell County, MO Cass County, MO Clay County, MO Clinton County, MO Jackson County, MO

      [[Page 30296]]

      Lafayette County, MO Platte County, MO Ray County, MO 28420..................... Kennewick-Richland-Pasco, WA..... 1.0520 Benton County, WA Franklin County, WA 28660..................... Killeen-Temple-Fort Hood, TX..... 0.9242 Bell County, TX Coryell County, TX Lampasas County, TX 28700..................... Kingsport-Bristol-Bristol, TN-VA. 0.8240 Hawkins County, TN Sullivan County, TN Bristol City, VA Scott County, VA Washington County, VA 28740..................... Kingston, NY..................... 0.9000 Ulster County, NY 28940..................... Knoxville, TN.................... 0.8548 Anderson County, TN Blount County, TN Knox County, TN Loudon County, TN Union County, TN 29020..................... Kokomo, IN....................... 0.8986 Howard County, IN Tipton County, IN 29100..................... La Crosse, WI-MN................. 0.9289 Houston County, MN La Crosse County, WI 29140..................... Lafayette, IN.................... 0.9067 Benton County, IN Carroll County, IN Tippecanoe County, IN 29180..................... Lafayette, LA.................... 0.8306 Lafayette Parish, LA St. Martin Parish, LA 29340..................... Lake Charles, LA................. 0.7935 Calcasieu Parish, LA Cameron Parish, LA 29404..................... Lake County-Kenosha County, IL-WI 1.0342 Lake County, IL Kenosha County, WI 29460..................... Lakeland, FL..................... 0.8930 Polk County, FL 29540..................... Lancaster, PA.................... 0.9883 Lancaster County, PA 29620..................... Lansing-East Lansing, MI......... 0.9658 Clinton County, MI Eaton County, MI Ingham County, MI 29700..................... Laredo, TX....................... 0.8747 Webb County, TX 29740..................... Las Cruces, NM................... 0.8784 Dona Ana County, NM 29820..................... Las Vegas-Paradise, NV........... 1.1378 Clark County, NV 29940..................... Lawrence, KS..................... 0.8644 Douglas County, KS 30020..................... Lawton, OK....................... 0.8212 Comanche County, OK 30140..................... Lebanon, PA...................... 0.8570 Lebanon County, PA 30300..................... Lewiston, ID-WA.................. 0.9314 Nez Perce County, ID Asotin County, WA 30340..................... Lewiston-Auburn, ME.............. 0.9562 Androscoggin County, ME 30460..................... Lexington-Fayette, KY............ 0.9359 Bourbon County, KY

      [[Page 30297]]

      Clark County, KY Fayette County, KY Jessamine County, KY Scott County, KY Woodford County, KY 30620..................... Lima, OH......................... 0.9330 Allen County, OH 30700..................... Lincoln, NE...................... 1.0208 Lancaster County, NE Seward County, NE 30780..................... Little Rock-North Little Rock, AR 0.8826 Faulkner County, AR Grant County, AR Lonoke County, AR Perry County, AR Pulaski County, AR Saline County, AR 30860..................... Logan, UT-ID..................... 0.9094 Franklin County, ID Cache County, UT 30980..................... Longview, TX..................... 0.8801 Gregg County, TX Rusk County, TX Upshur County, TX 31020..................... Longview, WA..................... 1.0224 Cowlitz County, WA 31084..................... Los Angeles-Long Beach-Glendale, 1.1732 CA. Los Angeles County, CA 31140..................... Louisville, KY-IN................ 0.9122 Clark County, IN Floyd County, IN Harrison County, IN Washington County, IN Bullitt County, KY Henry County, KY Jefferson County, KY Meade County, KY Nelson County, KY Oldham County, KY Shelby County, KY Spencer County, KY Trimble County, KY 31180..................... Lubbock, TX...................... 0.8777 Crosby County, TX Lubbock County, TX 31340..................... Lynchburg, VA.................... 0.9017 Amherst County, VA Appomattox County, VA Bedford County, VA Campbell County, VA Bedford City, VA Lynchburg City, VA 31420..................... Macon, GA........................ 0.9887 Bibb County, GA Crawford County, GA Jones County, GA Monroe County, GA Twiggs County, GA 31460..................... Madera, CA....................... 0.8521 Madera County, CA 31540..................... Madison, WI...................... 1.0306 Columbia County, WI Dane County, WI Iowa County, WI 31700..................... Manchester-Nashua, NH............ 1.0642 Hillsborough County, NH Merrimack County, NH 31900..................... Mansfield, OH.................... 0.9189 Richland County, OH 32420..................... Mayaguez, PR..................... 0.4493

      [[Page 30298]]

      Hormigueros Municipio, PR Mayaguez Municipio, PR 32580..................... McAllen-Edinburg-Pharr, TX....... 0.8602 Hidalgo County, TX 32780..................... Medford, OR...................... 1.0534 Jackson County, OR 32820..................... Memphis, TN-MS-AR................ 0.9217 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....................... 1.0575 Merced County, CA 33124..................... Miami-Miami Beach-Kendall, FL.... 0.9870 Miami-Dade County, FL 33140..................... Michigan City-La Porte, IN....... 0.9332 LaPorte County, IN 33260..................... Midland, TX...................... 0.9384 Midland County, TX 33340..................... Milwaukee-Waukesha-West Allis, WI 1.0076 Milwaukee County, WI Ozaukee County, WI Washington County, WI Waukesha County, WI 33460..................... Minneapolis-St. Paul-Bloomington, 1.1066 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..................... 0.9618 Missoula County, MT 33660..................... Mobile, AL....................... 0.7995 Mobile County, AL 33700..................... Modesto, CA...................... 1.1966 Stanislaus County, CA 33740..................... Monroe, LA....................... 0.7903 Ouachita Parish, LA Union Parish, LA 33780..................... Monroe, MI....................... 0.9506 Monroe County, MI 33860..................... Montgomery, AL................... 0.8300 Autauga County, AL Elmore County, AL Lowndes County, AL Montgomery County, AL 34060..................... Morgantown, WV................... 0.8730 Monongalia County, WV Preston County, WV 34100..................... Morristown, TN................... 0.7790 Grainger County, TN Hamblen County, TN Jefferson County, TN 34580..................... Mount Vernon-Anacortes, WA....... 1.0576 Skagit County, WA 34620..................... Muncie, IN....................... 0.8580 Delaware County, IN 34740..................... Muskegon-Norton Shores, MI....... 0.9741

      [[Page 30299]]

      Muskegon County, MI 34820..................... Myrtle Beach-Conway-North Myrtle 0.9022 Beach, SC. Horry County, SC 34900..................... Napa, CA......................... 1.2531 Napa County, CA 34940..................... Naples-Marco Island, FL.......... 1.0558 Collier County, FL 34980..................... Nashville-Davidson--Murfreesboro, 1.0086 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............... 1.2907 Nassau County, NY Suffolk County, NY 35084..................... Newark-Union, NJ-PA.............. 1.1687 Essex County, NJ Hunterdon County, NJ Morris County, NJ Sussex County, NJ Union County, NJ Pike County, PA 35300..................... New Haven-Milford, CT............ 1.1807 New Haven County, CT 35380..................... New Orleans-Metairie-Kenner, LA.. 0.9103 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-Wayne-White Plains, NY- 1.3311 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.......... 0.8847 Berrien County, MI 35980..................... Norwich-New London, CT........... 1.1596 New London County, CT 36084..................... Oakland-Fremont-Hayward, CA...... 1.5220 Alameda County, CA Contra Costa County, CA 36100..................... Ocala, FL........................ 0.9153 Marion County, FL 36140..................... Ocean City, NJ................... 1.0810 Cape May County, NJ 36220..................... Odessa, TX....................... 0.9798 Ector County, TX 36260..................... Ogden-Clearfield, UT............. 0.9216 Davis County, UT Morgan County, UT Weber County, UT

      [[Page 30300]]

      36420..................... Oklahoma City, OK................ 0.8982 Canadian County, OK Cleveland County, OK Grady County, OK Lincoln County, OK Logan County, OK McClain County, OK Oklahoma County, OK 36500..................... Olympia, WA...................... 1.1006 Thurston County, WA 36540..................... Omaha-Council Bluffs, NE-IA...... 0.9754 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, FL...................... 0.9742 Lake County, FL Orange County, FL Osceola County, FL Seminole County, FL 36780..................... Oshkosh-Neenah, WI............... 0.9099 Winnebago County, WI 36980..................... Owensboro, KY.................... 0.8434 Daviess County, KY Hancock County, KY McLean County, KY 37100..................... Oxnard-Thousand Oaks-Ventura, CA. 1.1105 Ventura County, CA 37340..................... Palm Bay-Melbourne-Titusville, FL 0.9633 Brevard County, FL 37460..................... Panama City-Lynn Haven, FL....... 0.8124 Bay County, FL 37620..................... Parkersburg-Marietta, WV-OH...... 0.8288 Washington County, OH Pleasants County, WV Wirt County, WV Wood County, WV 37700..................... Pascagoula, MS................... 0.7974 George County, MS Jackson County, MS 37860..................... Pensacola-Ferry Pass-Brent, FL... 0.8306 Escambia County, FL Santa Rosa County, FL 37900..................... Peoria, IL....................... 0.8886 Marshall County, IL Peoria County, IL Stark County, IL Tazewell County, IL Woodford County, IL 37964..................... Philadelphia, PA................. 1.0865 Bucks County, PA Chester County, PA Delaware County, PA Montgomery County, PA Philadelphia County, PA 38060..................... Phoenix-Mesa-Scottsdale, AZ...... 0.9982 Maricopa County, AZ Pinal County, AZ 38220..................... Pine Bluff, AR................... 0.8673 Cleveland County, AR Jefferson County, AR Lincoln County, AR 38300..................... Pittsburgh, PA................... 0.8736 Allegheny County, PA Armstrong County, PA Beaver County, PA

      [[Page 30301]]

      Butler County, PA Fayette County, PA Washington County, PA Westmoreland County, PA 38340..................... Pittsfield, MA................... 1.0439 Berkshire County, MA 38540..................... Pocatello, ID.................... 0.9601 Bannock County, ID Power County, ID 38660..................... Ponce, PR........................ 0.5006 Juana Daz Municipio, PR Ponce Municipio, PR Villalba Municipio, PR 38860..................... Portland-South Portland-

      1.0112 Biddeford, ME. Cumberland County, ME Sagadahoc County, ME York County, ME 38900..................... Portland-Vancouver-Beaverton, OR- 1.1403 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-Fort Pierce, FL... 1.0046 Martin County, FL St. Lucie County, FL 39100..................... Poughkeepsie-Newburgh-Middletown, 1.1363 NY. Dutchess County, NY Orange County, NY 39140..................... Prescott, AZ..................... 0.9892 Yavapai County, AZ 39300..................... Providence-New Bedford-Fall

      1.0929 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................... 0.9588 Juab County, UT Utah County, UT 39380..................... Pueblo, CO....................... 0.8752 Pueblo County, CO 39460..................... Punta Gorda, FL.................. 0.9441 Charlotte County, FL 39540..................... Racine, WI....................... 0.9045 Racine County, WI 39580..................... Raleigh-Cary, NC................. 1.0057 Franklin County, NC Johnston County, NC Wake County, NC 39660..................... Rapid City, SD................... 0.8912 Meade County, SD Pennington County, SD 39740..................... Reading, PA...................... 0.9215 Berks County, PA 39820..................... Redding, CA...................... 1.1835 Shasta County, CA 39900..................... Reno-Sparks, NV.................. 1.0456 Storey County, NV Washoe County, NV 40060..................... Richmond, VA..................... 0.9397 Amelia County, VA Caroline County, VA Charles City County, VA Chesterfield County, VA Cumberland County, VA Dinwiddie County, VA

      [[Page 30302]]

      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 Bernardino-Ontario, 1.0970 CA. Riverside County, CA San Bernardino County, CA 40220..................... Roanoke, VA...................... 0.8415 Botetourt County, VA Craig County, VA Franklin County, VA Roanoke County, VA Roanoke City, VA Salem City, VA 40340..................... Rochester, MN.................... 1.1504 Dodge County, MN Olmsted County, MN Wabasha County, MN 40380..................... Rochester, NY.................... 0.9281 Livingston County, NY Monroe County, NY Ontario County, NY Orleans County, NY Wayne County, NY 40420..................... Rockford, IL..................... 0.9626 Boone County, IL Winnebago County, IL 40484..................... Rockingham County-Strafford

      1.0221 County, NH. Rockingham County, NH Strafford County, NH 40580..................... Rocky Mount, NC.................. 0.8998 Edgecombe County, NC Nash County, NC 40660..................... Rome, GA......................... 0.8878 Floyd County, GA 40900..................... Sacramento--Arden-Arcade--

      1.1700 Roseville, CA. El Dorado County, CA Placer County, CA Sacramento County, CA Yolo County, CA 40980..................... Saginaw-Saginaw Township North, 0.9814 MI. Saginaw County, MI 41060..................... St. Cloud, MN.................... 1.0215 Benton County, MN Stearns County, MN 41100..................... St. George, UT................... 0.9458 Washington County, UT 41140..................... St. Joseph, MO-KS................ 1.0013 Doniphan County, KS Andrew County, MO Buchanan County, MO DeKalb County, MO 41180..................... St. Louis, MO-IL................. 0.9076 Bond County, IL Calhoun County, IL Clinton County, IL Jersey County, IL Macoupin County, IL Madison County, IL Monroe County, IL

      [[Page 30303]]

      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........................ 1.0556 Marion County, OR Polk County, OR 41500..................... Salinas, CA...................... 1.3823 Monterey County, CA 41540..................... Salisbury, MD.................... 0.9123 Somerset County, MD Wicomico County, MD 41620..................... Salt Lake City, UT............... 0.9561 Salt Lake County, UT Summit County, UT Tooele County, UT 41660..................... San Angelo, TX................... 0.8167 Irion County, TX Tom Green County, TX 41700..................... San Antonio, TX.................. 0.9003 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 Marcos, CA 1.1267 San Diego County, CA 41780..................... Sandusky, OH..................... 0.9017 Erie County, OH 41884..................... San Francisco-San Mateo-Redwood 1.4712 City, CA. Marin County, CA San Francisco County, CA San Mateo County, CA 41900..................... San German-Cabo Rojo, PR......... 0.5240 Cabo Rojo Municipio, PR Lajas Municipio, PR Sabana Grande Municipio, PR San German Municipio, PR 41940..................... San Jose-Sunnyvale-Santa Clara, 1.4722 CA. San Benito County, CA Santa Clara County, CA 41980..................... San Juan-Caguas-Guaynabo, PR..... 0.4645 Aguas Buenas Municipio, PR Aibonito Municipio, PR Arecibo Municipio, PR Barceloneta Municipio, PR Barranquitas Municipio, PR Bayam[oacute]n Municipio, PR Caguas Municipio, PR Camuy Municipio, PR Can[oacute]vanas Municipio, PR Carolina Municipio, PR Cata[ntilde]o Municipio, PR Cayey Municipio, PR Ciales Municipio, PR Cidra Municipio, PR Comero Municipio, PR Corozal Municipio, PR Dorado Municipio, PR Florida Municipio, PR Guaynabo Municipio, PR

      [[Page 30304]]

      Gurabo Municipio, PR Hatillo Municipio, PR Humacao Municipio, PR Juncos Municipio, PR Las Piedras Municipio, PR Lo[iacute]za Municipio, PR Manat[iacute] Municipio, PR Maunabo Municipio, PR Morovis Municipio, PR Naguabo Municipio, PR Naranjito Municipio, PR Orocovis Municipio, PR Quebradillas Municipio, PR R[iacute]o 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 Robles, CA.. 1.1118 San Luis Obispo County, CA 42044..................... Santa Ana-Anaheim-Irvine, CA..... 1.1611 Orange County, CA 42060..................... Santa Barbara-Santa Maria-Goleta, 1.0771 CA. Santa Barbara County, CA 42100..................... Santa Cruz-Watsonville, CA....... 1.4779 Santa Cruz County, CA 42140..................... Santa Fe, NM..................... 1.0909 Santa Fe County, NM 42220..................... Santa Rosa-Petaluma, CA.......... 1.2961 Sonoma County, CA 42260..................... Sarasota-Bradenton-Venice, FL.... 0.9629 Manatee County, FL Sarasota County, FL 42340..................... Savannah, GA..................... 0.9460 Bryan County, GA Chatham County, GA Effingham County, GA 42540..................... Scranton--Wilkes-Barre, PA....... 0.8543 Lackawanna County, PA Luzerne County, PA Wyoming County, PA 42644..................... Seattle-Bellevue-Everett, WA..... 1.1492 King County, WA Snohomish County, WA 43100..................... Sheboygan, WI.................... 0.8948 Sheboygan County, WI 43300..................... Sherman-Denison, TX.............. 0.9617 Grayson County, TX 43340..................... Shreveport-Bossier City, LA...... 0.9132 Bossier Parish, LA Caddo Parish, LA De Soto Parish, LA 43580..................... Sioux City, IA-NE-SD............. 0.9070 Woodbury County, IA Dakota County, NE Dixon County, NE Union County, SD 43620..................... Sioux Falls, SD.................. 0.9441 Lincoln County, SD McCook County, SD Minnehaha County, SD Turner County, SD 43780..................... South Bend-Mishawaka, IN-MI...... 0.9447 St. Joseph County, IN Cass County, MI 43900..................... Spartanburg, SC.................. 0.9519

      [[Page 30305]]

      Spartanburg County, SC 44060..................... Spokane, WA...................... 1.0660 Spokane County, WA 44100..................... Springfield, IL.................. 0.8738 Menard County, IL Sangamon County, IL 44140..................... Springfield, MA.................. 1.0176 Franklin County, MA Hampden County, MA Hampshire County, MA 44180..................... Springfield, MO.................. 0.8557 Christian County, MO Dallas County, MO Greene County, MO Polk County, MO Webster County, MO 44220..................... Springfield, OH.................. 0.8748 Clark County, OH 44300..................... State College, PA................ 0.8461 Centre County, PA 44700..................... Stockton, CA..................... 1.0564 San Joaquin County, CA 44940..................... Sumter, SC....................... 0.8520 Sumter County, SC 45060..................... Syracuse, NY..................... 0.9468 Madison County, NY Onondaga County, NY Oswego County, NY 45104..................... Tacoma, WA....................... 1.1078 Pierce County, WA 45220..................... Tallahassee, FL.................. 0.8655 Gadsden County, FL Jefferson County, FL Leon County, FL Wakulla County, FL 45300..................... Tampa-St. Petersburg-Clearwater, 0.9024 FL. Hernando County, FL Hillsborough County, FL Pasco County, FL Pinellas County, FL 45460..................... Terre Haute, IN.................. 0.8517 Clay County, IN Sullivan County, IN Vermillion County, IN Vigo County, IN 45500..................... Texarkana, TX-Texarkana, AR...... 0.8413 Miller County, AR Bowie County, TX 45780..................... Toledo, OH....................... 0.9524 Fulton County, OH Lucas County, OH Ottawa County, OH Wood County, OH 45820..................... Topeka, KS....................... 0.8904 Jackson County, KS Jefferson County, KS Osage County, KS Shawnee County, KS Wabaunsee County, KS 45940..................... Trenton-Ewing, NJ................ 1.0276 Mercer County, NJ 46060..................... Tucson, AZ....................... 0.8926 Pima County, AZ 46140..................... Tulsa, OK........................ 0.8690 Creek County, OK Okmulgee County, OK Osage County, OK Pawnee County, OK Rogers County, OK Tulsa County, OK

      [[Page 30306]]

      Wagoner County, OK 46220..................... Tuscaloosa, AL................... 0.8336 Greene County, AL Hale County, AL Tuscaloosa County, AL 46340..................... Tyler, TX........................ 0.9502 Smith County, TX 46540..................... Utica-Rome, NY................... 0.8295 Herkimer County, NY Oneida County, NY 46660..................... Valdosta, GA..................... 0.8341 Brooks County, GA Echols County, GA Lanier County, GA Lowndes County, GA 46700..................... Vallejo-Fairfield, CA............ 1.4279 Solano County, CA 46940..................... Vero Beach, FL................... 0.9477 Indian River County, FL 47020..................... Victoria, TX..................... 0.8470 Calhoun County, TX Goliad County, TX Victoria County, TX 47220..................... Vineland-Millville-Bridgeton, NJ. 1.0573 Cumberland County, NJ 47260..................... Virginia Beach-Norfolk-Newport

      0.8894 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.......... 0.9975 Tulare County, CA 47380..................... Waco, TX......................... 0.8146 McLennan County, TX 47580..................... Warner Robins, GA................ 0.8489 Houston County, GA 47644..................... Warren-Farmington Hills-Troy, MI. 1.0112 Lapeer County, MI Livingston County, MI Macomb County, MI Oakland County, MI St. Clair County, MI 47894..................... Washington-Arlington-Alexandria, 1.1023 DC-VA&-MD-WV. District of Columbia, DC Calvert County, MD Charles County, MD Prince George's County, MD Arlington County, VA Clarke County, VA Fairfax County, VA Fauquier County, VA Loudoun County, VA Prince William County, VA Spotsylvania County, VA Stafford County, VA Warren County, VA Alexandria City, VA Fairfax City, VA

      [[Page 30307]]

      Falls Church City, VA Fredericksburg City, VA Manassas City, VA Manassas Park City, VA Jefferson County, WV 47940..................... Waterloo-Cedar Falls, IA......... 0.8633 Black Hawk County, IA Bremer County, IA Grundy County, IA 48140..................... Wausau, WI....................... 0.9570 Marathon County, WI 48260..................... Weirton-Steubenville, WV-OH...... 0.8280 Jefferson County, OH Brooke County, WV Hancock County, WV 48300..................... Wenatchee, WA.................... 0.9427 Chelan County, WA Douglas County, WA 48424..................... West Palm Beach-Boca Raton-

      1.0362 Boynton Beach, FL. Palm Beach County, FL 48540..................... Wheeling, WV-OH.................. 0.7449 Belmont County, OH Marshall County, WV Ohio County, WV 48620..................... Wichita, KS...................... 0.9457 Butler County, KS Harvey County, KS Sedgwick County, KS Sumner County, KS 48660..................... Wichita Falls, TX................ 0.8332 Archer County, TX Clay County, TX Wichita County, TX 48700..................... Williamsport, PA................. 0.8485 Lycoming County, PA 48864..................... Wilmington, DE-MD-NJ............. 1.1049 New Castle County, DE Cecil County, MD Salem County, NJ 48900..................... Wilmington, NC................... 0.9237 Brunswick County, NC New Hanover County, NC Pender County, NC 49020..................... Winchester, VA-WV................ 1.0496 Frederick County, VA Winchester City, VA Hampshire County, WV 49180..................... Winston-Salem, NC................ 0.9401 Davie County, NC Forsyth County, NC Stokes County, NC Yadkin County, NC 49340..................... Worcester, MA.................... 1.0996 Worcester County, MA 49420..................... Yakima, WA....................... 1.0322 Yakima County, WA 49500..................... Yauco, PR........................ 0.4493 Gu[aacute]nica Municipio, PR Guayanilla Municipio, PR Pe[ntilde]uelas Municipio, PR Yauco Municipio, PR 49620..................... York-Hanover, PA................. 0.9150 York County, PA 49660..................... Youngstown-Warren-Boardman, OH-PA 0.9237 Mahoning County, OH Trumbull County, OH Mercer County, PA 49700..................... Yuba City, CA.................... 1.0363 Sutter County, CA Yuba County, CA

      [[Page 30308]]

      49740..................... Yuma, AZ......................... 0.8871 Yuma County, AZ

      Table 2b.--Proposed Inpatient Rehabilitation Facility Wage Index (Based on Proposed CBSA Labor Market Areas) for Rural Areas for Discharges Occurring on or After October 1, 2005

      Full wage CBSA code

      Nonurban area

      index

      01........................... Alabama....................... 0.7628 02........................... Alaska........................ 1.1746 03........................... Arizona....................... 0.8936 04........................... Arkansas...................... 0.7406 05........................... California.................... 1.0524 06........................... Colorado...................... 0.9368 07........................... Connecticut................... 1.1917 08........................... Delaware...................... 0.9503 10........................... Florida....................... 0.8574 11........................... Georgia....................... 0.7733 12........................... Hawaii........................ 1.0522 13........................... Idaho......................... 0.8227 14........................... Illinois...................... 0.8339 15........................... Indiana....................... 0.8653 16........................... Iowa.......................... 0.8475 17........................... Kansas........................ 0.8079 18........................... Kentucky...................... 0.7755 19........................... Louisiana..................... 0.7345 20........................... Maine......................... 0.9039 21........................... Maryland...................... 0.9220 22........................... Massachusetts \2\............. 1.0216 23........................... Michigan...................... 0.8786 24........................... Minnesota..................... 0.9330 25........................... Mississippi................... 0.7635 26........................... Missouri...................... 0.7762 27........................... Montana....................... 0.8701 28........................... Nebraska...................... 0.9035 29........................... Nevada........................ 0.9280 30........................... New Hampshire................. 0.9940 31........................... New Jersey \1\................ ......... 32........................... New Mexico.................... 0.8680 33........................... New York...................... 0.8151 34........................... North Carolina................ 0.8563 35........................... North Dakota.................. 0.7743 36........................... Ohio.......................... 0.8693 37........................... Oklahoma...................... 0.7686 38........................... Oregon........................ 0.9914 39........................... Pennsylvania.................. 0.8310 40........................... Puerto Rico \2\............... 0.4047 41........................... Rhode Island \1\.............. ......... 42........................... South Carolina................ 0.8683 43........................... South Dakota.................. 0.8398 44........................... Tennessee..................... 0.7869 45........................... Texas......................... 0.7966 46........................... Utah.......................... 0.8287 47........................... Vermont....................... 0.9375 48........................... Virgin Islands................ 0.7456 49........................... Virginia...................... 0.8049 50........................... Washington.................... 1.0312 51........................... West Virginia................. 0.7865 52........................... Wisconsin..................... 0.9492 53........................... Wyoming....................... 0.9182 65........................... Guam.......................... 0.9611

      \1\ All counties within the State are classified urban. \2\ Massachusetts and Puerto Rico have areas designated as rural, however, no short-term, acute care hospitals are located in the area(s) for FY 2006 under CBSA-based designations. Therefore, we are proposing to use FY 2001 MSA based hospital wage data.

      Table 3.--Inpatient Rehabilitation Facilities With Corresponding State and County Location; Current Labor Market Area Designation; and Proposed New CBSA-Based Labor Market Area Designation

      SSA State and FY 06 MSA FY 06 Provider number Provider name

      county code CBSA code code

      26T107......... 9TH FLOOR REHAB....... 26470 3760 28140 39T231......... DABINGTON MEMORIAL

      39560 6160 37964 HOSPITAL. 193067......... ACADIA REHABILITATION 19000 3880

      19 HOSPITAL. 24T043......... ACUTE CARE

      24230

      24

      24 REHABILITATION-ALMC. 42T070......... ACUTE REHAB UNIT AT

      42420 8140 44940 TUOMEY HEALTHCARE SYSTEM. 14T182......... ADVOCATE ILLINOIS

      14141 1600 16974 MASONIC MEDICAL CENTER. 14T223......... ADVOCATE LUTHERAN

      14141 1600 16974 GENERAL HOSPITAL. 19T202......... AHS SUMMIT HOSPITAL

      19160 0760 12940 LLC. 05T320......... ALAMEDA COUNTY MEDICAL 05000 5775 36084 CENTER. 02T017......... ALASKA REGIONAL

      02020 0380 11260 HOSPITAL. 33T013......... ALBANY MEDICAL CENTER 33000 0160 10580 HOSP. 14T258......... ALEXIAN BROTHERS

      14141 1600 16974 MEDICAL CENTER. 05T281......... ALHAMBRA HOSPITAL

      05200 4480 31084 MEDICAL CENTER. 52T096......... ALL SAINTS HEALTHCARE, 52500 6600 39540 INC.. 39T074......... ALLEGHENY GENERAL

      39010 6280 38300 HOSPITAL SUBURBAN CAMPUS. 17T116......... ALLEN COUNTY HOSPITAL. 17000

      17

      17 36T131......... ALLIANCE COMMUNITY

      36770 1320 15940 HOSPITAL. 393030......... ALLIED SERVICES INST

      39420 7560 42540 OF REHAB SERVICES. 05T305......... ALTA BATES MEDICAL

      05000 5775 36084 CENTER. 39T073......... ALTOONA HOSPITAL...... 39120 0280 11020 39T121......... ALTOONA REGIONAL

      39120 0280 11020 HEALTH SYSTEM. 35T019......... ALTRU REHABILITATION

      35170 2985 24220 CENTER. 05T583......... ALVARADO HOSPITAL

      05470 7320 41740 MEDICAL CENTER INC.. 33T010......... AMSTERDAM MEMORIAL

      33380 0160

      33 HOSPITAL.

      [[Page 30309]]

      01T036......... ANDALUSIA REGIONAL

      01190

      01

      01 HOSPITAL. 393051......... ANGELA JANE PAVILION.. 39620 6160 37964 423029......... ANMED HEALTHSOUTH

      42030 3160 11340 REHABILITATION HOSPITAL. 04T039......... ARKANSAS METHODIST

      04270

      04

      04 HOSPITAL. 39T163......... ARMSTRONG COUNTY

      39070

      39 38300 MEMORIAL HOSPITAL. 11T115......... ATLANTA MEDICAL CENTER 11470 0520 12060 15T074......... AUGUST F. HOOK REHAB

      15480 3480 26900 CENTER. 49T018......... AUGUSTA MEDICAL CENTER 49891

      49

      49 52T193......... AURORA BAYCARE MEDICAL 52040 3080 24580 CENTER. 52T102......... AURORA LAKELAND

      52630

      52

      52 MEDICAL CENTER REHAB UNIT. 52T035......... AURORA SHEBOYGAN

      52580 7620 43100 MEMORIAL MEDICAL CENTER REHAB UNI. 52T064......... AURORA SINAI MEDICAL

      52390 5080 33340 CENTER. 43T016......... AVERA MCKENNAN

      43490 7760 43620 HOSPITAL. 43T012......... AVERA SACRED HEART

      43670

      43

      43 HOSPITAL. 43T014......... AVERA ST. LUKE'S...... 43060

      43

      43 45T280......... BACHARACH INSTITUTE

      31000 1920 19124 FOR REHABILITATION. 313030......... BALL MEMORIAL HOSPITAL- 15170 0560 12100 REHAB. 15T089......... BAPTIST HEALTH

      04590 5280 34620 REHABILITATION INSTITUTE. 043026......... BAPTIST HEALTH SYSTEM. 45130 4400 30780 45T058......... BAPTIST HOSPITAL DAVIS 10120 7240 41700 CTR FOR REHABILITATION. 10T008......... BAPTIST HOSPITAL

      25160 5000 33124 DESOTO. 25T141......... BAPTIST HOSPITAL EAST. 18550 4920 32820 18T130......... BAPTIST HOSPITALS OF

      45700 4520 31140 SOUTHEAST TEXAS. 45T346......... BAPTIST MEMORIAL

      25350 0840 13140 HOSPITAL NORTH MISSISSIPPI. 25T034......... BAPTIST MEMORIAL MED

      04590

      25

      25 CENTER, NO LITTLE ROCK. 04T036......... BAPTIST REGIONAL

      18990 4400 30780 MEDICAL CENTER. 18T080......... BAPTIST REHAB CENTER.. 44180

      18

      18 44T133......... BAPTIST REHABILITATION 44780 5360 34980 GERMANTOWN. 44T147......... BARBERTON CITIZENS

      36780 4920 32820 HOSPITAL. 36T019......... BARTLETT REGIONAL

      02110 0080 10420 HOSPITAL. 02T008......... BASTROP REHABILITATION 19330

      02

      02 HOSPITAL. 193058......... BATON ROUGE GENERAL

      19160

      19

      19 MEDICAL CENTER. 19T065......... BAXTER REGIONAL

      04020 0760 12940 MEDICAL CENTER. 04T027......... BAY MEDICAL CENTER FOR 23080

      04

      04 REHABILITATION. 23T041......... BAYHEALTH MEDICAL

      08000 6960 13020 CENTER. 08T004......... BAYLOR ALL SAINTS

      45910 2190 20100 MEDICAL CENTER OF FORT WORTH. 45T137......... BAYLOR INSTITUTE FOR

      45390 2800 23104 REHABILITATION AT GASTON. 453036......... BAYLOR MEDICAL CENTER. 45390 1920 19124 45T079......... BAYLOR MEDICAL CENTER 45390 1920 19124 AT GARLAND. 45T097......... BAYSHORE MEDICAL

      45610 3360 26420 CENTER. 27T012......... BELLEVUE HOSPITAL

      33420 3040 24500 CENTRE. 33T204......... BELMONT COMMUNITY

      36060 5600 35644 HOSPITAL. 36T153......... BELOIT MEMORIAL

      52520 9000 48540 HOSPITAL. 52T100......... BENEDICTINE HOSPITAL.. 33740 3620 27500 33T224......... BENEFIS HEALTHCARE.... 27060

      33 28740 15T088......... BENNETT REHAB CENTER

      15470 3480 11300 SAINT JOHN'S HEALTH SYSTEM. 193070......... BENTON REHABILITATION 19160 0760 12940 HOSPITAL. 36T170......... BERGER HEALTH SYSTEM.. 36660 1840 18140 22T046......... BERKSHIRE MEDICAL

      22010 6323 38340 CENTER. 33T169......... BETH ISRAEL MEDICAL

      33420 5600 35644 CENTER. 36T179......... BETHESDA NORTH

      36310 1640 17140 HOSPITAL. 01T104......... BIRMINGHAM BAPT MED

      01360 1000 13820 CNTR MONTCLAIR SNU. 10T213......... BLAKE MEDICAL CENTER.. 10400 7510 42260 14T015......... BLESSING HOSPITAL..... 14000

      14

      14 23T135......... BOGALUSA COMMUNITY

      19580 2160 19804 REHABILITAION HOSPITAL. 193052......... BON SECOUR ST. FRANCIS 42220

      19

      19 INPATIENT REHAB CENTER. 42T023......... BONE AND JOINT

      37540 3160 24860 HOSPITAL REHAB CENTER. 37T105......... BOONE HOSPITAL CENTER. 26090 5880 36420 26T068......... BORGESS-PIPP HEALTH

      23380 1740 17860 CENTER. 23T117......... BOSTON MED CTR CORP/

      22160 3720 28020 UNIVE HOSP CAMPUS. 22T031......... BOTHWELL REGIONAL

      26790 1123 14484 HEALTH CENTER. 26T009......... BOTSFORD GENERAL

      23620

      26

      26 HOSPITAL. 23T151......... BOULDER COMMUNITY

      06060 2160 47644 HOSPITAL. 06T027......... BRANDYWINE HOSPITAL... 39210 1125 14500 39T076......... BRAZOSPORT MEMORIAL

      45180 6160 37964 HOSPITAL. 45T072......... BRIDGEPORT HOSPITAL... 07010 1145 26420 07T010......... BROADWAY METHODIST

      15440 3283 25540 REHAB.

      [[Page 30310]]

      15T132......... BROKEN ARROW

      37710 2960 23844 REHABILITATION. 37T176......... BROMENN REGIONAL

      14650 8560 46140 MEDICAL CENTER. 14T127......... BRONSON VICKSBURG

      23380 1040 14060 HOSPITAL. 23T190......... BROOKS REHABILITATION 10150 3720 28020 HOSPITAL. 103039......... BROOKWOOD MEDICAL

      01360 3600 27260 CENTER. 01T139......... BROTMAN MEDICAL CENTER 05200 1000 13820 05T144......... BROWNSVILLE GENERAL

      39330 4480 31084 HOSPITAL. 39T166......... BROWNWOOD REGIONAL

      45220 6280 38300 MEDICAL CENTER. 45T587......... BRUNSWICK HOSPITAL.... 33700

      45

      45 33T314......... BRYANLGH MEDICAL

      28540 5380 35004 CENTER WEST. 28T003......... BRYANT T. ALDRIDGE

      34630 4360 30700 REHABILITATION CENTER. 34T147......... BRYN MAWR

      39210 6895 40580 REHABILITATION HOSPITAL. 393025......... BSA HEALTH SYSTEM..... 45860 6160 37964 45T231......... BUFFALO MERCY

      33240 0320 11100 REHABILITATION UNIT. 33T279......... BURBANK REHABILITATION 22170 1280 15380 CENTER. 22T001......... BURKE REHABILIATION

      33800 1123 49340 HOSPITAL. 333028......... CABRINI MEDICAL CENTER 33420 5600 35644 39T160......... CALDWELL MEMORIAL

      19100 6280 38300 HOSPITAL. 33T133......... CAMERON REGIONAL

      26240 5600 35644 MEDICAL CTR. 19T190......... CANONSBURG GENERAL

      39750

      19

      19 HOSPITAL. 26T057......... CAPITAL REGION MEDICAL 26250 3760 28140 CENTER. 26T047......... CARDINAL HILL

      18330

      26 27620 REHABILITATION HOSPITAL. 183026......... CARILION HEALTH SYSTEM 49801 4280 30460 49T024......... CARLE FOUNDATION

      14090 6800 40220 HOSPITAL. 14T091......... CARLISLE REGIONAL

      39270 1400 16580 MEDICAL CENTER. 39T058......... CARLSBAD MEDICAL

      32070 3240 25420 CENTER. 32T063......... CAROLINAS HOSPITAL

      42200

      32

      32 SYSTEM. 42T091......... CARONDELET ST JOSEPHS 03090 2655 22500 HOSPITAL. 03T011......... CARONDELET ST MARYS

      03090 8520 46060 HOSPITAL. 03T010......... CARSON REHABILITATION 29120 8520 46060 CENTER. 293029......... CARTHAGE AREA HOSPITAL 33330

      29 16180 33T263......... CASA COLINA HOSP FOR

      05200

      33

      33 REHAB MEDICINE. 053027......... CATAWBA VALLEY MEDICAL 34170 4480 31084 CENTER. 34T143......... CATHOLIC MEDICAL

      30050 3290 25860 CENTER. 30T034......... CATSKILL REGIONAL

      33710 1123 31700 MEDICAL CENTER. 33T386......... CAYUGA MEDICAL CENTER. 33730

      33

      33 33T307......... CCMH INPATIENT REHAB.. 39640

      33 27060 39T246......... CEDARS-SINAI MEDICAL

      05200

      39

      39 CENTER. 44T161......... CENTENNIAL MEDICAL

      44180 5360 34980 CENTER. 05T625......... CENTINELA HOSPITAL

      05200 4480 31084 MEDICAL CENTER. 05T240......... CENTRAL ARKANSAS

      04720 4480 31084 HOSPITAL. 04T014......... CENTRAL KANSAS MEDICAL 17040

      04

      04 CENTER. 17T033......... CENTRAL MAINE

      20000

      17

      17 REHABILITATION CENTER. 20T024......... CENTRAL MONTGOMERY

      39560 4243 30340 MEDICAL CENTER. 39T012......... CENTURA HEALTH-ST.

      06150 6160 37964 ANTHONY CENTRAL HOSPITAL. 06T015......... CGRMC ACUTE

      03100 2080 19740 REHABILITATION UNIT. 03T016......... CHALMETTE MEDICAL

      19430 6200 38060 CENTER. 45T035......... CHAMBERSBURG HOSPITAL. 39350 3360 26420 45T237......... CHARLESTON AREA MED

      51190 7240 41700 CNTR. 19T185......... CHARLOTTE INSTITUTE OF 34590 5560 35380 REHABILITATION. 39T151......... CHATTANOOGA........... 44320

      39

      39 51T022......... CHELSEA COMMUNITY

      23800 1480 16620 HOSPITAL. 343026......... CHESHIRE MEDICAL

      30020 1520 16740 CENTER. 44T162......... CHESTNUT HILL

      39620 1560 16860 REHABILITATION HOSPITAL. 23T259......... CHNE REHAB............ 26940 0440 11460 30T019......... CHRISTUS JASPER

      45690

      30

      30 MEMORIAL HOSPITAL. 393032......... CHRISTUS SANTA ROSA

      45130 6160 37964 HOSPITAL. 26T180......... CHRISTUS SCHUMPERT

      19080 7040 41180 HEALTH SYSTEM. 45T573......... CHRISTUS SPOHN

      45830

      45

      45 HOSPITAL SHORELINE. 19T041......... CHRISTUS ST MICHAEL

      45170 7680 43340 REHAB HOSPITAL. 45T046......... CHRISTUS ST. FRANCES

      19390 1880 18580 CABRINI HOSPITAL. 453065......... CHRISTUS ST. JOHN..... 45610 8360 45500 19T019......... CHRISTUS ST. JOSEPH

      45610 0220 10780 HOSPITAL. 45T709......... CHRISTUS ST. PATRICK

      19090 3360 26420 HOSPITAL. 19T027......... CHS,INC DBA ST CHARLES 38080 3960 29340 MEDICAL CTR. 38T047......... CITRUS VALLEY MEDICAL 05200

      38 13460 CENTER-VQ CAMPUS. 05T369......... CJW INPATIENT REHAB... 49791 4480 31084

      [[Page 30311]]

      49T112......... CL.................... 45610 6760 40060 45T617......... CLAXTON-HEPBURN

      33630 3360 26420 MEDICAL CENTER. 33T211......... CLINCH VALLEY MEDICAL 49920

      33

      33 CENTER. 49T060......... CLINTON MEMORIAL

      36130

      49

      49 HOSPITAL. 36T175......... COASTAL REHABILITATION 34240

      36

      36 CTR. 36T172......... COLISEUM

      11090 1680 17460 REHABILITATION CENTER. 34T131......... COLLEGE STATION

      45190

      34

      34 MEDICAL CENTER. 11T164......... COLLETON MEDICAL

      42140 4680 31420 CENTER. 45T299......... COLORADO PLAINS

      06430 1260 17780 MEDICAL CTR. 42T030......... COLORADO RIVER MEDICAL 05460

      42

      42 CENTER. 06T044......... COLUMBIA HOSPITAL..... 52390

      06

      06 05T469......... COLUMBIA REGIONAL

      26090 6780 40140 HOSPITAL. 52T140......... COLUMBUS REGIONAL

      15020 5080 33340 HOSPITAL. 26T178......... COMANCHE COUNTY

      37150 1740 17860 MEMORIAL HOSPITAL. 15T112......... COMMUNITY GENERAL

      33520

      15 18020 HOSPITAL PM&R. 37T056......... COMMUNITY HEALTH

      36480 4200 30020 PARTNERS OF OH-WEST. 33T159......... COMMUNITY HOSPITAL LOS 05530 8160 45060 GATOS. 05T188......... COMMUNITY HOSPITAL OF 36110 7400 41940 SPRINGFIELD. 36T187......... COMMUNITY HOSPITAL/

      36870 2000 44220 WELLNESS CTRS MONTPELI. 36R327......... COMMUNITY HOSPITALS OF 36870

      36

      36 WILLIAMS COUNTY. 36T121......... COMMUNITY HOSPTIAL.... 15440

      36

      36 15T125......... COMMUNITY MEDICAL

      27310 2960 23844 CENTER. 27T023......... COMMUNITY MEMORIAL

      52660 5140 33540 HOSPITAL. 52T103......... COMMUNITY

      23100 5080 33340 REHABILITATION CENTER. 23T078......... COMMUNITY

      19400 0870 35660 REHABILITATION HOSPITAL OF COUSHATTA. 193080......... CONEY ISLAND HOSPITAL. 33331

      19

      19 33T196......... CORNERSTONE

      45650 5600 35644 REHABILITATION HOSPITAL. 453085......... CORONA REGINAL MEDICAL 05430 4880 32580 CENTER. 05T329......... CORPUS CHRISTI WARM

      45830 6780 40140 SPGS REHAB HOSP. 453055......... COTTAGE HOSPITAL...... 23810 1880 18580 45T040......... COVENANT HEALTH SYSTEM 45770 4600 31180 23T070......... COVENANT HEALTHCARE... 23720 6960 40980 16T067......... COVENANT MEDICAL

      16060 8920 47940 CENTER. 26T040......... COX HEALTH SYSTEMS.... 26380 7920 44180 05T008......... CPMC REGIONAL

      05480 7360 41884 REHABILITATION CENTER. 39T110......... CRICHTON

      39160 3680 27780 REHABILITATION CENTER. 04T042......... CRITTENDEN MEMORIAL

      04170 4920 32820 HOSPITAL. 23T254......... CRITTENTON REHABCENTRE 23730 2160 47644 44T175......... CROCKETT HOSPITAL

      44490

      44

      44 REHAB. 26T198......... CROSSROADS REGIONAL

      26910 7040 41180 MEDICAL CENTER. 193088......... CROWLEY REHAB HOSP,

      19000 3880

      19 LLC. 39T180......... CROZER CHESTER MEDICAL 39290 6160 37964 CENTER. 34T008......... CTR FOR REHAB SCOTLAND 34820

      34

      34 MEMORIAL HOSPIT. 39T233......... CTR. FOR ACUTE

      39800 9280 49620 REHABILITATIVE MEDICINE AT HANOVER. 07T033......... DANBURY HOSPITAL...... 07000 5483 14860 05T729......... DANIEL FREEMAN........ 05200 4480 31084 49T075......... DANVILLE REGIONAL

      49241 1950 19260 MEDICAL CENTER. 19T003......... DAUTERIVE HOSPITAL.... 19220

      19

      19 15T061......... DAVIESS COMMUNITY

      15130

      15

      15 HOSPITAL. 46T041......... DAVIS HOSPITAL AND

      46050 7160 36260 MEDICAL CENTER. 36T038......... DEACONESS HOSPITAL.... 36310 1640 17140 37T032......... DEACONESS HOSPITAL.... 37540 5880 36420 15T019......... DEACONESS ST. JOSEPHS. 15180

      15

      15 11T076......... DEKALB MEDICAL CENTER 11370 0520 12060 REHABILITATION. 03T093......... DEL E. WEBB MEMORIAL

      03060 6200 38060 HOSPITAL. 45T646......... DEL SOL MEDICAL CENTER 45480 2320 21340 39T081......... DELAWARE COUNTY

      39290 6160 37964 MEMORIAL HOSPITAL. 25T082......... DELTA REGIONAL MEDICAL 25750

      25

      25 CENTER. 45T634......... DENTON REGIONAL

      45410 1920 19124 MEDICAL CENTER. 06T011......... DENVER HEALTH MEDICAL 06150 2080 19740 CENTER. 49T011......... DEPAUL CENTER FOR

      49641 5720 47260 PHYSICAL REHABILITATION. 26T176......... DES PERES HOSPITAL.... 26940 7040 41180 05T243......... DESERT REGIONAL

      05430 6780 40140 MEDICAL CENTER. 45T147......... DETAR HOSPITAL........ 45948 8750 47020 19T115......... DOCTORS HOSPITAL...... 11840 7680 43340 11T177......... DOCTORS HOSPITAL OF

      19480 0600 12260 OPELOUSAS. 19T191......... DOCTORS HOSPITAL OF

      19080 3880

      19 SHREVEPORT.

      [[Page 30312]]

      36T151......... DOCTORS HOSPITAL OF

      36770 1320 15940 STARK COUNTY. 05T242......... DOMINICAN HOSPITAL.... 05540 7485 42100 39T203......... DOYLESTOWN HOSPITAL... 39140 6160 37964 46T021......... DRMC ACUTE

      46260

      46 41100 REHABILITATION. 39T086......... DUBOIS REGNL MED CNTR. 39230

      39

      39 34T155......... DURHAM REGIONAL

      34310 6640 20500 HOSPITAL. 23T230......... E W SPARROW INPATIENT 23320 4040 29620 REHAB. 19T146......... EAST JEFFERSON GENERAL 19250 5560 35380 HOSPITAL. 453072......... EAST TEXAS MED CTR

      45892 8640 46340 REHAB HOSP. 01T011......... EASTERN HEALTH REHAB

      01360 1000 13820 CENTER, MCE. 20T033......... EASTERN MAINE MEDICAL 20090 0733 12620 CENTER. 39T162......... EASTON HOSPITAL....... 39590 0240 10900 333029......... EDDY COHOES

      33000 0160 10580 REHABILITATION CTR. 45T119......... EDINBURG REGIONAL

      45650 4880 32580 MEDICAL. 36T241......... EDWIN SHAW

      36780 0080 10420 REHABILITATION HOSPITAL. 14T208......... EHS CHRIST HOSPITAL & 14141 1600 16974 MEDICAL CENTER. 03T080......... EL DORADO HOSPITAL.... 03090 8520 46060 15T018......... ELKHART GENERAL

      15190 2330 21140 HEALTHCARE SYSTEMS. 39T289......... ELKINS PARK HOSPITAL.. 39560 6160 37964 33T128......... ELMHURST HOSPITAL

      33590 5600 35644 CENTER. 11T010......... EMORY HOSPITAL CTR FOR 11370 0520 12060 REHAB. 05T158......... ENCINO-TARZANA

      05200 4480 31084 REGIONAL MEDICAL CENTER. 05T039......... ENLOE MEDICAL CENTER.. 05030 1620 17020 45T833......... ENNIS REGIONAL MEDICAL 45470 1920 19124 CENTER. 39T225......... EPHRATA COMMUNITY

      39440 4000 29540 HOSPITAL. 33T219......... ERIE COUNTY MEDICAL

      33240 1280 15380 CENTER. 19T078......... EUNICE COMMUNITY

      19480 3880

      19 MEDICAL CENTER. 39T013......... EVANGELICAL COMMUNITY 39720

      39

      39 HOSPITAL. 14T010......... EVANSTON NORTHWESTERN 14141 1600 16974 HEALTHCARE. 50T124......... EVERGREEN HEALTHCARE.. 50160 7600 42644 36T072......... FAIRFIELD MEDICAL

      36230 1840 18140 CENTER. 223029......... FAIRLAWN

      22170 1123 49340 REHABILITATION HOSPITAL. 36T077......... FAIRVIEW HOSPITAL..... 36170 1680 17460 11T125......... FAIRVIEW PARK HOSPITAL 11660

      11

      11 28T125......... FAITH REGIONAL HEALTH 28590

      28

      28 SERVICES. 10T236......... FAWCETT MEMORIAL

      10070 6580 39460 HOSPITAL. 33T044......... FAXTON-ST. LUKES

      33510 8680 46540 HEALTHCARE. 15T064......... FAYETTE MEMORIAL

      15200

      15

      15 HOSPITAL. 36T025......... FIRELANDS REGIONAL

      36220

      36 41780 MEDICAL CENTER. 34T115......... FIRSTHEALTH MOORE

      34620

      34

      34 REGIONAL HOSPITAL. 47T003......... FLETCHER ALLEN HEALTH 47030 1303 15540 CARE. 10T068......... FLORIDA HOSPITAL

      10630 2020 19660 ORMOND DIVISION. 10T007......... FLORIDA HOSPITAL

      10470 5960 36740 REHABILITATION AND SPORTS MEDICIN. 36T074......... FLOWER REHABILITATION 36490 8400 45780 CENTER. 11T054......... FLOYD MEDICAL CENTER.. 11460

      11 40660 39T267......... FORBES REGIONAL

      39010 6280 38300 HOSPITAL. 26T021......... FOREST PARK........... 26950 7040 41180 25T078......... FORREST GENERAL

      25170 3285 25620 HOSPITAL REHAB UNIT. 36T132......... FORT REHABILITATION

      36080 3200 17140 CENTER. 10T223......... FORT WALTON BEACH

      10450 2750 23020 MEDICAL CENT. 453041......... FORT WORTH

      45910 2800 23104 REHABILITATION HOSPITAL. 26T137......... FR.................... 26480 3710 27900 52T004......... FRANCISCAN SKEMP

      52310 3870 29100 MEDICAL CENTER REHAB. 18T040......... FRAZIER REHAB

      18550 4520 31140 INSTITUTE. 17T074......... FRED C BRAMLAGE

      17300

      17

      17 INPATIENT REHABILITATION UNIT. 52T177......... FROEDTERT MEMORIAL

      52390 5080 33340 LUTHERAN HOSPITAL. 34T116......... FRYE REGIONAL MEDICAL 34170 3290 25860 CENTER. 36T194......... GALION COMMUNITY

      36160 4800

      36 HOSPITAL. 23T244......... GARDEN CITY HOSPITAL.. 23810 2160 19804 05T432......... GARFIELD MEDICAL

      05200 4480 31084 CENTER. 44T035......... GATEWAY MEDICAL CENTER 44620 1660 17300 14T125......... GATEWAY REGIONAL

      14680 7040 41180 MEDICAL CENTER. 183031......... GATEWAY REHAB HOSPITAL 18550 4520 31140 183030......... GATEWAY REHABILITATION 18070 1640 17140 HOSPITAL. 33T058......... GE.................... 33530 6840 40380 393047......... GEISINGER HEALTHSOUTH 39580

      39

      39 REHABILITATION HOSPITAL. 39T270......... GEISINGER WYOMING

      39480 7560 42540 VALLEY MEDICAL CENTER.

      [[Page 30313]]

      36T039......... GENESIS HEALTH CARE

      36610

      36

      36 SYSTEM. 16T033......... GENESIS MEDICAL CENTER 16810 1960 19340 23T197......... GENESYS REGIONAL

      23240 2640 22420 MEDICAL CTR. 373026......... GEORGE NIGH

      37550

      37 46140 REBABILITATION CTR. 45T191......... GEORGETOWN HEALTHCARE 45970 0640 12420 SYSTEM. 11T087......... GLANCY................ 11530 0520 12060 05T239......... GLENDALE ADVENTIST

      05200 4480 31084 MEDICAL CENTER. 05T058......... GLENDALE MEMORIAL

      05200 4480 31084 HOSPITAL. 33T191......... GLENS FALLS HOSPITAL.. 33750 2975 24020 19T160......... GLENWOOD

      19360 5200 33740 REHABILITATION CENTER. 26T175......... GOLDEN VALLEY MEMORIAL 26410

      26

      26 HO INPATIENT REHAB FACILITY. 05T471......... GOOD SAMARITAN

      05200 4480 31084 HOSPITAL. 15T042......... GOOD SAMARITAN

      15410

      15

      15 HOSPITAL. 28T009......... GOOD SAMARITAN

      28090

      28

      28 HOSPITAL. 36T134......... GOOD SAMARITAN

      36310 1640 17140 HOSPITAL. 50T079......... GOOD SAMARITAN

      50260 8200 45104 HOSPITAL. 14T046......... GOOD SAMARITAN

      14490

      14

      14 REGIONAL HEALTH CENTER. 03T002......... GOOD SAMARITAN

      03060 6200 38060 REHABILITATION INSTITUTE. 39T031......... GOOD SAMARITAN-STINE

      39650

      39

      39 ACUTE REHAB. 45T037......... GOOD SHEPHERD MEDICAL 45570 4420 30980 CENTER. 393035......... GOOD SHEPHERD

      39470 0240 10900 REHABILITATION HOSPITAL. 393050......... GOOD SHEPHERD

      39590 0240 10900 REHABILITATION HOSPITAL. 24T064......... GRAND ITASCA CLINIC & 24300

      24

      24 HOSPITAL. 36T133......... GRANDVIEW MEDICAL

      36580 2000 19380 CENTER. 36T017......... GRANT/RIVERSIDE

      36250 1840 18140 METHODIST HOSPITALS. 23T030......... GRATIOT COMMUNITY

      23280

      23

      23 HOSPITAL. 16T057......... GREAT RIVER MEDICAL

      16280

      16

      16 CENTER. 09T008......... GREATER SOUTHEAST

      09000 8840 47894 COMMUNITY HOSPITAL. 363032......... GREENBRIAR

      36510 9320 49660 REHABILITATION HOSPITAL. 36T026......... GREENE MEMORIAL

      36290 2000 19380 HOSPITAL. 05T026......... GROSSMONT HOSPITAL

      05470 7320 41740 SHARP. 45T104......... GUADALUPE VALLEY

      45581 7240 41700 HOSPITAL. 45T214......... GULF COAST MEDICAL

      45954

      45

      45 CENTER. 52T087......... GUNDERSEN LUTHERAN

      52310 3870 29100 MEDICAL CENTER,INC.. 39T185......... GUNDERSON

      39480 7560 42540 REHABILITATION CENTER. 513028......... H/S REHAB HOSPITAL OF 51050 3400 26580 HUNTINGTON. 23T066......... HACKLEY HOSPITAL...... 23600 3000 34740 36T137......... HANNA HOUSE INPATIENT 36170 1680 17460 REHAB CENTER. 50T064......... HARBORVIEW MEDICAL

      50160 7600 42644 CENTER. 33T240......... HARLEM HOSPITAL/

      33420 5600 35644 COLUMBIA UNIVERSITY. 45T289......... HARRIS COUNTY HOSPITAL 45610 3360 26420 DISTRICT. 45T135......... HARRIS METHODIST FORT 45910 2800 23104 WORTH. 45T639......... HARRIS METHODIST HEB.. 45910 2800 23104 07T025......... HARTFORD HOSPITAL..... 07010 3283 25540 03T069......... HAVASU REGIONAL

      03070 4120

      03 MEDICAL CENTER. 17T013......... HAYS MEDICAL CENTER... 17250

      17

      17 18T029......... HAZARD ARH REGIONAL

      18960

      18

      18 MEDICAL CENTER. 013028......... HEALTH SOUTH REHAB

      01500 5240 33860 HOSPITAL OF MONTGOMERY. 23T275......... HEALTHSOURCE SAGINAW.. 23720 6960 40980 053031......... HEALTHSOUTH

      05140 0680 12540 BAKERSFIELD REHAB HOSPITAL. 223027......... HEALTHSOUTH BRAINTREE 22130 1123 14484 REHAB HOSPITAL. 443030......... HEALTHSOUTH CANE CREEK 44910

      44

      44 REHAB HOSPITAL. 113027......... HEALTHSOUTH CENTRAL GA 11090 4680 31420 REHAB HOSPITAL. 213028......... HEALTHSOUTH CHESAPEAKE 21220

      21 41540 REHAB HOSPITAL. 103040......... HEALTHSOUTH EMERALD

      10020 6015 37460 COAST REHABILITATION HOSPITAL. 393027......... HEALTHSOUTH

      39010 6280 38300 HARMARVILLE REHABILITATION HOSPITAL. 013025......... HEALTHSOUTH LAKESHORE 01360 1000 13820 REHABILITATION HOSPITAL. 033025......... HEALTHSOUTH MERIDIAN

      03060 6200 38060 POINT REHAB HOSP. 513030......... HEALTHSOUTH

      51300

      51 34060 MOUNTAINVIEW REGIONAL REHAB HOSPITAL. 393039......... HEALTHSOUTH NITTANY

      39200 8050 44300 VALLEY REHABILITATION HOSPITAL. 183027......... HEALTHSOUTH NORTHERN

      18580 1640 17140 KENTUCKY REHABILITATION. 393040......... HEALTHSOUTH OF

      39120 0280 11020 ALTOONA, INC. 423027......... HEALTHSOUTH OF

      42170 1440 16700 CHARLESTON, INC. 453047......... HEALTHSOUTH PLANO

      45310 1920 19124 REHABILITATION HOSP. 043032......... HEALTHSOUTH REHAB HOSP 04710 2580 22220 IN PART WITH RE. 453044......... HEALTHSOUTH REHAB HOSP 45940 0640 12420 OF AUSTIN. 183028......... HEALTHSOUTH REHAB HOSP 18460

      18 21060 OF CENTRAL KY.

      [[Page 30314]]

      063030......... HEALTHSOUTH REHAB HOSP 06200 1720 17820 OF COLORADO SPGS. 423026......... HEALTHSOUTH REHAB HOSP 42200 2655 22500 OF FLORENCE. 013029......... HEALTHSOUTH REHAB HOSP 01440 3440 26620 OF NORTH ALA. 103042......... HEALTHSOUTH REHAB HOSP 10260 8280 45300 OF SPRING HILL. 223030......... HEALTHSOUTH REHAB HOSP 22070 8003 44140 OF WESTERN MA. 033029......... HEALTHSOUTH REHAB

      03090 8520 46060 HOSPITAL. 103031......... HEALTHSOUTH REHAB

      10570 7510 42260 HOSPITAL. 103038......... HEALTHSOUTH REHAB

      10120 5000 33124 HOSPITAL OF MIAMI. 453059......... HEALTHSOUTH REHAB

      45801 3360 26420 HOSPITAL OF NORTH HOUSTON. 393026......... HEALTHSOUTH REHAB

      39110 6680 39740 HOSPITAL OF READING. 103033......... HEALTHSOUTH REHAB

      10360 8240 45220 HOSPITAL OF TALLHASSEE. 453054......... HEALTHSOUTH REHAB

      45960 9080 48660 HOSPITAL OF WICHITA FALLS. 453031......... HEALTHSOUTH REHAB

      45130 7240 41700 INSTITUTE OF SAN ANTONIO. 033028......... HEALTHSOUTH REHAB

      03090 8520 46060 INSTITUTE OF TUCSON. 393031......... HEALTHSOUTH REHAB OF

      39270 3240 25420 MECHANICSBURG-ACUTE REHAB. 393046......... HEALTHSOUTH

      39320 2360 21500 REHABILITATION HOSPITAL OF ERIE. 423028......... HEALTHSOUTH

      42450 1520 16740 REHABILITATION HOSPITAL. 443029......... HEALTHSOUTH

      44780 4920 32820 REHABILITATION CENTER OF MEMPHIS. 153027......... HEALTHSOUTH

      15330 3850 29020 REHABILITATION HOSP OF KOK. 393037......... HEALTHSOUTH

      39800 9280 49620 REHABILITATION HOSP YORK. 013030......... HEALTHSOUTH

      01340 2180 20020 REHABILITATION HOSPITAL. 043028......... HEALTHSOUTH

      04650 2720 22900 REHABILITATION HOSPITAL. 103037......... HEALTHSOUTH

      10510 8280 45300 REHABILITATION HOSPITAL. 153029......... HEALTHSOUTH

      15830 8320 45460 REHABILITATION HOSPITAL. 303027......... HEALTHSOUTH

      30060 1123 31700 REHABILITATION HOSPITAL. 323027......... HEALTHSOUTH

      32000 0200 10740 REHABILITATION HOSPITAL. 403025......... HEALTHSOUTH

      40640 7440 41980 REHABILITATION HOSPITAL. 443027......... HEALTHSOUTH

      44810 3660 28700 REHABILITATION HOSPITAL. 453029......... HEALTHSOUTH

      45610 3360 26420 REHABILITATION HOSPITAL. 453048......... HEALTHSOUTH

      45700 0840 13140 REHABILITATION HOSPITAL. 443031......... HEALTHSOUTH

      44780 4920 32820 REHABILITATION HOSPITAL-NORTH. 193031......... HEALTHSOUTH

      19090 3960 29340 REHABILITATION HOSPITAL OF ALEXANDRIA. 453040......... HEALTHSOUTH

      45910 2800 23104 REHABILITATION HOSPITAL OF ARLINGTON. 423025......... HEALTHSOUTH

      42390 1760 17900 REHABILITATION HOSPITAL OF COLUMBIA. 043029......... HEALTHSOUTH

      04150 3700 27860 REHABILITATION HOSPITAL OF JONESBORO. 293026......... HEALTHSOUTH

      29010 4120 29820 REHABILITATION HOSPITAL OF LAS VEGAS. 313029......... HEALTHSOUTH

      31310 5190 20764 REHABILITATION HOSPITAL OF NEW JERSEY. 453090......... HEALTHSOUTH

      45451 5800 36220 REHABILITATION HOSPITAL OF ODESSA. 393045......... HEALTHSOUTH

      39010 6280 38300 REHABILITATION HOSPITAL OF SEWICKLEY. 453053......... HEALTHSOUTH

      45170 8360 45500 REHABILITATION HOSPITAL OF TEXARKANA. 453056......... HEALTHSOUTH

      45892 8640 46340 REHABILITATION HOSPITAL OF TYLER. 463025......... HEALTHSOUTH

      46170 7160 41620 REHABILITATION HOSPITAL OF UTAH. 493028......... HEALTHSOUTH

      49430 6760 40060 REHABILITATION HOSPITAL OF VIRGINIA. 013032......... HEALTHSOUTH

      01270 2880 23460 REHABILITATION OF GADSDEN. 453057......... HEALTHSOUTH

      45794 5800 33260 REHABILITATION OF MIDLAND ODESSA. 293032......... HEALTHSOUTH

      29010 4120 29820 REHABILITIATION HOSPITAL OF HENDERSON. 103034......... HEALTHSOUTH SEA PINES 10050 2680 22744 REHABILITATION HOSPITAL. 193085......... HEALTHSOUTH SPECIALTY 19350 5560 35380 HOSPITAL. 45T758......... HEALTHSOUTH SPECIALTY 45390 1920 19124 HOSPTIAL, INC.. 103028......... HEALTHSOUTH SUNRISE

      10050 2680 22744 REHABILITATION HOSPITAL. 103032......... HEALTHSOUTH TREASURE

      10300

      10 46940 COAST REHAB HOSPITAL. 153025......... HEALTHSOUTH TRI-STATE 15810 2440 21780 REHABILITATION HOSPITAL. 053034......... HEALTHSOUTH TUSTIN

      05400 5945 42044 REHABILITATION HOSP. 033032......... HEALTHSOUTH VALLEY OF 03060 6200 38060 THE SUN. 513027......... HEALTHSOUTH WESTERN

      51530 6020 37620 HILLS REGIONAL REHAB HOSPITAL. 193074......... HEALTHWEST

      19250 5560 35380 REHABILITATION HOSPITAL. 26T006......... HEARTLAND REGIONAL

      26100 7000 41140 MEDICAL CENTER. 333027......... HELEN HAYES HOSPITAL.. 33620 5600 35644 04T085......... HELENA REGIONAL

      04530

      04

      04 REHABILITATION CENTER. 45T229......... HENDRICK CENTER FOR

      45911 0040 10180 REHABILITATION. 49T118......... HENRICO DOCTORS

      49430 6760 40060 HOSPITAL PARHA. 23T204......... HENRY FORD BI-COUNTY

      23490 2160 47644 HOSPITAL. 23T146......... HENRY FORD WYANDOTTE

      23810 2160 19804 HOSPITAL. 05T624......... HENRY MAYO NEWHALL

      05200 4480 31084 MEMORIAL HOSPITAL. 34T107......... HERITAGE HOSPITAL..... 34320 6895 40580 45T068......... HERMANN HOSPITAL...... 45610 3360 26420 23T120......... HERRICK MEMORIAL

      23450 0440

      23 HOSPITAL.

      [[Page 30315]]

      14T011......... HERRIN HOSPITAL....... 14990

      14

      14 34T004......... HIGH POINT REGIONAL

      34400 3120 24660 HOSPITAL. 453086......... HIGHLANDS REGIONAL

      45480 2320 21340 REHABILITATION HOS. 50T011......... HIGHLINE COMMUNITY

      50160 7600 42644 HOSPITAL. 45T101......... HILLCREST BAPTIST

      45780 8800 47380 MEDICAL CENTER. 37T001......... HILLCREST KAISER

      37710 8560 46140 REHABILITATION CENTER. 363026......... HILLSIDE

      36790 9320 49660 REHABILITATION HOSPITAL. 14T122......... HINSDALE HOSPITAL--

      14250 1600 16974 PAULSON REHAB NETWORK. 10T225......... HOLLYWOOD MEDICAL

      10050 2680 22744 CENTER. 10T073......... HOLY CROSS HOSPITAL... 10050 2680 22744 14T133......... HOLY CROSS HOSPITAL... 14141 1600 16974 52T107......... HOLY FAMILY MEMORIAL, 52350

      52

      52 INC. 36T054......... HOLZER MEDICAL CENTER. 36270

      36

      36 45T236......... HOPKINS COUNTY

      45654

      45

      45 MEMORIAL HOSPITAL. 44T046......... HORIZON MEDICAL CENTER 44210 5360 34980 33T389......... HOSPITAL FOR JOINT

      33420 5600 35644 DISEASES. 07T001......... HOSPITAL OF SAINT

      07040 5483 35300 RAPHAEL. 39T111......... HOSPITAL OF UNIV OF

      39620 6160 37964 PENNSYLVANIA. 04T076......... HOT SPRING COUNTY

      04290

      04

      04 MEDICAL CENTER. 153039......... HOWARD REGIONAL HEALTH 15330 3850 29020 SYSTEM-WEST CAMPUS. 52T091......... HOWARD YOUNG MEDICAL

      52420

      52

      52 CENTER. 11T200......... HUGHSTON ORTHOPEDIC

      11780 1800 17980 HOSPITAL. 05T438......... HUNTINGTON MEMORIAL

      05200 4480 31084 HOSPITAL. 23T132......... HURLEY MEDICAL CENTER. 23240 2640 22420 17T020......... HUTCHINSON HOSPITAL

      17770

      17

      17 CORP.. 133025......... IDAHO ELKS

      13000 1080 14260 REHABILITATION HOSPITAL. 13T018......... IDAHO REGIONAL MEDICAL 13090

      13 26820 CENTER. 28T081......... IMMANUEL

      28270 5920 36540 REHABILITATION CENTER. 26T095......... INDEPENDENCE REGIONAL 26470 3760 28140 HEALTH CENTER. 14T191......... INGALLS MEMORIAL

      14141 1600 16974 HOSPITAL. 23T167......... INGHAM REGIONAL

      23320 4040 29620 MEDICAL CENTER. INOVA MOUNT VERNON HOSPITAL. 45T132......... INPATIENT REHAB....... 45451 5800 36220 453025......... INSTUTUTE FOR REHAB & 45610 3360 26420 RESEARCH,THE. 37T106......... INTEGRIS SOUTHWEST

      37540 5880 36420 MEDICAL CENTER. 323029......... INTERFACE INC DBA

      32220

      32 22140 LIFECOURSE REHAB SERVICES. 16T082......... IOWA METHODIST MEDICAL 16760 2120 19780 CENTER. 15T024......... J.W. SOMMER

      01160 3480 26900 REHABILIATION UNIT. 01T157......... JACKSON MEMORIAL

      10120 2650 22520 HOSPITAL. 33T014......... JACOBI MEDICAL CENTER. 33020 5600 35644 10T022......... JAMAICA HOSPITAL

      33590 5000 33124 MEDICAL CENTER. 33T127......... JAMESON HOSPITAL...... 39450 5600 35644 39T016......... JANE PHILLIPS MEMORIAL 37730

      39

      39 MEDICAL CENTER. 37T018......... JEANES HOSPITAL....... 39620

      37

      37 39T080......... JEANNETTE HOSPITAL.... 39770 6160 37964 39T010......... JEFFERSON REGIONAL

      04340 6280 38300 MEDICAL CENTER. 04T071......... JEFFERSON REGIONAL

      39010 6240 38220 MEDICAL CENTER. 39T265......... JFK JOHNSON REHAB

      31270 6280 38300 INSTITUTE. 31T108......... JIM THORPE REHAB UNIT. 37190 5015 20764 37T029......... JOHN D. ARCHBOLD

      11890

      37

      37 MEMORIAL HOSPITAL. 11T038......... JOHN HEINZ INST OF

      39680

      11

      11 REHAB MEDICINE. 393036......... JOHN MUIR MEDICAL

      05060 3680

      39 CENTER. 05T180......... JOHNSON CITY MEDICAL

      44890 5775 36084 CTR. 44T063......... JOHNSON REGIONAL

      04350 3660 27740 REHABILITATION CENTER. 04T002......... JOHNSTON R. BOWMAN

      14141

      04

      04 HEALTH CTR.. 14T119......... JOINT TOWNSHIP

      36050 1600 16974 DISTRICT MEMORIAL HOSPITAL, REHABIL. 36T032......... KADLEC MEDICAL CENTER. 50020 4320

      36 33T005......... KAISER FOUNDATION

      05460 1280 15380 HOSPITAL-FONTANA REHAB CENTER. 50T058......... KAISER MEDICAL CENTER. 05580 6740 28420 05T140......... KALEIDA HEALTH........ 33240 6780 40140 05T073......... KALISPELL REGIONAL

      27140 8720 46700 MEDICAL CENTER. 27T051......... KANSAS REHABILITATION 17880

      27

      27 HOSPITAL, INC. 173025......... KANSAS UNIVERSITY

      17986 8440 45820 REHAB. 17T040......... KAPLAN REHABILITATION 19560 3760 28140 HOSPITAL. 193057......... KAWEAH DELTA

      05640

      19

      19 REHABILITATION HOSPITAL. 05T057......... KENMORE MERCY HOSPITAL 33240 8780 47300 33T102......... KENT COUNTY MEMORIAL

      41010 1280 15380 HOSPITAL.

      [[Page 30316]]

      41T009......... KEOKUK AREA HOSPITAL.. 16550 6483 39300 16T008......... KESSLER REHAB......... 31200

      16

      16 313025......... KESSLER ADVENTIST

      21150 5640 35084 REHABILITATION HOSPITAL. 213029......... KETTERING MEDICAL

      36580 8840 13644 CENTER. 36T079......... KINGMAN REGIONAL

      03070 2000 19380 MEDICAL CENTER. 03T055......... KINGS COUNTY HOSPITAL 33331 4120

      03 CENTER. 33T202......... KING'S DAUGHTER

      18090 5600 35644 MEDICAL CENTER. 18T009......... KINGSBROOK JEWISH

      33331 3400 26580 MEDICAL CENTER. 33T201......... KINGWOOD MEDICAL

      45610 5600 35644 CENTER. 45T775......... KOOTENAI MEDICAL

      13270 3360 26420 CENTER. 13T049......... LA PALMA

      05400

      13 17660 INTERCOMMUNITY HOSPITAL. 05T580......... LABETTE COUNTY MEDICAL 17490 5945 42044 CENTER. 17T120......... LAC/RANCHO LOS AMIGOS 05400

      17

      17 NATIONAL MED CTR. 05T717......... LAFAYETTE GENERAL

      19270 5945 42044 MEDICAL CENTER. 19T002......... LAGRANGE COMMUNITY

      15430 3880 29180 HOSPITAL. 15T096......... LAKE CHARLES MEMORIAL 19090

      15

      15 HOSPITAL. 19T060......... LAKE CUMBERLAND

      18972 3960 29340 REGIONAL HOSP. 18T132......... LAKE HOSPITAL SYSTEM

      36440

      18

      18 INC. 36T098......... LAKE REGION HEALTHCARE 24550 1680 17460 CORPORATION. 24T052......... LAKELAND HOSPITAL, ST. 23100

      24

      24 JOSEPH. 23T021......... LAKESHORE CARRAWAY

      01360 0870 35660 REHABILITATION HOSPITAL. 01T064......... LAKEWAY REGIONAL

      44310 1000 13820 HOSPITAL. 44T067......... LAKEWOOD HOSPITAL..... 36170

      44 34100 36T212......... LAKEWOOD REGIONAL

      05200 1680 17460 MEDICAL CENTER. 05T581......... LANCASTER COMMUNITY

      05200 4480 31084 HOSPITAL. 05T204......... LANCASTER GENERAL HOSP 39440 4480 31084 39T100......... LANCASTER REGIONAL

      39440 4000 29540 MEDICAL CENTER. 39T061......... LANDER VALLEY MEDICAL 53060 4000 29540 CENTER. 53T010......... LANE FROST HEALTH AND 37110

      53

      53 REHABILITATION CENTER. 373032......... LANE REHABILTATION

      19160

      37

      37 CENTER. 19T020......... LAPLACE REHABILITATION 19350 0760 12940 HOSPITAL. 193064......... LAPORTE HOSPITAL AND

      15450 5560 35380 HEALTH SERVICES. 45T029......... LAREDO MEDICAL CENTER. 45953 4080 29700 45T107......... LAS PALMAS

      45480 2320 21340 REHABILITATION HOSP. 05T095......... LAUREL GROVE HOSPITAL. 05000 5775 36084 10T246......... LAWNWOOD REGIONAL

      10550 2710 38940 MEDICAL CENT. 07T007......... LAWRENCE & MEMORIAL

      07050 5523 35980 HOSPITAL. 17T137......... LAWRENCE MEMORIAL

      17220 4150 29940 HOSPITAL. 46T010......... LDS HOSPITAL.......... 46170 7160 41620 32T065......... LEA REGIONAL MEDICAL

      32120

      32

      32 CENTER. 49T012......... LEE REGIONAL MEDICAL

      49520

      49

      49 CENTER. 10T084......... LEESBURG REGIONAL

      10340 5960 36740 MEDICAL CENTER. 193086......... LEESVILLE

      19570

      19

      19 REHABILITATION HOSPITAL LLC. 38T017......... LEGACY GOOD SAMARITAN 38250 6440 38900 HOSP & MED CTR. 34T027......... LENOIR MEMORIAL

      34530

      34

      34 HOSPITAL REHAB UNIT. 05T060......... LEON S. PETERS

      05090 2840 23420 REHABILITATION. 36T086......... LEVINE REHABILITATION 36110 2000 44220 CENTER. 49T048......... LEWIS GALE MEDICAL

      49838 6800 40220 CENTER. 15T006......... LIBERTY REHABILITATION 31230

      15 33140 INSTITUTE. 31T118......... LIMA MEMORIAL HEALTH

      36010 3640 35644 SYSTEM. 36T009......... LINCOLN PARK HOSPITAL. 14141 4320 30620 14T207......... LITTLE COMPANY OF

      05200 1600 16974 MARY--SAN PEDRO HOSPITAL REHAB. 05T078......... LIVINGSTON REGIONAL

      44660 4480 31084 HOSPITAL. 44T187......... LODI MEMORIAL HOSPITAL 05490

      44

      44 05T336......... LOGAN REGIONAL MEDICAL 51220 8120 44700 CENTER. 51T048......... LOMA LINDA UNIVERSITY 05460

      51

      51 MEDICAL CENTER. 05T327......... LONG BEACH MEDICAL

      33400 6780 40140 CENTER. 33T225......... LONG BEACH MEMORIAL

      05200 5380 35004 MEDICAL CENTER. 05T485......... LONG ISLAND COLLEGE

      33331 4480 31084 HOSPITAL. 33T152......... LONGVIEW REGIONAL

      45570 5600 35644 PHYSICAL REHABILITATION. 45T702......... LOS ROBLES HOSPITAL & 05660 4420 30980 MEDICAL CENTER. 05T549......... LOUIS A. WEISS

      14141 8735 37100 MEMORIAL HOSPITAL. 14T082......... LOUISIANA

      19500 1600 16974 REHABILIATAION HOSPITAL OF MORGAN CITY L. 193084......... LOURDES............... 18720

      19

      19 18T102......... LOURDES MEDICAL CENTER 50100

      18

      18 50R337......... LOURDES MEDICAL CENTER 50100 6740 28420 50T023......... LOYOLA UNIVERSITY

      14141 6740 28420 MEDICAL CENTER.

      [[Page 30317]]

      14T276......... LULING REHABILITATION 19440 1600 16974 HOSPITAL. 193060......... LUTHERAN HOSPITAL

      36170 5560 35380 ACUTE REHAB UNIT. 36T087......... LUTHERAN MEDICAL

      33331 1680 17460 CENTER. 33T306......... MADISON COUNTY

      36500 5600 35644 HOSPITAL INPATIENT REHAB. 45T032......... MADONNA REHABILITATION 28540 4420

      45 HOSPITAL. 36T189......... MAGEE REHABILITATION

      39620 1840 18140 HOSPITAL. 283025......... MAGNOLIA REGIONAL

      25010 4360 30700 HEALTH CENTER. 393038......... MAINLAND MEDICAL

      45550 6160 37964 HOSPITAL. 25T009......... MARIA PARHAM

      34900

      25

      25 HEALTHCARE ASSOCIATION, INC.. 45T530......... MARIANJOY

      14250 2920 26420 REHABILITATION HOSPITAL. 34T132......... MARIETTA MEMORIAL

      36850

      34

      34 HOSPITAL. 143027......... MARLETTE COMMUNITY

      23750 1600 16974 HOSP CTR FOR REHAB. 36T147......... MARLTON REHABILITATION 31150 6020 37620 HOSPITAL. 23T082......... MARQUETTE GENERAL

      23510

      23

      23 HOSPITAL. 313032......... MARY BLACK CENTER FOR 42410 6160 15804 REHAB. 23T054......... MARY FREE BED HOSPITAL 23400

      23

      23 & REHABILITATION CENTER. 42T083......... MARY GREELEY MEDICAL

      16840 3160 43900 CENTER. 233026......... MARYVIEW CENTER FOR

      49711 3000 24340 PHYSICAL REHABILITATION. 16T030......... MASSILLON COMMUNITY

      36770

      16 11180 HOSPITAL. 49T017......... MATAGORDA GENERAL

      45790 5720 47260 HOSPITAL. 36T100......... MAYO CLINIC HOSPITAL.. 03060 1320 15940 45T465......... MCALESTER REGIONAL

      37600

      45 HEALTH CENTER. 45............. MCKAY-DEE HOSPITAL.... 46280 6200 38060 37T034......... MCKEE MEDICAL CENTER.. 06340

      37

      37 46T004......... MCKENNA REHAB

      45320 7160 36260 INSTITUTE. 06T030......... MCLAREN REGIONAL

      23240 2670 22660 MEDICAL CENTER. 45T059......... MCO REHAB HOSPITAL.... 36490 7240 41700 23T141......... MEADOWBROOK REHAB

      17450 2640 22420 HOSPITAL. 36T048......... MEADOWBROOK REHAB

      10120 8400 45780 HOSPITAL OF WEST GAB. 04T088......... MEADOWBROOK

      45610

      04

      04 REHABILITAION HOSPITAL. 17T180......... MEADVILLE MEDICAL

      39260 3760 28140 CENTER. 103036......... MECOSTA COUNTY GENERAL 23530 5000 33124 HOSPITAL. 453052......... MED CTR OF LA AT NEW

      19350 3360 26420 ORLEANS. 39T113......... MEDCENTER ONE, INC.... 35070

      39

      39 23T093......... MEDCENTRAL HEALTH

      36710

      23

      23 SYSTEM. 19T005......... MEDICAL CENTER AT

      45730 5560 35380 TERRELL. 35T015......... MEDICAL CENTER OF

      45910 1010 13900 ARLINGTON. 36T118......... MEDICAL CENTER OF

      45310 4800 31900 PLANO. 45T683......... MEDICAL CENTER OF

      04690 1920 19124 SOUTH ARKANSAS. 45T675......... MEDICAL CITY DALLAS

      45390 2800 23104 HOSPITAL. 45T651......... MEDICAL CNTR OF

      08010 1920 19124 DELAWARE. 45T647......... MEDINA HOSPITAL....... 33550 1920 19124 08T001......... MEMORIAL HEALTH

      11220 9160 48864 UNIVERSITY MEDICAL CENTER. 33T053......... MEMORIAL HEALTHCARE

      23770 6840 40380 CENTER. 11T036......... MEMORIAL HERMAN

      45840 7520 42340 BAPTIST HOSP ORANGE. 23T121......... MEMORIAL HERMANN FT.

      45610

      23

      23 BEND INPATIENT REHABILITATION. 45T005......... MEMORIAL HERMANN

      45610 0840 13140 NORTHWEST HOSPITAL. 45T848......... MEMORIAL HOSPITAL..... 10050 3360 26420 45T184......... MEMORIAL HOSPITAL--

      15700 3360 26420 SOUTH BEND. 10T038......... MEMORIAL HOSPITAL AT

      25230 2680 22744 GULFPORT. 15T058......... MEMORIAL HOSPITAL OF

      41030 7800 43780 RI. 25T019......... MEMORIAL MED CENTER OF 45020 0920 25060 EAST TE. 41T001......... MEMORIAL MEDICAL

      14920 6483 39300 CENTER. 45T211......... MEMORIAL MEDICAL

      19350

      45

      45 CENTER--REHABILITATIO N INSTITUTE. 14T148......... MEMORIAL

      45794 7880 44100 REHABILITATION HOSPITAL. 19T135......... MENA MEDICAL CENTER... 04560 5560 35380 45T133......... MENORAH MEDICAL CENTER 17450 5800 33260 04T015......... MERCY FITZGERALD

      39290

      04

      04 HOSPITAL. 17T182......... MERCY FRANCISCAN

      36310 3760 28140 HOSPITAL MT. AIRY. 39T156......... MERCY FRANCISCAN

      36310 6160 37964 HOSPITAL WESTERN HILLS. 36T234......... MERCY GENERAL HEALTH

      23600 1640 17140 PARTNERS. 36T113......... MERCY GENERAL HOSPITAL 05440 1640 17140 23T004......... MERCY HEALTH CENTER... 17800 3000 34740 05T017......... MERCY HEALTH CENTER,

      37540 6920 40900 INC. 17T142......... MERCY HEALTH SYSTEM

      52520

      17

      17 CORP. 37T013......... MERCY HEALTH SYSTEM OF 17050 5880 36420 KANSAS. 52T066......... MERCY HOSPITAL........ 10120 3620 27500

      [[Page 30318]]

      17T058......... MERCY HOSPITAL........ 14141

      17

      17 10T061......... MERCY HOSPITAL OF

      39010 5000 33124 PITTSBURGH. 14T158......... MERCY HOSPITAL PORT

      23730 1600 16974 HURON. 39T028......... MERCY HOSPITAL

      34590 6280 38300 REHABILITATION UNIT. 23T031......... MERCY MEDICAL......... 01010 2160 47644 34T098......... MERCY MEDICAL CENTER.. 33400 1520 16740 013027......... MERCY MEDICAL CENTER.. 36770 5160

      01 33T259......... MERCY MEDICAL CENTER.. 52690 5380 35004 36T070......... MERCY MEDICAL CENTER- 16760 1320 15940 DES MOINES. 52T048......... MERCY MEDICAL CENTER- 16300 0460 36780 DUBUQUE. 16T083......... MERCY MEDICAL CENTER- 16960 2120 19780 SIOUX CITY. 16T069......... MERCY MEDICAL CENTER- 16160 2200 20220 NORTH IOWA. 16T153......... MERCY MEMORIAL HEALTH 37090 7720 43580 CENTER. 16T064......... MERCY PROVIDENCE

      39010

      16

      16 HOSPITAL. 37T047......... MERIDIA EUCLID

      36170

      37

      37 HOSPITAL. 39T136......... MERITCARE HEALTH

      35080 6280 38300 SYSTEM. 36T082......... MERITER HOSPITAL INC.. 52120 1680 17460 35T011......... MERWICK REHAB HOSPITAL 31260 2520 22020 52T089......... MESA GENERAL HOSPITAL. 03060 4720 31540 31T010......... MESA LUTHERAN HOSPITAL 03060 8480 45940 REHAB. 03T017......... MESQUITE COMMUNITY

      45390 6200 38060 HOSPITAL. 03T018......... METHODIST HOSPITAL.... 19350 6200 38060 45T688......... METHODIST HOSPITAL.... 19350 1920 19124 19T124......... METHODIST HOSPITAL.... 24260 5560 35380 19T200......... METHODIST HOSPITAL OF 05200 5560 35380 SOUTHERN CA. 24T053......... METHODIST HOSPITAL

      18500 5120 33460 REHABILITATION CENTER. 05T238......... METHODIST HOSPITAL,

      45610 4480 31084 THE. 18T056......... METHODIST MEDICAL

      45390 2440 21780 CENTER. 45T358......... METHODIST MEDICAL

      14800 3360 26420 CENTER OF ILLINOIS. 45T051......... METHODIST NORTHLAKE... 15440 1920 19124 14T209......... METHODIST SPECIALTY/

      45130 6120 37900 TRANSPLANT. 15T002......... METROHEALTH MEDICAL

      36170 2960 23844 CENTER. 45T631......... METROPOLITAN HOSPITAL. 33420 7240 41700 36T059......... METROPOLITAN HOSPITAL 23400 1680 17460 AND METRO HEALTH CORPORATION. 33T199......... METROPOLITAN METHODIST 45130 5600 35644 HOSP. 23T236......... MI LAND E. KNAPP

      24260 3000 24340 REHABILITATION CENTER. 45T388......... MIAMI VALLEY HOSPITAL. 36580 7240 41700 24T004......... MICHAEL REESE HOSPITAL 14141 5120 33460 36T051......... MID AMERICA

      17450 2000 19380 REHABILITATION HOSPITAL. 14T075......... MID JEFFERSON HOSPITAL 45700 1600 16974 173026......... MIDDLETOWN REGIONAL

      36080 3760 28140 HOSPITAL. 45T514......... MILLER DWAN MEDICAL

      24680 0840 13140 CENTER. 36T076......... MILLS HEALTH CENTER... 05510 3200 17140 24T019......... MILTON S HERSHEY

      39280 2240 20260 MEDICAL CENTER. 05T007......... MINDEN MEDICAL CENTER 19590 7360 41884 REHAB. 39T256......... MISSION HOSPITAL...... 05400 3240 25420 19T144......... MISSION HOSPITAL...... 45650 7680

      19 05T567......... MISSISSIPPI METHODIST 25240 5945 42044 REHABILITATION CENTER. 45T176......... MISSISSIPPI METHODIST 25240 4880 32580 REHABILITATION CENTER. 253025......... MISSOURI BAPTIST

      26940 3560 27140 MEDICAL CENTER. 25T152......... MISSOURI DELTA MEDICAL 26982 3560 27140 CENTER. 26T108......... MOBILE INFIRMARY...... 01480 7040 41180 26T113......... MODESTO REHABILITATION 05600

      26

      26 HOSPITAL. 01T113......... MONONGAHELA VALLEY

      39750 5160 33660 HOSPITAL. 053036......... MONTEFIORE MEDICAL

      33020 5170 33700 CENTER. 39T147......... MORGAN HOSPITAL &

      15540 6280 38300 MEDICAL CTR. 33T059......... MORTON PLANT NORTH BAY 10500 5600 35644 HOSPITAL. 15T038......... MOSES CONE HEALTH

      34400 3480 26900 SYSTEM. 34T091......... MOSS REHAB............ 39620 3120 24660 39T142......... MOUNT CARMEL REGIONAL 17180 6160 37964 MEDICAL CENTER. 17T006......... MOUNT SINAI MEDICAL

      10120

      17

      17 CENTER. 10T034......... MOUNTAINVIEW REGIONAL 32060 5000 33124 MEDICAL CENTER. 32T085......... MT CARMEL INPATIENT

      36250 4100 29740 REHAB UNIT. 36T035......... MT SINAI HOSPITAL..... 33420 1840 18140 33T024......... MUNSON MEDICAL CENTER. 23270 5600 35644 23T097......... MUSKOGEE REGIONAL

      37500

      23

      23 REHABILITATION CENTER. 37T025......... NACOGDOCHES COUNTY

      45810

      37

      37 HOSPITAL DISTRICT.

      [[Page 30319]]

      45T508......... NAPLES COMMUNITY

      10100

      45

      45 HOSPITAL, INC.. 10T018......... NASHVILLE

      44180 5345 34940 REHABILITATION HOSPITAL. 44T026......... NASSAU UNIVERSITY

      33400 5360 34980 MEDICAL CENTER. 33T027......... NATCHEZ REGIONAL

      25000 5380 35004 MEDICAL CENTER. 25T084......... NATIONAL PARK......... 04250

      25

      25 04T078......... NATIONAL

      09000

      04 26300 REHABILITATION HOSPITAL. 093025......... NAVARRO REGIONAL

      45820 8840 47894 HOSPITAL. 45T447......... NAZARETH HOSPITAL..... 39620

      45

      45 39T204......... NEBRASKA METHODIST

      28270 6160 37964 HEALTH SYSTEM. 28T040......... NEW ENGLAND REHAB

      20020 5920 36540 HOSPITAL OF PORTLAND. 203025......... NEW ENGLAND

      22090 6403 38860 REHABILITAION HOSPITAL-WOBURN. 223026......... NEW HANOVER REGIONAL

      34640 1123 15764 MEDICAL CENTER. 34T141......... NEW MEXICO

      32020 9200 48900 REHABILITATION CENTER. 323026......... NEW ORLEANS EAST

      19350

      32

      32 REHABILITATION. 193089......... NEW YORK METHODIST

      33331 5560 35380 HOSPITAL. 33T236......... NEW YORK PRESBYTERIAN 33420 5600 35644 HOSPITAL. 33T101......... NEWMAN REGIONAL HEALTH 17550 5600 35644 17T001......... NEWPORT HOSPITAL...... 41020

      17

      17 41T006......... NEWTON MEDICAL CENTER. 17390 6483 39300 17T103......... NEWTON MEMORIAL

      31360 9040 48620 HOSPITAL. 31T028......... NEXT STEP ACUTE

      39190 5640 35084 REHABILITATION CENTER. 39T194......... NIX HEALTH CARE SYSTEM 45130 0240 10900 45T130......... NOBLE HOSPITAL REHAB

      22070 7240 41700 UNIT. 10T063......... NORMAN REGIONAL

      37130 8280 45300 HOSPITAL. 22T065......... NORTH AUSTIN MEDICAL

      45940 8003 44140 CENTER. 37T008......... NORTH BROWARD MEDICAL 10050 5880 36420 CENTER. 45T809......... NORTH CAROLINA BAPTIST 34330 0640 12420 HOSPITALS. 10T086......... NORTH CENTRAL MEDICAL 45310 2680 22744 CENTER. 34T047......... NORTH COLORADO MEDICAL 06610 3120 49180 CENTER. 45T403......... NORTH COUNTRY REGIONAL 24030 1920 19124 HOSPITAL. 06T001......... NORTH DALLAS

      45620 3060 24540 REHABILITATION HOSPITAL. 24T100......... NORTH DALLAS

      45390

      24

      24 REHABILITATION HOSPITAL. 453032......... NORTH FULTON REGIONAL 11470 1920 19124 HOSPITAL. 11T198......... NORTH HILLS HOSPITAL.. 45910 0520 12060 45T087......... NORTH KANSAS CITY

      26230 2800 23104 HOSPITAL. 26T096......... NORTH MEMORIAL HEALTH 24260 3760 28140 CENTER. 24T001......... NORTH MISS. MEDICAL

      25400 5120 33460 CENTER. 25T004......... NORTH MONROE MEDICAL

      19360

      25

      25 CENTER. 19T197......... NORTH OAKLAND MEDICAL 23620 5200 33740 CENTERS. 23T013......... NORTH OAKS REHAB HOSP 19520 2160 47644 INC. 193044......... NORTH SHORE REGIONAL

      19510

      19

      19 MEDICAL CENTER. 19T204......... NORTH SHORE UNIVERSITY 33400 5560 35380 33T181......... NORTH SUBURBAN MEDICAL 06000 5380 35004 CENTER. 06T065......... NORTHEAST GEORGIA

      11550 2080 19740 MEDICAL CENTER. 11T029......... NORTHEAST METHODIST

      45130

      11 23580 HOSPITAL. 45T733......... NORTHEAST OKLAHOMA

      37710 7240 41700 REHABILITATION ASSOCIATES, LP. 373029......... NORTHEAST REGIONAL

      26000 8560 46140 MEDICAL CENTER. 26T022......... NORTHEAST

      30070

      26

      26 REHABILITATION HOSPITAL. 303026......... NORTHERN CALIFORNIA

      05550 1123 40484 REHABILITATION HOSPITAL. 05T699......... NORTHERN ILLINOIS

      14640 6690 39820 MEDICAL CENTER. 14T116......... NORTHERN MICHIGAN

      23230 1600 16974 HOSPITAL. 23T105......... NORTHERN NEVADA

      29150

      23

      23 MEDICAL CENTER. 29T032......... NORTHLAKE MEDICAL

      11370 6720 39900 CENTER. 11T033......... NORTHPORT MEDICAL

      01620 0520 12060 CENTER. 01T145......... NORTHRIDGE HOSPITAL

      05200 8600 46220 MEDICAL CENTER. 05T116......... NORTHWEST HEALTH

      04710 4480 31084 SYSTEM. 04T022......... NORTHWEST HOSPITAL.... 50160 2580 22220 50T001......... NORTHWEST MISSISSIPPI 25130 7600 42644 REGIONAL MED CTR. 25T042......... NORTHWEST REGIONAL

      45830

      25

      25 HOSPITAL. 45T131......... NORWALK HOSPITAL

      07000 1880 18580 ASSOCIATION. 07T034......... OAK FOREST HOSPITAL... 14141 5483 14860 14T301......... OAKLAND REGIONAL

      23620 1600 16974 HOSPITAL. 233028......... OAKWOOD HERITAGE

      23810 2160 47644 HOSPITAL. 23T270......... OCHSNER REHABILITATION 19250 2160 19804 CENTER. 19T036......... OGDEN REGIONAL MEDICAL 46280 5560 35380 CENTER. 46T005......... OHIO STATE UNIVERSITY 36250 7160 36260 HOSPITAL. 36T085......... OHIO VALLEY GENERAL

      39010 1840 18140 HOSPITAL ARU.

      [[Page 30320]]

      39T157......... OM.................... 18290 6280 38300 18T038......... OPELOUSAS GENERAL

      19480 5990 36980 HOSPITAL. 19T017......... ORANGE REGIONAL

      33540 3880

      19 MEDICAL CENTER. 33T001......... ORANGE REGIONAL

      33540 5660 39100 MEDICAL CENTER. 33T126......... OREGON REHABILITATION 38190 5660 39100 CENTER. 38T033......... ORLANDO REGIONAL

      10470 2400 21660 HEALTHCARE-CMR. 10T006......... OSTEOPATHIC MEDICAL

      45910 5960 36740 CENTER OF TEXAS. 45T121......... OU MEDICAL CENTER..... 37540 2800 23104 37T093......... OUR LADY OF LOURDES

      31160 5880 36420 MEDICAL CENTER. 31T029......... OUR LADY OF LOURDES

      19270 6160 15804 REG MED CENTER. 19T102......... OUR LADY OF THE LAKE

      19160 3880 29180 REGIONAL MEDICAL CENTER. 19T064......... OVERLAKE HOSPITAL

      50160 0760 12940 MEDICAL CENTER. 50T051......... PALESTINE REGIONAL

      45000 7600 42644 REHAB HOSPITAL. 45T113......... PALMYRA MEDICAL CENTER 11390

      45

      45 11T163......... PALOMAR MEDICAL CENTER 05470 0120 10500 05T115......... PAMPA REGIONAL MEDICAL 45563 7320 41740 CENTER. 45T099......... PARADISE VALLEY

      05470

      45

      45 HOSPITAL. 05T024......... PARIS REGIONAL MEDICAL 45750 7320 41740 CENTER. 45T196......... PARK PLACE MEDICAL

      45700

      45

      45 CENTER. 45T518......... PARK PLAZA HOSPITAL... 45610 0840 13140 45T659......... PARKLAND HEALTH AND

      45390 3360 26420 HOSPITAL SYSTEM. 45T015......... PARKRIDGE MEDICAL

      44320 1920 19124 CENTER. 44T156......... PARKVIEW HOSPITAL..... 15010 1560 16860 15T021......... PARKVIEW MEDICAL

      06500 2760 23060 CENTER. 06T020......... PARKVIEW REGIONAL

      45758 6560 39380 HOSPITAL. 45T400......... PARKWAY REGIONAL

      10120

      45

      45 MEDICAL CENTER. 10T114......... PARMA COMMUNITY

      36170 5000 33124 GENERAL HOSPITAL. 36T041......... PATRICIA NEAL

      44460 1680 17460 REHABILITATION CENTER. 44T125......... PENINSULA HOSPITAL

      33590 3840 28940 CENTER. 33T002......... PENNYSLVANIA HOSPITAL, 39620 5600 35644 ACUTE REHABILITATION UNIT. 39T226......... PENROSE HOSPITAL/

      06200 6160 37964 ELEANOR-CAPRON. 06T031......... PETERSON

      51340 1720 17820 REHABILITATION HOSPITAL AND GERIATIC CEN. 513025......... PHELPS COUNTY REGIONAL 26800 9000 48540 MED CENTER. 26T017......... PHELPS MEMORIAL

      33800

      26

      26 HOSPITAL. 33T261......... PHOEBE PUTNEY......... 11390 5600 35644 11T007......... PHOENIX BAPTIST

      03060 0120 10500 HOSPITAL. 03T030......... PHYSICAL

      16890 6200 38060 REHABILITAITON UNIT AT OTTUMWA REGIONAL H. 16T089......... PIEDMONT HOSPITAL..... 11470

      16

      16 11T083......... PIKEVILLE METHODIST

      18970 0520 12060 REHABILITATION HOSPITAL. 18T044......... PINECREST

      10490

      18

      18 REHABILITATION HOSPITAL. 103030......... PINNACLE REHAB........ 37540 8960 48424 373025......... PINNACLEHEALTH

      39280 5880 36420 HOSPITALS. 39T067......... PITT COUNTY MEMORIAL

      34730 3240 25420 HOSPITAL. 34T040......... PLAZA MEDICAL CENTER.. 45910 3150 24780 45T672......... POPLAR BLUFF REGIONAL 26110 2800 23104 MEDICAL CENTER. 26T119......... PORTER ADVENTIST

      06150

      26

      26 HOSPITAL. 06T064......... PORTNEUF MEDICAL

      13020 2080 19740 CENTER. 13T028......... POTTSTOWN MEMORIAL

      39560 6340 38540 MEDICAL CENTER. 39T123......... POTTSVILLE HOSPITAL-

      39650 6160 37964 WARNE CLINIC. 39T030......... POUDRE VALLEY HEALTH

      06340

      39

      39 CARE INC. 06T010......... PREMIER REHABILITATION 19360 2670 22660 HOSPITAL. 14T007......... PRESBYTERIAN HOSPITAL 45390 1600 16974 OF DALLAS. 193082......... PRESBYTERIAN

      05200 5200 33740 INTERCOMMUNITY HOSPITAL. 45T462......... PROVENA COVENANT

      14090 1920 19124 MEDICAL CENTER REHAB. 05T169......... PROVENA SAINT JOSEPH

      14530 4480 31084 HOSPITAL. 14T113......... PROVENA ST. JOSEPH

      14989 1400 16580 MEDICAL CENTER. 14T217......... PROVIDENCE ALASKA

      02020 1600 16974 MEDICAL CENTER. 02T001......... PROVIDENCE CENTRALIA

      50200 0380 11260 HOSPITAL. 50T019......... PROVIDENCE EVERETT

      50300

      50

      50 MEDICAL CENTER. 50T014......... PROVIDENCE HOLY CROSS 05200 7600 42644 MEDICAL CENTER. 05T278......... PROVIDENCE HOSPITAL... 23620 4480 31084 23T019......... PROVIDENCE MEDFORD

      38140 2160 47644 MEDICAL CENTER. 38T075......... PROVIDENCE PORTLAND

      38250 4890 32780 MEDICAL CENTER. 38T061......... PROVIDENCE SAINT

      05200 6440 38900 JOSEPH MEDICAL CENTER. 05T235......... PROVIDENCE ST. PETER

      50330 4480 31084 HOSPITAL. 50T024......... QUEEN OF ANGELS-

      05200 5910 36500 HOLLYWOOD PRESBYTERIAN MEDICAL C. 05T063......... QUEEN OF THE VALLEY

      05380 4480 31084 HOSPITAL.

      [[Page 30321]]

      05T009......... QUEENS HOSPITAL CENTER 33590 8720 34900 33T231......... RANCHO REHABILITATION. 29010 5600 35644 29T007......... RAPID CITY REGIONAL

      43510 4120 29820 HOSPITAL. 43T077......... REBSAMEN MEDICAL

      04590 6660 39660 CENTER. 04T074......... REDMOND REHABILITATION 11460 4400 30780 CENTER. 11T168......... REGIONAL MEDICAL

      18530

      11 40660 CENTER. 18T093......... REGIONAL REHAB CENTER 34850

      18

      18 AT HUGH CHATHAM. 34T097......... REGIONAL REHAB CENTER 49661

      34

      34 OF NORTON COMMUNITY HOSPITAL. 49T001......... REGIONAL

      42280

      49

      49 REHABILITATION CENTER. 42T036......... REGIONAL

      01500

      42

      42 REHABILITATION HOSPITAL. 013033......... REGIONS HOSPITAL REHAB 24610 5240 33860 INSTITUTE. 24T106......... REHAB CARE CENTER AT

      39390 5120 33460 INDIANA REGIONAL MEDICAL CTR. 39T173......... REHAB CENTER OF MARION 36520

      39

      39 36T011......... REHAB HOSP OF R I..... 41030

      36

      36 413025......... REHAB HOSP OF THE CAPE 22000 6483 39300 AND ISLANDS. 223032......... REHAB HOSPITAL OF

      19160 0743 12700 BATON ROUGE. 193028......... REHAB INSTITUTE AT

      05520 0760 12940 SANTA BARBARA,THE. 053028......... REHAB INSTITUTE AT

      44180 7480 42060 TCMC. 44T135......... REHAB MEDICINE ST.

      11260 5360 34980 MARY'S ATHENS. 11T006......... REHAB UNIT OF PACIFIC 05200 0500 12020 ALLIANCE MEDICAL CENTER. 05T018......... REHABCARE CENTER AT

      40560 4480 31084 HOSPITAL DR. PILA. 40T003......... REHABILITATION CENTER 15780 6360 38660 AT LAFAYETTE HOME HOSPITAL. 15T109......... REHABILITATION CENTER 03020 3920 29140 OF NORTHERN ARIZONA. 03T023......... REHABILITATION

      15010 2620 22380 HOSPITAL. 153030......... REHABILITATION

      07010 2760 23060 HOSPITAL OF CONNECTICUT,THE. 073025......... REHABILITATION

      15480 3283 25540 HOSPITAL OF INDIANA. 153028......... REHABILITATION

      15480 3480 26900 HOSPITAL OF INDIANA AT ST VINCENT. 153038......... REHABILITATION

      44780 3480 26900 HOSPITAL OF MEMPHIS. 44T152......... REHABILITATION

      32000 4920 32820 HOSPITAL OF NEW MEXICO. 323028......... REHABILITATION

      31190 0200 10740 HOSPITAL OF SOUTH JERSEY. 313036......... REHABILITATION

      12020 8760 47220 HOSPITAL OF THE PACIFIC. 123025......... REHABILITATION

      31290 3320 26180 HOSPITAL OF TINTON FALLS. 313035......... REHABILITATION

      31300 5190 20764 INSTITUTE AT MORRISTOWN MEMORIAL. 31T015......... REHABILITATION

      14141 5640 35084 INSTITUTE OF CHICAGO. 143026......... REHABILITATION

      45650 1600 16974 INSTITUTE OF MCALLEN. 45T811......... REHABILITATION

      23810 4880 32580 INSTITUTE OF MICHIGAN. 233027......... REHABILITATION

      26940 2160 19804 INSTITUTE OF ST LOUIS, THE. 263028......... REHABILITATION PATIENT 06200 7040 41180 CARE UNIT. 06T022......... REID HOSP-ACUTE REHAB 15880 1720 17820 UNIT. 15T048......... RENO REHAB ASSOCIATES, 29150

      15

      15 LIMITED PARTNERSHIP. 293027......... RESEARCH MEDICAL

      26070 6720 39900 CENTER. 26T027......... RESURRECTION MEDICAL

      14141

      26

      26 CENTER. 14T117......... RHD MEMORIAL MEDICAL

      45390 1600 16974 CENTER. 45T379......... RICHLAND PARISH

      19410 1920 19124 REHABILITATION HOSPITA. 193075......... RILEY MEMORIAL

      25370

      19

      19 HOSPITAL. 25T081......... RIO VISTA REHAB

      45480

      25

      25 HOSPITAL. 453033......... RIVER PARK HOSPITAL... 44880 2320 21340 44T151......... RIVER REGION HEALTH

      25740

      44

      44 SYSTEM. 25T031......... RIVER WEST MEDICAL

      19230

      25

      25 CENTER. 19T131......... RIVERSIDE MEDICAL

      14540

      19 12940 CENTER. 14T186......... RIVERSIDE REHAB

      49622 3740 28100 INSTITUTE. 493027......... RIVERVIEW HOSPITAL.... 15280 5720 47260 15T059......... RIVERVIEW MEDICAL

      31290 3480 26900 CENTER. 31T034......... ROCHESTER GENERAL

      33370 5190 20764 HOSPITAL. 33T125......... ROGER C. PEACE........ 42220 6840 40380 42T078......... ROGERS CITY

      23700 3160 24860 REHABILITATION HOSPITAL. 233029......... ROME MEMORIAL HOSPITAL 33510

      23

      23 33T215......... ROPER REHABILITATION

      42090 8680 46540 HOSPITAL. 42T087......... ROWAN REGIONAL MEDICAL 34790 1440 16700 CENTER. 34T015......... ROXBOROUGH............ 39620 1520

      34 39T304......... RUSH OAK PARK HOSPITAL 14141 6160 37964 14T063......... RUSH-COPLEY MEDICAL

      14530 1600 16974 CENTER. 14T029......... RUSK INSTITUTE........ 33420 1600 16974 33T214......... RUSK REHABILITATION

      26090 5600 35644 CENTER LLC. 263027......... RUTLAND REGIONAL

      47100 1740 17860 MEDICAL CENTER. 47T005......... SACRED HEART HOSPITAL. 52170

      47

      47 52T013......... SACRED HEART REHAB

      52390 2290 20740 INST.

      [[Page 30322]]

      523025......... SADDLEBACK MEMORIAL

      05400 5080 33340 MEDICAL CENTER. 05T603......... SAGE REHAB INSTITUTE.. 19160 5945 42044 193078......... SAINT ALPHONSUS

      13000 0760 12940 REGIONAL MEDICAL CENTER. 13T007......... SAINT ANTHONY'S HEALTH 14680 1080 14260 CENTER. 14T052......... SAINT FRANCIS HOSPITAL 31230 7040 41180 313037......... SAINT FRANCIS HOSPITAL 33230 3640 35644 33T067......... SAINT FRANCIS HOSPITAL 44780 2281 39100 44T183......... SAINT FRANCIS MEDICAL 14800 4920 32820 CENTER. 14T067......... SAINT FRANCIS MEMORIAL 05480 6120 37900 HOSPITAL. 05T152......... SAINT JOHNS MERCY

      26940 7360 41884 MEDICAL CENTER. 26T020......... SAINT JOSEPH HEALTH

      26470 7040 41180 CENTER. 26T085......... SAINT JOSEPH HOSPITAL. 14141 3760 28140 14T224......... SAINT JOSEPH REGIONAL 15700 1600 16974 MEDICAL CENTER. 15T012......... SAINT LUKE'S SOUTH

      17450 7800 43780 HOSPITAL. 17T185......... SAINT MARY OF NAZARETH 14141 3760 28140 HOSPITAL. 14T180......... SAINT MARYS REGIONAL

      29150 1600 16974 MEDICAL CENTER. 29T009......... SAINT VINCENT CATHOLIC 33420 6720 39900 MEDICAL CENTERS OF NEW YORK. 33T290......... SAINT VINCENT HEALTH

      39320 5600 35644 CENTER. 39T009......... SALEM HOSPITAL

      38230 2360 21500 REGIONAL REHABILITATION CENTER. 38T051......... SALINA REGIONAL HEALTH 17840 7080 41420 CENTER. 17T012......... SALINE MEMORIAL

      04620

      17

      17 HOSPITAL. 04T084......... SALT LAKE REGIONAL

      46170 4400 30780 MEDICAL CENTER. 46T003......... SAM KARAS ACUTE REHAB 05370 7160 41620 AT NATIVIDAD MEDICAL CENTER. 05T248......... SAMARITAN MEDICAL

      33330 7120 41500 CENTER. 33T157......... SAN ANGELO COMMUNITY

      45930

      33

      33 MEDICAL CENTER. 45T340......... SAN ANTONIO WARM

      45130 7200 41660 SRPINGS REHABILITATION HOSPITAL. 453035......... SAN CLEMENTE HOSPITAL. 05400 7240 41700 05T585......... SAN JACINTO METHODIST 45610 5945 42044 HOSPITAL. 45T424......... SAN JOAQUIN GENERAL

      05490 3360 26420 HOSPITAL. 05T167......... SAN JOAQUIN VALLEY

      05090 8120 44700 REHABILITATION HOSP. 053032......... SAN JOSE MEDICAL

      05530 2840 23420 CENTER. 05T215......... SAN LUIS VALLEY

      06010 7400 41940 REGIONAL MEDICAL CENTER. 06T008......... SANTA CLARA VALLEY

      05530

      06

      06 MEDICAL CENTER. 05T038......... SANTA ROSA MEMORIAL

      05590 7400 41940 HOSPITAL. 05T174......... SARASOTA MEMORIAL

      10570 7500 42220 HOSPITAL. 10T087......... SATILLA REGIONAL

      11940 7510 42260 REHABILITATION INSTITUTE. 11T003......... SAVOY MEDICAL CENTER.. 19190

      11

      11 19T025......... SCHWAB REHABILITATION 14141

      19

      19 HOSPITAL. 143025......... SCOTT & WHITE......... 45120 1600 16974 45T054......... SCOTTSDALE HEALTHCARE 03060 3810 28660 INPATIENT REHAB. 03T038......... SCRIPPS MEMORIAL

      05470 6200 38060 HOSPITAL ENCINITAS. 05T503......... SENTARA NORFOLK

      49641 7320 41740 GENERAL HOSPITAL. 49T007......... SEWICKLEY VALLEY

      39010 5720 47260 HOSPITAL. 39T037......... SHANDS REHAB HOSPITAL. 10000 6280 38300 10T113......... SHANNON WEST TEXAS

      45930 2900 23540 MEMORIAL HOSPITAL. 45T571......... SHARON REGIONAL HEALTH 39530 7200 41660 SYSTEM. 39T211......... SHARP MEMORIAL

      05470 7610 49660 REHABILITATION CENTER. 05T100......... SHELTERING ARMS

      49430 7320 41740 REHABILITATION HOSPITAL. 493025......... SHORE REHABILITATION

      31310 6760 40060 INSTITUTE. 313033......... SHREVEPORT

      19080 5190 20764 REHABILITATION HOSPITAL. 193083......... SID PETERSON MEMORIAL 45734 7680 43340 HOSPITAL. 45T007......... SIERRA VISTA REGIONAL 05500

      45

      45 MEDICAL CENTER. 05T506......... SILVER CROSS HOSPITAL. 14989 7460 42020 14T213......... SIMI VALLEY HOSPITAL & 05660 1600 16974 HEALTH CARE SVC. 05T236......... SINAI-GRACE HOSPITAL.. 23810 8735 37100 23T024......... SINGING RIVER HOSPITAL 25290 2160 19804 25T040......... SIOUX VALLEY HOSPITAL. 43490 0920 37700 43T027......... SISKIN HOSPITAL FOR

      44320 7760 43620 PHYSICAL REHABILITATION. 443025......... SISTER KENNY REHAB

      24260 1560 16860 INSTITUTE--ABBOTT NORTHWESTERN. 24T057......... SISTER KENNY REHAB

      24610 5120 33460 INSTITUTE--UNITED HOSPITAL. 24T038......... SKYLINE REHABILITATION 44180 5120 33460 CENTER. 44T006......... SLIDELL MEMORIAL

      19510 5360 34980 HOSPITAL. 19T040......... SOUTH FULTON.......... 11470 5560 35380 11T219......... SOUTH GEORGIA MEDICAL 11700 0520 12060 CENTER. 11T122......... SOUTH MIAMI HOSPITAL

      10120

      11 46660 PHYSICAL MEDICINE & REHAB. 10T154......... SOUTH POINTE HOSPITAL. 36170 5000 33124 36T144......... SOUTH TEXAS REGIONAL

      45060 1680 17460 SPECIALTY HOSPITAL.

      [[Page 30323]]

      45T165......... SOUTHCOAST HOSPITALS

      22150

      45 41700 GROUP, INC.. 22T074......... SOUTHEAST MISSOURI

      26150 1123 14484 HOSPITAL. 26T110......... SOUTHEASTERN REGIONAL 34250

      26

      26 REHABILITATION CENTER. 34T028......... SOUTHERN HILLS

      51270 2560 22180 REGIONAL REHAB. 513026......... SOUTHERN INDIANA

      15210

      51

      51 REHABILITATION HOSPITAL. 153037......... SOUTHERN KENTUCKY

      18986 4520 31140 REHABILITATION HOSPITAL. 183029......... SOUTHERN OHIO MEDICAL 36740

      18 14540 CENTER. 36T008......... SOUTHERN TENNESSEE

      44250

      36

      36 MEDICAL CENTER. 44T058......... SOUTHSIDE HOSPITAL.... 33700

      44

      44 33T043......... SOUTHWEST GENERAL

      45130 5380 35004 HOSPITAL. 45T697......... SOUTHWEST MEDICAL

      19270 7240 41700 CENTER. 19T205......... SOUTHWEST MISSISSIPPI 25560 3880 29180 REGIONAL MEDICAL CENTER. 25T097......... SOUTHWEST WASHINGTON

      50050

      25

      25 MEDICAL CENTER. 50T050......... SOUTHWESTERN MEDICAL

      37540 6440 38900 CENTER. 37T097......... SOUTHWESTERN

      23120 5880 36420 REHABILITATION HOSPITAL. 233025......... SPAIN REHABILITATION

      01360 3720 12980 CENTER. 01T033......... SPALDING

      06150 1000 13820 REHABILITATION HOSPITAL. 063027......... SPRING BRANCH MEDICAL 45610 2080 19740 CENTER. 45T630......... SSM DEPAUL HEALTH

      26940 3360 26420 CENTER. 26T104......... SSM REHABILITATION

      26940 7040 41180 INSTITUTE. 263025......... SSM ST. JOSEPH

      26940 7040 41180 KIRKWOOD. 26T081......... ST. FRANCIS MEDICAL

      19360 7040 41180 CTR. 04T007......... ST. AGNES MEDICAL

      39620 4400 30780 CENTER. 19T125......... ST. ALEXIUS MEDICAL

      35070 5200 33740 CENTER. 39T022......... ST. ANTHONYS MEDICAL

      26940 6160 37964 CENTER. 35T002......... ST. ANTHONY'S

      10050 1010 13900 REHABILITATION HOSPITAL. 26T077......... ST. CATHERINE'S

      10120 7040 41180 REHABILITATION HOSPITAL. 103027......... ST. DAVIDS

      45940 2680 22744 REHABILITATION CENTER. 103026......... ST. EDWARD MERCY

      04650 5000 33124 MEDICAL CENTER. 453038......... ST. ELIZABETH HEALTH

      36510 0640 12420 CENTER. 04T062......... ST. FRANCIS MEDICAL

      26260 2720 22900 CENTER. 36T064......... ST. JOHN DETROIT

      23810 9320 49660 RIVERVIEW HOSP. 26T183......... ST. JOHN MACOMB

      23490

      26

      26 HOSPITAL. 23T119......... ST. JOHN MEDICAL

      37710 2160 19804 CENTER, INC.. 23T195......... ST. JOHN NORTH SHORES 23490 2160 47644 HOSPITAL. 37T114......... ST. JOHNS REGIONAL

      26480 8560 46140 MEDICAL CENTER. 23T257......... ST. JOHN'S REGIONAL

      05660 2160 47644 MEDICAL CENTER. 26T001......... ST. JOHN'S

      19250 3710 27900 REHABILITATION HOSPITAL. 05T082......... ST. JOSEPH HEALTH

      41030 8735 37100 SERVICES OF RI. 193061......... ST. JOSEPH HOSPITAL... 05110 5560 35380 41T005......... ST. JOSEPH HOSPITAL... 30050 6483 39300 05T006......... ST. JOSEPH HOSPITAL & 15330

      05

      05 HEALTH CENTER. 30T011......... ST. JOSEPH REGIONAL

      45190 1123 31700 REHAB. 15T010......... ST. JOSEPHS HOSPITAL.. 52390 3850 29020 45T011......... ST. JOSEPH'S MERCY

      04250 1260 17780 HEALTH CENTER. 52T136......... ST. LAWRENCE

      31260 5080 33340 REHABILITATION CENTER. 04T026......... ST. LUKES EPISCOPAL

      45610

      04 26300 HOSPTIAL. 313027......... ST. LUKES HOSPITAL OF 26470 8480 45940 KANSAS CITY. 45T193......... ST. LUKES NORTHLAND

      26230 3360 26420 HOSPITAL. 26T138......... ST. LUKE'S

      19270 3760 28140 REHABILITATION HOSPITAL OF LAFAYETTE. 26T062......... ST. LUKES

      50310 3760 28140 REHABILITATION INSTITUTE. 193087......... ST. MARGARET MERCY

      15440 3880 29180 HLTHCARE CTRS. 503025......... ST. MARY MEDICAL

      05200 7840 44060 CENTER. 15T004......... ST. MARY MEDICAL

      50350 2960 23844 CENTER. 05T191......... ST. MARY-CORWIN

      06500 4480 31084 MEDICAL CENTER. 50T002......... ST. MARYS HOSPITAL.... 24540

      50

      50 06T012......... ST. MARY'S HOSPITAL

      26470 6560 39380 BLUE SPRINGS. 24T010......... ST. MARYS MEDICAL

      15810 6820 40340 CENTER. 26T193......... ST. MARYS MEDICAL

      44460 3760 28140 CENTER. 15T100......... ST. MARY'S MEDICAL

      05480 2440 21780 CENTER. 44T120......... ST. MARY'S WEST PALM

      10120 3840 28940 BEACH. 05T457......... ST. NICHOLAS HOSPITAL. 52580 7360 41884 10T288......... ST. PAUL HOSPITAL..... 45390 5000 33124 52T044......... ST. VINCENT HEALTHCARE 27550 7620 43100 45T044......... ST. VINCENT HOSPITAL.. 32240 1920 19124 27T049......... ST. VINCENT HOSPITAL.. 52040 0880 13740 32T002......... ST. VINCENT REHAB HOSP 04590 7490 42140 IN PART HLTHSOUT.

      [[Page 30324]]

      52T075......... ST. AGNES HOSPITAL.... 52190 3080 24580 043031......... ST. ALEXIUS HOSPITAL.. 26940 4400 30780 52T088......... ST. ANTHONY HOSPITAL

      37540

      52 22540 REHAB CENTER. 26T210......... ST. ANTHONY MEDICAL

      15440 7040 41180 CENTER. 37T037......... ST. ANTHONY MEMORIAL

      15450 5880 36420 HEALTH CENTERS. 15T126......... ST. CHARLES HOSPITAL

      33700 2960 23844 AND REHABILITATION CENTER. 15T015......... ST. CHARLES MERCY

      36490

      15 33140 HOSPITAL. 33T246......... ST. CLAIR HOSPITAL.... 39010 5380 35004 36T081......... ST. CLAIRE MC......... 18975 8400 45780 39T228......... ST. CLOUD HOSPITAL.... 24720 6280 38300 18T018......... ST. ELIZABETH HOSPITAL 52430

      18

      18 24T036......... ST. ELIZABETH HOSPITAL 14900 6980 41060 REHAB. 52T009......... ST. FRANCIS HOSPITAL

      08010 0460 11540 REHAB. 14T187......... ST. JAMES HOSPITAL AND 14141 7040 41180 HEALTH CENTERS. 08T003......... ST. JOHN NORTHEAST

      23810 9160 48864 COMMUNITY HOSPITAL. 14T172......... ST. JOHNS REGIONAL

      26380 1600 16974 HEALTH CENTER. 23T065......... ST. JOSEPH HOSPITAL... 50360 2160 19804 26T065......... ST. JOSEPH MEDICAL

      50260 7920 44180 CENTER. 50T030......... ST. JOSEPH MERCY

      23800 0860 13380 HOSPITAL-ANN ARBOR. 50T108......... ST. JOSEPHS HOSPITAL.. 03060 8200 45104 23T156......... ST. JOSEPH'S HOSPITAL. 33070 0440 11460 03T024......... ST. JOSEPH'S HOSPITAL. 52700 6200 38060 33T108......... ST. JOSEPH'S MERCY OF 23490 2335 21300 MACOMB. 52T037......... ST. JOSEPH'S WAYNE

      31320

      52

      52 HOSPITAL. 23T047......... ST. JUDE MEDICAL

      05400 2160 47644 CENTER. 31T116......... ST. LUKE'S............ 24680 0875 35644 05T168......... ST. LUKE'S/ROOSEVELT

      33420 5945 42044 HOSPITAL CENTER. 24T047......... ST. LUKES ACUTE REHAB. 03060 2240 20260 33T046......... ST. LUKES HOSPITAL.... 16560 5600 35644 03T037......... ST. LUKE'S HOSPITAL... 26940 6200 38060 16T045......... ST. LUKE'S HOSPITAL... 36490 1360 16300 26T179......... ST. LUKE'S REHAB UNIT 52580 7040 41180 AT ST. LUKE'S SOUTH SHORE. 36T090......... ST. MARY MEDICAL

      39140 8400 45780 CENTER. 52T138......... ST. MARY MEDICAL

      15440 7620 43100 CENTER INC. 39T258......... ST. MARYS HOSPITAL AND 06380 6160 37964 MEDICAL CENTER. 15T034......... ST. MARY'S REGIONAL

      04570 2960 23844 MEDICAL CENTER. 06T023......... ST. MARY'S REGIONAL

      37230 2995 24300 MEDICAL CENTER. 04T041......... ST. PETERS HOSPITAL... 33000

      04

      04 37T026......... ST. RITA'S MEDICAL

      36010 2340

      37 CENTER. 33T057......... ST. ROSE DOMINICAN

      29010 0160 10580 HOSPITAL. 36T066......... ST. TAMMANY PARISH

      19510 4320 30620 HOSPITAL. 29T012......... ST. VINCENT INFIRMARY 04590 4120 29820 MEDICAL CENTER. 19T045......... ST. VINCENT'S MEDICAL 07000 5560 35380 CENTER. 07T028......... ST. FRANCIS HEALTH

      17880 5483 14860 CENTER. 17T016......... ST. JOSEPH HOSPITAL

      15010 8440 45820 REHAB UNIT. 15T047......... STAMFORD HOSPITAL..... 07070 2760 23060 073026......... STANFORD HOSPITAL &

      05530

      07

      07 CLINICS. 05T441......... STANLY MEMORIAL

      34830 7400 41940 HOSPITAL. 34T119......... STARKE MEMORIAL

      15740 1520

      34 HOSPITAL. 15T102......... STATEN ISLAND HOSPITAL 33610

      15

      15 33T160......... STERLINGTON REHAB

      19360 5600 35644 HOSPITAL. 193069......... STILLWATER MEDICAL

      37590 5200 33740 CENTER. 37T049......... STRONG MEMORIAL

      33370

      37

      37 HOSPITAL. 33T285......... SUMMA HEALTH SYSTEM... 36780 6840 40380 29T041......... SUMMERLIN HOSPITAL

      29010 4120 29820 MEDICAL CENTER. 36T020......... SUMNER REGIONAL

      44820 0080 10420 MEDICAL CENTER. 44T003......... SUMTER REGIONAL

      11870 5360 34980 HOSPITAL. 11T044......... SUN COAST HOSPITAL.... 10510

      11

      11 10T015......... SUN HEALTH ROBERT H

      05460 8280 45300 BALLARD REHAB HOSPITAL. 053037......... SUNNYVIEW HOSPITAL AND 33650 6780 40140 REHABILITATION CENTER. 333025......... SUNRISE HOSPITAL &

      29010 0160 10580 MEDICAL CEN. 29T003......... SUNY DOWNSTATE MEDICAL 33331 4120 29820 CENTER. 33T350......... SUTTER AUBURN FAITH

      05410 5600 35644 HOSPITAL. 05T498......... SWEDISH COVENANT

      14141 6920 40900 HOSPITAL. 14T114......... SWEDISH GENERAL

      06020 1600 16974 REHABILITATION. 06T034......... SWEDISH MEDICAL CENTER 50160 2080 19740 50T025......... TAH INPATIENT REHAB

      39260 7600 42644 UNIT.

      [[Page 30325]]

      39T122......... TAKOMA ADVENTIST

      44290

      39

      39 HOSPITAL. 44T050......... TAMPA GENERAL

      10280

      44

      44 REHABILATION CTR. 10T128......... TARRANT COUNTY

      45910 8280 45300 REHABILITATION HOSPITAL. 453042......... TEMPLE UNIVERSITY

      39620 2800 23104 HOSPITAL. 39T027......... TERREBONNE GENERAL

      19540 6160 37964 MEDICAL CENTER. 19T008......... TEXOMA MEDICAL CENTER. 45564 3350 26380 28T061......... THE ACUTE REHAB UNIT

      28780

      28

      28 AT REGIONAL WEST MEDICAL CENT. 20T018......... THE AROOSTOOK MEDICAL 20010

      20

      20 CENTER. 36T163......... THE CHRIST HOSPITAL

      36310 1640 17140 REHAB UNIT. 09T001......... THE GEORGE WASHINGTON 09000 8840 47894 UNIVERSITY ARU. 39T066......... THE GOOD SAMARITAN

      39460 3240 30140 HOSPITAL. 33T004......... THE KINGSTON HOSPITAL 33740

      33 28740 REHABILITATION CENTER. 25T099......... THE LEFLORE

      25410

      25

      25 REHABILITATION CENTER. 33T056......... THE PARKSIDE ACUTE

      33331 5600 35644 REHABILITATION CENTER. 33T049......... THE PAUL ROSENTHAL

      33230 2281 39100 REHABILITATION CENTER AT NDH. 39T044......... THE READING HOSPITAL

      39110 6680 39740 AND MEDICAL CENTER. 42T068......... THE REGIONAL MEDICAL

      42370

      42

      42 CENTER REHABCENTRE. 15T051......... THE REHAB CENTER AT

      15520 1020 14020 BLOOMINGTON HOSPITAL. 11T024......... THE REHAB CENTER AT

      11220 7520 42340 CANDLER. 44T059......... THE REHAB CENTER AT

      44700

      44

      44 COOKEVILLE RMC. 16T146......... THE REHAB CENTER AT

      16960 7720 43580 ST. LUKE'S. 11T043......... THE REHAB CENTER AT

      11220 7520 42340 ST. JOSEPHS. 15T008......... THE REHABILITATION

      15440 2960 23844 CENTER AT ST. CATHERINE HOSPITA. 10T012......... THE REHABILITATION

      10350 2700 15980 HOSPITAL. 20T039......... THE REHABILITATION

      20050

      20

      20 INSTITUTE AT MGMC. 42T067......... THE REHABILITATION

      42060

      42

      42 UNIT AT BEAUFORT MEMORIAL HOSPI. 36T211......... THE TRINITY

      36420 8080 48260 REHABILITATION CENTER. 39T042......... THE WASHINGTON

      39750 6280 38300 HOSPITAL ACUTE REHABILITATION UNIT. 52T045......... THEDA CLARK MEDICAL

      52690 0460 36780 CENTER. 19T004......... THIBODAUX REGIONAL

      19280 3350 26380 MEDICAL CENTER. 39T174......... THOMAS JEFFERSON

      39620 6160 37964 UNIVERSITY HOSPITAL. 343025......... THOMS REHABILITATION

      34100 0480 11700 HOSP. 23T015......... THREE RIVERS

      23740

      23

      23 REHABILITATION PAVILION. 11T095......... TIFT REGIONAL MEDICAL 11900

      11

      11 CENTER. 45T080......... TITUS REGIONAL MEDICAL 45531

      45

      45 CENTER. 45T324......... TOMBALL REGIONAL

      45610 7640 43300 HOSPITAL. 45T670......... TOURO REHABILITATION

      19350 3360 26420 CENTER. 193034......... TRI-CITY MEDICAL

      05470 5560 35380 CENTER. 05T128......... TRI PARISH

      19050 7320 41740 REHABILITATION HOSPITAL LLC. 193050......... TRINITY MEDICAL CENTER 14890

      19

      19 14T280......... TRINITY REHABCARE

      35500 1960 19340 CENTER. 35T006......... TULANE INPATIENT REHAB 19350

      35

      35 CENTER. 19T176......... TULSA REGIONAL MEDICAL 37710 5560 35380 CENTER. 37T078......... TWELVE OAKS MEDICAL

      45610 8560 46140 CENTER. 45T378......... TWIN RIVERS REGIONAL

      26340 3360 26420 MEDICAL CENTER. 26T015......... U W HOSPITAL & CLINIC. 52120

      26

      26 52T098......... UAB MEDICAL WEST

      01360 4720 31540 REHABILITATION UNIT. 01T114......... UC DAVIS MEDICAL

      05440 1000 13820 CENTER. 05T599......... UCLA MED CTR-RRU...... 05200 6920 40900 05T262......... UHS HOSPITALS......... 33030 4480 31084 33T394......... UNC HOSPITALS......... 34670 0960 13780 34T061......... UNION HOSPITAL........ 15830 6640 20500 15T023......... UNIONTOWN HOSPITAL.... 39330 8320 45460 39T041......... UNITED MEDICAL CENTER 53100 6280 38300 ARU. 53T014......... UNITED MEDICAL

      19350 1580 16940 REHABILITATION HOSPITAL. 193079......... UNITY HEALTH CENTER... 37620 5560 35380 37T149......... UNITY HEALTH SYSTEM... 33370 5880

      37 33T226......... UNIV OF CA IRVINE MED 05400 6840 40380 CTR. 05T348......... UNIV OF PITTSBURGH MED 39010 5945 42044 CTR-MUH. 39T164......... UNIVERSITY COMMUNITY

      10280 6280 38300 HOSPITAL. 10T173......... UNIVERSITY HEALTH

      45130 8280 45300 SYSTEM. 45T213......... UNIVERSITY HOSPITAL... 33520 7240 41700 33T241......... UNIVERSITY MEDICAL

      44940 8160 45060 CENTER. 44T193......... UNIVERSITY MEDICAL

      45770 5360 34980 CENTER. 45T686......... UNIVERSITY OF COLORADO 06150 4600 31180 HOSPITAL. 06T024......... UNIVERSITY OF ILLINOIS 14141 2080 19740 MEDICAL CENTER AT CHICAGO. 14T150......... UNIVERSITY OF MICHIGAN 23800 1600 16974 HOSPITAL.

      [[Page 30326]]

      23T046......... UNIVERSITY OF UTAH

      46170 0440 11460 HOSPITAL. 46T009......... UNIVERSITY OF

      50160 7160 41620 WASHINGTON MED CTR. 50T008......... UNIVERSITY

      25240 7600 42644 REHABILITATION CENTER. 25T001......... UPMC HORIZON.......... 39530 3560 27140 39T178......... UPMC LEE REGIONAL

      39160 7610 49660 REHAB UNIT. 39T011......... UPMC MCKEESPORT....... 39010 3680 27780 39T002......... UPMC NORTHWEST........ 39730 6280 38300 39T091......... UPMC PASSAVANT-

      39010

      39

      39 REHABILITATION CENTER. 39T107......... UPMC REHABILITATION

      39010 6280 38300 HOSPITAL. 393042......... UPMC SOUTHSIDE........ 39010 6280 38300 39T131......... UPMC ST MARGARET...... 39010 6280 38300 39T102......... UPPER VALLEY MEDICAL

      36560 6280 38300 CENTER. 36T174......... UTAH VALLEY REGIONAL

      46240 2000 19380 MEDICAL CENTER- REHABILITATION. 46T001......... UVA-HEALTHSOUTH

      49191 6520 39340 REHABILITATION HOSPITAL. 493029......... VALLEY BAPTIST HEALTH 45240 1540 16820 SYSTEM REHAB UNIT. 45T033......... VALLEY HOSPITAL

      29010 1240 15180 MEDICAL CENTER REHABILITAION UNIT. 29T021......... VALLEY MEMORIAL

      05000 4120 29820 HOSPITAL. 05T283......... VALLEY PRESBYTERIAN

      05200 5775 36084 HOSPITAL. 05T126......... VALLEY VIEW HOSPITAL.. 06070 4480 31084 06T075......... VALLEY VIEW REGIONAL

      37610

      06

      06 HOSPITAL. 37T020......... VAN MATRE HEALTHSOUTH 14991

      37

      37 REHABILITATION HOSPITAL. 143028......... VANDERBILT STALLWORTH 44180 6880 40420 REHAB HOSPITAL. 443028......... VCUHS................. 49791 5360 34980 49T032......... VERMILION

      19480 6760 40060 REHABILITATION HOSPITAL. 193047......... VIA CHRISTI

      17860 3880

      19 REHABILITATION CENTER. 173028......... VICTORIA WARM SPRINGS 45948 9040 48620 REHAB HOSPITAL. 453083......... VICTORY MEMORIAL

      33331 8750 47020 HOSPITAL. 33T242......... VIRGINIA BAPTIST

      49551 5600 35644 HOSPITAL. 49T021......... VIRGINIA MASON MEDICAL 50160 4640 31340 CENTER. 50T005......... VIRGINIA REGIONAL

      24680 7600 42644 MEDICAL CENTER. 24T084......... VISTA HEALTH ST.

      14570 2240 20260 THERESE REHAB UNIT. 14T033......... WACCAMAW

      42210 1600 29404 REHABILITATION CENTER. 42T098......... WADSWORTH RITTMAN

      36530

      42

      42 HOSPITAL. 36T195......... WAKEMED REHAB......... 34910 1680 17460 34T069......... WALTER O. BOSWELL

      03060 6640 39580 MEMORIAL HOSPITAL. 03T061......... WALTON REHABILITATION 11840 6200 38060 HOSPITAL. 113026......... WARMINSTER HOSPITAL... 39140 0600 12260 39T286......... WASHOE MEDICAL CENTER 29120 6160 37964 REHABILITATION HOSPITAL. 29T049......... WASHOE VILLAGE REHAB.. 29150

      29 16180 293030......... WAUKESHA MEMORIAL

      52660 6720 39900 HOSPITAL. 52T008......... WAUSAU HOSPITAL....... 52360 5080 33340 52T030......... WELDON CENTER FOR

      22070 8940 48140 REHABILITATION. 22T066......... WELLSTAR COBB HOSPITAL 11290 8003 44140 11T143......... WELLSTAR KENNESTONE

      11290 0520 12060 INPATIENT REHAB. 11T035......... WENATCHEE VALLEY

      50030 0520 12060 HOSPITAL REHABILITATION CENTER. 50T148......... WESLACO REHABILITATION 45650

      50 48300 HOSPITAL. 453091......... WESLEY REHABILITATION 17860 4880 32580 HOSPITAL. 173027......... WESLEY WOODS GERIATRIC 11370 9040 48620 HOSPITAL. 11T203......... WEST ALLIS MEMORIAL

      52390 0520 12060 HOSPITAL. 52T139......... WEST FLORIDA REHAB

      10160 5080 33340 INSTITUTE. 10T231......... WEST HOUSTON MEDICAL

      45610 6080 37860 CENTER. 45T644......... WEST JEFFERSON MEDICAL 19250 3360 26420 CENTER. 19T039......... WEST TENNESSEE

      44560 5560 35380 REHABILITATION CENTER. 44T002......... WEST VIRGINIA REHAB

      51190 3580 27180 HOSP. 513029......... WESTCHESTER MEDICAL

      33800 1480 16620 CENTER. 33T234......... WESTERN PENNSYLVANIA

      39010 5600 35644 HOSPITAL. 39T090......... WESTERN PLAINS MEDICAL 17280 6280 38300 COMPLEX. 17T175......... WESTLAKE HOSPITAL..... 14141

      17

      17 14T240......... WESTMORELAND REGIONAL 39770 1600 16974 HOSPITAL. 39T145......... WESTVIEW HOSPITAL..... 15480 6280 38300 15T129......... WHITAKER

      34330 3480 26900 REHABILITATION CENTER. 34T014......... WHITE COUNTY MEDICAL

      04720 3120 49180 CENTER. 04T100......... WHITE MEMORIAL MEDICAL 05200

      04

      04 CENTER. 05T103......... WHITE RIVER MEDICAL

      04310 4480 31084 CENTER. 04T119......... WHITTIER

      22040

      04

      04 REHABILITATION HOSPITAL. 223028......... WHITTIER REHABILTATION 22170 1123 21604 HOSPITAL. 223033......... WICHITA VALLEY

      45960 1123 49340 REHABILITATION HOSPITAL.

      [[Page 30327]]

      453088......... WILLAMETTE VALLEY

      38350 9080 48660 MEDICAL CENTER. 38T071......... WILLIAM BEAUMONT

      23620 6440 38900 HOSPITAL. 23T130......... WILLIAM N. WISHARD

      15480 2160 47644 MEMORIAL HOSPITAL. 39T045......... WILLIAMSPORT HOSPITAL 39510 9140 48700 REHAB. 19T111......... WILLIS-KNIGHTON

      19080 7680 43340 MEDICAL CENTER. 45T469......... WILSON N. JONES

      45564 7640 43300 MEDICAL CENTER-MAIN CAMPUS. 45T393......... WILSON N. JONES

      45564 7640 43300 MEDICAL CENTER-NORTH CAMPUS. 49T005......... WINCHESTER

      49962

      49 49020 REHABILITATION CTR. 15T014......... WINONA MEMORIAL

      15480 3480 26900 HOSPITAL. 10T052......... WINTER HAVEN HOSPITAL. 10520 3980 29460 33T239......... WOMANS CHRISTIAN

      33060 3610

      33 ASSOCIATION. 33T396......... WOODHULL MEDICAL

      33331 5600 35644 CENTER. 45T484......... WOODLAND HEIGHTS

      45020

      45

      45 MEDICAL CENTER. 53T012......... WYOMING MEDICAL CENTER 53120 1350 16220 50T012......... YAKIMA REGIONAL....... 50380 9260 49420 07T022......... YALE-NEW HAVEN

      07040 5483 35300 HOSPITAL. 033034......... YUMA REHABILITATION

      03130 9360 49740 HOSPITAL. 45T766......... ZALE LIPSHY UNIVERSITY 45390 1920 19124 HOSPITAL.

      [FR Doc. 05-10264 Filed 5-19-05; 4:00 pm]

      BILLING CODE 4120-01-P